Radiation exposure from outpatient radioactive iodine (131I) therapy for thyroid carcinoma

CONTEXT

In May 1997, the US Nuclear Regulatory Commission (NRC) revised its patient release regulations, allowing for outpatient administration of larger activities of sodium iodide 131I than previously permitted.

OBJECTIVE

To measure the radiation exposure to household members from patients receiving outpatient 131I therapy for thyroid carcinoma in accordance with the new regulations.

DESIGN

Consecutive case series from October 1998 to June 1999.

SETTING AND PATIENTS

Thirty patients who received outpatient 131I therapy following thyroidectomy for differentiated thyroid carcinoma were enrolled, along with their 65 household members and 17 household pets.

MAIN OUTCOME MEASURE

Radiation exposure to household members and 4 rooms in each home, as monitored with dosimeters for 10 days following 131I administration.

RESULTS

The patients received 131I doses ranging from 2.8 to 5.6 GBq (mean, 4.3 GBq). The radiation dose to 65 household members ranged from 0.01 mSv to 1.09 mSv (mean, 0.24 mSv). The dose to 17 household pets ranged from 0.02 mSv to 1.11 mSv (mean, 0.37 mSv). The mean dose to the 4 rooms ranged from 0.17 mSv (kitchen) to 0.58 mSv (bedroom).

CONCLUSION

In our study, 131I doses to household members of patients receiving outpatient 131I therapy were well below the limit (5.0 mSv) mandated by current NRC regulations.

Value of saphenous vein graft markers during subsequent diagnostic cardiac catheterization

BACKGROUND

Although saphenous vein graft (SVG) markers have been available for many years, they have not been widely used in coronary artery bypass graft (CABG) surgery. This is likely due to the paucity of data regarding the utility of these markers in postsurgery cardiac catheterization.

METHODS

We performed a prospective study of all post-CABG patients undergoing cardiac catheterization at Barnes-Jewish Hospital over a 6-month period to test our hypothesis that SVG markers would have a beneficial effect on these procedures. Differences in total procedure (arterial) time, time to image only the SVGs, fluoroscopy time, amount of contrast used, number of aortotomies, and number of views required were compared in patients with and without markers.

RESULTS

Post-CABG patients undergoing catheterization who had markers (n = 76) required significantly less total procedure time (p = 0.007), fluoroscopy time (p = 0.02), and contrast use (p = 0.008). Even after adjusting for the numbers of SVG ostia and numbers of cine views, patients with markers still required less catheterization and fluoroscopy time (p < 0.01, p < 0.02) and time to image only the SVGs (p < 0.05) than those without markers (n = 106).

CONCLUSIONS

SVG markers improve the efficiency of post-CABG catheterizations; they decrease the exposure of patients and cardiologists to ionizing radiation, and they decrease the exposure of patients to potentially toxic contrast agents. SVG markers are beneficial to the vast majority of post-CABG patients.

Radiation dose to patients and personnel during intraoperative digital subtraction angiography

BACKGROUND AND PURPOSE

The use of intraoperative angiography to assess the results of neurovascular surgery is increasing. The purpose of this study was to measure the radiation dose to patients and personnel during intraoperative angiography and to determine the effect of experience.

METHODS

Fifty consecutive intraoperative angiographic studies were performed during aneurysmal clipping or arteriovenous malformation resection from June 1993 to December 1993 and another 50 from December 1994 to June 1995. Data collected prospectively included fluoroscopy time, digital angiography time, number of views, and amount of time the radiologist spent in the room. Student's t-test was used to assess statistical significance. Effective doses were calculated from radiation exposure measurements using adult thoracic and head phantoms.

RESULTS

The overall median examination required 5.2 minutes of fluoroscopy, 55 minutes of operating room use, 40 seconds of digital angiographic series time, and four views and runs. The mean room time and the number of views and runs increased in the second group of patients. A trend toward reduced fluoroscopy time was noted. Calculated effective doses for median values were as follows: patient, 76.7 millirems (mrems); radiologist, 0.028 mrems; radiology technologist, 0.044 mrems; and anesthesiologist, 0.016 mrems.

CONCLUSION

Intraoperative angiography is performed with a reasonable radiation dose to the patient and personnel. The number of angiographic views and the radiologist's time in the room increase with experience.

