RESEARCH PROPOSAL FOR SUB-TASK IN NUCLEAR WEAPONS EFFECTS RESEARCH Item 1. Weapons Effects Board Number and Title. WEB No. 03. 009 Item 2. DASA CMAS Code.A 3c Item 3. Directing Agency. Defense Atomic Support Agency Item 4. Contractor. Department of Radiology, University of Cincinnati, College of Medicine Item 5. Contract Number. DA-49-146-XZ-029 Item 6. Estimated Funding (Thousands $) 62 35 FY 63 40 FY 64 45 FY 65 45 FY 66 50 Item 7. Estimated Completion Date.1967 Item 8. Justification. In handling individuals or large groups of people exposed to nuclear radiations in high doses, it is necessary to know much more concerning their metabolic changes. At present the chance of survival at dose level above 600 rad appears to be minimal. By means of detailed studies of changes at levels of 50-200r it may be possible to find metabolic changes which will help prolong survival at higher dose ranges. The biochemical and immunological changes within the human during the first several weeks post exposure have received little attention. The only estimates of dose radiation received are at present provided by personnel dosimeters, film badges and serial blood counts. The dosimeters may not be available or of the correct range. The film badges require special and difficult laboratory processing. Blood counts are sometimes difficult to do especially for masses of people. Little is known of nutritional requirements of exposed individuals. The studies being carried out seek to find new biochemical and immunological tests to evaluate damage. The detailed clinical studies will provide new data useful in the prognosis and therapy of such individuals. University of Cincinnati College of Medicine Mailing Address Radioisotope Laboratory Cincinnati General Hospital Cincinnati 29, Ohio (2) May 8, 1961 Project No. GB-029 Item 9. Brief Proposal and Objective A. Brief: The problem is that of obtaining detailed data of the clinical and laboratory findings in humans who have received total body radiation therapy in order to obtain new diagnostic tests and to obtain information to aid in their management. B. Approach These studies are designed to obtain new information about the metabolic effects of total body and partial body irradiation so as to have a better understanding of the acute and subacute effects of irradiation in the human. The initial studies are pointed toward the elucidation of biological indicators of radiation effects in humans. The major parameters being investigated at present are urinary amino-aciduria and alterations in immunological patterns. Certain other parameters such as creatine and creatinine excretion and hematological effects are also being followed. The long term program envisions carrying out the various observations at dose levels of 100 rad and gradually increasing the dose to 150, 200, 250 and 300 rad. Eventually doses up to 600 rad are anticipated. Also comparison of effects of radiomimetic drugs with total body radiation will be studied. Comparison of effects of total vs. partial body radiation will be studied. Selection of Patients. Patients must he in relatively good nutritional status, i.e., able to maintain their body weight. Women with an active menstrual cycle are usually not utilized because of variations in aminoaciduria with menstruation. The patients usually have normal hematological values. During the first year only patients with metastatic malignancy were selected. It now appears feasible to include cancer patients who do not necessarily have distant metastases. Technique of Study. For an individual entering the study, his program is divided into two phases: A pre-irradiation (control) period of about 2 weeks and a post irradiation period of 4 - 5 weeks. The pre-irradiation period allows for the most part at least six determinations of each test to be done. These observations are listed in Table I. University of Cincinnati College of Medicine Mailing Address Radioisotope Laboratory Cincinnati General Hospital Cincinnati 29, Ohio (3) May 8, 1961 Project No. GB-029 Item 9. Approach(Technique of study - continued) Table I PRE AND POST IRRADIATION OBSERVATIONS 1. Complete history and physical examination 2. Temperature, pulse, respiration 3. Body weight 4. Urine a) Volume b) Routine urinalysis c) Creatine and creatinine d) Chromatography for amino acids 5. Hematology - Hg; RBC; WBC; Differential; Hematocrit; Platelets; Reticulocytes; Erythrocyte sedimentation rate 6. Fluid intake 7. Medications - Fluids, Antibiotics; Steroids; Narcotics 8. UNREADABLE TEXT 9. Blood total proteins; urea nitrogen; sodium potassium; chlorides; CO2; creatinine All data is reviewed by the medical group prior to irradiation to be certain that the values are within normal limits and that there are no glaring technical errors. Several sham irradiations are given to permit accurate dosimetry. The patient is told that he is to receive treatment to help his sickness. There is no discussion of subjective reactions resulting from the treatment. Other physicians, nurses and ward personnel are instructed not to discuss these aspects with the patient. The patient is then given total bode irradiation. All of the tests are then performed on the following days after exposure: l, 2, 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33 and 36. It would be desirable to have each patient on a metabolic ward but at present this facility is only in the planning phase. When it becomes operative, one bed will be allotted for this program. Meanwhile through the cooperation of the Department of Psychiatry a bed has been made available on the Psychosomatic Ward of the hospital. In addition to the studies described above, the patient is given a careful psychiatric evaluation and more individual attention than is possible on the Tumor Ward. The environment is far more attractive and there are no other patients receiving radiation therapy with whom the patient can exchange experience. Thus the emotional and psychometric response of the patient can be better evaluated in this milieu. University of Cincinnati College of Medicine Mailing Address Radioisotope Laboratory Cincinnati General Hospital Cincinnati 29, Ohio (4) May 8, 1961 Project No. GB-02 Item 9.B. Approach (continued) Analysis of data The design of the study at present is such that the patient serves as his own control. Since the radio sensitivity of the underlying neoplasm is either known or determinable, it will also be possible to make comparison of patients with radio resistant or radiosensitive tumors. The collection of data follows with some modifications the plan described (J Occup. Med. 1:420-447, 1959) and described in tables VI and VII of Saenger's paper (Am. J Roentgenol, Rad. Therapy and Nuc. Med. 84:715-728, 1960) All data are recorded on score sheets (5 at present) for transfer to IBM cards in the usual way. It thus will be possible to perform any type of analysis either in our laboratory or elsewhere. These sheets can be readily adapted to other similar studies to facilitate comparison of raw data between institutions. The major difficulties to be overcome are as follows: The appropriate immunological techniques are not well understood. At present we utilize the standard paper electrophoresis of blood proteins which is insensitive. Initial studies with immuno-electrophoresis using polyvalent anti-human sera from the goat and horse provided patterns whose interpretation was too complex to be useful. This aspect of the work is being reoriented towards the use of univalent sera. Techniques for identification of breakdown products of DNA by paper chromatography are just being developed and will be improved over the next several years. C. Related Sub-Tasks The projects