Influence of DTPA Treatment on Internal Dose Estimates

Key topics for making decisions on decorporation terapies

Decorporation therapies increase the excretion of the incorporated material and therefore may reduce the probability of the occurrence of stochastic effects and may avoid deterministic effects in persons internally contaminated with radionuclides. The decision to initiate decorporation therapy should consider the effects of treatment in relation to the benefit provided. The literature presents threshold values above which treatment is recommended. The objective of this work is to collect and summarize recommendations on decorporation therapy. Ten key topics are presented for consideration by a multidisciplinary team when assessing the risk-benefit balance for performing decorporation therapy.

Modelling DTPA therapy following Am contamination in rats

A major challenge in modelling the decorporation of actinides (An), such as americium (Am), with DTPA (diethylenetriaminepentaacetic acid) is the fact that standard biokinetic models become inadequate for assessing radionuclide intake and estimating the resulting dose, as DTPA perturbs the regular biokinetics of the radionuclide. At present, most attempts existing in the literature are empirical and developed mainly for the interpretation of one or a limited number of specific incorporation cases. Recently, several approaches have been presented with the aim of developing a generic model, one of which reported the unperturbed biokinetics of plutonium (Pu), the chelation process and the behaviour of the chelated compound An-DTPA with a single model structure. The aim of the approach described in this present work is the development of a generic model that is able to describe the biokinetics of Am, DTPA and the chelate Am-DTPA simultaneously. Since accidental intakes in humans present many unknowns and large uncertainties, data from controlled studies in animals were used. In these studies, different amounts of DTPA were administered at different times after contamination with known quantities of Am. To account for the enhancement of faecal excretion and reduction in liver retention, DTPA is assumed to chelate Am not only in extracellular fluids, but also in hepatocytes. A good agreement was found between the predictions of the proposed model and the experimental results for urinary and faecal excretion and accumulation and retention in the liver. However, the decorporation from the skeletal compartment could not be reproduced satisfactorily under these simple assumptions.

Dose Assessment Following a 238 Pu Inhalation Incident at Los Alamos National Laboratory

A glovebox breach at the plutonium facility at Los Alamos National Laboratory potentially exposed 15 individuals to 238 Pu aerosols. One of the individuals (P0) received two 1-g intravenous DTPA treatments, one on the day of the intake and another the following day. Several urine samples were collected from the individuals involved in the incident. Particle size analysis on the PPE and solubility analysis of the particles on a filter sample were conducted in vitro. The applicability of the results from the in vitro studies for dose assessment was questionable because of the effect of the cloth mask the workers were wearing for COVID-related protection. Based on several considerations, including the effect of cloth masks on the "effective" particle size inhaled and the analysis of fecal-to-urine ratio, the default Type M 1 μm AMAD model was used to estimate intakes and doses. Using the urinary excretion data collected after 100 d post last chelation treatment, the committed effective dose, E(50), for P0 was calculated to be 5.2 mSv. For all others, the bioassay data were consistent with no intakes or very small intakes [corresponding to E(50) less than 0.1 mSv].

Four-decade follow-up of a plutonium-contaminated puncture wound treated with Ca-DTPA

Contaminated wounds are a common route of internal deposition of radionuclides for nuclear and radiation workers. They may result in significant doses to radiosensitive organs and tissues in an exposed individual's body. The United States Transuranium and Uranium Registries' whole-body donor (Case 0303) accidentally punctured his finger on equipment contaminated with plutonium nitrate. The wound was surgically excised and medically treated with intravenous injections of Ca-DTPA. A total of 16 g Ca-DTPA was administered in 18 treatments during the 2 months following the accident. Ninety-three urine samples were collected and analysed over 14 years following the accident. An estimated²³⁹Pu activity of 73.7 Bq was excreted during Ca-DTPA treatment. Post-mortem radiochemical analysis of autopsy tissues indicated that 40 years post-accident 21.6 ± 0.2 Bq of²³⁹Pu was retained in the skeleton, 12.2 ± 0.3 Bq in the liver, and 3.7 ± 0.1 Bq in other soft tissues; 1.35 ± 0.02 Bq of²³⁹Pu was measured in tissue samples from the wound site. To estimate the plutonium intake, late urine measurements, which were unaffected by chelation, and post-mortem radiochemical analysis results were evaluated using the IMBA Professional Plus software. The application of the National Council on Radiation Protection and Measurements wound model with an assumption of intake material as a predominantly strongly retained soluble plutonium compound with a small insoluble fraction adequately described the data (p= 0.46). The effective intake was estimated to be 50.2 Bq of plutonium nitrate and 1.5 Bq of the fragment. The prompt medical intervention with contaminated tissue excision and subsequent Ca-DTPA decorporation therapy reduced²³⁹Pu activity available for uptake and long-term retention in this individual's systemic organs by a factor of 38.