Risk of radiation induced skin injuries from arrhythmia ablation procedures

Catheter guided ablation of cardiac arrhythmias is an effective and safe procedure for the treatment of most supraventricular and selected ventricular tachycardias. Because catheter manipulation is fluoroscopically guided, there is risk of radiation induced injury, especially during prolonged procedures. The Food and Drug Administration has recently issued a bulletin warning of the risks of acute skin injury occurring during fluoroscopically guided procedures that result in an exposure level exceeding 2 Gray units (Gy). This study was performed as an investigation into the risk of radiation induced skin injury during arrhythmia ablation procedures. The amount of radiation exposure for 500 patients who underwent ablation was calculated based upon fluoroscopy times and the entrance dose of radiation (0.02 Gy/min). The mean radiation exposure was 0.93 +/- 0.62 Gy. Although 5.6% of patients (n = 28) received enough radiation exposure to reach the threshold dose (2 Gy) for early transient erythema, no clinical manifestations of acute radiation induced skin injury were observed. No patients achieved the threshold dose for irreversible skin injury. Patients undergoing AV node ablation or modification received significantly less radiation (0.39 +/- 0.40 Gy and 0.79 +/- 0.44 Gy, respectively) than patients undergoing other ablation procedures (0.94-1.45 Gy, P < 0.05). There was no association between the magnitude of radiation exposure and the presence of underlying heart disease. Patients undergoing ablation of accessory pathways were exposed to more radiation if there was a right-sided pathway (1.69 +/- 0.93 Gy) compared to other sites (0.87-1.24 Gy, P < 0.05). This study demonstrates that the risk of significant radiation induced skin injury during arrhythmia ablation procedures is low provided that precautions are taken to minimize radiation exposure.

Radiation exposure to patients and medical personnel during radiofrequency catheter ablation for supraventricular tachycardia

Radiofrequency catheter ablation is an effective alternative to medical therapy for patients with supraventricular arrhythmias. The purpose of this study was to determine the risks to the patient and to medical personnel due to radiation exposure from fluoroscopy during radiofrequency ablation of supraventricular tachycardia. One hundred eight consecutive patients with Wolff-Parkinson-White syndrome or atrioventricular nodal reentry who underwent the ablation procedure were studied. The ablation procedure was successful in 95% of the patients studied. Preexcitation or supraventricular tachycardia recurred in 5% of the patients during a mean follow-up of 9 +/- 4 months. The mean fluoroscopy time was 50 +/- 31 minutes. An anthropomorphic radiologic phantom was used to determine organ exposure and the effective dose equivalents for the patient and medical personnel. The patient's effective dose equivalent during a representative ablation procedure was 1.7 rems, which is comparable to other invasive cardiovascular procedures. The risk of inducing a fatal cancer from this exposure is 1 chance in 745, which is 1% of the spontaneous risk. The risk of a serious birth defect is 1 chance in 80,000, which is 0.1% of the current incidence of serious birth defects in the United States. The cardiologist who receives the highest exposure among medical personnel, would incur 1.8 mrems per case or 450 mrems per year if 250 procedures were performed. This exposure is 9% of the recommended annual limit. These results demonstrate the efficacy of radiofrequency energy ablation of supraventricular tachycardia and confirm that radiation exposure to patients and medical personnel is within established guidelines.

Radiation absorbed dose estimates for oxygen-15 radiopharmaceuticals (H2(15)O, C15O, O15O) in newborn infants

In preparation for measurement of regional cerebral oxygen metabolism by positron emission tomography, radiation absorbed dose estimates for 19 internal organs, blood, and total body were calculated for newborn infants following bolus intravenous administration of H2(15)O and brief inhalation of C15O and O15O. Cumulated activity for each radiopharmaceutical was calculated from a compartmental model based on the known biologic behavior of the compound. Values for mean absorbed dose/unit cumulated activity (S) for internal organs and total body were based on a newborn phantom. S was separately calculated for blood. Total radiopharmaceutical absorbed dose estimates necessary to measure cerebral oxygen metabolism in a 3.51-kg infant based on 0.7 mCi/kg H2(15)O and 1 mCi/kg C15O and O15O were determined to be 1.6 rad to the lung (maximum organ dose), 0.28 rad to the marrow, 0.46 rad to the gonads, and 0.22 rad to total body. These values are similar to those for current clinical nuclear medicine procedures employing 99mTc in newborn infants.