of Drs. James Nickson at Memorial Hospital, New York; Dr. Vincent Collins at Baylor University, Houston, Texas; and of the group at the Naval Medical Center, Bethesda, Maryland, are investigating other aspects from somewhat similar view points. There is close cooperation between out laboratory and that of Dr. A. Luzzio at the Army Medical Research Laboratory in Ft. Knox, Ky. Dr. Luzzio is working on the development of complement fixation tests as an immunological technique utilizing in part blood from patients irradiated by us. May 8, 1961 Project No. GB University of Cincinnati College of Medicine (5) Mailing Address Radioisotope Laboratory Cincinnati General Hospital Cincinnati 29, Ohio Item 9. D. Other information. The project is supported by a team composed of qualified investigators from several departments of the University of Cincinnati College of Medicine. The project director is E.L. Saenger, M.D. , Associate Clinical Professor of Radiology and Director of the Radioisotope Laboratory. All physical aspects of the study such as dosimetry and supervision of certain laboratory studies is under the direction of J. G. Kereiakes, Ph.D., Assistant Professor of Radiology and Director of Physics, Department of Radiology. Total body therapy and the partial body irradiation is directed by H. Perry, M.D., Assistant Professor of Radiology assisted by H. Horwitz, M.D., Assistant Professor of Radiology. Drs. Perry and Horwitz are also concerned with clinical care of the patient. The selection of patients, their workup, clinical care and supervision many of the laboratory studies is under the direction of B.I. Friedman, M.D. Assistant Clinical Professor of Medicine and T. Wright, M.D. Instructor in Medicine. Aminoaciduria and some preliminary studies of purine and pyrimidine metabolism are carried out by H. Barry, M.S., Research Associate in Pediatrics and G. Guest, M.D., Research Professor of Pediatrics. The design of the study and analysis of data is directed by T. Sterling Ph.D., Assistant Professor of Preventive Medicine. Certain aspects of patient care and preliminary studies of some psychometric tests administered before and after irradiation are directed by D. Ro M.D., Associate Professor of Psychiatry and S. Kaplan, M.D., Assistant Professor of Psychiatry. This study is therefore a cooperative one of the Departments of Radiology Internal Medicine, Pediatrics, Psychiatry and Preventive Medicine. A new metabolic ward will be built within the next several years. At this time these study patients will be assigned to that ward. E. Background History and Progress. (1) The background of this project is presented as follows: Several have described changes in nitrogen metabolism following irradiation. All have shown increase in nitrogen excretion following total body irradiation to various laboratory animals. Mefford and Martens have studied aminoaciduria by paper chromatography in rats. Katz and Hasterlik, and Hempelmann, Lisco and Hoffman have studied aminoaciduria following radiation in humans by means paper chromatography. Hempelmann, et al, found aminoaciduria in 3 of the 9 cases. University of Cincinnati College of Medicine Mailing Address Radioisotope Laboratory Cincinnati General Hospital Cincinnati 29, Ohio (6) May 8, 1961Project No. GB- Item 9. E. Background History and Progress. (l continued) Katz and Hasterlilt reported increases of as high as ten times normal values of total daily amino acid excretion in 4 patients. Quantities of individual amino acids excreted varied from 2 - 20 times normal values. Abnormal values were found as early as 12 hours following exposure, and increased levels persisted for as long as 5 months. No direct quantitative relation to radiation could be established. These findings suggest that aminoaciduria may serve as an indicator the biological response of humans to irradiation. The reports of amino acid in humans have described the findings in individuals exposed in reactor accidents and no control measurements were possible. Studies of 5 patients exposed the Y-l2 accident at Oak Ridge in June 1958 showed elevated excretion of bet aminoisobutyric acid with levels related to the total dose received by the individual. (2) The project was initiated as of February 1, 1960 and only the first year of work has been completed. In that time six patients have been studied thoroughly and the annual report is being compiled at present. It is too early to define progress in terms of the final goals of the proposal but the investigative program for each patient is functioning quite smoothly and results of the first year will be submitted in approximately two months. F. Future Plans. During the next two years patients will be studied as outlined above. As the various tests are evaluated, certain non-contributory ones will be dropped. Over a five year period plans include the development of the following aspects: 1. Studies of nucleic acid metabolism before and after irradiation utilizing appropriately tagged intermediate metabolites (using C-14 or H-3). 2. Intensification of newer immunological techniques. 3. Chromosome studies of white blood cells. 4. Newer tests of clotting mechanisms. The entire program will be accelerated by the rebuilding of the General Hospital for which $17. 5 million have been voted. Our laboratory facilities capabilities will be greatly expanded. G. References. Additional information may be obtained from Dr. Eugene L. Saenger, Radioisotope Laboratory, Cincinnati General Hospital, Cincinnati 29. Ohio Preparing Institution: University of Cincinnati College of Medicine Cincinnati General Hospital Cincinnati, Ohio 45229 Principal Investigator: Eugene L. Saenger, M.D. Title of Project: Metabolic Changes in Humans Following Total Body Irradiation Report Period: February, 1960 through October, 1961 Contract No.: DA-49-146-XZ-029 Supported by: Defense Atomic Support Agency Washington 25, DC TABLE OF CONTENTS ORGANIZATION 1. Aims of the Project 1 2. Organization 1 3. Selection of Patients 3 4. Technique of Study 3 5. Analysis of Data 4 DOSIMETRY l. Cobalt-60 13 2. X-Ray 15 CLINICAL OBSERVATIONS l. Symptoms 20 2. Profile Scoring 20 3. Case Histories 27 STUDIES OF Aminoaciduria l. Procedure 47 2. BAIBA 48 3. Conclusions 48 CREATINE/CREATININE EXCRETIONS 55 SERUM ELECTROPHORESIS 57 IMMUNOLOGY l. Immunoelectrictrophoresis 58 2. Quantitative Precipitin Test 58 SUMMARY 60 Page Table 1 Pre and Post Irradiation Observations 6 Table II Instructions for Recording of Symptoms Following Irradiation 7 Table III Patient Dosimetry (Colbalt 60) 18 Table IV Dosimeter Measurements 19 Table V Profile Values Assigned for Various Ranges of Abnormality 22 Table VI Partition of Profile Scores Based on "Net Erythrocyte" Score 23 Table VII Partition of Profile Scores Based on Hematocrit versus Red Cell Count 24 Table VIIISample Profile Score Sheet 25 FIGURES Figure 1 Dosimeter Measurements in a Masonite Phantom 16 Figure 2 Relative Depth Dose for Lateral Exposures 17 Figure 3 Urinary Excretion of Beta Amino Isobutyric Acid Before and After Total Body Radiation. #007 and 008 50 Figure 4 Urinary Excretion of Beta Amino Isobutyric Acid Before and After Total Body Radiation. #010 and 011 51 Figure 5 Urinary Excretion of Beta Amino Isobutyric Acid Before and After Total Body Radiation. #013 and 015 52 Figure 6 Urinary Excretion of Beta Amino Isobutyric Acid Before and After NH2. #016 53 Figure 7 Urinary Excretion of Beta Amino Isobutyric Acid Before and After Total Body Radiation. #017 54 ORGANIZATION 1. Aims of the Project: These studies are designed to obtain new information about the metabolic effects of total body and partial body irradiation so as to have a better understanding of the acute and subacute effects of irradiation in the human. The initial studies are pointed toward the elucidation of biological indicators of radiation effects in humans. The major parameters being investigated at present are urinary amino aciduria and alterations in immunological patterns. Certain other parameters such as creatine and creatinine excretion and hematological effects are also being followed. The long-term program envisions carrying out the various observations at dose levels of 100 rad and gradually increasing the dose to 150, 200, 250 and 300 rad. Eventually doses up to 600 rad are anticipated. Also comparison of effects of radiomimetic drugs with total body radiation will be studied. 