Operational Topic

New radiation safety measures were developed and implemented in order to

give a cancer patient an optimal treatment dose and to protect the hospital
personnel.

Radiation Safety Protocol for High

Dose 131I Therapy of Thyroid
Carcinoma in Patients on
Hemodialysis for Chronic Renal
Failure
Homayoun Modarresifar,* Samuel Almodovar,† William B. Bass,‡
and Buddhiwardhan Ojha†
Abstract: Iodine ablation therapy for thy- patient and the HD nurse, and HD monitor- renal disease (ESRD), many of
roid cancer on patients receiving dialysis ing by two alternating nurses to reduce their which require undergoing hemo-
poses unique radiation safety challenges. Ex- radiation exposure. Film badges were used to
measure radiation exposure to the nursing
dialysis (HD) as part of their man-
posure to gamma and beta negative particles
by the hemodialysis (HD) staff is a concern staff. Dosimetry calculations were obtained agement (Toubert et al. 2001).
that has not been well studied. A 53-y-old to determine radiation absorbed doses by the There were more than 100,00
male patient on HD for chronic renal failure optic lens, skin, and whole body. Quality new ESRD patients reported in
was scheduled for 131I high dose therapy as control verification for this shielding arrange-
ment proved to be effective in protecting the
the United States in 2002, and
treatment for thyroid papillary carcinoma.
The patient was on HD every other day, prior HD staff against gamma and beta negative recently this count has been ris-
to ablation. A high dose of 131I (3,607.5 MBq) radiation from recent 131I high dose therapy. ing by 2– 4% per year (Wolfe
was required. The patient was admitted for Implementation of this model proved to be an 2005). There is scientific evidence
131
I therapy, and continued HD. Thyroid can- effective and adequate radiation safety proto-
col for limiting radiation exposure to the HD
that supports an increased risk of
cer ablation therapy was administered ac-
cording to our institutional protocol. New staff. The patient was given 3607.5 MBq for thyroid cancer among patients
radiation safety measures were developed and optimal treatment after HD. Hemodialysis with ESRD (Maisonneuve et al.
implemented in order to give the patient an was repeated after approximately 48 and 1999). Papillary and follicular can-
optimal treatment dose, reduce radiation to 96 h to remove excess 131I and reduce ra-
diation to the patient. Health Phys.
cers, together, are termed differ-
the patient (critical organs and whole body),
and to protect the HD personnel. This in- 92(Supplement 1):S45–S49; 2007 entiated thyroid cancers (DTC),
cluded placing two lead shields between the Key words: operational topics; 131
I; radia- comprise the majority of thyroid
tion safety; shielding carcinomas, and with adequate
* Department of Radiation Oncology, University of
management have favorable
Alabama at Birmingham, 1824 6th Avenue South, prognosis. Once a diagnosis of
Spain Wallace Cancer Center, 1st Floor, Room INTRODUCTION DTC is made, the usual treat-
T-110, Birmingham, AL 35233; † Department of
Radiology, Division of Nuclear Medicine, University In recent years, there has been ment includes near-total or total
of Alabama at Birmingham, Birmingham, AL a significant increase in the num- thyroidectomy, followed by 131I
35233; ‡ Radiation Safety Program, University Of
Alabama at Birmingham, Birmingham, AL 35233. ber of patients with end stage ablation (Lupoli et al. 2005).
The usual dose of 131I adminis-
tered for treatment of DTC is usu-
Homayoun Modarresifar graduated from Isfahan University of Medical Sciences in Iran
ally greater than 1,110 MBq, and
in March 1991. Following mandatory army service and underserved area service, he can go up to 5,550 MBq (Magne
practiced as ER director and physician in his home town of Isfahan for a few years.
Homayoun decided to seek specialty training in the United States and entered residency
et al. 2002) depending on the risk
in 1999. After two years of radiology residency and two years of nuclear medicine factors and findings on the diag-
residency, he is currently working as an Instructor/Fellow in the Department of
Radiation Oncology at the University of Alabama at Birmingham. His email address is
nostic whole body scan. There
sepahan@myway.com. are only a few reports in the
Operational Radiation Safety S45

H. Modarresifar et al.
literature on 131I ablation therapy
of thyroid carcinoma in dialysis
patients, which is not a common
occurrence (Demko et al. 1998).
