TY - JOUR
AU - Tamam, Muge, Oner
AB - Abstract The aim of this study is to evaluate the radiation safety of caregiving people contacting the child and adolescent patients with thyroid cancer who received radioactive iodine-131 (RIT) treatment by comparison with external dose rate measurements of adult patients according to their administered activities and days of hospitalization. We retrospectively evaluated external dose rate measurement of 158 children and adolescent patients and 158 adult patients. During the RIT, the hospitalization time were grouped as 2, 3 and 4 d, and the administered activities as <3700, 3700 and >3700 MBq. The values of external dose rate measurements of children and adolescents were statistically significantly higher than the adult group. Different approaches in radiation safety rules are required for children and adolescents. In terms of radiation safety, we suggest that more specific regulations for family members and caregivers should be established and informed. INTRODUCTION Radioactive iodine therapy (RIT) is an effective treatment modality for children and adults with well-differentiated thyroid cancer. The physical half-life of iodine-131 is 8.04 d, with beta energy and 364.5 keV gamma energy. The exposure of other persons by patients who have received radionuclide therapy can occur in the following ways: (a) external irradiation of persons close to the patient; (b) internal contamination of persons as a result of excreted or exhaled radionuclides. The annual effective dose limit for the population, excluding natural radiation and medical irradiation, is 1 mSv. This is the basis for ensuring that other people around the patient (such as family members, colleagues) do not receive more than 1 mSv of effective dose after RIT. This limit value may not apply to people in the family of the patient and those who knowingly and willingly care for the patient. For this reason, children and their relatives and caregivers outside of pregnancy may be allowed to take doses up to 5 mSv during treatment. However, it should be targeted to be kept below 3 mSv within the framework of the optimization principle of radiation protection(1, 2). In general, the doses people around the patient will receive, due to external irradiation, are dependent on factors: the amount and distribution of radioactive material remaining in the body during the patients discharge, the specific dose rate of radionuclide, the absorption factor of the radiation in the patient’s body, the physical and biological half-life of radionuclide and compliance with the instructions(1–3). Other factors that determine the residual activity are residual thyroid tissue after surgery, metabolism of the patient and metastases. The urine, sweat and saliva secretions of the patient increase the risk of radiation exposure for family members and caregivers of the patients. In the first few days, this risk is higher(4). According to bioassay studies, after the first 5 d iodine is given, a large part of it is thrown away from the body. Patients hospitalized during treatment should have a dose rate of <30 μSv h−1 and a residual activity of <600 MBq, as is the legal limit in our country for radiation dosimetry from 1 m distance to the abdomen during discharge(1–3). Pediatric patients, unlike adults, are more likely to have histopathologic features such as lymph node metastases, lung metastases, more advanced stage and treatment resistance when diagnosed(5–7). In childhood, the frequency of lymph node and lung metastases are, respectively, 40–90% and 20–30%, whereas in adults, respectively, 20–50% and 20%. Multifocality is around 40% in children. The recurrence rate is higher in children under 10 y of age(5). In particular, children under 10 y of age are more deprived of care and attention. So they spend more time with their family or caregivers at closer distances. In addition, there is a higher risk of contamination in toilet cleaning (incontinence of urine) in children. The inability to provide adequate hydration is also a factor that increases the risk of external irradiation(1–3). However, metabolisms are usually faster than adults. After becoming a discharge, it may be