2. Organization: The project is supported by a team composed of qualified investigators from several departments of the University of Cincinnati College of Medicine. The project director is E. L. Saenger, M. D., Associate Clinical Professor of Radiology and Director of the Radioisotope Laboratory. 2. All physical aspects of the study such as dosimetry and supervision of certain laboratory studies are under the direction of J. G. Kereiakes, Ph.D., Assistant Professor of Radiology and Director of Physics, Department of Radiology. Total body therapy and the partial body irradiation is directed by H. Perry, M. D. Assistant Professor of Radiology, assisted by H. Horowitz, M.D. Assistant Professor of Radiology. Drs. Perry and Horowitz are also concerned with clinical care of the patient. The selection of patients, their workup, and the clinical care and supervision of many of the laboratory studies is under the direction of B.L.Friedman, M.D., Assistant Clinical Professor of Medicine, and T, Wright, M.D., Instructor in Medicine. Aminoaciduria and some preliminary studies of purine and pyrimidine metabolism are carried out by H. Berry, M.S., Research Associate in Pediatrics and G. Guest, M.D., Research Professor of Pediatrics. Since July, 1961, Dr. Clark West, M.D, Associate Professor of Pediatrics, directs the immunological studies. The design of the study and analysis of data is directed by T. Sterling. Ph.D., Associate Professor of Preventive Medicine. Certain aspects of patient care and preliminary studies of some psychometric tests administered before and after irradiation are directed by D. Ross, M.D. Associate Professor of Psychiatry, and S. Kaplan, M.D., Assistant Professor of Psychiatry. This study is therefore a cooperative one of the Departments 3. of Radiology, Internal Medicine, Pediatrics, Psychiatry and Preventive Medicine. Immunological Studies utilizing a quantitative precipitin test are carried out by Dr. A. Luzzio of the, Army Medical Research Laboratory, Fort Knox, Kentucky. 3. Selection of Patients: Only Patients with proven metastatic or far advanced cancer are selected. They must be in relatively good nutritional status, i.e. able to maintain their body weight. Women with an active menstrual cycle are usually not utilized because of variations in aminoaciduria with menstruation. The patients usually have normal hematological values. 4. Technique of Study: When an individual enters the study, his program is divided into two phases: a pre-irradiation (control) period of about 2 weeks and a post-irradiation period of 4-5 weeks. The pre-irradiation period allows, for the most part, at least six observations of each test to be done. Those observations are listed in Table I. All data are reviewed by the medical group prior to irradiation to be certain that the contribution of underlying disease can be evaluated. Several sham irradiations are given to permit accurate dosimetry The patient is told that he is to receive treatment to help his sickness. There is no discussion of subjective reactions resulting from the treatment. Other physicians,nurses and 4. ward personnel are instructed not to discuss these aspects with the patient with the patient. The patient is then given total body irradiation. All of the tests are then performed on the following days after exposure: l, 2, 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33 and 36. It would be desirable to have each patient on a metabolic ward, but at present this facility is only in the planning phase. When it becomes operative, one bed will be allotted for this program. Meanwhile, through the cooperation of the Department of Psychiatry, a bed has been made available on the Psychosomatic Ward of the hospital. In addition to the studies described above, the patient is given a careful psychiatric evaluation and more individual attention than is possible on the Tumor Ward. The environment is far more attractive and there are no other patients receiving radiation therapy with whom the patient can exchange experiences. Thus the emotional and psychometric response of the patient can be better evaluated in this milieu. Table II is the form on which clinical symptoms are recorded following exposure. 5. Analysis of Data The design of the study at present is such that the patient serves as his own control. Since the radiosensitivity of the underlying neoplasm is either known or determinable, it will also be possible to make comparison of patients with radioresistant vs. radiosensitive tumors. The collection of data follows with some modifications the plan described by Thomas and Wald (J. Occup. Med. 1:420-447, 1959) and 5. described in Tables VI and VII of Saenger's paper (Am. J. Roentgenol., Rad. Therapy and Nuc. Med. 84:715-7828, 1960) All data recorded are on score sheets (5 at present) for transfer to IBM cards in the usual way. Copies of these sheets are included. It thus will be possible to perform any type of data analysis either in our laboratory or elsewhere. These sheets can be readily adapted to other similar studies to facilitate comparison of raw data between institutions. 6. TABLE 1 PRE AND POST IRRADIATION OBSERVATIONS 1. Complete history and physical examination 2. Temperature, pulse, respiration 3. Body weight 4. Urine a) Volume b) Routine urinalysis c) Creatine and creatinine a) Chromatography for amino acids 5. Hematology - Hg; RBC; WBC; Differential; Hematocrit; Platelets; Reticulocytes; Erythrocyte sedimentation rate. 6. Fluid intake 7. Medications - Fluids; Antibiotics; Steroids; Narcotics 8. Blood (UNREADABLE TEXT) ... quantitative precipitin tests 9. Blood total proteins; urea nitrogen; sodium potassium; chlorides; CO2; creatinine. 7. TABLE II INSTRUCTIONS FOR RECORDING OF SYMPTOMS FOLLOWING IRRADIATION DEPARTMENT OF RADIOLOGY GENERAL HOSPITAL Date:_________________ PATIENT_______________________ NO.______ WARD_____ TIME OF THERAPY__________ This patient has just received total body radiation for therapeutic purposes. It is possible that the symptoms listed below may develop within the next several days. Please note carefully the time at which these symptoms develop and note their duration and severity. DO NOT ASK THE PATIENT WHETHER HE HAS THESE SYMPTOMS Time of Onset Duration Severity Date Hr. Anorexia Nausea Vomiting Abdominal Pain Diarrhea Weakness Prostration Mental Confusion E.L. Saenger, M.D, line 207 H. Perry, M. D., line 200 8 Daily - Card No. 1 FOR REFERENCE SEE (2bb02) GRAPHIC 9 Daily - Card No. 2 FOR REFERENCE SEE (2bb03) GRAPHIC 10 Daily - Card No. 3 FOR REFERENCE SEE (2bb04) GRAPHIC 11 Daily - Card No. 4 FOR REFERENCE SEE (2bb05) GRAPHIC 12 Microscopic - Blood and Urine - Card No. 5 FOR REFERENCE SEE (2bb06) GRAPHIC 13. DOSIMETRY Eleven patients have been exposed to total body irradiation. Ten of these patients received Cobalt-60 gamma radiation and one received 100 kvp x-radiation. 