Treatment of radiological contamination: a review

After nuclear accidents, people can be contaminated internally via ingestion, inhalation and via intact skin or wounds. The assessment of absorbed, committed doses after internal exposure is based on activity measurement byin vivoorin vitrobioassay. Estimation of dose following internal contamination is dependent on understanding the nature and form of the radionuclide. Direct counting methods that directly measureγ-rays coming from within the body or bioassay methods that measure the amount of radioactive materials in urine or feces are used to estimate the intake, which is required for calculating internal exposure doses. The interpretation of these data in terms of intake and the lifetime committed dose requires knowledge or making assumptions about a number of parameters (time, type of exposure, route of the exposure, physical, biological and chemical characteristics) and their biokinetics inside the body. Radioactive materials incorporated into the body emit radiation within the body. Accumulation in some specific organs may occur depending on the types of radioactive materials. Decorporation therapy is that acceleration of the natural rate of elimination of the contaminant will reduce the amount of radioactivity retained in the body. This article presents an overview of treatment of radiological contamination after internal contamination.

Dose Assessment Following a 238Pu-contaminated Wound Case with Chelation and Excision

The urinary excretion and wound retention data collected after a Pu-contaminated wound were analyzed using Markov Chain Monte Carlo (MCMC) to obtain the posterior distribution of the intakes and doses. An empirical approach was used to model the effects of medical treatments (chelation and excision) on the reduction of doses. It was calculated that DTPA enhanced the urinary excretion, on average, by a factor of 17. The empirical analysis also allowed calculation of the efficacies of the medical treatments-excision and chelation averted approximately 76% and 5.5%, respectively, of the doses that would have been if there were no medical treatment. All bioassay data are provided in the appendix for independent analysis and to facilitate the compartmental modeling approaches being developed by the health physics community.

Chelation Modeling: The Use of Ad Hoc Models and Approaches to Overcome a Dose Assessment Challenge

Chelating agents are administered to treat significant intakes of radioactive elements such as plutonium, americium, and curium. These drugs may be used as a medical countermeasure after radiological accidents and terrorist acts. The administration of a chelating agent, such as Ca-DTPA or Zn-DTPA, affects the actinide's normal biokinetics. It enhances the actinide's rate of excretion, posing a dose assessment challenge. Thus, the standard biokinetic models cannot be directly applied to the chelation-affected bioassay data in order to assess the radiation dose. The present study reviews the scientific literature, from the early 1970s until the present, on the different studies that focused on developing new chelation models and/or modeling of bioassay data affected by chelation treatment. Although scientific progress has been achieved, there is currently no consensus chelation model available, even after almost 50 y of research. This review acknowledges the efforts made by different research groups, highlighting the different methodology used in some of these studies. Finally, this study puts into perspective where we were, where we are, and where we are heading in regards to chelation modeling.

Evaluating Plutonium Intake and Radiation Dose Following Extensive Chelation Treatment

A voluntary partial-body donor (US Transuranium and Uranium Registries case 0785) was accidentally exposed to Pu via inhalation and wounds. This individual underwent medical treatment including wound excision and extensive chelation treatment with calcium ethylenediaminetetraacetic acid and calcium diethylenetriaminepentaacetic acid. Approximately 2.2 kBq of Pu was measured in the wound site 44 y after the accident. Major soft tissues and selected bones were collected at autopsy and radiochemically analyzed for Pu, Pu, and Am. Postmortem systemic retention of Pu, Pu, and Am was estimated to be 32.0 ± 1.4 Bq, 2,172 ± 70 Bq, and 394 ± 15 Bq, respectively. Approximately 3% of Pu whole-body activity was still retained in the lungs 51 y after the accident indicating exposure to insoluble plutonium material. To estimate the intake and calculate radiation dose, urine measurements not affected by chelation treatment, in vivo chest counts, and postmortem radiochemical analysis data were simultaneously fitted using Integrated Modules for Bioassay Analysis Professional Plus software. The currently recommended International Commission on Radiological Protection Publication 130 human respiratory tract model and National Council on Radiation Protection and Measurements Report 156 wound model were used with default parameters. The intake, adjusted for Pu removed by chelation treatment, was estimated at approximately 79.5 kBq with 68% resulting from inhalation and 32% from the wound. Inhaled plutonium was predominantly insoluble type S material (74%) with insoluble plutonium fragments deposited in the wound. Only 1.3% reduction in radiation dose was achieved by chelation treatment. The committed effective dose was calculated to be 1.49 Sv. Using urine data available for this case, the effect of chelation therapy was evaluated. Urinary excretion enhancement factors were calculated as 83 ± 52 and 38 ± 17 for initial and delayed calcium ethylenediaminetetraacetic acid treatments, respectively, and as 18 ± 5 for delayed calcium diethylenetriaminepentaacetic acid. The enhancement factor decreases proportionally to an inverse cubic root of time after intake. For delayed calcium ethylenediaminetetraacetic acid treatment, with five consecutive daily administrations, the enhancement factor increased from day 1 to 4, followed by approximately a 50% drop on day 5. The half-time of plutonium ethylenediaminetetraacetic acid complex removal in urine was evaluated to be 1.4 d.

