Screening Internal Contamination of Inhaled and Ingested Radionuclides with Hand-held Survey Meters

During the aftermath of a radiological accident or attack, the rapid identification of individuals who have internalized medically significant amounts of material is paramount to guide medical and public health decisions. This paper explores the utility of hand-held, pancake GM detectors to determine if an individual has inhaled Sr, Cs, Pu, Pu, or Am in quantities requiring treatment. Additionally, ingestion of Sr or Cs was considered. Both Sr and Cs were modeled in equilibrium with their progeny, but the progeny of Pu, Pu, and Am were excluded. Treatment thresholds are defined using the National Council on Radiation Protection & Measurements' (NCRP) clinical decision guides (CDGs). Using Monte Carlo N-Particle (MCNP) modeling software, a human phantom and detector were modeled to determine the activity required to achieve a detector reading of twice background 1, 7, or 30 d post-ingestion or post-inhalation. Modeling found that inhaled Pu, Pu, and Am are detectable only if the contaminated individual inhaled thousands-fold more material than the CDG. This lack of detectability means that hand-held GM detectors are inappropriate for initial screening for americium or plutonium and that more intensive screening is necessary to confirm suspected contamination. Cesium-137, by contrast, could be detected at levels 10- to 100-fold lower than the amount requiring treatment, allowing quick differentiation between contaminated and uncontaminated individuals. Surprisingly, Sr was detectable within a factor of 2 of the amount requiring treatment. Detection of Sr was due primarily to bremsstrahlung radiation from beta interactions with calcium in bone. While rapid screening could identify individuals contaminated by Cs and possibly with Sr, further screening of identified individuals is necessary to establish medical need. However, these contaminated individuals could still be prioritized for further testing and possible presumptive treatment. Based on the findings of this study, concepts of operation for the use of hand-held survey meters should be developed for the screening of individuals potentially internally contaminated with Cs and Sr.

Mesenchymal stem and progenitor cells of rats' bone marrow under chronic action of ionizing radiation

Under the influence of ionizing radiation on hematopoietic system, the level of its injury is determined not only by the radiosensitivity of hematopoietic stem cells, but also by radiation induced changes in microenvironment func tioning, in particular, mesenchymal stem cells as its components.

OBJECTIVE

to define functioning characteristics of mesenchymal stem and progenitor cells of rats' bone marrow under prolonged action of ionizing radiation as a result of 90Sr incorporation.

MATERIALS AND METHODS

We applied the model of Wistar rats' internal irradiation with 90Sr radionuclide and per formed the in vitro cultivation of their bone marrow mesenchymal cells. Colony forming efficiency in the in vitro cell culture was determined, as well as the possibility of these cells to form feeder layers and to support rat bone mar row hematopoietic cells in the culture of diffusion chambers in vitro.

RESULTS AND CONCLUSIONS

We established that chronic action of incorporated 90Sr radionuclide induced considerable decrease in proliferative activity of mesenchymal stem cells comparing to control, as well as the inhibition of the capability to prolonged support of hematopoietic processes in vitro by their feeder layers.Thus, bone marrow mesenchymal stem cells and their closest progeny - progenitor cells were characterized by rather high radiosensitivity under the influence of ionizing radiation, which was revealed in considerable decline of their functional activity in cell culture in vitro comparing to control indices as a result of irradiation.

Plasma Retention and Systemic Kinetics of 90Sr Intramuscularly Injected in Female Nonhuman Primates

Thirteen female Rhesus macaques were intramuscularly injected with Sr(NO3)2 diluted in sodium citrate solution. The biokinetic data from these animals were compared against the predictions of the NCRP 156 wound models combined with the ICRP systemic models. It was observed that the activities measured in plasma of these nonhuman primates (NHPs) were consistently lower than those predicted by the default human biokinetic models. The urinary excretion from the NHPs at times immediately after injection was much greater than that in humans. The fecal excretion rates were found to be in relatively better agreement with humans. Similarly, the activities retained in the skeleton of the NHPs were lower than those in humans. These differences were attributed to the higher calcium diet of the NHPs (0.03 to 0.12 g d kg body weight) compared to that of humans. These observations were consistent with the early animal and human studies that showed the effect of calcium on strontium metabolism, specifically urinary excretion. Strontium is preferentially filtered at a much higher rate in kidneys than calcium because it is less completely bound to protein than is calcium. These differences, along with large inter-animal variability, should be considered when estimating the behavior of strontium in humans from the metabolic data in animals or vice versa.

Assessing the reliability of dose coefficients for ingestion and inhalation of 226Ra and 90Sr by members of the public

Assessments of risk to a population group resulting from internal exposure to a particular radionuclide can be used to assess the reliability of the appropriate International Commission on Radiological Protection (ICRP) dose coefficient, E(50), used as a radiation protection device for the specified exposure pathway. An estimate of the uncertainty on the risk is important for informing judgements on reliability. This paper describes the application of parameter uncertainty analysis to quantify uncertainties resulting from internal exposures to radioisotopes of the alkaline earth metals, (90)Sr and (226)Ra, by members of the UK public. The study derives uncertainties in biokinetic model parameter values to calculate the distributions of the effective dose per unit intake using the ICRP Publication 60 formalism. The distributions are used to infer the uncertainty on the mean effective dose per unit intake to inform the derivation of uncertainty factors (UF) for the appropriate ICRP Publication 72 dose coefficients. Here, a UF indicates a 95 % probability that the best estimate of risk per unit intake is within a factor, UF, of the nominal risk associated with the appropriate ICRP dose coefficient, E(50), with respect to uncertainties in the biokinetic model parameter values. Ingestion: it is assumed that exposure occurs through the ingestion of radionuclides present in food and water. The results for both radionuclides suggest a UF of within 3 for all age groups, with median values close to the ICRP values. Inhalation: it is assumed that environmental exposure to radium occurs primarily due to insoluble forms present in fly ash discharged from coal-fired power stations; for strontium, exposure is assumed to occur due to residual aerosols produced as a result of atmospheric nuclear testing and nuclear reactor accidents. The results suggest a UF of around 3 and 6 for inhalation of (90)Sr and (226)Ra, respectively, by members of the public.

Reconstruction of long-lived radionuclide intakes for Techa riverside residents: 137Cs

Radioactive contamination of the Techa River (Southern Urals, Russia) occurred from 1949-1956 due to routine and accidental releases of liquid radioactive wastes from the Mayak Production Association. The long-lived radionuclides in the releases were Sr and Cs. Contamination of the components of the Techa River system resulted in chronic external and internal exposure of about 30,000 residents of riverside villages. Data on radionuclide intake with diet are used to estimate internal dose in the Techa River Dosimetry System (TRDS), which was elaborated for the assessment of radiogenic risk for Techa Riverside residents. The Sr intake function was recently improved, taking into account the recently available archival data on radionuclide releases and in-depth analysis of the extensive data on Sr measurements in Techa Riverside residents. The main purpose of this paper is to evaluate the dietary intake of Cs by Techa Riverside residents. The Cs intake with river water used for drinking was reconstructed on the basis of the Sr intake-function and the concentration ratio Cs-to-Sr in river water. Intake via Cs transfer from floodplain soil to grass and cows' milk was evaluated for the first time. As a result, the maximal Cs intake level was indicated near the site of releases in upper-Techa River settlements (8,000-9,000 kBq). For villages located on the lower Techa River, the Cs intake was significantly less (down to 300 kBq). Cows' milk was the main source of Cs in diet in the upper-Techa River region.

[Possibilities of systemic radiotherapy with high-purity 89Sr chloride in the treatment of bone metastases]

OBJECTIVE

To study the efficiency of treatment via single administration of high-purity 89Sr chloride in the standard activity of 150 MBq for pain syndrome in patients with multiple bone metastases.

SUBJECTS AND METHODS

The authors carried out clinical trials of high-purity 89Sr chloride used to treat 30 patients with multiple bone metastases from cancers at various sites. The results of treatment were analyzed in 30 patients with multiple bone metastases, who had received systemic radiation therapy with high-purity 89Sr chloride in the standard activity of 150 MBq. These were assessed using some indicators: the intensity of pain syndrome and the blood concentrations of hemoglobin, leukocytes, and platelets.