1. Cobalt-60 The radiation was delivered by a Cobalt-60 Teletherapy Unit under the following exposure conditions. The radiation beam was directed horizontally at a wall 338 cm. away with the patient midline at 282 cm. from the source. The beam area for the 50 percent isodose curve at the patient midline distance is a square approximately 67 cm. by 67 cm. The patient was placed in a sitting position with legs raised and head tilted slightly forward. The irradiation was given by delivering half the specified exposure laterally through one side of the patient. The patient is then turned over and the other half exposure delivered laterally through the other side. The variation of air dose with distance from the source was determined with a Victoreen 25 r chamber. The results indicated no departure from the inverse square law relationship for distances used in the study. Therefore, no correction was required for a possible dose contribution to the patient due to backscatter from the wall. Preliminary measurements were made in a masonite phantom using dosimeters placed on lateral surfaces and at the midline of the 14. head, trunk and knee portions of the phantom. These results are shown in Figure 1. It is seen that if the midline doses to the trunk, head and knees compared, the maximum variation in these doses is about 16 percent. The exposure to the patient was determined as follows. The percentage depth dose at different depths for a 400 cm2 field area and a source-skin distance of 80 cm is given by Johns (1). The depth dose at the greater source-skin distances used for patients was found by multiplying the depth doses at 80 cm by the "F" factor postulated by Maynoerd and Laberton (2) F = (Dd)f2 _ f2 f1+d 2 (Dd)f1 f1 f2+d where f1 and f2 are source-skin distances and d is the depth. By using the corrected depth dose at the patient midline (one-half lateral dimension of the trunk) and a conversion factor of 0.97 rads per roentgen for Cobalt gamma radiation, the surface dose and midline air dose required to give a desired midline absorbed dose in rads was calculated. The results of these calculations are given in table III. A direct comparison of the calculated and measured (phantom) doses was made for one patient who had the same lateral trunk dimensions as the phantom. The relative depth dose for each lateral exposure to this patient is given in figure 2. The doses indicated 15. by crosses are measurements made in the phantom and compare quite well with the calculated doses. The combined dose of the two radiation fields is also given in this figure and shows a good homogenous dose distribution through this patient. The maximum variation level in lateral dose distribution was + 13 percent for one patient having a lateral trunk dimension of 36 cm. As an experimental check of the radiation exposure conditions, dosimeters were placed on lateral sides of the trunk, head, and knees of the patients during the exposure. The dosimeter readings at these positions are given in Table IV, and compared well. 2. X-Ray The following exposure conditions were used: A General Electric unit operated at 100 kvp, .146 mm Al added filter, half-value layer of .13 mm Al, target-surface distance of 117.5 cm, and a surface dose rate of 16 r/min. The patient (#014) received 975 r in 3 weeks (given to each of 3 anterior and 3 posterior fields). The only areas spared this treatment were the upper one-half of the head front and back and the soles of the feet. With a surface area of 9500 cm2 and a tissue half-value layer of 3.7 mm (measured in a masonite phantom), an integral dose of 0. 5 megagram .r was calculated for this patient. (1) Johns, H.E., "X-Rays and Teleisotope Gamma-rays," Radiation Dosimetry. Edited by G.J. Hine and E.L. Brownell. Academic Press Inc., New York, p. 562. (2) Mayneord, W.V. and L.F. Lamerton. Brit. J. Radiol. 14:255,1941. 16. Figure 1 Decameter Measurements in a Masonite Phantom FOR REFERENCE SEE (2bb07) GRAPHIC 17. Figure 2 Relative Depth Dose (solid lines indicate calculated and crosses indicate doses measured in a masonite phantom) For Lateral Exposure FOR REFERENCE SEE (2bb08) GRAPHIC 18. TABLE III PATIENT DOSIMETRY (COBALT 60) Trunk Lateral Trunk Midline Trunk Midline Dimension Air Dose Tissue Dose Patient cm r rad 004 26 100 66 006 35 100 54 007 31 167 100 008 36 185 100 009(l) 29 50 32 010 28 157 100 011 32 170 100 013(2) 32 255 150 015 30.5 165 100 017 25.5 49 100 (1) patient received two doses (16 rad each) (2) patient received three doses (50 rad each) 19. TABLE IV DOSIMETER MEASUREMENTS Calculated Calculated Patient Trunk Head Trunk Trunk Trunk Trunk Lateral Lateral Lateral Midline Midline Surface Beam (1) Wall(1) Dimen- Dimen- Tissue Air Dose(1) sion sion Dose Dose cm cm rad r r r r 004 26 13 66 100 80 76 76 006 35 15 54 100 72 73 73 007 31 14 100 167 108 103 - 008 36 15 100 185 120 126 126 009 29 - 32 50 34 - - 010 28 15 100 157 105 109 104 011 32 15.5 100 170 111 115 108 013 32 15 150 255 166 169 168 015 30.5 14 100 165 109 115 108 017 25.5 15 100 149 101 109 106 ______________ TABLE IV CONTINUED: Head Lateral Left Beam(1) Wall(1) Knee Lateral Beam (1) r r r 69 68 77 87 84 78 117 - - 142 124 114 - - - 112 108 120 107 104 118 57 53 176 121 115 113 85 81 97 20. CLINICAL OBSERVATIONS 1. Symptoms: Seventeen patients have been studied. Cases 1, 2, 3, and 5 received partial body irradiation and are not included in this report. Case #12 was deemed unsatisfactory for total body radiation and was taken off study before therapy. Of the patients treated, only those receiving 100 rad manifested symptoms. Nausea and vomiting for one day occurred in four patients. Mild gastroenteric discomfort persisted in two patients for 4-6 days. The patient who received nitrogen mustard had nausea, vomiting and anorexia for five days. 2. Profile Scoring: One would like to assess the effects of total body radiation on normal individuals. Our patients of course all have incurable and/or metastatic cancer and although in reasonably good clinical condition, cannot be considered as normal. In examining the hematological changes, we elected to use the profile scoring method of Wald and Thoma (ORNL, 2748 Part B), This method provides a way of assigning rank scores for deviations from normality of certain blood values (Table V) and running them to yield test scores which can be related to clinical degrees of injury. In performing these calculations 21. it became immediately obvious that most of our patients had positive scores prior to total body radiation. We assumed that these scores were due to the neoplastic process and related complications. We further assumed that for a relatively short time, i.e., 4-6 weeks, the daily contribution to the profile score would be constant. Thus a mean disease score calculated from pre-treatment values was subtracted from the daily post treatment score. In this way, it has been possible to partition the effect of cancer from that of the irradiation. The effects of these calculations for several of these patients is shown in Table VI. In addition the significant differences between "erythrocyte" score consists of the sum of the scores derived from hemoglobin, hematocrit, and red cell count divided by three. Utilizing all three values corrects for alteration in cell size or hemoglobin content. To further illustrate the calculations used to correct for disease effects we have included a sample profile score sheet at the end of this section (Table VIII). On it we have indicated the derivation of the figures in each column. Page 26 indicates the calculations on a representative patient. 