Americium Systemic Biokinetic Model for Rats

In this work, a baseline compartmental model of the distribution and retention of americium in the rat for a systemic intake was derived. The model was derived from data obtained from a study designed to evaluate the behavior of americium in the first 28 days after incorporation. A pharmacokinetic (PK)-front-end modeling approach was used to specify transfer to and from the extracellular fluids (ECF) in the various tissues in terms of vascular flow and volumes of ECF. Back-end rates representing transport into and out of the cells were determined empirically. Uncertainties in transfer rates were investigated using Markov chain Monte Carlo (MCMC). The combination of PK-front-end model and the back-end model structure used allowed for extrapolation to the earliest times with small uncertainty. This approach clearly demonstrated the rapid transfer of material from ECF to liver and bone. This model provides a baseline for modeling the action of decorporation agents, such as DTPA.

Biokinetics of 238Pu oxides: inferences from bioassay data

The bioassay data collected from several workers involved in ²³⁸Pu inhalation incidents have been analysed using the most recent biokinetic models described in the Occupational Intakes of Radionuclides (OIR) series of publications. Although all exposures were thought to be to ²³⁸Pu oxides, the observed urinary excretion patterns differed in different inhalation incidents. The urinary excretion from individuals involved in one of the incidents increased steadily with time, peaking around two to three years before decreasing. This pattern is described in Part 4 of the OIR series using the '²³⁸PuO₂, ceramic' model. This non-monotonic behaviour, explained as being due to fragmentation and dissolution, was not specific to the incident, but observed in other incidents. The urinary excretion data collected from individuals involved in another incident showed dissolution behaviour between Type M and Type S. Finally, the bioassay data from yet another incident showed a pattern that appears to represent behaviour more insoluble than Type S, which is possibly a result of self-heating due to the decay heat from ²³⁸Pu. The urinary excretion patterns and corresponding dose coefficients have been calculated and compared.

AN ACCIDENT OF INTERNAL CONTAMINATION WITH PLUTONIUM AND AMERICIUM AT A NUCLEAR FACILITY IN JAPAN: A PRELIMINARY REPORT AND THE POSSIBILITY OF DTPA ADMINISTRATION ADDING TO THE DIAGNOSIS

This article introduces the first accident of internal contamination with plutonium (Pu) or americium (Am) in Japan for which treatment was carried out. An accident of internal contamination with Pu and Am occurred at a Pu research facility at Oarai-town of Ibaraki prefecture in Japan. A plastic bag containing these radionuclides ruptured when five workers were inspecting a storage container in a hood. As a consequence, these workers were internally contaminated with Pu and Am. Although contamination on the body surface was observed in all five workers, a positive nasal swab was detected in only three of them. A chelating agent, calcium diethylenetriaminepenta-acetate (CaDTPA), was administered to all of them including the two workers without a positive nasal swab. However, bioassay detected a significant amount of Pu and Am in urine after administration of DTPA in these two workers, whereas the levels of these nuclides were below minimum detectable levels in urine before the administration. Since the prevalence of adverse reactions in DTPAs is low, the present results suggest that administration of DTPA can be used for the diagnosis of internal contamination even when a nasal swab is negative or contamination around body orifices is not detected.