RESULTS

There was evidence for the use of high-purity 89Sr chloride in the therapy of patients with cancer at various sites with multiple bone metastases. The major indicators (pain syndrome, the blood concentrations of hemoglobin, leukocytes, and platelets) were compared before and after the treatment. These were also compared with those obtained with the use of usual 89Sr chloride.

CONCLUSION

The therapeutic action of high-purity 89Sr chloride is comparable with that of 89Sr chloride in the standard activity; moreover, the analgesic effect of high-purity 89Sr chloride is being significantly higher. It has less significant myelotoxic activity than usual 89Sr chloride. High-purity 89Sr chloride is an effective radiopharmaceutical agent and may be used for systemic radiotherapy in patients with multiple bone metastatic lesion.

[Strontium-89 therapy and subarachnoid phenol block successfully eliminated intractable pain of metastasis in the patient with advanced urachal carcinoma]

We report a case of a 39-year-old man with intractable multifocal pain caused by metastatic urachal carcinoma to the bone. The patient underwent a partial cystectomy in May 2008, and lung metastasis occurred 9 months after the surgery. He then received salvage chemotherapy, but developed metastasis to the liver, brain, and bone. He was hospitalized due to a shoulder pain, a lower back pain, buttocks pain, numbness in both legs, and drop foot in right leg. MRI revealed metastases to the spine, and lumbar spinal canal stenosis with cauda equina compression. Even a combination of fentanyl-patch, oral acetaminophen, gabapentin and paroxetine was not effective for pain control. Strontium-89 therapy and subarachnoid phenol block successfully eliminated intractable pain. The patient could be discharged from hospital and received a palliative care at home for a short period of time.

Biokinetics of 90Sr after chronic ingestion in a juvenile and adult mouse model

The aim of our study was to define the biokinetics of (90)Sr after chronic contamination by ingestion using a juvenile and adult murine model. Animals ingested (90)Sr by drinking water containing 20 kBq l(-1) of (90)Sr. For the juvenile model, parents received (90)Sr before mating and their offspring were killed between birth and 20 weeks of ingestion. For the adult model, (90)Sr ingestion started at 9 weeks of age and they were killed after different ingestion periods up to 20 weeks. The body weight, food and water consumption of the animals were monitored on a weekly basis. Before killing and sampling of organs, animals were put in metabolic cages. (90)Sr in organs and excreta was determined by liquid scintillation β counting. Highest (90)Sr contents were found in bones and were generally higher in females than in males, and (90)Sr retention varied according to the skeletal sites. An accumulation of (90)Sr in the bones was observed over time for both models, with a plateau level at adult age for the juvenile model. The highest rate of (90)Sr accumulation in bones was observed in early life of offspring, i.e. before the age of 6 weeks. With the exception of the digestive tract, (90)Sr was below the detection limit in all other organs sampled. Overall, our results confirm that (90)Sr mainly accumulates in bones. Furthermore, our results indicate that there are gender- and age-dependent differences in the distribution of (90)Sr after low-dose chronic ingestion in the mouse model. These results provide the basis for future studies on possible non-cancerous effects during chronic, long-term exposure to (90)Sr through ingestion in a mouse model, especially on the immune and hematopoietic systems.

Reconstruction of long-lived radionuclide intakes for Techa riverside residents: strontium-90

Releases of radioactive materials from the Mayak Production Association in 1949-1956 resulted in contamination of the Techa River; a nuclide of major interest was 90Sr, which downstream residents consumed with water from the river and with milk contaminated by cows' consumption of river water and contaminated pasture. Over the years, several reconstructions of dose have been performed for the approximately 30,000 persons who make up the Extended Techa River Cohort. The purpose of the study described here was to derive a revised reference-90Sr-intake function for the members of this cohort. The revision was necessary because recently discovered data have provided a more accurate description of the time course of the releases, and more is now known about the importance of the pasture grass-cow-milk pathway for the members of this cohort. The fundamental basis for the derivation of the reference-90Sr-intake function remains the same: thousands of measurements of 90Sr content in bone with a special whole-body counter, thousands of measurements of beta-activity of front teeth with a special tooth-beta counter, and a variety of other measurements, including post mortem measurements of 90Sr in bone, measurements of 90Sr in cow's milk, and measurements of beta activity in human excreta. Results of the new analyses are that the major intake started in September 1950 and peaked somewhat later than originally postulated. However, the total intake for adult residents has not changed significantly. For children of some birth years, the intake and incorporation of Sr in bone tissue have changed substantially.

Clinical dosimetry in the treatment of bone tumors: old and new agents

Treatment of multisite, sclerotic bone metastases is successfully performed by radionuclide therapy. Pain palliation is the most common aim for the treatment. Two radiopharmaceuticals are currently approved by the European Medicines Agency ((153)Sm-EDTMP and (89)Sr-Cl₂) whilst other radiopharmaceuticals are at different stages of development, or are approved in some European countries ((186)Re-HEDP, (117)Snm-DTPA and (223)Ra-Cl₂). The tissues at risk for the treatment are bone marrow and normal bone. A review of the methods applied for dosimetry for these tissues and for tumours is performed, including the calculation of S values (the absorbed dose per decay) and optimal procedures on how to obtain biodistribution data for each radiopharmaceutical. The dosimetry data can be used to individualise and further improve the treatment for each patient. Dosimetry for radionuclide therapy of bone metastases is feasible and can be performed in a routine clinical practice.

90Sr therapy for oral squamous cell carcinoma in two cats

Two cats with a superficial oral squamous cell carcinoma responded favorably to treatment using a 90Sr probe. From one to six fields were applied per tumor, depending on tumor size. The surface dose per treatment ranged from 75 to 150 Gy and the total surface dose ranged from 200 to 500 Gy. Adverse effects were minimal. The cats survived 7 months and 5 years 9 months from the time of diagnosis. These data indicate that with careful patient selection 90Sr may be useful for the treatment of feline oral squamous cell carcinoma in some patients.

Biomaterials for the decorporation of (85)Sr in the rat

Although four stable isotopes of strontium occur naturally, Sr is produced by nuclear fission and is present in surface soil around the world as a result of fallout from atmospheric nuclear weapons tests. It can easily transfer to humans in the event of a nuclear/radiological emergency or through the plant-animal-human food chain causing long-term exposures. Strontium is chemically and biologically similar to calcium, and is incorporated primarily into bone following internal deposition. Alginic acid (alginate) obtained from seaweed (kelp) extract selectively binds ingested strontium in the gastrointestinal tract blocking its systemic uptake and reducing distribution to bone in rats, while other natural polysaccharides including chitosan and hyaluronic acid had little in vivo affinity for strontium. Alginate exhibits the unique ability to discriminate between strontium and calcium and has been previously shown to reduce intestinal absorption and skeletal retention of strontium without changing calcium metabolism. In our studies, the effect of commercially available alginate on intestinal absorption of strontium was examined. One problem associated with alginate treatment is its limited solubility and gel formation in water. The aqueous solubility of sodium alginate was improved in a sodium chloride/sodium bicarbonate electrolyte solution containing low molecular weight polyethylene glycol (PEG). Furthermore, oral administration of the combined alginate/electrolyte/PEG solution accelerated removal of internal strontium in rats when compared to treatment with individual sodium alginate/electrolyte or electrolyte/PEG solutions. Importantly, both alginate and PEG are nontoxic, readily available materials that can be easily administered orally in case of a national emergency when potentially large numbers of the population may require medical treatment for internal depositions. Our results suggest further studies to optimize in vivo decorporation performance of engineered alginate material via modification of its chemical and physicochemical properties are warranted.