Since patients with renal failure
cannot undergo usual procedures
to minimize radiation, such as
drinking plenty of fluids and
emptying the urinary bladder
often, 131I ablation among this
population presents additional
radiation safety challenges. They
must undergo HD at an optimal
time, which for this patient was
determined to be at 45 h and 95 h
after oral administration of 131I.
131
I is readily hemodialized and is
present in blood as it passes
through the HD equipment. This
poses potential risks of radiation
exposure for the HD staff during
the HD procedure (Sinsakul and
Alit 2004; Jimenez et al. 2001).
One of the essential questions
that arises regarding the adminis-
tration of high dose 131I ablation
therapy in a patient receiving HD
is what special precautions
should be observed in order to
minimize the risk of radiation ex-
posure to the nurses and medical
personnel (Holst et al. 2005).
ESRD is very prevalent among
our patient population. Recently,
we received a request for a high
dose 131I ablation therapy for pap-
illary carcinoma of the thyroid
on a 53-y-old male patient with
ESRD on a fixed schedule of HD.
The planning and preparation
prior to this therapy required
unique modifications in order to
allow for the scheduled HD ses-
sions, following 131I administra-
tion. There are no definitive
guidelines for radioiodine abla-
tion therapy under these particu-
lar circumstances. We had a spe-
cial interest in providing the
quality of care required for defi-
nite thyroid cancer treatment,
while limiting the radiation ex-
posure to the nursing staff super-
vising the HD sessions. In this
paper we present a radiation
safety protocol implemented in
our institution for 131I therapy of
S46
thyroid cancer in patients with
ESRD undergoing HD. This
model proved to be an effective
and adequate radiation safety
protocol for limiting radiation
exposure to the HD staff.
METHODOLOGY
Methodology for the imple-
mented protocol followed the
guidelines established in the Uni-
versity of Alabama at Birmingham
(UAB) 2005 Radiation Safety Proce-
dures During Dialysis Manual, the
UAB Hospital 2006 Hazardous Ma-
terials and Waste Management
Plan, and the UAB Nuclear Medi-
cine Division Procedure Manual,
Revision 2/2006.
MATERIALS
● Geiger-Mueller counters, model
3 survey meter (Ludlum Mea-
surements, Inc., Sweetwater,
TX);
● Optical-stimulated lumines-
cence (OSL) dosimeter (Land-
auer, Inc., Glenview, IL) for x,
gamma, beta and neutron radi-
ation badges;
● Two lead shields (Radium
Chemical Co., Inc., New York,
NY), 5.0 cm thick, 56 cm high,
90 cm wide;
● N95 surgical mask (3M, St.
Paul, MN);
● Dura-fit shoe covers with skid
resistant sole (Cardinal Health,
Inc., Dublin, OH) and;
● Yellow gowns and hats (Cardi-
nal Health, Inc., Dublin, OH).
Hemodialysis equipment
HD Machines, with a Poluflux
Dialyser Filter and cartridge
blood set.
131
I physical and biological
properties
131
I emits beta negative parti-
cles and gamma radiation with a
half-life of 8.04 d. In our patient,
the first HD session is scheduled
at approximately 48 h after 131I
dose administration. There is not
131
High dose I therapy of thyroid carcinoma
much physical decay of radioac-
tive 131I during the first 48 h prior
to dialysis. After two days the
remaining activity is 84% of the
initial patient dose. Very little 131I
will be eliminated from the body
as solid waste.
Exposure at the time of dosing
at patient’s bedside was measured
as 1 mSv h⫺1. The dialysis takes
place over an approximate 4-h
period. During this period, the
amount of radioactivity in the
patient drops by a factor of 2.0 to
3.0, so that the residual activity
in the patient is less than 30% of
the initial dose (0.19 mSv h⫺1).
During HD, the radiation expo-
sure levels in the room should
not change significantly, as only
the location of the radioactivity
would change. No significant de-
cay will take place during the 4-h
period.
