Radiation safety of personnel during catheter-based Ir-192 coronary brachytherapy

Catheter-based brachytherapy using Ir-192 seed sources has shown significant reduction in the rate of restenosis among patients with coronary in-stent restenosis. High-energy gamma rays from Ir-192 raise some radiation safety issues of personnel. The aim of this study was to fully analyze the radiation safety issues associated with Ir-192 brachytherapy in the cardiac cath lab environment. Measurements were made to assess the penetrating ability of Ir-192 gamma rays through tissues, concrete and lead. Radiation exposure levels were measured around a large number of patients undergoing Ir-192 brachytherapy. Personnel were carefully monitored for any additional dose received from brachytherapy for the last five years covering > 500 cases. Our results showed that with a proper radiation safety program in place, the dose to cath lab staff was negligible. It was concluded that radiation safety of personnel was easy to maintain during catheter-based coronary brachytherapy using Ir-192 seed sources.

A comparison of the enhancement of radiation sensitivity and DNA polymerase inactivation by hyperthermia in human glioma cells

Two human glioma cell lines (U87MG and U373MG) were evaluated for their thermal enhancement of radiation sensitivity and its correlation to the degree of inactivation of DNA polymerase alpha and beta. The data showed that hyperthermia increased radiation sensitivity in a time- and temperature-dependent manner. The differential heat sensitivity of the two cell lines was reflected in the degree of polymerase inactivation. Polymerase inactivation was also dependent on time and temperature and was greater for polymerase beta than alpha. The degree of polymerase inactivation correlated well with the thermal enhancement ratio (TER) calculated at the 1.0% survival level. This correlation was poor for the TER at the 50% survival level. The correlations were better for polymerase beta than alpha. The small differences in thermal sensitivity between the two cell lines primarily at 41 and 42 degrees C could not be explained by correlation between polymerase inactivation and TER. Incubation between hyperthermia and irradiation resulted in recovery of polymerase activity and loss of radiosensitization. Levels of polymerase beta after hyperthermia may be used to predict thermal enhancement of radiosensitivity for low survival levels, but possibly not in the shoulder region of the radiation survival curve. Small cell line-dependent differences in thermal sensitivity may not be resolved in these comparisons.

A comparison of the effect of hyperthermia on DNA polymerase in hamster and human glioma cells

The hyperthermia response of two human glioma cells lines (87MG and 373MG) was compared to the CHO cell line for cell killing and DNA polymerase inactivation. Glioma cells were found to be more thermally resistant than CHO cells over a temperature range of 41-46 degrees C. Inactivation of polymerase alpha and beta by hyperthermia was also more resistant in glioma cells than in CHO cells. The relative order of resistance for both killing and polymerase inactivation was 373MG > 87MG > CHO. While polymerase inactivation correlated with cell killing at high thermal doses, such correlation at low doses was absent; i.e. thermal killing was characterized by survival curves with shoulders while polymerase inactivation was not. Thus at low thermal doses the mechanism of thermal cell killing is probably not related to the degree of polymerase inactivation. Arrhenius analysis of the survival data showed that the inactivation energy for the glioma cells was 133-135 kcal/mol. The inactivation energies of alpha and beta polymerase were also evaluated and were 102-104 and 140-146 kcal/mol, respectively. Further analysis of the temperature-time relationship of hyperthermia treatment resulting in 50% cell kill showed the degree of polymerase beta inactivation to be a good indicator of thermal dose.

Nuclear protein redistribution in heat-shocked cells

An increase was observed in the total protein mass of nuclei isolated from Chinese hamster ovary cells heated at 45 degrees C or 45.5 degrees C. An increase in the fractional recovery of DNA polymerase alpha and beta, and of DNA topoisomerase activity coincided with this increase in the protein mass of nuclei from heated cells. Nuclear protein mass which was soluble in 2.0 M NaCl decreased 0.5 fold, while DNA-associated and nuclear matrix-associated protein mass increased 2.2 and 3.4 fold, respectively. The results indicate that the increase in nuclear protein mass observed in nuclei from heated cells is due in part to an increased binding, or precipitation, of nuclear proteins onto the cell's DNA and nuclear matrix.