Strontium-90 Induced Bone Tumours in Beagle Dogs: Effects of Route of Exposure and Dose Rate

Bone tumours from beagles exposed by inhalation to 90SrCl2 at the Inhalation Toxicology Research Institute (ITRI), by chronic ingestion of 90Sr at the Laboratory of Energy-Related Health Research (LEHR), and by injection of 90Sr citrate at the University of Utah were analysed to determine if the bone tumour characteristics differed among the three studies. The range of average skeletal doses at which the bone tumours occurred was similar in all three studies, but differences in the skeletal distribution, histological phenotype, and time to death were observed. The differences observed were attributed to the difference in dose-rate pattern obtained in the chronic ingestion study, in contrast to the inhalation and injection studies. In general, however, the differences noted in bone tumour characteristics were subtle, and would be unlikely to make an impact on models developed to assess the risk of human exposure to 90Sr.

Reconstruction of (90)Sr intake for breast-fed infants in the Techa riverside settlements

The Techa River (Southern Urals, Russia) was contaminated as a result of radioactive releases by the Mayak plutonium production facility during 1949-1956. The persons born after the onset of the contamination have been identified as the "Techa River Offspring Cohort" (TROC). The TROC has the potential to provide direct data on health effects in progeny that resulted from exposure of a general parent population to chronic radiation. The purpose of the present investigation is the estimation of (90)Sr intake from breast milk and river water in the period from birth to 6 months of life, necessary for an infant dose calculation. The investigation is based on all available data concerning radioactive contamination due to global fallouts and Mayak releases in the Southern Urals where extensive radiometric and radiochemical investigations of human tissues and environmental samples were conducted during the second half of the twentieth century. The strontium transfer factor from mother's daily diet to breast milk was estimated as 0.05 (0.01-0.13) d L(-1). Based on this transfer factor and data on (90)Sr water contamination, the average total (90)Sr intake for an infant born in the middle Techa River region was found to be equal to 60-80 kBq in 1950-1951. For the same period, calculations of (90)Sr intake using ICRP models gave values of 70-100 kBq. From 1952 onwards, the differences in intakes calculated using the two approaches increased, reaching a factor of 2-3 in 1953. The Techa River data provide the basis for improving and adapting the ICRP models for application to Techa River-specific population.

Reconstruction and forecast of doses due to ingestion of 137Cs and 90Sr after the Chernobyl accident

The assessment doses due to ingestion of (137)Cs and (90)Sr for the population suffering from the Chernobyl accident was performed on the basis of the new mechanistic ecological model for assessment of radiological consequences of agricultural lands contamination (EMARC). The EMARC model allows estimation of internal doses based on ecological factors influencing the contamination of foodstuff, for the post-accidental years in the countries of the former Soviet Union. The EMARC model allows estimation of all quantities required in radiation hygiene practice. For example, the proposed analytical method may be used for both retrospective dose reconstruction and prospective estimates of annual dose and integrated "life-time" dose, for different age intervals. According to the EMARC model, estimated reference "life-time" doses for adults are between 7 and 269 microSv kBq(-1) m(2) for (137)Cs, and between 25 and 235 microSv kBq(-1) m(2) for (90)Sr. Maximal doses were estimated for persons who were 3, 9 and 11 years old, at the time of the accident and these doses exceed those for adults by a factors of 1, 5 for (90)Sr, and 1.4 for (137)Cs.

Influence of human biokinetics of strontium on internal ingestion dose of 90Sr and absorbed dose of 89Sr to organs and metastases

The objective of the present work is to apply the plasma clearance parameters to strontium, previously determined in our laboratory, to improve the biokinetic and dosimetric models of strontium-90 ((90)Sr) used in radiological protection; and also to apply this data for the estimation of the radiation doses from strontium-89 ((89)Sr) after administration to patients for the treatment of the painful bone metastases. Plasma clearance and urinary excretion of stable strontium tracers of strontium-84 ((84)Sr) and strontium-86 ((86)Sr) were measured in GSF-National Research Center for Environment and Health (GSF) in 13 healthy German adult subjects after intravenous injection and oral administration. The biological half-life of strontium in plasma was evaluated from 49 plasma concentration data sets following intravenous injections. This value was used to determine the transfer rates from plasma to other organs and tissues. At the same time, the long-term retention of strontium in soft tissue and whole body was constrained to be consistent with measured values available. A physiological urinary path was integrated into the biokinetic model of strontium. Parameters were estimated using our own measured urinary excretion values. Retention and excretion of strontium were modeled using compartmental transfer rates published by the International Commission on Radiological Protection (ICRP), the SENES Oak Ridge Inc. (SENES), and the Urals Research Center for Radiation Medicine (TBM). The results were compared with values calculated by applying our GSF parameters (GSF). For the dose estimation of (89)Sr, a bone metastases model (GSF-M) was developed by adding a compartment, representing the metastases, into the strontium biokinetic model. The related parameters were evaluated based on measured data available in the literature. A set of biokinetic parameters was optimized to represent not only the early plasma kinetics of strontium but also the long-term retention measured in soft tissue and whole body. The ingestion dose coefficients of (90)Sr were computed and compared with different biokinetic model parameters. The ingestion dose coefficients were calculated as 2.8 x 10(-8), 2.1 x 10(-8), 2.5 x 10(-8) and 3.8 x 10(-8) Sv Bq(-1) for ICRP, SENES, TBM and GSF model parameters, respectively. Moreover, organ absorbed dose for the radiopharmaceutical of (89)Sr in bone metastases therapy was estimated based on the GSF and ICRP biokinetic model parameters. The effective doses were 3.3, 1.8 and 1.2 mSv MBq(-1) by GSF, GSF-M, and ICRP Publication 67 model parameters, respectively, compared to the value of 3.1 mSv MBq(-1) reported by ICRP Publication 80. The absorbed doses of red bone marrow and bone surface, 17 and 21 mGy MBq(-1) calculated by GSF parameters, and 7.1 and 8.8 mGy MBq(-1) by GSF-M parameters, are comparable to the clinical results of 3-19 mGy MBq(-1) for bone marrow and 16 mGy MBq(-1) for bone surface. Based on the GSF-M model, the absorbed dose of (89)Sr to metastases was estimated to be 434 mGy MBq(-1). The strontium clearance half-life of 0.25 h from the plasma obtained in the present study is obviously faster than the value of 1.1 h recommended by ICRP. There are no significant changes for ingestion dose coefficients of (90)Sr using different model parameters. A model including the metastases was particularly developed for dose estimation of (89)Sr treatment for the pain of bone metastases.

[The diet, fortified with fluorine and its influence on strontium accumulation in bone tissue of animals]

The research work was devoted to accumulation of strontium-90 (Sr-90) in bone tissue of animals (white rats) and its dependence on the diet, enriched with Fluorine (F). Totally each rat received 18,5 MBk of strontium-90. Insertion of rusks, fortified with sodium fluoride to the rats dietary intake, reduces accumulation of strontium-90 in bone tissue for 26% comparatively to control group of animals. Stimulation action of fluorine on hematopoietic function of irradiated animals were also determined.