insufficient for children to comply with radiation safety rules at home (such as separate sleeping, distance rules, shower, etc.). For this reason, the doses of family or caregivers may be higher in these patients. MATERIALS AND METHODS The data of external dose rate measurement received during discharge of 158 children and young patients and 158 adult patients who underwent RIT for well-differentiated thyroid cancer were evaluated retrospectively in University of Health Sciences, Okmeydani Training and Research Hospital, Department of Nuclear Medicine. The maximum age for young patients was 21. Those older than 21 y constituted the adult patient group. During the course of RIT treatment, hospitalization was classified as 2, 3 and 4 d, while RIT-administrated activities were classified as <3700, 3700 and >3700 MBq. The distance for external measurement was 1 m at the abdominal level. Geiger Mueller Hand Monitor (Turkey In Cekmece Nuclear Research and Education Center (CANEM) NEB-211, Turkey) was used for external measurement. The device is calibrated with Cesium 137 every year in dosemeter laboratory of Turkey Atomic Energy Institution Cekmece Nuclear Research and Education Center with energy dependence in the range from 45 keV–1.3 MeV. The device gives results in mR h−1 of exposure rate. One miliRoentgen is approximately equivalent to 10 mSv of ambient dose and the units were converted. Children and adolescents and adult patient groups were first compared in terms of administered activities, days of hospitalization and external dose rate measurements, followed by a comparison of the two groups. Statistical analysis: IBM Statistical Package for Social Sciences SPSS Statistics 22 program was used for statistical analysis (IBM SPSS, Turkey). The normal distribution fitness of the parameters was assessed by the Shapiro–Wilk test. Tamhane’s T2 test was used to determine the group that caused the difference between the groups with normal distribution in the comparison of the descriptive statistical methods (mean, standard deviation (SD) and frequency) as well as the quantitative data when the study data were evaluated. Student’s t-test was used for the comparison of normal distribution of the two groups. Chi square test was used for comparison of qualitative data. Significance was assessed at P < 0.05 level. This study was performed after the ethical committee approval from our institute. RESULTS The study was conducted with 158 children and adolescent patients and 158 adult patients between 1984 and 2018. In children and adolescent group, the mean age of the patients was 17.3 ± 3.5, ranging from 3 to 21 y. The administered activities ranged from 1110 to 7400 MBq with a mean of 4320.5 ± 1453.7. The external dose rate ranged from 1 to 30 μSv h−1 with a mean of 10.5 ± 7.9. The data of children and adolescent group are presented in Table 1. There was no statistically significant difference between administered activities groups in terms of external dose rate measurement values (P > 0.05). There was a statistically significant difference (p : 0.005; P < 0.05) between the days of hospitalization in terms of external dose rate measurement values. As a result of the binary comparisons made for the determination of the difference, the external dose rate values of the 4-d group were found to be statistically significantly lower (p1:0.013, p2:0.009, P < 0.05) than the 2-d and 3-d groups. There was no statistically significant difference between the 2-d and 3-d groups in terms of external dose rate values (P > 0.05). Table 1. Distribution of study parameters in children and adolescents group. No. of patients (n: 158) Percentage of patients Gendern,%  Male 30 19  Female 128 81 Age group,%  ≤10 8 5.1  11–17 y 59 37.3  18–21 y 91 57.6 Administered activities group n,%  <3700 MBq 20 12.7  3700 MBq 74 46.8  >3700 MBq 64 40.5 Hospitalization days n,%  2 42 28  3 61 40.7  4 47 31.3 External dose rate measurements n,%  1–10 μSv h−1 99 62.7  11–20 μSv h−1 39 24.7  21–30 μSv h−1 20 12.7 No. of patients (n: 158) Percentage of patients Gendern,%  Male 30 19  Female 128 81 Age group,%  ≤10 8 5.1  11–17 y 59 37.3  18–21 y 91 57.6 Administered activities group n,%  <3700 MBq 20 