The technology enhanced re-
moval rate of iodine (the time
required for half of iodine to be
removed from an organ or sys-
tem) has been measured as 2.7 h
(162 min) using a typical dialysis
unit; this represents a removal
rate per minute of 0.43% (natural
Log of 2 divided by removal rate
in minutes) of the total blood
volume (5,000 mL) per minute
(21.4 mL min⫺1). Considering an
average 400 mL min⫺1 blood flow
through the filter, the fractional
clearance is 21.4 mL min⫺1 di-
vided by 400 mL min⫺1, which is
approximately 5.35% of the
blood flow through the HD ma-
chine. The glomerular filtration
rate (GFR) represents the ability
of the kidney to filter the waste
products—in this case mediated
by the HD filter. The higher the
GFR, the less 131I remains circulat-
ing in the patient’s plasma and
vice-versa. The amount of radia-
tion exposure from the patient’s
body is inversely proportional to
the GFR. Only the removable
parts of the HD equipment will
be in direct contact with 131I
present in blood. Adequate
disposal of these parts will be
February 2007
The Radiation Safety Journal
conducted following the radia-
tion safety measures that follow.
Radiation safety measures required
for hemodialysis after high dose 131I
therapy
The UAB 2005 Radiation Safety
Procedures During Dialysis was
used as guidelines. Personnel ra-
diation monitors must be worn
by dialysis nurses as well as other
nurses attending the patient.
Schematic presentation of room
preparation and shield place-
ments are presented on Fig. 1.
HD is conducted in a private,
shielded room. Two lead shields
are placed in the patient’s room,
one positioned adjacent to the
bed and one at a distance of ap-
proximately 2 m, behind which
the dialysis technician is located
most of the time while in the
room. A small sitting chair is
placed behind the 2 m distant
shield to keep the dialysis techni-
cian’s body in a position that
provides almost complete body
shielding. The patient uses the
bathroom prior to onset of the
Figure 1. Room diagram. A: Patient’s bedside (in front of and behind the shield 1); B: Foot
of the bed; C and D: Wall opposite to the patient’s bed at 1 m and 2 m from K; E: Patient’s
bathroom (measurements made 15 cm above the toilet); F: Outside the patient’s room,
behind the door in the hallway; G: Stairs; H: Neighboring room wall opposite to patient’s
bed; I: Bed in the next door room; K: Inside part of the door in patient’s room; RO Unit:
Pump that drains HD filtered elute into the toilet.
Operational Radiation Safety
dialysis procedure. However, dur-
ing dialysis the patient has to
remain in bed, as is routine for
HD. Placement of HD units
should be at bedside such that
the dialysis nurse may read the
monitor from behind the shield.
The 131I dose is given soon after
completion of a HD session and
after all room arrangements are
made. Unnecessary room furni-
ture should be removed. The
patient is not allowed to have
visitors other than required hos-
pital personnel. The HD unit
should be placed in the room,
and the tread of the wheels of HD
unit should be covered with a
protective layer of tape (i.e.,
masking tape). The nearest dis-
tance from the patient’s midline
that the technicians operate
should be kept at 1 m. A bedside
lead shield shadowing the ab-
dominal area of the dialysis
worker is required to reduce the
total effective equivalent dose to
the whole body by decreasing the
dose to the more radiation sensi-
tive organs and to a possible em-
Vol. 92, suppl 1 February 2007
bryonic/fetal entity. Nurses work-
ing in proximity of the patient
should spend no more than 15 min.
For our patient, the radiation
absorbed dose at a 30 cm distance
is 2.37 mGy h⫺1, immediately af-
ter the patient is dosed. At a dis-
tance of 1 m, the radiation ab-
sorbed dose is 0.26 mGy h⫺1. The
radiation absorbed dose at 1 m
for a 15-min period represents an
exposure equivalent to 0.07 mSv.
The use of the lead shield will
reduce the effective whole body
dose to approximately 0.03 mSv
during the 15-min period. As the
dialysis progresses, the dialysis
filter will be collecting radioio-
dine activity with the radiation
levels from it increasing gradu-
ally. Personnel must treat this
part of the unit as they treat the
patient and keep a safe distance
from the unit for the duration of
treatment. The hose for the dis-
posal of the effluent urine waste
should be placed in the patient’s
bathroom toilet to dispose through
the sanitary sewerage. The health
physicist on call should make read-
ings at 15 cm above the toilet in
the patient’s bathroom at 1, 2, 3,
and 4 h following initiation of di-
alysis to monitor the radioiodine
removal rate (since the draining
hose from the HD machine is emp-
tied into the toilet). The toilet
should be flushed immediately fol-
lowing each survey reading.