Systemic radionuclide therapy in pain palliation

Several radiopharmaceuticals were investigated to determine their efficacy and toxicity in the palliation of painful bone metastases. Data on the influence of rhenium-188 hydroxyethylidene diphosphonate (188Re-HEDP), rhenium-186 hydroxyethylidene diphosphonate (186Re-HEDP), and strontium-89 (89Sr) on pain symptoms, quality of life, and bone-marrow function were obtained in 64 patients with breast and prostate cancer. Thirty-one patients were treated with 188Re-HEDP (3194 +/- 387 MBq), 15 patients with 186Re-HEDP (1358 +/- 158 MBq), and 18 patients with 89Sr (152 +/- 19 MBq). The 188Re-HEDP group included six breast cancer patients and 25 prostate cancer patients; the 186Re-HEDP group included three breast cancer patients and 12 prostate cancer patients; and the 89Sr group included three breast cancer patients and 15 prostate cancer patients. All subjects participated in an interview using a standardized sets of questions before and after the 12-week term of therapy. Blood counts were taken weekly for six weeks and after 12 weeks. Results showed that 77 percent of patients reported pain relief after treatment with 188Re-HEDP, 67 percent after treatment with 186Re-HEDP, and 72 percent after treatment with 89Sr. Sixteen percent of patients treated with 188Re-HEDP, 13 percent treated with 186Re-HEDP, and 17 percent treated with 89Sr were able to discontinue their analgesics and were pain-free. Patients described an improvement on Karnofsky performance status (KPS) from 73 +/- 7 percent to 85 +/- 8 percent 12 weeks after 188Re-HEDP (p < 0. 05), from 72 +/- 13 percent to 79 +/- 12 percent after 186Re-HEDP (p = 0.251), and from 62 +/- 14 percent to 69 +/- 16 percent after 89Sr (p = 0.415). Only three patients undergoing 188Re-HEDP therapy, one undergoing 186Re-HEDP therapy, and three undergoing 89Sr therapy had thrombocytopenia (platelet count below 100 x 10(3)/microl) following treatment. The maximum nadir of platelet and leukocyte counts was observed between the second and fifth week after treatment for all radionuclides and was reversible within 12 weeks. The nadir was earlier for 188Re-HEDP with a shorter physical half-life compared with 89Sr. There were no significant differences in bone marrow toxicity (p = 0.123-0.421). Results of this study indicate that all evaluated radiopharmaceuticals were effective in pain palliation without induction of severe side effects. The increase in KPS after 188Re-HEDP was the only statistically significant finding (p = 0.001).

[Use of strontium-89 in the analgesic treatment of cancer patients with bone metastases]

The aim of this article was to review the available literature regarding to the use of strontium-89 in the palliation of osteoblastic bone pain. The data of many researchers showed that approximately 80% of patients with pain from osteoblastic lesions resulting from prostate or breast cancer experience significant pain relief by administration of strontium-89, with only mild levels of hematotoxicity. The duration of pain relief in some cases exceeded 3-6 months. Indications for administration of strontium-89, effectiveness and duration of the treatment, side effects are reviewed in this article.

Radioisotopes for the palliation of metastatic bone cancer: a systematic review

Strontium-89 and samarium-153 are radioisotopes that are approved in the USA and Europe for the palliation of pain from metastatic bone cancer, whereas rhenium-186 and rhenium-188 are investigational. Radioisotopes are effective in providing pain relief with response rates of between 40% and 95%. Pain relief starts 1-4 weeks after the initiation of treatment, continues for up to 18 months, and is associated with a reduction in analgesic use in many patients. Thrombocytopenia and neutropenia are the most common toxic effects, but they are generally mild and reversible. Repeat doses are effective in providing pain relief in many patients. The effectiveness of radioisotopes can be greater when they are combined with chemotherapeutic agents such as cisplatin. Some studies with 89Sr and 153Sm indicate a reduction of hot spots on bone scans in up to 70% of patients, and suggest a possible tumoricidal action. Further studies are needed to address the questions of which isotope to use, what dose and schedule to use, and which patients will respond.

[The kinetics of 90Sr: genotypic determining]

The genotypic component of the variability (intrafamily correlation) of body mass, mass of thigh-bones and concentration of 90Sr in bone tissue were evaluated in the progeny of the laboratory mice of CBA line which were in the conditions of normal or slow development of skeleton since their birthday and which got a single injection of 90Sr in the late ontogenesis. The evaluation was made with the control of the effects of sex and age membership of animals and also taking into account the conditions of their development. Significant intrafamily correlation of the concentration of 90Sr was revealed. It can be compared with the morphological signs, which are the evidence of existence of genotypic determinacy of the kinetics of 90Sr.

Two-year clinical follow-up of 90Sr/90 Y beta-radiation versus placebo control for the treatment of in-stent restenosis

BACKGROUND

It is an ongoing concern that intracoronary brachytherapy may possibly just delay the problem of in-stent restenosis ("late catch up"). For gamma-radiation, 3 placebo-controlled studies have shown the maintenance of the initially positive effect after 2 years, but similar data do not exist for beta-radiation. STents And Restenosis Trial (START) was the first placebo-controlled randomized trial for in-stent restenosis with beta-radiation; herein, we report the 2-year clinical follow-up.

METHODS AND RESULTS

Two hundred and forty-four patients were randomized to active treatment, 232 patients to placebo (nonactive source train) treatment. The primary end point of efficacy was target vessel revascularization (TVR); primary safety end point was any major adverse cardiac event (MACE) at 8 months and 2 years. Two-year clinical outcome in patients receiving brachytherapy was based on 195 of 244 original patients (79.9%) and in the placebo arm on 183 of 232 original patients (78.9%). TVR was significantly reduced by 25%; from 36.6% (placebo) to 27.5% (brachytherapy) remained significant after 2 years (RR .7 [.57-.98], 95% CI -9.2 [-17.5-0.8]). The Kaplan-Meier analysis for TVR and MACE showed improvement beginning approximately 90 days after radiation and remained almost constant for the 2 following years. Freedom from TVR was significantly increased from 62.4% +/- 3.8% to 71.6% +/- 3.3% (P = .027) and freedom from MACE from 58.9% +/- 3.7% to 68.0% +/- 3.4% (P = .035).

CONCLUSIONS

The START trial shows for the first time that the initial beneficial effects of intracoronary brachytherapy with beta-radiation using 90 Sr/ 90 Y are maintained at 2-year clinical follow-up period.

[Compensatory adjustment of hemopoietic stem cell pool of CBA mice after acute intake of 90Sr]

It was investigated the functional status of stem cell pool (CFUs) of bone marrow, spleen and peripheral blood in mice (CBA) in early (1-30 days) and late (180-360 days) period after acute intake of 90Sr (29.6 kBq/g). Cumulative dose in red bone marrow due to incorporated 90Sr was 0.98-87.7 Gy. The kinetics, proliferative and differentiative potential of stem hemopoietic cells (CFUs) and productivity of hemopoietic tissues were significantly influenced by dose rate, absorbed dose and degree of suppresssion of bone marrow functions. The obtained results indicated that the sarcomogenous doses of 90Sr (29.6 kBq/g) resulted in realization of compensatory reactions in hemopoietic stem cell pool to support the life ability of irradiated animals: higher proliferative potential of CFUs and its repopulation, redistribution of cell subpopulations during differentiation and activation of spleens hemopoiesis.

[Contamination of the food chain with caesium-137 and strontium-90 in Switzerland]

One task of the field physiology of nutrition is the monitoring of the quality of feedstuffs. Rations may consequently be prepared with unadulterated components. This review uses the example of contamination with the radionuclides caesium-137 und strontium-90 and shows how these two unwanted substances reach the end host via the food chain and how their untoward effects are expressed in animals and humans. The extent of the contamination with artificial radioactivity is followed with periodical measurements according to the program of the Division for Radiological Protection of the Swiss Federal Office of Public Health. The interpretation of the measurements and the directives of this division are designed to protect primarily human health, but also that of animals.

Improving patient-specific dosimetry for intravascular brachytherapy

PURPOSE

Accurate patient-specific dosimetry in intravascular brachytherapy (IVBT) is generally difficult due to the extremely high-dose gradient, complexity of treatment device, and patient-specific geometry (e.g., calcification, stent, curvature, movement of target). The purpose of this study is to analyze quantitatively and systematically the dose effects of calcification, stent, guidewire, and source curvature on clinical dosimetry in an IVBT procedure, and propose a method that can be used to assess these effects in routine clinical practice.

METHODS AND MATERIALS

Monte Carlo techniques were used to calculate 3-D dose distribution in both homogeneous and inhomogeneous media for three most commonly used IVBT sources: (90)Sr beta (Novoste), (192)Ir gamma (Cordis/Best), and (32)P beta (Guidant). Dosimetric perturbations in the presence of metallic stents, calcified plaques, metallic guide wires, and source curvature were studied for situations commonly encountered in the clinic. The importance of each of these perturbations and their practical influence on patient-specific dosimetry were analyzed. Factors (plaque, stent, guidewire, and curvature) that may be used to correct/reduce these perturbations were introduced to prevent dosimetric cold spots during IVBT. Practical methods of using these correction factors are proposed.