12.7  3700 MBq 74 46.8  >3700 MBq 64 40.5 Hospitalization days n,%  2 42 28  3 61 40.7  4 47 31.3 External dose rate measurements n,%  1–10 μSv h−1 99 62.7  11–20 μSv h−1 39 24.7  21–30 μSv h−1 20 12.7 Table 1. Distribution of study parameters in children and adolescents group. No. of patients (n: 158) Percentage of patients Gendern,%  Male 30 19  Female 128 81 Age group,%  ≤10 8 5.1  11–17 y 59 37.3  18–21 y 91 57.6 Administered activities group n,%  <3700 MBq 20 12.7  3700 MBq 74 46.8  >3700 MBq 64 40.5 Hospitalization days n,%  2 42 28  3 61 40.7  4 47 31.3 External dose rate measurements n,%  1–10 μSv h−1 99 62.7  11–20 μSv h−1 39 24.7  21–30 μSv h−1 20 12.7 No. of patients (n: 158) Percentage of patients Gendern,%  Male 30 19  Female 128 81 Age group,%  ≤10 8 5.1  11–17 y 59 37.3  18–21 y 91 57.6 Administered activities group n,%  <3700 MBq 20 12.7  3700 MBq 74 46.8  >3700 MBq 64 40.5 Hospitalization days n,%  2 42 28  3 61 40.7  4 47 31.3 External dose rate measurements n,%  1–10 μSv h−1 99 62.7  11–20 μSv h−1 39 24.7  21–30 μSv h−1 20 12.7 In Adult group, the ages of the cases ranged from 24 to 77, with a mean of 50.49 ± 11.5. The administered activities ranged from 1850 to 7400 MBq with a mean of 4320.5 ± 1308.3. The external dose rate ranges from 1 to 30 μSv with a mean of 8.6 ± 7.5. The data of adult group are presented in Table 2. There was a statistically significant difference between administered activities groups in terms of external dose measurement values (p:0.000, P < 0.05). As a result of the binary comparisons made for the determination of the difference, the external dose values of the group with <3700 MBq of treatment were statistically significantly lower than those of 3700 MBq of treatment and >3700 MBq of administered activities (p1:0.002, p2:0.000, P < 0.05). The external dose values of the group with 3700 MBq of treatment were found to be statistically significantly lower than the group with more than 3700 MBq above administered activities (p:0.032, P < 0.05). Table 2. Distribution of study parameters in adult group. No. of patients (n: 158) Percentage of patients Gender n,%  Male 41 25.9  Female 117 74.1 Administered activities group n,%  <3700 MBq 17 10.8  3700 MBq 78 49.4  >3700 MBq 63 39.9 Hospitalization days n,%  2 d 48 30.4  3 d 61 38.6  4 d 49 31 External dose rate measurements n,%  1–10 μSv h−1 109 69  11–20 μSv h−1 32 20.3  21–30 μSv h−1 17 10.8 No. of patients (n: 158) Percentage of patients Gender n,%  Male 41 25.9  Female 117 74.1 Administered activities group n,%  <3700 MBq 17 10.8  3700 MBq 78 49.4  >3700 MBq 63 39.9 Hospitalization days n,%  2 d 48 30.4  3 d 61 38.6  4 d 49 31 External dose rate measurements n,%  1–10 μSv h−1 109 69  11–20 μSv h−1 32 20.3  21–30 μSv h−1 17 10.8 Table 2. Distribution of study parameters in adult group. No. of patients (n: 158) Percentage of patients Gender n,%  Male 41 25.9  Female 117 74.1 Administered activities group n,%  <3700 MBq 17 10.8  3700 MBq 78 49.4  >3700 MBq 63 39.9 Hospitalization days n,%  2 d 48 30.4  3 d 61 38.6  4 d 49 31 External dose rate measurements n,%  1–10 μSv h−1 109 69  11–20 μSv h−1 32 20.3  21–30 μSv h−1 17 10.8 No. of patients (n: 158) Percentage of patients Gender n,%  Male 41 25.9  Female 117 74.1 Administered activities group n,%  <3700 MBq 17 10.8  3700 MBq 78 49.4  >3700 MBq 63 39.9 Hospitalization days n,%  2 d 48 30.4  3 d 61 38.6  4 d 49 31 External dose rate measurements n,%  1–10 μSv h−1 109 69  11–20 μSv h−1 32 20.3  21–30 μSv h−1 17 10.8 There was a statistically significant difference between the days of hospitalization in terms of external dose rate measurement values (p:0.000, P < 0.05). As a result of the binary comparisons made for the determination of the difference, the external dose values of the 4-d-old group were statistically significantly lower (p:0.000, P < 0.05) than the groups of 2 and 3 d. There was no statistically significant difference between the 2-d and 3-d groups in terms of external dose values (P > 0.05). The external dose rate measurements of children and adolescents were statistically significantly higher than the adult group (p:0.023, P < 0.05). The values of external dose rate measurements of children and