Content of nonhistone protein in nuclei after hyperthermic treatment

When nuclei were isolated from Chinese hamster ovary cells after being heated, there was a large increase in the amount of 3H-tryptophan labeled nonhistone protein in the nucleus relative to the whole cell. After 15 min or 30 min of heating at 45.5 degrees C, the nuclear nonhistone protein content increased by 1.6 or 1.8, respectively. In contrast, when the nuclear nonhistone protein content was determined in the intact cell by using autoradiography to quantify 3H-tryptophan labeled protein in the nucleus and cytoplasm in sections of fixed cells, the nuclear nonhistone protein content increased by only 1.14 or 1.28 for 15 or 30 min at 45.5 degrees C, respectively. Therefore, heat does not induce a massive movement of cytoplasmic protein into the nucleus.

Precision radiation therapy for optic nerve sheath meningiomas

A more precise radiation therapy technique to treat unilateral optic nerve sheath meningioma is presented. It uses an immobilization device to align the ipsilateral optic nerve with a vertical axis and employs three small half-beam blocked fields to deliver radiation to a small conformal volume, thereby reducing the dose to the optic chiasm and the contralateral optic nerve. Three patients were successfully treated with this technique, and a fourth patient with optic nerve glioma was also treated in a similar fashion and was included in this study. The new technique irradiates a much smaller volume of tissue to high dose levels: 58 cm3 is irradiated to the 80% isodose level and only 18 cm3 to the 95% level. In contrast, the opposed lateral technique irradiates 171 and 73 cm3 to these levels, respectively. Thus, a considerable reduction in the volume of normal tissue irradiated was accomplished. Doses to the pituitary and contralateral optic nerve were 4% of the treatment dose for the new technique, whereas these doses were 40% and 100% for opposed laterals and 10% and 3% for wedged pair, respectively. The average setup error for this technique was very small, 50% of the setups measured were less than 1 mm off, and 92.5% were less than 3 mm off. However, for the conventional setups without a mask, only 21% of the setups were less than 1 mm off and 55% less than 3 mm off. We recommend this technique for localized unilateral optic nerve sheath meningioma and other optic nerve lesions that may require radiation therapy.

Lack of correlation between urea kinetic indices and clinical outcomes in CAPD patients

We examined the predictive value of urea kinetics for patient outcomes in CAPD by measuring dialysis index (DI; a means of quantifying CAPD dose using urea kinetics), KT/V and normalized protein catabolic rate (PCRN) on 222 occasions in 76 new patients at the time of starting CAPD and at subsequent six month intervals. We investigated how these indices altered with time and in relation to each other, and how they correlated with a wide range of subsequent patient outcomes. DI, KT/V and PCRN all tended to decrease with time on CAPD (P less than 0.0004, less than 0.0001 and 0.0005, respectively). DI and KT/V were highly correlated with each other (r = 0.89, P less than 0.0001) and both correlated with PCRN (r = 0.57, P less than 0.0001 and r = 0.60, P less than 0.0001, respectively). DI and KT/V both correlated inversely with subsequent values for serum creatinine (P less than 0.0001), urea (P less than 0.0002), potassium (P less than 0.02) and phosphate (P less than 0.002), and directly with bicarbonate (P less than 0.0001). PCRN correlated inversely with serum creatinine (P less than 0.0002) and directly with urea (P less than 0.0001) and with the number of blood transfusions received (P less than 0.03). None of these indices correlated with levels of hemoglobin, PTH, alkaline phosphatase or albumin, or with nerve conduction velocity or any other subsequent clinical outcomes including death, technique failure, hospital days, peritonitis rate and subjective indices of fatigue, pruritus and insomnia. We conclude that the urea kinetic model is predictive of some biochemical outcomes but not of clinical outcomes in CAPD patients.

The role of intracellular pH and its variance in low pH sensitization of killing by hyperthermia

Average intracellular pH (pHi) was measured in Chinese hamster ovary (CHO) and murine NG 108-15 neuroblastoma cells by the weak acid, [14C]5,5-dimethyl-2,4-oxazolidinedione-2 [( 14C]-DMO). Intercell variance in pHi in CHO cells was determined by flow cytometry (FCM) and automated image analysis using the pH-sensitive fluorescent dye, 2',7'-bis-(carboxyethyl)-5(and-6)- carboxyfluorescein. Our results are summarized as follows: (i) When extracellular pH (pHe) ranged from 6.1 to 7.9, the relationship between pHe and average pHi was similar for both cell lines, except that pHi of NG108 cells was 0.3 to 0.2 pH units higher than that of CHO cells. (ii) When both cell lines were heated at 43.5 degrees C to give an isosurvival of 0.1 at pHe 7.2, lowering pHe (6.1-6.9) reduced survival more for CHO cells than for NG108-15 cells. However, plots of survival versus average pHi were identical for the two cell lines. (iii) Values of average pHi measured by [14C]DMO agree with those measured by FCM techniques. (iv) A distribution of pHi values was obtained for a population of cells. However, when the cells were sorted on the basis of low or high values of pHi and reanalyzed, the distributions of the sorted populations were almost identical to the distribution of the original population. These results indicated that the distribution of pHi for a cell population is much more homogeneous than that observed by FCM. (v) These observations indicate that pHi at the time of heating and not pHe is responsible for the low pH sensitization of heat killing.