External quantification of myocardial perfusion by exponential infusion of positron-emitting radionuclides

A technique was developed and evaluated using the exponential infusion of positron-emitting diffusible tracers to quantitate myocardial perfusion. The approach employs a parameter that rapidly reaches a constant value as a function of tracer delivery rate, isotope decay constant, and the monotonically increasing tissue radioactivity. Isolated rabbit hearts with controlled flow were used to evaluate the approach, because tracer kinetics in such preparations mimic those in vivo. Accordingly, exponential infusions of H2 15O and [11C]butanol were administered to 25 isolated rabbit hearts perfused with Krebs-Henseleit solution (KH) alone or KH enriched with erythrocytes (KH-RBC, hematocrit = 40). With flow varied from 1.2 to 5 ml/g per min in eight KH hearts infused with H2 15O, actual and estimated flow correlated closely (r = 0.95, n = 52 determinations). For the KH-RBC hearts, flow was varied from 0.3 to 1.5 ml/g per min. Actual and estimated flow correlated significantly for both the 14 KH-RBC hearts infused with H2 15O (r = 0.90, n = 89 determinations) and the 3 KH-RBC hearts infused with [11C]butanol (r = 0.93, n = 13 determinations). In addition, the required exponentially increasing arterial tracer concentrations were shown to be attainable in vivo in dogs and rhesus monkeys after intravenous exponential administrations of tracer. The results suggest that the approach developed employing exponential tracer infusion permits accurate measurement of myocardial perfusion and that it should prove useful in the noninvasive measurement of regional myocardial perfusion in vivo by positron emission tomography.

Measurement of regional cerebral blood volume by emission tomography

The technique of positron emission tomography was used to measure cerebral blood volume (CBV) in 10 normal right-handed human volunteers following inhalation of trace quantities of cyclotron-produced, 11C-labeled carbon monoxide. In scans obtained 4 cm above the orbitomeatal line, CBV was 4.3 ml per 100 gm of tissue, whereas in scans obtained 8 cm above the orbitomeatal line, CBV was significantly less (3.3 ml per 100 gm; p less than 0.001). This difference reflects the greater proportion of gray matter in the lower scan. Furthermore, the CBV was significantly larger (p less than 0.001) in the left cerebral hemisphere in the tomographic scans obtained 4 cm above the orbitomeatal line. These scans include the region of the superior surface of the temporal lobe (planum temporale), which is thought to be larger in individuals with left cerebral dominance for speech. This observation is the first in vivo demonstration of a structural correlate of a known functional difference in the cerebral hemispheres of man.

Central neuroendocrine regulation of brain water permeability

The brain vasculature, especially capillaries, may function in a very dynamic fashion under neuroendocrine control to regulate the internal environment of the brain. This is exemplified by new observations on the regulation of brain water permeability using the tracer H215O in vivo in adult rhesus monkeys. These studies reveal that brain water permeability, and hence brain water content and volume, are, at least in part, under the influence of the central noradrenergic system and centrally released vasopressin.

Cerebral blood flow, oxygen utilization, and blood volume in dementia

Patients with dementia had significant decreases in cerebral blood flow and cerebral oxygen utilization and a mild, but not significant, increase in cerebral blood volume. These studies were not useful in distinguishing patients with cerebral atrophy from patients with normal pressure hydrocephalus, as similar changes in cerebral circulation and metabolism were seen in both groups. Changes in cerebral blood flow after acute decrease in the intracranial pressure also were not helpful differentiating patients with normal pressure hydrocephalus from patients with cerebral atrophy.

Determination of radionuclide concentrations with positron CT scanning (PETT): concise communication

A series of experiments was undertaken to evaluate the response of a positron emission transverse tomograph (PETT) to measured radionuclide concentrations similar to those encountered in human studies. The correlation between the response of the imaging system (mean PETT number/min), and the concentration of the radioactivity producing the output data, was linear with a computed sensitivity of 2720 PETT number/min, per micronCi/ml, per picture element, for a radionuclide (100% beta+) contained in either of two phantoms and imaged with a reduction of 1.5 cm. It was concluded that the output data are essentially independent of the imaged object's physical dimensions for the range of 18-28-cm diam and faithfully reflect the regional radioactivity concentration within the object, provided valid attenuation correction is achieved and the sampled area is not compromised by the imaging system's limitations of spatial resolution.

Effects of subarachnoid hemorrhage on cerebral blood volume, blood flow, and oxygen utilization in humans

Forty-five studies of regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and regional cerebral oxygen utilization (rCMRO2) were performed in 30 patients undergoing diagnostic cerebral angiography for evaluation of a subarachnoid hemorrhage due to a ruptured intracranial aneurysm. Tracer methods employing radioactive oxygen-15 were used to measure rCBV, rCBF, and rCMRO2. The patient studies were divided into groups based on their neurological status and the presence or absence of cerebral vasospasm. Subarachnoid hemorrhage, with and without vasospasm, produced significant decreases in CBF and CMRO2. In general, patients with more severe neurological deficits, and patients with more severe degrees of vasospasm, had a more marked depression of CBF and CMRO2. The most striking finding was a significant (p less than 0.001) increase in CBV (to 58% above normal) in patients with severe neurological deficits associated with severe cerebral vasospasm. This large increase suggests that cerebral vasospasm consists of constriction of the large, radiographically visible extraparenchymal vessels accompained by a massive dilation of intraparenchymal vessels.