adolescents were statistically significantly higher than the adult group (p:0.002; P < 0.05), when treatment lower than 3700 MBq (<3700) is administered (Table 3). The values of external dose rate measurements of children and adolescents were statistically significantly higher than the adult group (p:0.018, P < 0.05), when 3700 MBq treatment is administered (Table 3). There was no statistically significant difference between the groups in terms of external dose rate measurement averages (P > 0.05), when treatment higher than 3700 MBq (>3700) is administered (Table 3) (Figure 1). Table 3. Evaluation of individual groups in terms of external dose rate measurement in treatment dose groups and hospitalization days. External dose rate measurement (μSv h−1) Children and adolescents group Adult group P Mean ± SD Mean ± SD Administered activities group  <3700 MBq 10.5 ± 7.8 3.8 ± 3.2 0.002*  3700 MBq 10.6 ± 8.4 7.6 ± 6.5 0.018*  >3700 MBq 10.5 ± 7.3 11 ± 8.5 0.714 Hospitalization days  2 d 12 ± 9 11.2 ± 8.2 0.682  3 d 10.9 ± 6.9 9.9 ± 7 0.441  4 d 7.2 ± 5.7 4.3 ± 3.5 0.015* External dose rate measurement (μSv h−1) Children and adolescents group Adult group P Mean ± SD Mean ± SD Administered activities group  <3700 MBq 10.5 ± 7.8 3.8 ± 3.2 0.002*  3700 MBq 10.6 ± 8.4 7.6 ± 6.5 0.018*  >3700 MBq 10.5 ± 7.3 11 ± 8.5 0.714 Hospitalization days  2 d 12 ± 9 11.2 ± 8.2 0.682  3 d 10.9 ± 6.9 9.9 ± 7 0.441  4 d 7.2 ± 5.7 4.3 ± 3.5 0.015* Student’s t-test *P < 0.05. Table 3. Evaluation of individual groups in terms of external dose rate measurement in treatment dose groups and hospitalization days. External dose rate measurement (μSv h−1) Children and adolescents group Adult group P Mean ± SD Mean ± SD Administered activities group  <3700 MBq 10.5 ± 7.8 3.8 ± 3.2 0.002*  3700 MBq 10.6 ± 8.4 7.6 ± 6.5 0.018*  >3700 MBq 10.5 ± 7.3 11 ± 8.5 0.714 Hospitalization days  2 d 12 ± 9 11.2 ± 8.2 0.682  3 d 10.9 ± 6.9 9.9 ± 7 0.441  4 d 7.2 ± 5.7 4.3 ± 3.5 0.015* External dose rate measurement (μSv h−1) Children and adolescents group Adult group P Mean ± SD Mean ± SD Administered activities group  <3700 MBq 10.5 ± 7.8 3.8 ± 3.2 0.002*  3700 MBq 10.6 ± 8.4 7.6 ± 6.5 0.018*  >3700 MBq 10.5 ± 7.3 11 ± 8.5 0.714 Hospitalization days  2 d 12 ± 9 11.2 ± 8.2 0.682  3 d 10.9 ± 6.9 9.9 ± 7 0.441  4 d 7.2 ± 5.7 4.3 ± 3.5 0.015* Student’s t-test *P < 0.05. Figure 1. Open in new tabDownload slide The comparison of the external dose rate measurement of children and adolescent patients with adult patients according to administered activities groups. Figure 1. Open in new tabDownload slide The comparison of the external dose rate measurement of children and adolescent patients with adult patients according to administered activities groups. For 2-d hospitalization, there was no statistically significant difference between groups in terms of external dose rate measurement averages (P > 0.05) (Table 3). For 3-d hospitalization, there was no statistically significant difference between the groups in terms of external dose rate measurement averages (P > 0.05). For 4-d hospitalization, the values of external dose rate measurements of children and adolescents were statistically significantly higher than the adult group (p:0.015, P < 0.05) (Table 3). DISCUSSION The rules that should be followed at home after the patients, who underwent RIT, discharged from the hospital, are explained for the adult patients in the guidelines(1–3). However, it is a little difficult to apply these rules in cases where the patient is a child, due to the facts that the disease is metastatic in children, higher recurrence rate than adults, and inability to apply the radiation protection rules as strict as adults. Also, childhood and adolescence are terms that require more attention and care. Thus, different approaches in radiation safety rules might be required for children and adolescents. Currently, there is no study of external measurements of pediatric patients and the doses taken at home after the discharge of parents or caregivers from children. Our study showed that children and adolescent patients had emitted significantly higher external dose rate than adults, both according to some administered activities