Effects of pH on heat sensitization of mammalian cells with procaine hydrochloride

The enhancement of heat killing of CHO cells by treatment with 7 mM procaine HCl increased when cells were treated under alkaline conditions. Below a pH of 6.9, very little heat sensitization was observed; however, as the pH was increased to 7.4 and above, considerable heat sensitization occurred. There were no changes in intracellular pH at the beginning of heating that could be responsible for this phenomenon.

Comparison of DMO and flow cytometric methods for measuring intracellular pH and the effect of hyperthermia on the transmembrane pH gradient

Intracellular pH (pHi) was measured in both unheated and heated cells by the distribution of the weak acid, 5,5-dimethyl-2,4-oxazolidinedione-2-14C (14C-DMO), and by the fluorescence intensity ratio (I530/I630) of the pH sensitive fluorescent dye, 2',7'-bis(carboxyethyl)-5,6-carboxy-fluorescein (BCECF), analyzed by flow cytometry (FCM). BCECF-loaded Chinese hamster ovary (CHO) cells were analyzed by FCM after they had incubated in fresh medium at 37 degrees C for 90 min, during which time a decrease in fluorescence ratio stabilized. After stabilization, the pHi determined for CHO cells by the FCM method at pHe values of 6.0-8.1 agreed-within 0.1 pH units with that determined by the 14C-DMO method. There is a pH gradient across the plasma membrane that is not affected by heat. In CHO cells, the gradient, determined by DMO and FCM, is less or greater than pHe by 0.30 and 0.15 pH units at pHe 7.4 and 6.3, respectively, and in NG108-15 cells, the gradient determined by DMO increases to 0.50 pH units at pHe 6.3. Both cells maintained their pH gradients for at least 4 h after heating, although 99.9% of the cells were reproductively dead (survival of 10(-3)) after heating at 45.5 degrees C either at the normal pHe of 7.4 or at a low pHe of 6.4-6.7.

The role of low intracellular or extracellular pH in sensitization to hyperthermic radiosensitization

Previous work showed that intracellular pH (pHi) and not extracellular pH (pHe) was the determinant in the low pH sensitization of hyperthermic killing. The present studies show that the same is true for heat-induced radiosensitization and loss of cellular DNA polymerase activities. Chinese hamster ovary cells after they had adapted to low pH (6.7) had an increase in pHi which rendered cells partially resistant to the low pH sensitization of heat-induced cell killing, radiosensitization, and loss of cellular DNA polymerase activities. These results were quantified by plotting versus pHe, both the thermal enhancement ratio (TER), defined as the ratio of the X-ray dose without heat to the X-ray dose with heat to give an isosurvival value of 0.01, and the thermal enhancement factor (TEF), defined as the ratio of the D0 of the radiation survival curve to the D0 of the radiation survival curve for heat plus radiation. Both the TER and TEF were higher for the unadapted cells than for the adapted cells, i.e., 1.3-1.4 fold higher at a pHe of 6.3. However, the TER or TEF plotted versus pHi was identical for the two cell types. Finally, heat-induced loss of cellular DNA polymerase activities correlated with pHi and not pHe. Therefore, we conclude that pHi and not pHe is responsible for the increase by acid in heat-induced radio-sensitization and loss of cellular DNA polymerase activities.