Correlation between regional cerebral blood flow and oxidative metabolism. In vivo studies in man

To test the hypothesis that regional cerebral blood flow (rCBF) is normally regulated by regional metabolic activity, rCBF and the regional cerebral metabolic rate for oxygen (rCMRO2) were compared in selected human subjects. In normal subjects and patients with chronic, stable diseases of brain, rCBF correlated well with rCMRO2. In one individual with mild dementia, rCBF and rCMRO2 were measured before and during exercise of the hand and forearm contralateral to the hemisphere studied. Appropriate parallel changes occurred in both rCBF and rCMRO2 during hand exercise. In patients with acute diseases affecting the hemisphere studied, however, the correlation between rCBF and rCMRO2 was unpredictable.

Measurement of brain oxygen utilization with radioactive oxygen-15: experimental verification

This study was designed to provide direct experimental evidence in support of the method employing radioactive 15O-tagged hemoglobin for the in vivo and regional measurement of the cerebral oxygen utilization rate (CMRO2). This was accomplished by simultaneously measuring in vivo the mean CMRO2 in monkeys and human beings by the 15O method and a direct appeal to the Fick principle using measured arteriovenous oxygen differences of brain. The correlation between the 2 methods was excellent, with a correlation coefficient of 0.90 (P less than 0.001) in monkeys and 0.88 (P less than 0.001) in human beings.

Blood-brain barrier permeability of 11C-labeled alcohols and 15O-labeled water

The extraction of 11C-labeled methanol, ethanol, and isopropanol, as well as 15O-labeled water by the brain during a single capillary transit, was studied in vivo in six adult rhesus monkeys by external detection of the time course of these tracers subsequent to their internal carotid artery injection. The data demonstrate the feasibility of accurately measuring brain permeability of highly diffusible substances by this technique and show that neither water nor the alcohols studied freely equilibrate with brain when the cerebral blood flow exceeds 30 ml/100 g min-1. At a cerebral blood flow of 50 ml/100 g min-1 only about 93% of an injected bolus of labeled water freely exchanges with brain, compared with methanol (93%), ethanol (97%), and isopropanol (99%). The brain capillary permeability-surface area (PS) products computed from these data were 0.023 cm3/s g-1 (water), 0.024 cm3/s g-1 (methanol), 0.030 cm3/s g-1 (ethanol), and 0.062 cm3/s g-1 (isopropanol). This sequence of PS products is consistent with the individual lipid solubilities of the alcohols studied and underscores the unique brain permeability characteristics of lipid-insoluble water.

In vivo determination of cerebral blood volume with radioactive oxygen-15 in the monkey

A method for the in vivo determination of cerebral blood volume was tested in 15 adult rhesus monkeys. The technique utilized external residue detection and required the serial measurement of two mean transit times, namely, that of an intravascular tracer, C15O-hemoglobin, and that of a diffusible tracer, H215O. In computing the mean transit time for the intravascular tracer, the conventional Hamilton extrapolation of the downslope of the recording obtained for the washout of the tracer from the brain subsequent to an intracarotid bolus injection was found to be inadequate, yielding a mean transit time that systematically underestimated that parameter. Alternatively, the use of a power law extrapolation, as proposed by Huang, allowed a more accurate prediction of the vascular mean transit time. The preliminary studies testing the method predicted that the relationship between cerebral blood volume (CBV) and cerebral blood flow (CBF) was adequately represented by the equation CBV = 0.80CBF0.38, with a correlation coefficient of r = 0.90 for the cerebral blood flow range of 16 to 134 ml/100 g min-1 with a normocapnic cerebral blood volume of 3.5 ml/100 g perfused brain tissue (arterial Pco2 = 37 torr, CBF = 50 ml/100 g min-1).