22. TABLE V PROFILE VALUES ASSIGNED FOR VARIOUS RANGES OF ABNORMALITY Hematology - Peripheral Counts _____________________________________________________________________ Profile Value Test Units Normal* ---------------------------------------- 1 2 3 4 1 2 3 4 ______________________________________________________________________ (for increase above (For decrease below normal) normal) Hemoglobin gm. per M-15.8 18 19 20 21 14 12 10 8 cent F-13.9 16 17 18 19 11.5 10 8.5 7 Erythrocytes Mill./ M- 5.4 6.0 7.0 8.0 9.0 4.5 3.5 2.5 1.5 mm. 3 F- 4.8 5.5 6.5 7.5 8.5 4.0 3.0 2.0 1.0 Hematocrit Volume M-47 54 56 58 60 40 35 30 25 percent F-42 47 49 51 53 37 32 27 22 Leukocytes 1,000/ 7.4 12 18 24 30 4.0 3.0 2.0 1.0 mm.3 Neutrophils 1,000/ 4.4 7.7 14 21 28.0 1.8 1.3 0.9 0.5 mm. 3 Lymphocytes 1,000/ 2.5 4.8 7.0 10 12.0 1.0 0.75 0.5 0.3 mm. 3 Platelets 1,000/ mm. 3 Rees-Ecker 405 545 700 850 1.000 273 200 100 30 Brecher- Cronkite 257 440 600 750 900 140 100 50 30 Fonio 234 350 500 650 800 130 100 50 30 Dameshek 716 900 1,000 1,500 2,000 500 350 100 30 Reticulocytes per cent red blood cells 1.5 4 8 15 25 .5 0 Erythrocyte Sedimentation Rate mm./hr. M-5 10 20 30 40 F-10 20 30 40 50 ________________________________________________________________________ * Expressed as "universal mean" value. Taken from Standard Values in Blood. Being the First Fascicle of a Handbook of Biological Data. E. C. Albritton, Editor. W. B. Saunders Company, Philadelphia, 1952 23 TABLE VI PARTITION OF PROFILE SCORES BASED ON NET ERYTHROCYTE SCORE Case No. Disease Score Radiation Score Total Score Test Cumula- Test Cumula- Test Cumulative tive tive 004 4.11 49.32 .00 12.01 4.00 61.33 (30) 006 1.25 10.00 .00 .00 .33 2.00 (18) 007 0.9 9.99 12.76 74.10 13.66 83.96 (27) 008 1.56 17.22 .00 2.38 .66 19.60 (27) 010 1.16 12.76 3.50 11.17 4.66 23.93 (27) 011 2.33 28.00 .00 10.33 .33 38.33 (30) 013 1.6 19.2 2.73 18.13 4.33 37.33 (30) 015 .55 6.6 7.11 37.4 7.66 44.00 (30) 016 3.1 37.2 2.56 19.8 5.66 57.00 (27) 017 .00 .00 7.33 47.33 7.33 47.33 (30) ( ) days of observation post total body radiation 24. TABLE VII COMPARISON OF PROFILE SCORES BASED ON HEMATOCRIT VERSUS RED CELL COUNT Case no. Total Score Total Score based on hematocrit based on red blood cell count test cumulativetest cumulative 004 5 62 (30) 2 27 (30) 006 0 0 (18) 1 3 (18) 007 13 83 (27) 15 81 (27) 008 1 25 (27) 0 12 (27) 010 5 28 (27) 4 17 (27) 011 1 41 (30) 0 37 (30) 013 5 86 (27) 4 73 (27) 014 5 86 (27) 4 73 (27) 015 8 50 (30) 7 38 (30) 016 6 63 (27) 5 50 (27) 017 7 39 (30) 8 37 (30) ( ) days of observation post total body radiation 25 007 JT. age 62. cm TABLE VII SAMPLE PROFILE SCORE SHEET 1 2 3 4 5 6 7 8 9 STT Day of H Rbc. Hct. Net RBC WBC Neutro- Lymph Observ. phile T.C T C T C T C T C T C T C 10 11 12 13 Platelet Disease Radiation Total Score Score Score T C T C T C T C T = Test score C = Cumulative score Col. 1 STT refers to standard test times (Thoma & Wald) Col. 2 Day of observation corresponding to standard test time. Col. 3,4,5 Profile score based on observed Hgb, Rbc and Hct. Col. 6 Calculated "net Erythrocyte" score, i.e., T3 + T4 +T5 C3 + C4 + C5 T6 = ---------------- C6 = ------------ 3 3 Col. 7,8,9,10 Profile score based on observed Wbc, Neutrophile, Lymphocyte and Platelet Counts Col. 11 T11 = Calculated disease mean daily test score (DMTS) = C 11 (at end of pre Rx period -------------------------------- No. of Observations posts to Rx in the past Rx period T11 = DMTS in the past Rx period C12 = DMTS is number of observation in the post Rx period Col. 12 T12 (Radiation test score) = T13 - T11 C12 (Radiation cumulative score) = C13 - C11 Col. 13 T 3 (Total test score) = T6 + T7 + T8 + T9 + T10 C13 (Total cumulative score) = C6 + C7 + C8 + C9 + C10 26. Profile Score Sheet - Total Body Radiation Study FOR REFERENCE SEE (2bb09) GRAPHIC 27. 3. Case Histories: Study No. 004Patient: JW Chart No. 232557 The patient was a 67 year old negro male with carcinoma of the left tonsil. Multiple courses of x-ray therapy and radium implantations had been given from 1948 through 1960. A feeding gastrostomy was required in the fall of 1959. On 5/24/60 the patient was given total body irradiation and received 66 rad to the midplane of the body. Following total body irradiation, the patient's course was satisfactory. Weight varied from 44 Kg to 45 Kg which was within the same range as that of pre-total body irradiation. Palliative x-ray to 4 x 7 x 4 cm left anterior cervical metastasis was started on 6/21/60. Total tumor dose was 2,400 r in 17 days. The cervical mass improved with x-ray, but the patient's condition progressively deteriorated and he expired 8/5/60. Autopsy report is appended. Pathology Reports: 5/24/48 Anterior pillow of the left tonsil: Surg. Spec. No. 48-971; 34-16566 Diagnosis: Squamous call carcinoma grade 2. 3/15/50 Biopsy in EN clinic: Surg. Spec. No. 50-631 Diagnosis: Recurrent squamous cell carcinoma. 10/6/59 Biopsy of the palate: Surg. Spec. No. 59-2625 Diagnosis: Squamous cell carcinoma. 28. Anatomic Diagnosis - Necropsy No. N-60-405 Miscellaneous 1. Squamous cell carcinoma originating in the left tonsil with extension to the posterior pharynx and metastases to the upper anterior chest wall. 2. Regional anterior cervical lymph bode metastases with abscess formation on the left and a sinus tract to the left posterior pharynx. 3. Status post radiation therapy to pharynx and neck. 4. Emaciation, severe. Respiratory System 1. Lobular pneumonia, bilateral, severe, organizing. 2. Pulmonary congestion and edema, moderate. 3. Pulmonary emphysema, moderate. 4. Plural adhesions, bilateral, apical. Cardiovascular System 1. Serious atrophy of epicardial fat. 2. Thrombosis of abdominal aorta just above bifurcation, non-occlusive. 3. Generalized atherosclerosis, moderate. Alimentary System 1. Status post-operative feeding gastrostomy, old, functional. 2. Cholelithiasis, solitary large stone, and chronic cholecystitis. 3. Bile duct dilation without obstruction. Hematopoietic System 1. Lymphocytic lymphoma, chronic, focally evident in the small intestine. Genitourinary System 1. Benign prostatic hyperplasia. Endocrine System 1. Neurofibroma of adrenal. 29. Study No. 006 Patient: AT Chart No. 380-1-74 This 67 year old white male was operated on November 4, 1959, at the Duval Medical Center, Jacksonville, Florida, where an exploratory laparotomy revealed a carcinoma of the rectum with metastasis to the liver. A colostomy was performed. He had been an inmate of the Florida penitentiary for two years but because of his medical problem he was paroled. He was admitted to the General Hospital as a disposition problem. System review was essentially negative. Physical examination showed a blood pressure of 140/80, pulse 104 and respirations 16. The patient was obese, elderly and in no acute distress. There was a midline double barrel colostomy with some ulceration of the surrounding skin. A large mass was palpitated from the rectum. The rectal lesion was biopsied and found to be an adenocarcinoma of the rectum. The initial admission was on 3/4/60. He was discharged on 3/19/60. He was readmitted to the hospital on 5/6/60, because of bleeding from the rectum and from the colostomy and was admitted to ward A-3. At that time a sigmoidoscopy was done showing an annular mass with papillary edges at 6-1/2 cm. There was a necrotic ulcer at the center and measured about 3 cm. in diameter. The biopsy (SP 60-1659) revealed adenocarcinoma of the rectum. The patient was then put on the Total Body Study and on 7/4/60 30. received radiation which began at 9:45 A.M. and completed at 10:30 A.M. He received a trunk midline dose of 54 rad. There were no symptoms following this exposure. The patient had an essentially uncomplicated course following this treatment and was finally discharged to Drake Hospital on 8/12/60. During the time he remained in the hospital he had several rectal hemorrhages, he maintained his weight well at approximately 160-166 lbs. during the entire second admission. He showed a moderate anemia but was otherwise in satisfactory condition. He continues to do well at the Drake Hospital. 