RESULTS

Dose perturbations are significant due to the presence of source curvature, metallic stents, calcified plaques, and metallic guide wires, especially for beta sources. These perturbations can be as high as 30% under normal clinical conditions, although they can be much higher in extreme situations. Empirical relationships of plaque factor with the thickness of calcified plaque, stent factor with stent metallic surface area, guidewire with guidewire thickness, and curvature factor with the bending angle are derived. These relationships are found to be useful in improving clinical dose accuracy in IVBT treatment planning or dose evaluation after treatment.

CONCLUSIONS

Significant dose perturbations due to the presence of source curvature, metallic stents, calcified plaques, and guide wires have been found in IVBT for in-stent restenosis. Because it has been reported that, with the current prescriptions for IVBT, higher doses consistently improve treatment outcomes, the empirical method derived from this work can be used to assess cold spots dosimetrically, thus improving patient-specific dosimetry for IVBT.

Difficulty in dislodging in vivo fixed radiostrontium

Many trials based on the basic phenomena of isotopic dilution, adsorption, ion exchange, chelation, etc., have been attempted for the decorporation of radiostrontium, particularly Sr, after its entry in the in vivo system. We have recently demonstrated a non-isotopic carrier effect of some common calcium salts (calcium = 9 mg mL) to reduce the whole body retention of radiostrontium, if administered within 2 h after radiostrontium exposure and furthermore once daily, in rats, supplemented with calcium fortified diet. However, 25-30% of radiostrontium (compared to 50-60% in untreated animals) was still found to be retained in the animal even after 2 wk of treatment. Trial of some simple interventional measures, which would not adversely affect the animal metabolism, like pyrophosphate and magnesium sulfate, sodium citrate, chitin (a bio-absorbent), crown ether (a metal-chelator), and ammonium chloride, was therefore attempted to dislodge this remaining radiostrontium by switching over these animals to normal diet and subjecting them to different lines of treatment with these simple interventions through diet and drinking water separately for a further 4 wk. However, this remaining portion of radiostrontium is fixed in the bone and is difficult to dislodge.

Increased dosage during intracoronary irradiation due to overlapped source stepping shows no long-term adverse changes in vessel morphology

PURPOSE

The purpose of this analysis was to evaluate if overdosage during intracoronary irradiation due to overlapped source stepping may result in long-term morphologic changes in vessel anatomy.

METHODS

Baseline angiograms of patients with in-stent restenosis undergoing coronary reintervention followed by intracoronary irradiation with source stepping were analyzed. Overlapping was considered present for the segment with overlapped reference isodose length (RIL) (RIL = segment with > or = 90% of reference dose at 1 mm vessel wall depth). Baseline and 6-months follow-up volumetric intravascular ultrasound (IVUS) analysis were performed for the overlapped segment and for proximal and distal segments of equal length.

RESULTS

Overlapping was found in six patients (three patients: (32)P treatment; three patients: (90)Sr/Y treatment); final analysis was performed in four patients. Comparison of the baseline and follow-up IVUS volumetric parameters revealed no significant change in lumen or vessel volumes at segments of overlaps in comparison to proximal and distal reference segments.

CONCLUSION

Increased dosage due to overlapping during source stepping is not associated with morphologic changes in vessel anatomy at follow-up.

Radiotoxicity on bone marrow after 89Sr therapy radiosensitized by nicotinamide and carbogen in mice

OBJECTIVE

To investigate the radiotoxicity to bone marrow after 89Sr therapy radiosensitized by nicotinamide and carbogen.

METHODS

Chinese Kunming, NIH, BALB/c and F1 mice were divided into five groups: negative control (saline), positive control (89Sr), 89Sr+nicotinamide, 89Sr+carbogen and 89Sr+nicotinamide+carbogen. 89SrCl containing activities of 7400 kBq (200 microCi) in 200 microl of saline was administrated by injection into the tail vein. An equal volume of saline only was given to the negative control group. Chinese Kunming and NIH mice were killed on days 1, 2, 3, 4, 6, 8, 15, 20, 30, 60 and 90 after injection. BALB/c and F1 mice were killed on days 60 and 90. Femoral marrow reticulocytes were separated for assay of micronuclei.

RESULTS

The average frequency of the reticulocytes is shown in a dual-peak curve after injection. The first maximum frequency occurred between the second and the fourth days, and the second between the tenth and the 14th days. A significant statistical difference in frequency was found between the negative and the positive control groups (P<0.001, F=15.517), while no difference was found among the 89Sr+nicotinamide+carbogen, 89Sr, 89Sr+nicotinamide and 89Sr+carbogen groups (P>0.05, F=0.717) and among the NIH groups, 89Sr, 89Sr+nicotinamide, 89Sr+carbogen and 89Sr+nicotinamide+carbogen (P>0.05, F=1.734). There is also no significant difference in the frequency of reticulocytes between Chinese Kunming, NIH, BALB/c and F1 mice (P>0.05). Although the intervention of the radiosensitizer accelerated the occurrence of micronuclei in reticulocytes, there was no significant statistical difference between the group with radiosensitizer and the groups without it.

CONCLUSIONS

The administration of radiosensitizer did not aggravate the toxicity on bone marrow.

Uncertainties in dose coefficients from ingestion of 131I, 137Cs, and 90Sr

Quantification of uncertainties in doses from intakes of radionuclides is important in risk assessments and epidemiologic studies of individuals exposed to radiation. In this study, the uncertainties in the doses per unit intake (i.e., dose coefficients) for ingestion of 131I, 137Cs, and 90Sr by healthy individuals have been determined. Age-dependent thyroid dose coefficients were derived for 131I. The analysis for 131I uses recent measurements of thyroid volume obtained by ultrasonography, which indicate a thyroid mass lower than that previously obtained using autopsy measurements. The coefficients for 137Cs are determined using the relationship between the biological half-lives and the amount of potassium in the human body. The most recent International Commission on Radiological Protection biokinetic model was employed to determine the uncertainties for 90Sr. For 137Cs and 90Sr, the dose coefficients represent exposure in adulthood and they were determined for all organs of radiological importance. The uncertainty in the estimated dose coefficients represent state of knowledge estimates for a reference individual, and they are described by lognormal distributions with a specified geometric mean (GM) and geometric standard deviation (GSD). The estimated geometric means vary only slightly from the dose coefficients reported by ICRP publications. The largest uncertainty is observed in the dose coefficients for bone surface (GSD = 2.6), and red bone marrow (GSD = 2.4) in the case of ingestion of 90Sr. For most other organs, the uncertainty in the 90Sr dose coefficients is characterized by a GSD of 1.8 (or less for some organs). For 131I, the uncertainty in the thyroid dose coefficients is well represented by a GSD of 1.7 for both sexes and all ages other than infants for whom a GSD of 1.8 is more appropriate. The lowest uncertainties are obtained for the dose coefficients from ingestion of 137Cs (GSD = 1.24 for males; 1.4 for females). A dominant source of uncertainty in the ingestion dose coefficients is the variation of the biokinetic parameters. For 131I, the largest contribution to the uncertainty comes from the variation in the thyroid mass, but the contribution of the biokinetic parameters is comparable. The biokinetic parameters with the largest contribution to the uncertainty are (a) the fractional uptake from blood to thyroid in the case of ingestion of 131I, (b) the absorbed fraction from the gastrointestinal tract (f1) in the case of 90Sr, and (c) the amount of potassium in the body for 137Cs. The contribution to the uncertainty of the absorbed fraction (which accounts for the fraction of energy deposited in the target organ) is the smallest contributor to the uncertainty in the dose coefficients for most organs. To reduce the uncertainty in the dose estimated for a real individual, one should determine the above-mentioned parameters for the specified individual rather than to rely on assumptions for a reference individual.