and on some day of hospitalization. The hospitalization period is one of the important criteria for determining the external dose rate measurements of these patients. In a study of 1859 patients with external dose rate measurements of adult patients, Mulazimoglu and his colleagues revealed that 99.6% of patients at all doses had values <30 μSv h−1 limit on day 3, and there was a significant difference in between 3 and 4 d of hospitalization group in terms of external dose rate measurements. Patients with high external dose rate measurements have been determined to have metastases, the presence of residual tissue and failure to follow recommended guidelines(7). In their studies involving 27 patients with thyroid cancer who received 4625–40 MBq of RIT from Culver et al., the mean exposure rates were 10 ± 8 μSv h−1 (0.7–29 μSv) at 2–4 d following hospital discharge and 8 ± 14 μSv h−1 (0.5–37 μSv h−1) at 5–7d following hospital discharge. Especially, patients with metastasis were reported not to be discharged before 72 h(8). In our study, similar results were obtained in both adults and children. Three-day hospitalization is usually sufficient for <30 μSv dose limit. However, in some patients, this process may not be adequate. We found that external measurements were significantly lower in 4-d hospitalization compared to 3-d hospitalization. However, in adult–children comparison, we have determined that the external measurements of children in 4-d hospitalization are significantly higher than adults (p:0.015, P < 0.05). The explanation of this fact is that children and adolescent patients may have poor hygiene and low accordance to radiation safety regulations. A potential radiation exposure pathway is ingestion of 131I excreted/secreted by the treated patient, via contacting with areas contaminated with urine or saliva(9). Hygiene precautions are meant to reduce not only external exposure but also ingestion of 131I from secretions and excretions of the patient(10). ICRP, IAEA, European Commission and Turkish Atomic Energy Autority, the highest acceptable dose constrain for adult relatives and parents of pediatric patients who are in need of care is 5 mSv(1–3). The dose constrains for children’s family members during radioactive iodine therapy of their relatives is 1 mSv. However, according to the optimization principle, it is recommended not to exceed 0.3 mSv in children under 18 y of age and 3 mSv in adult family members(1, 3). In the study of Remy and colleagues, the cumulative dose of radiation taken by relatives of patients within the first 7 d after discharge were measured as 51.5 μSv(11). Pant et al. studied 297 family members of patients receiving up to 7.4 GBq RIT for thyroid cancer. The family members were divided into three groups depending upon the mode of transport and facilities available at home to avoid close proximity with the patient. Group A consisted of those family members who traveled back home with the patient in their private vehicle or by air and had a separate room with attached toilet at home for the patient. Group B included those who used public transport (train or bus) for the journey back home and had reasonable facilities at home to avoid proximity with the patient. Group C consisted of those who also used public transport (train or bus) for the journey back home and had limited resources to avoid close proximity with the patient at home. Most of them were from the economically weaker section of the society. Group A with 25 family members received a dose ranging from 0 to 0.9 mSv (mean 0.4 mSv), group B with 96 family members received a dose ranging from 0 to 8.5 mSv (mean 0.8 mSv) and group C with 176 family members received a dose ranging from 0 to 5.0 mSv (mean 0.8 mSv)(12). In their calculation model study, Dewji et al. showed that public transportation scenario, standing face-to-face 10 cm separation, provided the highest dose rate for public exposure on public transportation. From the seated cases alone, patient seated behind member of public provided the highest dose rate for public exposure for the seated cases(13). Gabriel et al., in their study including 48 family members of 38 patients receiving RIT for thyroid