The role of low intracellular or extracellular pH in sensitization to hyperthermia

Cells are more sensitive to heat when they are heated in an acidic environment, and this study confirms (K. G. Hofer and N. F. Mivechi, J. Natl. Cancer Inst., 65, 621, 1980) that intracellular pH (pHi) and not extracellular pH (pHe) is responsible for the sensitization. The relationship between pHe, pHi, and heat survival of cells heated in vitro in various buffers at pHe 6.3-8.0 was investigated. Cells' adaptation to low environmental pH in terms of increases in pHi and heat survival also was investigated. Finally, we studied the relationships among pHe, pHi, and survival from heat for cells heated in sodium-free reconstructed medium. Intracellular pH was measured by the distribution of the weak acid, [2-14C]5,5-dimethyl-2,4-oxazolidinedione. Our results are summarized as follows: (1) CHO cells maintained the same relationship between pHe and pHi in four different media or buffers (McCoy's 5a medium buffered with CO2 and NaHCO3 or 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (Hepes) and 2-(N-morpholino)ethanesulfonic acid (Mes), Krebs-Ringer bicarbonate solution, and Krebs-Ringer phosphate solution) with pHi being 0.05 to 0.20 pH units higher than pHe as it varied from 7.0 to 6.4; furthermore, heat sensitization by acid was the same in medium buffered with NaHCO3 or Hepes and Mes. (2) The low pHe adapted cells multiplied with an increased doubling time of 20.7 +/- 0.7 h and appeared morphologically similar to the unadapted cells. However, the pHi of these cells was 0.15-0.30 pH units higher than that of the unadapted cells when pHe was varied between 7.0 and 6.3. (3) After being heated at 43.5 degrees C for 55 min or at 42.5 degrees C for 150 min at pHe 6.3-7.2, the pHi of the adapted cells increased by 0.2-0.1 pH units. However, heat caused no significant change in the unadapted cells. (4) Heat survival plotted versus pHe was 1000-fold higher for the adapted cells than for the unadapted cells at pHe of 6.3. However, heat survival plotted versus pHi was identical for the two cell types. (5) In sodium-free reconstructed McCoy's 5a medium, pHi was 0.25-0.1 pH units lower than that in the sodium-containing counterpart at pHe 6.3-7.2, and heat sensitization increased accordingly; however, heat survival plotted versus pHi was identical for the two types of media.

Effect of cycloheximide on heat-induced cell killing, radiosensitization, and loss of cellular DNA polymerase activities in Chinese hamster ovary cells

A whole-cell assay technique for DNA polymerase alpha and beta was used to measure the activities of both enzymes in Chinese hamster ovary cells after hyperthermic treatment at 43 degrees C in the presence or absence of 10 micrograms/ml cycloheximide (CHM). In the same experiments, the effect of CHM on heat killing and heat radiosensitization was also investigated. CHM treatment before and during heating protected the cells for all three end points, i.e., heat-induced cell killing, radiosensitization, and loss of cellular DNA polymerase activities.

Effect of hyperthermia on intracellular pH in Chinese hamster ovary cells

Chinese hamster ovary cells were heated at 45.5 or 43.0 degrees C at acidic pH (6.7) or normal physiological pH (7.4) to have a survival of 10(-3). The weak acid, 5,5-dimethyl-2,4-oxazolidinedione-2-14C), was used to measure the intracellular pH (pHi) both during and following hyperthermia. Tritiated water and a Particle Data machine were used to measure cellular volume as well. With 99.9% of the cell population destined to die clonogenically, the physiologically alive cells, as determined by the exclusion of trypan blue dye, maintained their pH differential between pHe and pHi as well as unheated cells. Furthermore, the cell's ability to regulate its pHi in response to changes in pHe was not affected by the same hyperthermic treatment. However, cellular volume decreased by 15-30% by 5 h after the onset of heat treatment. We conclude that heat does not perturb the cellular regulation of intracellular H+ concentration. Therefore, there is no thermal damage to the pHi-regulatory mechanism that could be responsible for either heat-induced reproductive cell death or low pH sensitization of heat killing.

Dose levels outside radiotherapy beams

The specification of a radiotherapy generator calls for the leakage radiation through the housing of the source to be 0.1% (the ICRP has recently (1982) changed this figure to 0.2% of the dose rate inside the useful beam). When a patient is irradiated, the dose level outside the useful beam is not only determined by this leakage radiation, but also by scattered radiation from the beam-defining system and from the treatment volume of the patient. Measurements have been made on a 300 kV X-ray unit, and on two different 4 MV and one 8 MV linear accelerators to determine the levels of leakage radiation and scattered radiation in air, and in a phantom comparable in size to the trunk of the patient. Similar measurements have also been made for a 15 MeV neutron generator. It is shown that for all these generators the dose delivered outside the radiation beam is determined mainly by the two scattering processes mentioned, and it is argued that for linear accelerators it would be feasible to increase the permitted level of leakage radiation by a factor of 2 or 3 without a significant increase in the stray radiation delivered to the patient.