Treatment of bifurcation in-stent restenotic lesions with beta radiation using strontium 90 and sequential positioning pullback technique: procedural details and clinical outcomes

BACKGROUND

In-stent restenotic lesions have been problematic for many patients with the need for multiple repeat percutaneous coronary interventions (PCI). The need for repeat PCI has been significantly reduced in patients since the advent of vascular brachytherapy. In-stent restenosis resulting in bifurcation presents even more of a challenge. The use of radiation therapy for the treatment of this kind of lesion has not yet been reported. The purpose of this paper is to present five cases of radiation therapy in bifurcation in-stent restenotic lesions using the intraluminal beta radiation catheter delivery system (Beta-Cath System, Novoste Corporation, Norcross, Georgia).

METHODS

We reviewed the database of patients enrolled in our Compassionate Use Registry between August 1999 and April 2002. The data is reported for 5 patients who received radiation in both branches of bifurcation lesions with the Beta-Cath catheter system.

RESULTS

The mean diameter of the vessels was 3.1 mm 0.5 mm. The dose administered was from 18.3 to 23 Gy, with an overlap of 3.3 to 10.3 mm; the hinge angle between the branches went from 43.3 to 65.4 . Angiographic follow-up was obtained at 6 months in 4 patients, with a single patient showing a focal (< 5 mm) edge lesion treated by balloon angioplasty (TVR no TLR). No aneurysms or zones of ectasia were noted.

CONCLUSION

Beta radiation with the Beta-Cath catheter system appears to be safe, secure and clinically useful in in-stent restenotic bifurcation lesions.

Effects of low chronic doses of ionizing radiation on antioxidant enzymes and G6PDH activities in Stipa capillata (Poaceae)

Stipa capillata (Poaceae) seeds were harvested from a control area (displaying a gamma dose rate of 0.23 micro Sv h(-1)) (C plants) and from two contaminated areas (5.4 and 25 micro Sv h(-1)) on the Semipalatinsk nuclear test site (SNTS) in Kazakhstan. The plants were grown for 124 d in a greenhouse under controlled conditions and exposed to three different treatments: (0) control; (E) external gamma irradiation delivered by a sealed 137Cs source with a dose rate of 66 micro Sv h(-1); (E+I) E treatment combined with internal beta irradiation due to contamination by 134Cs and 85Sr via root uptake from the soil. The root uptake led to a contamination of 100 Bq g(-1) for 85Sr and 5 Bq g(-1) for 134Cs (of plant dry weight) as measured at harvest. The activity of SOD, APX, GR, POD, CAT, G6PDH, and MDHAR enzymes was measured in leaves. Under (0) treatment, all enzymes showed similar activities, except POD, which had higher activity in plants originating from contaminated areas. Treatment (E) induced an enhancement of POD, CAT, GR, SOD, and G6PDH activities in plants originating from contaminated areas. Only control plants showed any stimulation of APX activity. Treatment (E+I) had no significant effect on APX, GR, CAT, and POD activities, but MDHAR activity was significantly reduced while SOD and G6PDH activities were significantly increased. The increase occurred in plants from all origins for SOD, with a greater magnitude as a function of their origin, and it occurred only in plants from the more contaminated populations for G6PDH. This suggests that exposure to a low dose rate of ionizing radiation for almost a half century in the original environment of Stipa has led to natural selection of the most adapted genotypes characterized by an efficient induction of anti-oxidant enzyme activities, especially SOD and G6PDH, involved in plant protection against reactive oxygen species.

Measured TG-60 dosimetric parameters of the Novoste Beta-Cath 90Sr/Y source trains for intravascular brachytherapy

Measurements were performed on the 30, 40 and 60-mm 90Sr/Y beta-emitter source trains used in the Novoste Beta-Cath system to determine the dosimetric characteristics of the sources at millimeter distances and provide the necessary TG-60 dosimetry parameters for mapping the dose distributions. These measurements were carried out in a Solid Water phantom where MD-55-2 Gafchromic films were placed in direct contact with a 5 French (F) catheter used for the 30 and 60-mm source trains and a 3.5 F catheter used for a thinner 40-mm source train. The dosimetric analysis was performed according to the AAPM TG-60 formalism. For the 30-mm source train, data were collected with the source axis at distances of 0.41 and 1.19 mm from the film surface, respectively, in order to investigate possible dosimetric effects due to the intrinsic off centering of the source train lumen within the 5 F catheter. Absolute dose rates at 2 mm were determined by calibrating the radiochromic film in a high energy electron beam from a radiotherapy accelerator. The dose rates at a radial distance of 2 mm were found to be within 10% of the values provided by Novoste. Radial dose functions from this study were in good agreement (< or = 10%) with a 30-mm, 90Sr/Y source train dose data generated from C. G. Soares et al. 90Sr/Y single seed data. However, larger differences were observed at distances shorter than 1 mm when compared to radial dose functions from the Novoste Monte Carlo data.

[Evaluation of the effect of dose rate and dose absorption on the long-term radiation consequences in rats chronically taking in 90Sr]

The effects of exposure to 90Sr which was given with food with daily doses 18.5 kBq per animal for 1-12 months, 37 kBq per animal for 1-10 months, 74 kBq per animal for 1-8 months and 148 kBq per animal for 1-6 months on mortality patterns in unimbred white rats were investigated. Hazard models were used to evaluate dose rate and accumulated dose influence on radiation-related trends in mortality. The time-dependent risk of death from all causes and from osteosarcomas depended on the dose rate. The risk of death from causes other than osteosarcoma depended on the dose rate and the accumulated dose. To predict time-dependent risk of death it was better to use the least time to calculate the dose rate--1 day.

Uptake of cesium-137 and strontium-90 from contaminated soil by three plant species; application to phytoremediation

A field test was conducted to determine the ability of three plant species to extract 137Cs and 90Sr from contaminated soil. Redroot pigweed (Amaranthus retroflexus L.), Indian mustard [Brassica juncea (L.) Czern.], and tepary bean (Phaseolus acutifolius A. Gray) were planted in a series of spatially randomized cells in soil that was contaminated in the 1950s and 1960s. We examined the potential for phytoextraction of 90Sr and 137Cs by these three species. Concentration ratios (CR) for 137Cs for redroot pigweed, Indian mustard, and tepary bean were 2.58, 0.46, and 0.17, respectively. For 90Sr they were substantially higher: 6.5, 8.2, and 15.2, respectively. The greatest accumulation of both radionuclides was obtained with redroot pigweed, even though its CR for 90Sr was the lowest, because of its relatively large biomass. There was a linear relationship between the 137Cs concentration in plants and its concentration in soil only for redroot pigweed. Uptake of 90Sr exhibits no relationship to 90Sr concentrations in the soil. Estimates of time required for removal of 50% of the two contaminants, assuming two crops of redroot pigweed per year, are 7 yr for 90Sr and 18 yr for 137Cs.

Topical application of beta-radiation to reduce intimal hyperplasia after carotid artery balloon injury in rabbit. A possible application for brachytherapy in vascular surgery

PURPOSE

Endovascular brachytherapy for the prevention of intimal hyperplasia (IH) and restenosis after balloon/stent angioplasty has proven effective both in animal preparations and clinical trials. A variety of beta-emitting isotopes and catheter-based devices have been developed for the delivery of low-dose radiation in clinical coronary and peripheral trials. No platform, however, has yet been developed for brachytherapy in concert with vascular surgical operations. The purpose of this study was to evaluate the vascular histopathologic response following balloon injury to rabbit carotid arteries with and without topically applied low-dose beta-radiation.

METHODS

The beta-emitting isotope strontium-90 (Sr-90) was conjugated onto the matrix of polypropylene (PLYP) mesh. Rabbit carotid arteries were balloon-injured with a #2 embolectomy catheter. Six carotid arteries were wrapped with nonradioactive PLYP mesh (controls) and Sr-90 ( approximately 90 microCi) PLYP mesh in order to deliver low-dose radiation to the vessel wall from the external (adventitial) surface. Tissue was harvested at 6 weeks and processed for histologic examination.

RESULTS

There was consistent blockade of fibrocellular neointima formation with virtually no neointima present in all treated segments, compared to moderate neointima formation in controls. Medial thinning and smooth muscle cell (SMC) necrosis were also associated with topical brachytherapy.