Dialysis technicians may go
through their usual routine, but
must try to remain at least 2 m
from the patient for the majority
of their time in the room and
must stay behind the lead shield.
As determined on our initial mea-
surement calculations, the expo-
sure rate at this distance is 0.07
mGy h⫺1 (without the shield) for
a 3,700 MBq dose. The local pro-
tection provided by the lead
shield is greater (much more than
50%) than without the shield.
The health physicist should
measure radiation from the pa-
tient at 1 m, just prior to dialysis.
Additional measurements should
S47

H. Modarresifar et al.
Table 1. Radiation equivalent doses to HD nurse 1 and 2 during patient
admission.
HD staff Deep tissues
HD nurse 1 0.06 (mSv)
HD nurse 2 0.01 (mSv)
Table 2. HD treatment post radioactive iodine therapy. Survey for exposure
rates on Day 1 and Day 2 post-therapy, at different intervals:
(mGy h⫺1) at 1
m from patient Date and time
(D) location of survey
0.13 Day 1, 9:30 h
0.08 Day 1, 11:30 h
0.07 Day 1, 12:30 h
0.062 Day 1, 14:30 h
0.038 Day 2, 11:50 h
0.018 Day 2, 14:50 h
0.018 Day 2, 16:05 h
be made at the patient’s bedside,
where the nurse will work, 2 m
from the patient’s midline. The
health physicist on call will also
survey the patient upon comple-
tion of dialysis. The patient will
be raised to a sitting position and
a measurement is taken at a
distance of 1 m. Comparison of
measurements must be made
with the original survey. The pa-
tient may be discharged if the
radiation absorbed dose is 0.05
mGy h⫺1 or less or the radioactiv-
ity is determined to be less than
1,110 MBq. At discharge, after
successful completion of the
scheduled in-house HD sessions
(96 h after dosing), the patient
must follow the regular post 131I
therapy precautions and be com-
pliant with the HD schedule.
From a radiation safety stand-
point, no additional instructions
are necessary. The health physi-
cist on call should survey the di-
alysis filter and associated HD
tubing for radioactivity and keep
record of radiation levels being
emitted. The health physicist on
call will call and/or page the Haz-
ardous Materials Facility (HMF)
to respond for room/dialysis
equipment release. If there is a
problem due to leak or malfunc-
S48
131
High dose I therapy of thyroid carcinoma
personnel was determined. Fol-
lowing the previously described
Shallow tissues Eye UAB Radiation Safety Guidelines,
the total exposure to each of the
0.07 (mSv) 0.06 (mSv)
0.02 (mSv) 0.01 (mSv) two nurses assigned to attend the
HD sessions was measured after
the completion of the second day
of HD. Indices of exposure to
deep tissues, shallow tissues, and
the eyes were calculated. For
(mGy h⫺1) at shield 1 (mGy h⫺1) at shield 2 nurse 1, the equivalent dose to
(A) locations at both 1 m away from either
sides of the shield 1 sides of the shield 2
deep tissue was 0.06 mSv, to shal-
low tissue was 0.07 mSv, and to
Beside HD unit: 0.008 Beside chair: 0.003
At the bedside: 0.25 Beside HD: 0.01
the eyes was 0.06 mSv. Nurse 2
Beside HD unit: 0.006 Beside HD: 0.001 values were deep tissues 0.01
Beside HD: 0.005 Beside HD: 0.001 mSv, shallow tissues 0.02 mSv,
Beside HD: 0.003 Beside HD: 0.0005
Beside HD: 0.008 Beside HD: 0.001
and the eyes 0.01 mSv (Table 1).