Central noradrenergic regulation of cerebral blood flow and vascular permeability

Anatomical studies employing the immunofluorescence localization of dopamine-beta-hydroxylase [= dopamine beta-monooxygenase; 3,4-dihydroxyphenylethylamine, ascorbate:oxygen oxidoreductase (beta-hydroxylating); EC 1.14.17.1] have demonstrated in brain central noradrenergic nerve fibers on small intraparenchymal blood vessels, including capillaries. This system is distinct from the peripheral noradrenergic system inervating the large extraparenchymal blood vessels. From these anatomical findings evolved the working hypothesis that the central noradrenergic system is analogous to the peripheral sympathetic system except that it is specialized for performing specific functions related to the brain microvasculature. To test this hypothesis cerebral blood flow and the brain vascular permeability of water (H215O) were measured in four adult rhesus monkeys (three with bilateral superior cervical ganglionectomies) with stereotaxically placed cannulae permanently located in the lateral ventricles and the locus coeruleus for the injection of drugs. Our data demonstrate that stimulation of the noradrenergic cell bodies in the locus coeruleus with carbachol (8 mug) produces a prompt reduction in hemispheric cerebral blood flow and an increase in brain vascular permeability of water. The intraventricular administration of the alpha-adrenergic blocker phentolamine (25--50 mug) has the opposite effect. These preliminary data support the hypothesis that the central noradrenergic system is analogous to the peripheral sympathetic system with the special function of regulating brain vascular permeability as well as blood flow.

Evidence of the limitations of water as a freely diffusible tracer in brain of the rhesus monkey

The extraction of 15 O-labeled water by the brain during a single capillary transit was studied in vivo in 20 adult rhesus monkeys by external detection of the time course of the tracer subsequent to the internal carotid injection of 0.2 ml of whole blood labeled with H 2 15 O. The data showed that labeled water does not freely equilibrate with the exchangeable water in the brain when the mean cerebral blood flow exceeds 30 ml/100 g min -1 . At the normal cerebral blood flow in the rhesus monkey (∼50 ml/100 g min -1 ), only 90% of the H 2 15 O is extracted during a single capillary transit. In addition, cerebral blood flow was determined with H 2 15 O and 133 Xe in these monkeys using residue detection and employing the central volume principle. The data supported the hypothesis that a diffusible tracer, H 2 15 O, need not be in complete equilibrium between the phases of a system for the application of the central volume principle to be valid. Finally, the brain capillary permeability-surface area product was computed from these data; it was approximately 0.023 cm 3 /sec g -1 .

The effects of changes in PaCO2 on cerebral blood volume, blood flow, and vascular mean transit time

The relationships between cerebral blood volume (CBV), cerebral blood flow (CBF), and the cerebral vascular mean transit time (t v ) during acute changes in the Pa CO 2 over a range of 15 to 76 torr were investigated in vivo in rhesus monkeys by serially determining the mean transit time of a vascular tracer, 15 O-labeled carboxyhemoglobin, and the mean transit time of a diffusible tracer, 15 O-labeled water. Over this range of Pa CO 2 , a significant linear relationship of CBV = 0.041 Pa CO 2 + 2.0 was found. For each one torr change in Pa CO 2 , there is a change in CBV of 0.041 ml/100 gm of perfused tissue. At a normocarbic value of Pa CO 2 (37 torr), an average value of 3.5 ml/100 gm was found. A nonlinear relationship of CBV and CBF was found. This relationship is expressed in the equation, CBV = 0.80 CBF 0.38 . A significant linear relationship was found between CBF and Pa CO 2 . This was described by the equation, CBF = 1.8 Pa CO 2 - 16.75. For each one torr change in the PaCO 2 , there is a 1.8 ml/100 gm per minute change in the CBF. At a normocarbic value of Pa CO 2 (37 torr), an average value of CBF of 50 ml/100 gm per minute was found. The relationship of CBV and t v was nonlinear and was expressed in the equation, t C15O = 41 CBF -0.62 .

The measure in vivo of regional cerebral oxygen utilization by means of oxyhemoglobin labeled with radioactive oxygen-15

Regional cerebral oxygen utilization rate is measured in vivo by the following method:A small volume of blood with radioactive oxygen-15-tagged hemoglobin is rapidly injected into the internal carotid artery of the patient under study. The first injection is followed by the injection carried out under identical circumstances but with blood labeled with water-(15)O. After each injection, the distribution of the radioactive label in the brain is measured and recorded, as a function of time, by six collimated scintillation probes placed over the subject's head. The recording, subsequent to the first injection, reflects (a) the arrival of the labeled oxygen into the tissues, (b) its partial conversion into water of metabolism, and (c) the washout of labeled water from the brain. The ratio of the amount of labeled water formed to the amount of oxygen perfusing the tissues, which can be derived from the recording, is a measure of fractional oxygen utilization. The second injection provides a measure of blood flow by the interpretation of the washout of labeled water from brain tissues. The product, fractional oxygen utilization x blood flow x arterial oxygen content, gives a measure of oxygen utilization rate. Some aspects of the validity of this method are tested by the injection of a nondiffusible indicator, carboxyhemoglobin-(15)O. Regional cerebral oxygen utilization rates for a series of patients with cerebral pathology are reported.