CONCLUSION

beta-Radiation applied by an externally wrapped PLYP mesh labeled with Sr-90 markedly suppressed neointima formation in an animal vascular surgical injury model. Further studies, however, are necessary to determine a suitable isotope and dosage for clinical application.

A mathematical model for calculation of 90Sr absorbed dose in dental tissues: elaboration and comparison to EPR measurements

A mathematical model for calculation of the 90Sr absorbed doses in dental tissues is presented. The results of the Monte-Carlo calculations are compared to the data obtained by EPR measurements of dental tissues. Radiometric measurements of the 90Sr concentrations. TLD and EPR dosimetry investigations were performed in animal (dog) study. The importance of the irregular 90Sr distribution in the dentine for absorbed dose formation has been shown. The dominant dose formation factors (main source-tissues) were identified for the crown dentine and enamel. The model has shown agreement with experimental data which allows to determine further directions of the human tooth model development.

A multicentre observational study of radionuclide therapy in patients with painful bone metastases of prostate cancer

A multicentre observational study was conducted by the Italian Association of Nuclear Medicine between 1996 and 1998. Twenty-nine Nuclear Medicine Departments participated. The aims of the study were to systematically evaluate the efficacy, toxicity and repeatability of radionuclide therapy of painful bone metastases (RTBM) in a large number of patients and to assess its incidence in patients with prostate cancer. Out of 818 treatments performed with a single i.v. dose of 148 MBq of strontium-89 chloride or 1,295 MBq of rhenium-186 hydroxyethylidene diphosphonate (HEDP), 610 could be evaluated (527 with 89Sr and 83 with 186Re-HEDP). Eighty-one patients received multiple (up to five) RTBM. The total number of retreatments was 100. Patients were followed up for a period of 3-24 months. Results, assessed according to pain relief and consumption of analgesic drugs, were expressed at four levels: 1, no response; 2, mild response; 3, good response; 4, excellent response. Responses were: level 1 in 19%, level 2 in 21.3%, level 3 in 33.3% and level 4 in 26.4% of cases. Retreatments showed significantly (P<0.01) worse responses (48% levels 3+4), in comparison to first RTBM. Duration of palliation was 5.0+/-3.5 months, and was longer in cases of excellent response, in first RTBM, in patients with limited metastases and when 89Sr was used. Better responses were found in cases of limited skeletal disease, under good clinical conditions, when life expectancy exceeded 3 months, and in radiologically osteoblastic or mixed bone lesions. The only statistically significant predictive factor was life expectancy (P<0.001). Flare phenomenon (14.1% of cases) did not correlate with the response. Haematological toxicity (mild to moderate in most cases) mainly affected platelets, and was observed in 25.5% of cases overall and in 38.9% of retreatments. RTBM did not seem to prolong life, though in some cases scintigraphic regression of bone metastases was observed. The two radiopharmaceuticals did not show any statistically significant differences in palliative efficacy and toxicity, either in first RTBM or in retreatments.

ESR dosimetry of 89Sr and 153Sm in bone

The radiation absorbed dose in the rabbit bone delivered by 153Sm-EDTMP (samarium ethylenediaminetetra methylene diphosphonic acid) and 89SRCl2 (strontium chloride) was measured by means of electron spin resonance (ESR). These radioisotopes are used in systemic radiotherapy for palliation of painful bone metastases. The knowledge of the dose is important in order to avoid side effects to the bone marrow. The ESR radiation dose signal was calibrated by the additive dose method using cobalt-60 gamma rays. For 153Sm-EDTMP, the bone doses in three rabbits were (4 +/- 2), (5 +/- 1) and (5 +/- 2) cGy kg/MBq. For 89SrCl2, a dose of (2 +/- 1) cGy kg/MBq was found in one rabbit.

[Late stent thrombosis after intracoronary brachytherapy. A case report and review of the literature]

Intracoronary irradiation is currently the most promising approach to reduce restenosis after percutaneous transluminal coronary angioplasty. Meanwhile numerous data are available concerning efficacy and safety of this novel method. These data confirm the results of preclinical studies that reported a dramatic reduction of neo-intima proliferation and negative remodeling. However, the number of reports on an elevated incidence of late stent thrombosis (> 30 days post intervention) are increasing. It is commonly suggested that the delayed neo-intima formation within vascular stents is responsible for this new phenomenon. We report the case of a 48-year-old man who underwent coronary irradiation therapy after stent placement in a de-novo/restenotic lesion. Despite an explicit recommendation of a combined anti-aggregatory therapy consisting of ticlopidine and acetysalicylic acid for at least 6 months, ticlopidine was withdrawn after 4 weeks. Two weeks later, the patient was readmitted to an external hospital with an acute myocardial infarction and successfully treated with thrombolysis. The angiographic and intravascular control, which was conducted after another two weeks, showed absolutely no neointima formation within the implanted stent. Thus, a late thrombotic occlusion of the implanted stent appears most likely to be the cause underlying the myocardial infarction. This case underlines, together with other existing reports, the importance of a prolonged, combined anti-aggregatory therapy after stent placement and subsequent intracoronary irradiation.

[Evaluation of late radiation-induced changes in superficial microcirculation after acute beta-irradiation. II. Prognostic importance of cutaneous Doppler laser]

OBJECTIVE

The changes that occur in the tissular microcirculation after accidental acute irradiation account for some of the early effects of such irradiation, especially at the cutaneous level. The prognostic importance of the cutaneous laser doppler was tested in an experimental model of acute beta-irradiation.

METHODS

Ten pigs were given beta-irradiation with a high single localized dose of 90Sr/90Y (32 or 64 Gy, 7 mg/cm2) delivered to the flank, and were evaluated 2, 7, 14, 21 and 28 days thereafter. Each individual was its own control. The local microcirculation was measured in the resting state and during thermal stimulation at 42 degrees C, using a Periflux cutaneous Doppler laser with p413 probes. Three periods of six minutes each were continuously recorded: period 1 (P1) represented basal resting cutaneous perfusion, with the slope p corresponding to the increase in perfusion when two minutes of thermal stimulation at 42 degrees C began; P2 to plateau perfusion during this stimulation; and P3 to perfusion on the return to equilibrium.

RESULTS

After acute beta-irradiation in the pig, all the cutaneous microcirculation parameters measured (P1, p, P2 and P3) had risen at day 2 in the irradiated area by a factor of 2 to 4, depending on the dose (p < 0.001), compared to the adjacent control area. On the other hand, as from day 7, the resting and the stimulated microcirculation varied little, except for a reduction of the slope p by a factor of 2 (p < 0.05) after the strongest radiation dose.

CONCLUSION

After acute irradiation, the increase in the resting cutaneous microcirculation may correspond to immediate but transitory capillary vasodilatation that accompanies the initial erythema in accidental irradiation. The absence of vascular response to thermal stimulation seems to be a good means of reaching an early diagnosis of delayed cutaneous radiation necrosis.

Treatment of bone metastases of prostate cancer with strontium-89 chloride: efficacy in relation to the degree of bone involvement

This retrospective study evaluated the toxicity and efficacy of strontium-89 chloride (Metastron, Amersham) in 94 patients with painful bone metastases of prostate cancer (117 injections of 150 MBq) and compared the efficacy of treatment in patients with moderate and extensive bone involvement. The predictive value of flare response with regard to analgesic response was also studied. High-grade leukothrombopenias were observed after only 5% of injections. An improvement in quality of life was obtained in 65% of cases, a decrease in pain in 78% (31% complete response) and a reduction of analgesics in 60%. Efficacy was significantly better for pain decrease (P=0.005) and reduction of analgesics (P=0.018), and response was significantly longer (P<0.0035) in patients with moderate than in patients with extensive bone involvement. The flare response observed in 23% of cases was not predictive of pain response (P=0.919) or reduction of analgesics (P=0.353). A second dose prolonged analgesia in three-quarters of cases without any apparent increase in toxicity. These results confirm the benefit of 89Sr chloride for the treatment of metastatic bone pain and suggest that internal radiotherapy should be started earlier. A bone scan could be proposed at the time of hormonal escape resulting in bone pain, and internal radiotherapy could be initiated when several metastatic foci exist, even if only one is painful. In this way, pain-free follow-up could be prolonged, and the transition to other therapeutic approaches, particularly opioids, delayed.