At the bedside: 0.1 Beside chair: 0.01 Measurements of radiation ex-
Beside HD: 0.002 Beside HD: 0.001 posure were obtained following
Beside HD: 0.001 Beside HD: 0.0005
the UAB Radiation Safety Proce-
dure Manual. At the end of the
day of 131I high dose therapy ad-
tion of the HD machine the RSO ministration, it was determined
must be notified. to be 1,517 MBq at 1 m from the
The HD filter and disposable patient.
tubing are to be picked up by the The exposure survey shows that
HMF personnel and placed in a shielding has significantly de-
freezer at that facility until it de- creased the exposure in the room
cays to background levels. No to the nurses and medical person-
other HD equipment compo- nel. On the day of the first session
nents are in direct contact with of HD, the radiation exposure at
the radioactive iodine in the pa- 1 m from the patient, behind and
tient’s extra-cellular fluid. The in front of shield 1 and shield 2,
HD filter and disposable tubing was measured at 9:30, 11:30,
should be rinsed and bagged by 12:30, and 14:30 hours. The trend
the HD nurse. Final surveys are of the exposure associated with the
conducted by the health physi- timing showed a declining mea-
cist on call. The HD machine sure of exposure behind shields 1
should not be taken from the and 2. Results of these measure-
patient room until the patient is ments are presented in Table 2.
discharged and the machine is Inter-dialysis measurements
released by the health physicist were obtained on the day between
on call. The HMF personnel will the two HD sessions. Radiation
retrieve the filter and tubing that safety survey was performed on 8/
is bagged and take it to HMF 5/05 at 15:45. Results are shown in
freezers for decay until release at Table 3.
background levels. The total time of the first HD
session was 4 h, during which the
nurses were exposed intermit-
DISCUSSION AND tently, due to alternating shifts.
RESULTS The exposure measurement de-
During the 6-d hospitalization termined behind shield 2 was
of the ESRD patient on HD, who 0.002 mGy h⫺1.
was treated with 3,607.5 MBq of On the day of the second ses-
131
I for thyroid cancer on 8/2/ sion of HD, the radiation expo-
2005 at 12:25 p.m., the radiation sure at 1 m from the patient,
exposure to nurses and medical behind (beside HD unit closer to
February 2007
The Radiation Safety Journal
Table 3. Inter-dialysis survey for exposure rates at different points in the room, as identified on the room diagram. H
and I were not measured because the room was occupied (another patient dosed) at the inter-dialysis survey time
period. For E see methodology.
(mGy h⫺1)
1 m away (mGy h⫺1) (mGy h⫺1)
from A beside B at the
the patient the bed foot of the bed
0.045 0.14 0.05
the shield 1) and in front of
shield 1, was measured. Exposure
in front of shield 2 (beside HD
unit at the side closer to the
shield 2) and behind shield 2 (be-
side the nurse’s chair) was mea-
sured at 11:50, 14:50, and 16:05
hours. Once again, the trend of
the exposure associated with the
timing showed a declining mea-
sure of exposure behind shields 1
and 2. Results of these measure-
ments are presented in Table 2.
CONCLUSION
Our data suggest that ESRD pa-
tients undergoing HD benefit
from admission to the hospital
during high dose thyroid abla-
tion therapy because their HD
schedule would be followed as
required. On the other hand, the
risk of unnecessary radiation ex-
posure to the nurses/personnel
can be minimized by careful fol-
low up of a comprehensive radi-
ation safety protocol, including a
well-designed room, shield place-
ment, and careful monitoring of
the nurses in the patient’s room
during therapy. Adequate han-
Operational Radiation Safety
(mGy h⫺1) at (mGy h⫺1)
C (patient) D (patient)
1 m away from 2 m away from
point K (physicist) point K (physicist)
0.045 0.015
dling of the HD machine and
disposable parts and timing of
the HD relative to the administra-
tion of the adjusted radioactive
131
I dose are important factors in
limiting unnecessary radiation
exposure to the nursing and para-
medical personnel. The radiation
quantification data from this study
proves that our protocol efficiently
limits the radiation exposure to
the nurses and keeps it within the
acceptable limits for medical per-
sonnel. The detailed procedure
guidelines implemented in this
protocol and room preparation
can be used as a basic guideline for
other medical facilities where high
dose 131I protocols for thyroid can-
cer treatment in ESRD patients un-
dergoing HD are in the process of
being instituted.
Acknowledgment: The authors would like to thank Hong-
Gang Liu, Department of Radiology/Division of Nuclear
Medicine, University of Alabama at Birmingham.
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