31. Study No. 007 Patient: JT Chart No. 351-6-51 The patient was a 62 year old colored male who, on 12/16/57, had a right total colectomy with ileotransverse colostomy for adenocarcinoma of cecum (SP 57-3607). Following this procedure the patient did very well until June, 1960, when a routine chest film revealed multiple metastatic nodules in the lung while the patient continued asymptomatic. On 10/6/60 patient was admitted to the Cincinnati General Hospital with a 10-day history of weakness in his legs and repeated seizures. Physical examination at this time was not remarkable except for weakness in his right lower extremity. The consensus of opinion was that his central nervous system disease was secondary to cerebral metastasis. While in the hospital his seizures were well controlled with dilantin and phenobarbital. On 10/28/60 patient received total body irradiation with a dose of 100 rad at body midplane. There were no symptoms at attributable to this x-ray therapy nor was there any symptomatic response. In view of the patient's progressively deteriorating course of lethargy and paralysis, patient was begun on x-ray therapy to his head on 11/7/60 which continued until shortly before his death. His course was one of continued progression of neurological disease with quadriplegia and he expired on 11/29/60. 32. Anatomic Diagnosis - Necropsy No. N-60-637 Respiratory System 1. Lobular pneumonia, left lower lobe. 2. Pulmonary edema, moderately severe. 3. Emphysema. Alimentary System 1. Adenocarcinoma of colon (treated surgically and by x-rays) with metastasis to lungs, adrenals, and brain. Genitourinary System 1. Benign prostatic hypertrophy. 33. Study No. 008 Patient: CH Chart No. 261-8-92 The patient was a 60 year old colored female who on 3/18/58 had left simple mastectomy followed by post-operative radiation through 5 ports of 1120 roentgen in air which was completed in May, 1958. Pathological diagnosis was anaplastic inflammatory carcinoma of breast (SP 58-836). Following this, patient did well until April, 1960, when she had the appearance of left pleural effusion necessitating thoracentesis, on 4/14/60. A second tap was necessary two weeks later, at which time 30 mg. of nitrogen mustard was instilled in the left pleural space. Four weeks later it was noted that patient had appearance of nodules in her surgical scar. One of these was biopsied on 7/2/60 and showed metastatic carcinoma, (SP 60-1708). On 10/13/60 patient was admitted to A-3 and one week later transferred to N-3. During her pre-study period there was a gradual accumulation of right pleural fluid and this necessitated thoracentesis on 11/4/60. Patient received total body irradiation 11/8/60, receiving 100 rad to the midplane. This was followed by some nausea and weakness beginning 12 hours post-radiation therapy and lasted approximately 24 hours. Following total body irradiation patient seemed to be benefitted considerably subjectively and there seemed to be some softening and regression of the metastatic nodules on her chest wall. Retapping of her pleural effusion was not necessary until 12/27/60 when she was re-admitted to the hospital. 34. Her course was one of steady deterioration due to multiple pulmonary infarctions and cor pulmonale. She expired 2/7/61. Anatomic Diagnosis - Necropsy No. N-61-75 Miscellaneous 1. Status post-operative simple mastectomy with post-operative radiation treatment for inflammatory carcinoma of the left breast, 1958. 2. Adenocarcinoma with discriminated lymphatic metastasis to lungs, pleura, diaphragm, skin and muscles of the left anterior thoracic wall, right breast, peritoneum, retroperitonium and rectum. 3. Status post total body radiation. 4. Status post operative hysterectomy with appendectomy, old. 5. Edema, left lower extremity, due to thrombosis of left common iliac vein. Respiratory System 1. Pulmonary thrombosis, right major pulmonary artery and thrombo emboli, small vessels, left. 2. Hydrothorax, right. 1200 ccs. with pleuritis. 3. Pleural fibrosis, left, marked. 4. Organizing lobular pneumonia. 5. Pulmonary odema. mild. 6. Atelectasis, right lung. 7. Pulmonary fibrosis, focal. 8. Pulmonary congestion, moderate. Cardiovascular System 1. Cardiomegaly, 470 grams, consistent with cor pulmonary thrombo emboli of the right pulmonary artery. 2. Coronary atherosclerosis, moderate. 3. Myocardial fibrosis, interventricular septum. 4. Aortic atherosclerosis, moderate. Genitourinary System 1. Chronic pyelonephritis, focal, 2. Arterio and arteriolar nephrosclerosis, mild. 3. Organizing thrombi, microscopical. 35. Alimentary System 1. Centrolobular congestion, liver, acute. Hemotoietic System 1. Acute splenitis, slight. 36. Study No. 009 Patient: BB Chart No. 381-C-31 This patient is a 67 year old colored female who was seen at Cincinnati General Hospital in March 1960, with generalized lympha- denopathy and hepatosplenomegaly. Node biopsies, bone marrow examination and peripheral blood were non-diagnostic at that time. Patient was readmitted on 10/7/60 because of increasing dysphagia and orthopnea. Patient had two lymph node biopsies on 10/11/60, both of which were interpreted as malignant lymphoma, follicular type (SP 60-2471 and 60-2483). At this time also the diagnosis of chronic pyelonephritis was established with a slight elevation in the patient's BUN. The patient was begun on intramuscular oxytetra- cycline (Terramycin). On 11/4/60 through 11/7/60 patient received 350 roentgen to her anterior mediastinum. This was followed on 11/9/60 and 11/11/60 by total body radiation of 16 rad each. Several days before total body irradiation patient had developed nausea and vomiting which did not seem to be aggravated by irradiation therapy. However, it became progressively more severe and when a rising BUN gas was noted, total body irradiation therapy was discontinued and patient was given 900 roentgen to her spleen from 11/21/60 to 12/1/60. Associated with this therapy there was excellent control of her disease process. The nausea and vomiting subsided promptly when intramuscular tetracycline discontinued. On January 24, 1961, patient was on chlorambucil because 37. of enlarging lymph nodes and residual hepatomegaly. Some improvement was noted, but on April 3, 1961, local x-ray to inguinal nodes was started because of lymphedema. At present no improvement in edema has been noted. 38. Study No. 010 Patient: LT Chart No. 261-5-69 The patient was a 66 year old colored female whose past history was remarkable in the fact that she had compensated hypertensive cardiovascular disease. On July 13, 1953, patient had a right radical mastectomy followed by post-operative radiation, the sum of doses to all fields being 10,700 roentgens in air. The pathological diagnosis (SP 53-1385) reported as showing carcinoma of breast with metastases to 2 of 35 lymph nodes. Following this therapy the patient did well until October, 1954, when she had a left radical mastectomy for carcinoma of the left breast. Histologically this was read as medullary carcinoma of breast with 2 of 14 nodes involved (SP 54-2358). No further radiation therapy was given at this time. Patient continued to do well until December, 1958, when she developed skin metastasis of the right chest wall. One of these were biopsied and the biopsy report (SP 58-3276) was interpreted as metastatic medullary carcinoma. In January, 1959, she had 3,200 r to the skin metastasis with some regression. At this time she also developed for the first time right pleural effusion and had her first thoracentesis followed by the installation of 85 millicuries of colloidal Au-198. Following the installation of the radioactive gold, one further thoracentesis was necessary on 2/24/59, but following this she remained relatively asymptomatic until October, 1959, when lenticular metastasis of 39. left chest wall appeared. Following their appearance they showed little increase in size until November, 1960, when patient also developed a left pleural effusion. On November 15, 1960, patient was given 24 mg. of nitrogen mustard in the left pleural space which was followed by a systemic reaction with nausea and vomiting, decrease in the size of lenticular metastasis and also decrease in her WBC count. On 12/4/60 patient received total body radiation of 100 rad to the midplane of the body. No toxic symptoms or signs were noted. Pleural effusion recurred though the lenticular metastases improved. On January 1, 1961, she had onset of convulsions. X-ray therapy to the skull was of no avail and she expired 1/22/61. No autopsy was obtained. 