Does body size contribute to sensitivity of bone tumor induction by radionuclide exposure?

Investigation of a possible increase in sensitivity to occurrence of radionuclide-induced skeletal malignancy with increasing body size was analyzed among 358 beagles injected as young adults with either 226Ra or monomeric 239Pu and maintained for their lifespans. Corresponding analyses were performed for about 240 other beagles injected as young adults with 90Sr, 228Ra, or 228Th. Body masses at the time of injection ranged between about 5.6 and 16 kg. Logistic regression analysis using body mass and cumulative skeletal radiation dose as the independent variables indicated that there could not be established a dependency of tumor occurrence upon body mass, although skeletal dose was found to be significantly correlated with occurrence of bone cancer. Regression analysis indicated that for any dosage group there could not be established a correlation between body mass and skeletal dose. Each dosage group having similar injected kBq kg(-1) for each nuclide was divided into 2 subgroups of equal size, one containing the less massive dogs and the other containing the more massive dogs. These subgroups within a roughly uniform value of skeletal dose-rate were compared by Fisher's Exact Test, and the less massive subgroups were combined within each nuclide for an additional, separate analysis against the combined more massive subgroups using the same method. In only one instance (the dosage group given 3607 kBq 90Sr kg(-1)) was there indicated a substantially greater tumor occurrence among dogs in the more massive subgroup (p = 0.061). However, for the group given 0.382 kBq 239Pu kg(-1) there was indicated a significant difference between subgroups, but the effect was exactly opposite to that found for the highest level 90Sr dogs in that the less massive subgroup had a higher relative tumor occurrence than the most massive (p = 0.042). For all groups with a p-value < 0.10, a possible correlation was investigated between survival and body mass at injection (since bone tumor occurrence might be a function of longevity), but a significant relationship could not be determined. No significant differences could be established between the combined more massive and the combined less massive subgroups for any radionuclide. We conclude that, for the conditions in our experiment, relative size within a species does not contribute importantly to the sensitivity (lifetime occurrence) for induction of skeletal malignancy.

[The effect of internal exposure to 90Sr on hematopoietic stem cells in CBA mice]

After acute intake of 90Sr the changes of d-9 CFUs number in mice (CBA) bone marrow, spleen and peripheral blood were investigated. The obtained results indicated similar quantitative changes in bone marrow and spleen CFUs on exposure to the 90Sr when radiation doses did not cause the decrease in life-time (1.11 kBq/g). Sarcomogeneous doses of 90Sr (29.6 kBq/g) resulted in drastic changes of hemopoietic system: spleen haematopoiesis activation and suppression of bone marrow functions. On the first day after 90Sr injection (29.6 kBq/g) the increase in number of peripheral blood CFUs (circulating pool) was observed.

Calibration of strontium-90 eye applicator using a strontium external beam standard

Four techniques for measuring the dose rate from Sr-90 concave eye plaques are presented. The techniques involve calibrating a concave eye plaque against a Sr-90 teletherapy unit using X-Omat film, radiochromic film, black LiF TLD discs and LiF chips. The mean dose rate predicted by these dosimeters is 7.5 cGy s(-1). The dose rate quoted by the manufacturer is 33% lower than this value, which is consistent with discrepancies reported by other authors. Calibration against a 6 MV linear accelerator was also carried out using each of the above dosimetric devices, and appropriate sensitivity correction factors have been presented.

Relative efficacy of 32P and 89Sr in palliation in skeletal metastases

32p and 89Sr have been shown to produce significant pain relief in patients with skeletal metastases from advanced cancer. Clinically significant pancytopenia has not been reported in doses up to 12 mCi (444 MBq) of either radionuclide. To date, no reports comparing the relative efficacy and toxicity of the two radionuclides in comparable patient populations have been available. Although a cure has not been reported, both treatments have achieved substantial pain relief. However, several studies have used semiquantitative measures such as "slight," "fair," "partial" and "dramatic" responses, which lend themselves to subjective bias. This report examines the responses to treatment with 32P or 89Sr by attempting a quantification of pain relief and quality of life using the patients as their own controls and compares toxicity in terms of hematological parameters.

METHODS

Thirty-one patients with skeletal metastases were treated for pain relief with either 32P (16 patients) or 89Sr (15 patients). Inclusion criteria were pain from bone scan-positive sites above a subjective score of 5 of 10 despite analgesic therapy with narcotic or non-narcotic medication, limitation of movement related to the performance of routine daily activity and a predicted life expectancy of at least 4 mo. The patients had not had chemotherapy or radiotherapy during the previous 6 wk and had normal serum creatinine, white cell and platelet counts. 32P was given orally as a 12 mCi dose, and 89Sr was given intravenously as a 4 mCi (148 MBq) dose. The patients were monitored for 4 mo.

RESULTS

Complete absence of pain was seen in 7 of 16 patients who were given 32P and in 7 of 15 patients who were given 89Sr. Pain scores fell by at least 50% of the pretreatment score in 14 of 16 patients who were given 32P and 14 of 15 patients who were given 89Sr. Mean duration of pain relief was 9.6 wk with 32P and 10 wk with 89Sr. Analgesic scores fell along with the drop in pain scores. A fall in total white cell, absolute granulocyte and platelet counts occurred in all patients. Subnormal values of white cells and platelets were seen in 5 and 7 patients, respectively, with 32P, and in 0 and 4 patients, respectively, after 89Sr therapy. The decrease in platelet count (but not absolute granulocyte count) was statistically significant when 32P patients were compared with 89Sr patients. However, in no instance did the fall in blood counts require treatment. Absolute granulocyte counts did not fall below 1000 in any patient. There was no significant difference between the two treatments in terms of either efficacy or toxicity.

CONCLUSION

No justification has been found in this study for the recommendation of 89Sr over the considerably less expensive oral 32P for the palliation of skeletal pain from metastases of advanced cancer.

Strontium-89 (89Sr) analgesia for rare thymic carcinoid tumor with bony metastases

The authors report the cases of two patients in whom strontium-89 (89Sr) was used to relieve diffuse metastatic bone pain. The type of cancer involved, thymic carcinoid tumor, is itself rare and the risk of its metastasizing to the bone is very low. Both patients showed a measure of response to treatment, suggesting that this analgesic method has value for some patients. The marked benefit of one patient for a total of 9 months was attributable to two 89Sr injections, whereas the other patient improved for only 5 weeks after one injection.

Strontium-89 chloride in the treatment of bone metastases from breast cancer

Sixty-four patients with painful metastatic breast cancer in bone were treated with 2 MBq/kg of strontium-89 chloride as a single intravenous injection. Patients were followed with records of medication, hematology parameters, serial bone and Sr-89 bremsstrahlung images and with a point pain score scale (10-0). The response was assessed during a 6-month period of follow-up. Fifty-two of 64 patients (81%) showed at least a moderate improvement. Eighteen out of the 52 responders showed a dramatic decrease in bone pain (35%), 21 (40%) presented a satisfactory response and in 13 cases (25%) the response was moderate. Only 12 patients (19%) from the whole group did not feel any improvement on pain palliation. A statistically significant decrease of pretreatment levels of platelets and leukocyte counts was observed after 4-6 weeks of therapy in 50 (70%) patients. Although most patients showed no change in their bone scans after 3 months of treatment, an obvious improvement was observed in 3 of them. Furthermore no additional painful metastases on their bone scintigraphic images were observed. The selective strontium-89 local uptake in metastatic sites was also confirmed directly by bremsstrahlung scans which were absolutely comparable to the respective 99mTc bone scans. Precautions have been taken against Sr-89 contamination from the patients' blood or excretions.