Radiation Protection Considerations for Cancer Patients with End-stage Renal Disease Receiving 131 I Treatment

Abstract

Differentiated thyroid cancer (DTC) is commonly treated first with a partial or complete thyroidectomy, followed by radioiodine (RAI) ablative therapy to eliminate remaining cancer cells. In such treatments, physical decay and urinary excretion are the primary means of 131 I. As such, patients with impaired urinary ability clearance, such as patients with end-stage renal disease (ESRD) whose urinary ability is impaired by dysfunction, can retain abnormally high activities of RAI, posing a concern to both the patient and those with whom the patient interacts. Additionally, ESRD patients are commonly administered dialysis therapy, wherein their blood is externally cycled through a dialyzer (hemodialysis) or filtered by instilling a dialysate fluid into the peritoneum (peritoneal dialysis) to filter uremic toxins from their blood that accumulate due to kidney dysfunction. These factors make determining release and dosing for ESRD patients receiving RAI therapy dependent on a plurality of variables. An evaluation of the current patient release guidelines, as given in US Nuclear Regulatory Commission (US NRC) Regulatory Guide 8.39 Rev. 1 for ESRD patients receiving RAI, has yet to be addressed. In this study, a biokinetic model for 131 I in ESRD patients receiving dialysis has been developed, improving on traditional two-compartment models, reflective of kinetics from multi-compartment models with updated transfer coefficients modified to reflect the different physiological functions of compartments. This updated biokinetic model was integrated with Monte Carlo radiation transport calculations using stylized computational hermaphroditic phantoms to calculate dose rate coefficients in exposure scenarios and compared with those of the point source models of NRC Reg Guide 8.39 Rev. 1 (and the proposed verbiage in Rev. 2). Results demonstrated that the baseline models of Rev. 1 and Rev. 2 overestimated the effective dose rate to an exposed individual for the majority of time post-administration, where both models overestimated the total dose to the maximally exposed individual. However, the application of several patient-specific modifying factors to the Rev. 2 model resulted in an overestimation by only a factor of 1.25, and in general, the results produced with the patient-specific modifications provide improved convergence with the dose rate coefficients computed in this study for ESRD patients.