40. Study No. 011 Patient: ZW Chart No. 387229 The patient was a white male who had a proved carcinoma of the right upper lobe resected by lobectomy in 1959. Following surgery he received local 250 KV and Cobalt 60 x-ray, 5 fluorouracil, chlorambucil and steroids. He received total body radiation on February 9, 1961, receiving 100 rad to the midplane of the body. Nausea and vomiting occurred within 2 hours one time, anorexia and weakness lasted 24 hours. No change in the clinical problem of pain was noted. His subsequent course has necessitated cordotomy and continuous narcotics. In October, 1961, the possibility of tumor involving the esophagus appeared likely because of dysphagia. Barium swallow was interpreted as showing invasion. 41. Study No. 013 Patient: DR Chart No. 312-8-09 Patient was a 49 year old negro male with Kaposi's sarcoma since July, 1960. This lesion progressed rapidly and in January, 1961, he had massive edema of the legs and groin in addition to lesions on the nose and over the eye. Sp 61-1674 and SP 61-232 were both interpreted as revealing Kaposi's sarcoma. Fifty rad of total body radiation was given on 5/19/61 without sequelas. Five days later, on 5/24/61, another 50 rad; and 12 days later a final 50 rad were given without symptoms. Minimal improvement in the skin lesions occurred. In spite of local x-ray, the patient followed a progressively deteriorating course and expired on 9/9/61. Anatomic Diagnosis - Necropsy No. N-61-470 General 1. Kaposi's sarcoma with involvement of skin, retro-peritoneal and mediastinal lymph nodes, peripelvic tissue of kidneys, small bowel, breast, and adrenal cortex. Respiratory System 1. Pulmonary edema, moderate. 2. Lobular pneumonia. 3. Pleuritis, chronic. 42. Study No. 014 Patient: RP Chart No. 384247 This patient was a 59 year old negro female who had the diagnosis of probably lymphatic leukemia and mycosis fungoides made in July, 1960. SP 61-415 confirmed this diagnosis. Therapy had consisted of Chlorambucil and I.V. Medrol with improvement noted. Oral Prednisone had been given with moderate relief of erythema and itching. Total body radiation was given in multiple doses at 100 KV. The therapy began on 3/2/61 and was completed 4/6/61. Weakness was prominent and no significant improvement in the itching was noted. Her general condition deteriorated progressively in spite of treatment. Itching, skin infections, anemia and a white cell level of 20-40,000 with 50-70% lymphocytes persisted. The patient expired in November, 1961. 43. Study No. 015 Patient: JD Chart No. 163-3-44 The patient was a 61 year old negro male who had a combined abdominoperineal resection for carcinoma of the rectum January 25, 1957. SP 57-265 revealed adenocarcinoma invading the muscularis. He was asymptomatic on follow-up visits to Tumor Clinic until April 26, 1961, when post prandial epigastric fullness and constant RVQ pain occurred. Physical examination revealed an adequately nourished patient with a liver palpable to the umbilicus. The patient received total body radiation 5/18/61, receiving 100 rad to the midplane of the body. He had nausea and vomiting that night and anorexia. Gas pains and anorexia associated with weakness lasted six days. No change in the abdominal mass occurred. In view of continued pain and clinical deterioration with a large liver, he was given x-ray therapy to the liver in July, 1961. He was readmitted on 8/31/61. deteriorated rapidly, and expired on 9/16/61. Anatomic Diagnosis - Necropsy No. N-61-483 Digestive System 1. Status post abdomino-perineal resection for adenocarcinoma of ------. 2. Massive metastases to liver. 3. Ascites (2,000 cc.). Respiratory System 1. Hydrothorax (500 cc.), left. 2. Mild pulmonary edema, right lung. 3. Chronic pleuritis, right lung. 44. Cardiovascular System 1. Generalized arteriosclerosis, mild. Genitourinary System 1. Hemorrhagic cystitis. 45. Study No. 016 Patient: Chart No. 387353 The patient was a 34 year old white male with osteogenic carcoma of the left ilium. This lesion had been treated with 6,000 r of Cobalt 60 and I.V. nitrogen mustard therapy. In May, 1961, he was readmitted because of extensive local involvement and a right pulmonary metastasis. He received 20mgm. of intra-arterial nitrogen mustard (0.31 mgm/kilo) on 5/18/61, this therapy being used in place of total body radiation. Tourniquets were not used. Nausea, vomiting and anorexia lasted for 5 days. Relief of pain in the leg occurred in 2 weeks, but was evanescent, lasting for only one week. Subsequently he has had a transverse colostomy for bared obstruction. He has received intrathecal phenol injections for pain with minimal relief. He has continued a downhill course. 46. Study No. 017 Patient: MP Chart No. 204753 The patient was a 39 year old negro female who had a hysterectomy for uterine fibroids in September, 1955. In January, 1951, the patient had a partial glossectomy and right radical neck dissection for muco-epidermoid carcinoma of the tongue. From 1951 until December, 1960, the only complaints were of a chronic and recurrent sore throat. A small mass on the tongue was noted and repeatedly biopsied. SP 61-70, SP 61-202, and SP 61-955 revealed recurrent mucoepidermoid carcinoma. No other physical findings were noted. Total body radiation was given 5/18/61, the dose being 100 rad to the midplane of the body. Within 3 hours she had nausea, vomiting and diarrhea. Anorexia and weakness were present for 4 days and then cleared. On 8/11/61 excision of the recurrent carcinoma was performed. Her course has remained satisfactory with weight gain and no evidence of tumor when seen last October 17, 1961. 47. STUDIES OF AMINOACIDURIA 1. Procedure Fasting morning urine specimens, preserved with thymol and refrigerated, were subjected to two-dimensional chromatography with particular emphasis on amino acid content. A phenol lutidine solvent combination was used. Quantitative estimation was obtained by comparing minimum density readings on a Photovolt Model 525 densitometer with appropriate curves prepared from known mixtures of amino acids. Our hope was to obtain levels of urinary amino acids post- exposure which would be significantly higher than the pre-exposure values. The amino acids analyzed were as follows: Glutamic acid Valine Phenylalanine Serine Taurine Proline Glycine Beta-aminoisobutyric Histidine Threonine acid Aspartic acid Alanine Lysine Cystine Glutamine Tyrosine Methyl histidine Beta-alanine Leucine Ethanolamine Other substances sought for included indole acids, phenolic acids, organic acids, sugars and inorganic salts. Glucuronic acid was occasionally noted. At times peptides were found. These data were analyzed for statistical significance, comparing the mean pre-treatment levels of each amino acid vs. the mean post-treatment levels for these morning specimens. Values were recorded in terms of micrograms per ml. No significant differences were found. 