Rapid Response, Dose Assessment, and Clinical Management of a Plutonium-contaminated Puncture Wound

Internalization of radionuclides occurs not only by inhalation, ingestion, parenteral injection (i.e., administration of radioactive material for a medical purpose), and direct transdermal absorption, but also by contaminated wounds. In June 2010, a glove-box operator at the U.S. Department of Energy's Savannah River Site sustained a puncture wound while venting canisters containing legacy materials contaminated with Pu. To indicate the canisters had been vented, a flag was inserted into the vent hole. The shaft of the flag penetrated the protective gloves worn by the operator. Initial monitoring performed with a zinc-sulfide alpha detector indicated 300 dpm at the wound site. After being cleared by radiological controls personnel, the patient was taken to the site medical facility where decontamination was attempted and diethylenetriaminepentaacetic acid (DTPA) was administered intravenously within 1.5 h of the incident. The patient was then taken to the Savannah River Site In Vivo Counting Facility where the wound was counted with a Canberra GL 2820 high-purity germanium detector, capable of quantifying contamination by detecting low-energy x rays and gamma rays. In addition to the classic 13, 17, and 20 keV photons associated with Pu, the low-yield (0.04%) 43.5 keV peak was also detected. This indicated a level of wound contamination orders of magnitude above the initial estimate of 300 dpm detected with handheld instrumentation. Trace quantities of Am were also identified via the 59.5 keV peak. A 24 h urine sample collection was begun on day 1 and continued at varying intervals for over a year. The patient underwent a punch biopsy at 3 h postincident (14,000 dpm removed) and excisional biopsies on days 1 and 9 (removal of an additional 3,200 dpm and 3,800 dpm, respectively). The initial post-DTPA urine sample analysis report indicated excretion in excess of 24,000 dpm Pu. Wound mapping was performed in an effort to determine migration from the wound site and indicated minimum local migration. In vivo counts were performed on the liver, axillary lymph nodes, supratrochlear lymph nodes, and skeleton to assess uptake and did not indicate measurable activity. Seventy-one total doses of DTPA were administered at varying frequencies for 317 d post intake. After allowing 100 d for removal of DTPA from the body, five 24 h urine samples were collected and analyzed for dose assessment by using the wound model described in National Council on Radiation Protection and Measurements Report No. 156. The total effective dose averted via physical removal of the contaminant and DTPA administration exceeded 1 Sv, demonstrating that rapid recognition of incident magnitude and prompt medical intervention are critical for dose aversion.

Some Considerations for Chelation Treatment and Surgical Excision Following Incorporation of Plutonium in Wounds

After a plutonium-contaminated wound, the role of an internal dosimetrist is to inform the patient and the physician of the dosimetric considerations. The doses averted due to medical treatments (excision or chelation) are higher if the treatments are administered early; therefore, the internal dosimetrist needs to rely on limited information on wound counts and process knowledge for advising the physician. Several wound cases in the literature were reviewed to obtain estimates of the efficacies of surgical excision and chelation treatment after plutonium-contaminated wounds. The dose coefficients calculated by coupling the NCRP 156 wound model with the systemic model were used to derive the decision guidelines that may indicate medical treatment based on 1) the concept of saved doses proposed by the NCRP 156 wound model, 2) the limits recommended by the CEC/DOE guidebook, and 3) the Clinical Decision Guidelines proposed in NCRP Report No. 161. These guidelines by themselves, however, are of limited use for several reasons, including 1) large uncertainties associated with wound measurements, 2) exposure to forms of radionuclides that cannot be assigned to a single category in the NCRP 156 framework, 3) inability of the NCRP 156 model to explain some of the wound cases in the literature, 4) neglect of the local doses to the wound site and the pathophysiological response of the tissue, 5) poorly understood relationship between effective doses and risks of late health effects, and 6) disregard of the psychological aspects of radionuclide intake.

Interpretation of Urinary Excretion Data From Plutonium Wound Cases Treated With DTPA: Application of Different Models and Approaches

After a chelation treatment, assessment of intake and doses is the primary concern of an internal dosimetrist. Using the urinary excretion data from two actual wound cases encountered at Los Alamos National Laboratory (LANL), this paper discusses several methods that can be used to interpret intakes from the urinary data collected after one or multiple chelation treatments. One of the methods uses only the data assumed to be unaffected by chelation (data collected beyond 100 d after the last treatment). This method, used by many facilities for official dose records, was implemented by employing maximum likelihood analysis and Bayesian analysis methods. The impacts of an improper assumption about the physicochemical behavior of a radioactive material and the importance of the use of a facility-specific biokinetic model when available have also been demonstrated. Another method analyzed both the affected and unaffected urinary data using an empirical urinary excretion model. This method, although case-specific, was useful in determining the actual intakes and the doses averted or the reduction in body burdens due to chelation treatments. This approach was important in determining the enhancement factors, the behavior of the chelate, and other observations that may be pertinent to several DTPA compartmental modeling approaches being conducted by the health physics community.