cancer, reported that the level of radiation exposure of family members is a positive correlation with the radiation level of the patient but this correlation is impaired if the prescribed rules are followed(14). In a study conducted by Monsieurs et al. on 94 family members of 65 patients receiving RIT for thyroid cancer with their 14-d thermoluminescence dosimetry follow-up, the mean external dose rate received by family members was 281 μSv on the 14th day after discharge, and only 2 out of 19 patients relatives were observed to exceed 1 mSv y−1, the limit of EUROTOM 96/29(15). Marriott et al. reported that the mean penetration doses of the patients’ caregivers during hospitalization were a maximum of 283 μSv, and an average of 98 ± 64 μSv. In the study conducted by Jeong et al., the caregivers of patients hospitalized for 3–4 d spent 5 h a day with the patients and the external effective doses were 0.12 mSv ± 0.10 mSv. In most studies with adult patients, the doses taken by family members are revealed to be within the allowable dose limits(16, 17). Gains and colleagues have shown that the highest doses were taken by caregivers from children and adolescents during hospitalization. Caregivers of younger children have been reported to have taken a higher dose, due to the need for care and support for younger children, even if the activity is higher in older children. The highest dose was given as 5280 to 3104 μSv(18). However, there is no study of the parents and caregivers who perform home care after these children are discharged. Factors such as sleeping habits of children, prognosis of the disease, toilet habits and nutrition cause the family members and /or caregivers to contact for longer time and closer distance. Also, especially in the patients below 10 y of age, there is a higher risk of contamination from urine, sweat, saliva. Indicating the need for special precautions for children and adolescents, due to the facts that the disease is metastatic in children, need for repetitive administered activities due to higher recurrence rate than adults and inability to apply the radiation protection rules as strict as adults, different approaches in radiation safety rules are required for children and adolescents. In terms of radiation safety in childhood and adolescence, we suggest that more specific regulations for family members and caregivers should be established and informed. CONCLUSION Longer hospital stays may be required in patients who have low care and/ or lower socio-economic status to enable them to avoid close proximity with caregivers and family members. Besides hospitalization, the cleaning rules especially for sweat, saliva and urine contaminations that patients should follow must be strongly emphasized in radiation safety training. We suggest that more specific regulations for family members and caregivers should be established and informed. Further studies on doses taken by family members and caregivers of child or adolescent patients will provide more information on this issue. REFERENCES 1 Turkish Atomic Energy Autority : Guidance on the Discharge of Patients Receiving Radionuclide Therapy, RSGD-KLV-009. 2 IAEA (International Atomic Energy Agency, Release of Patients After Radionuclide Therapy, with contributions from the ICRP (International Commission on Radiological Protection), Safety Reports Series No:63 ( 2009 ). 3 Radiation Protection 97 . Radiation protection following Iodine-131 therapy Directorate-General Environment, Nuclear Safety and Civil Protection, European Commission ( 1998 ). 4 D’Alessio , D. , Giliberti , C. , Benassi , M. and Strigari , L. Potential third-party radiation exposure from patients undergoing therapy with I-131 for thyroid cancer or metastases . 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TI - THE COMPARISON OF THE EXTERNAL DOSE RATE MEASUREMENT OF CHILDREN AND ADOLESCENT PATIENTS WITH ADULT PATIENTS TREATED WITH RADIOIODINE THERAPY
JO - Radiation Protection Dosimetry
DO - 10.1093/rpd/ncy195
DA - 2019-08-01
UR - https://www.deepdyve.com/lp/oxford-university-press/the-comparison-of-the-external-dose-rate-measurement-of-children-and-GQqSY5jSOc
SP - 168
VL - 184
IS - 2
DP - DeepDyve
ER -