48. 2. BAIBA: BAIBA has been reported as being elevated in patients exposed to whole body radiation (Rubin et al., Proc. Soc. Exp. Biol. & Med. 100: 130-133, 1959; and Gerber et al., Radiation Research 15:314-318, 1961). In a group of 237 normal males 50% showed less than 13 mg/ml and 95% lens than 70 mg/ml. The range was 0-250 mg/ml (Berry, H. Kg, Am. J. Phys. Anthropology 11:559-576, 1953). The 24-hour values were calculated for 8 patients by multiplying the individual morning level by the 24-hour urine volume. (See Figures 3, 4, 5, 6, and 7.) Two (007 and 008) patients show increased peaks of BAIBA excretion after treatment. Four patients (010, 011, 015, and 017 show pre-treatment peaks as high or higher than post-treatment levels. One patient (013), whose treatment was given in 3 divided doses of 50 rad each, showed no increase in excretion. Of particular interest was the very high level of 198 mg shown by patient 017 on the day preceding radiation. Previous studies by Berry (Metabolism 9:373-376, 1960) showed increased levels of BAIBA following surgery and infection in children. It may well be that the changes shown in our patients are due to non specific stress or to the presence of coexistent disease (cancer). 3. Conclusions: If one has pre-exposure values of amino acids, it does not seem possible to show an association of aminoaciduria with radiation dose in cancer patients given 50 and 100 rad. Also, it seems doubtful 49. that meaningful values for amino acids for use as physiological indicator of response to radiation can be based on determinations of single urine specimen and without 24-hour volumes. 50 Figure 3 URINARY EXCRETION OF B AMINO ISOBUTYRIC ACID BEFORE AND AFTER TOTAL BODY RADIATION FOR REFERENCE SEE (2bb10) Graphics FIGURE 4 51. URINARY EXCRETION OF B AMINO ISOBUTYRIC ACID BEFORE AND AFTER TOTAL BODY RADIATION FOR REFERENCE SEE (2bb11) GRAPHIC 52. FIGURE 5 URINARY EXCRETION OF B AMINO ISOBUTYRIC ACID BEFORE AND AFTER TOTAL BODY RADIATION FOR REFERENCE SEE (2bb12) GRAPHIC FIGURE 6 53. URINARY EXCRETION OF B AMINO ISOBUTYRIC ACID BEFORE AND AFTER NH2 FOR REFERENCE SEE (2bb13) GRAPHIC FIGURE 7 54. URINARY EXCRETION OF B AMINO ISOBUTYRIC ACID BEFORE AND AFTER TOTAL BODY RADIATION FOR REFERENCE SEE (2bb14) GRAPHIC CREATINE/CREATININE EXCRETION 55. Creatine/Creatinine was examined as an indication of protein breakdown. In a similar study, Glickleman (1) found four out of six patients showing increased creatine/creatinine excretion in the 2-3 week period following total body irradiation exposure. Kurohara, Rubin and Hempelman (2) observed fatigue symptoms in therapeutically irradiated patients showing a high degree of creatinuria. Creatinine was analyzed by the modified Jaffe reaction; that is, treatment of the sample with alkaline picrate solution to produce a red coloration. The same technique was applied either to the diluted urine sample or to the tungstic acid filtrate of the blood serum. Creatine is calculated from the increase in creatinine content after autoclaving. The determinations were made at a wave-length of 510 mu in a Coleman Junior Spectrophotometer. The percent creatine of total daily urinary creatine plus creatinine is indicative of protein breakdown in the body. No significant alterations have been noted. In spite of the reported constancy of creatinine excretion we have not found this constancy in healthy volunteers and this group of patients. Several other observers also have noted this lack of constancy. Recently, Gerber et al. (3) have reported significant increases in creatine excretion following radiation, both whole and partial body in animals and humans. Their technique for identification of creatine successfully removes chromagens but is too complex for 56. is too complex for routine clinical use. In spite of the fact that there may be some increase in creatine excretion in some patients, this approach does not appear practical at present for use as a biological dosimeter. (1) Glicksman, A., personal communication (2) Kurohara, S., P. Rubin and L. Hempelmann, Creatinuria as a Possible Index to Radiation Fatigue. Radiology 74:103, 1960. (3) Gerber et al., Radiation Research 15:314-318, 1961. 57. SERUM ELECTROPHORESIS Serum protein fractionation was performed by paper electrophoresis utilizing the Spinco apparatus. The paper strips were then analyzed by the Spinco Analytrol. The electrophoretic patterns were determined for each patient pre- and post-irradiation and comparisons made of the serum protein fraction distribution. No changes after total body radiation have been found. 58. IMMUNOLOGY 1. Immunoelectrophoresis: A micro-method involving the same principle as the standard procedure for electrophoresis was used for the immunoelectrophoresis studies. Two wells and a trough were cut on agar surface of microscopic slide. The wells were filled with serum (one pre- irradiation and one post-irradiation sample from patient on the same slide). A power supply was then connected to the electrodes of the electrophoresis cell and current allowed to flow for about 40-50 minutes. The trough was then filled with an appropriate human antiserum and the slides left at room temperature for 12-24 hours for antigen-antiserum reaction to take place. The serum protein fractions were then compared. Since June, 1961, bivalent goat human antiserum is being used and all slides are being dried and stained for permanency. This study has, at present, indicated no difference in the post-irradiation serum immunoelectrophoretic patterns as compared to pre-irradiation patterns on the same patient at doses of 50-100 rad. In the patient who received nitrogen mustard intra- arterially Beta 2A and Beta 2M globulins were absent on the 6th day post therapy. They had reappeared by Day 9. 2. Quantitative Precipitin Test Dr. Luzzio has begun to evaluate our patients utilizing a 59. quantative precipitin test. The patient's pre-irradiation specimens must be checked as a base. The patient's serum serves as antigen for an antibody against irradiated protein. All specimens are studied on standard test times. In the one patient investigated an increase in precipitation was observed on the 9th day following total body radiation and prolonged increasing precipitation was seen from the 26th to 33rd day. Falling values were seen on the 35th and 39th day. These studies imply an antigen-antibody response which is being investigated in all patients in this series. 60. SUMMARY 1. In the period from February, 1960, through October, 1961, eleven cancer patients receiving total body radiation were studied in detail. Ten patients were treated with Cobalt-60 and one patient received 100 KV radiation. Doses for Cobalt-60 expressed in rad at the midline of the trunk were 50 rad in 3 patients, 100 rad in 6 patients, and 150 rad in one patient in divided doses. One patient received 975 r in 3 weeks with 100 KV radiation (3.7 mm in masonite). One patient received nitrogen mustard. 2. Three patients receiving approximately 50 rad showed no clinical symptoms. In four of the patients receiving 100 rad, transient nausea and vomiting was observed during the first 24 hours. Mild symptoms of nausea and anorexia were noted in 3 patients for the first 4-5 days. No other symptoms or signs attributable to radiation were noted over the 30-day observation period in any of the patients. From this small group of cancer patients one can conclude that doses up to 100 rad are well tolerated clinically by moderately ill individuals providing no work is required of them. 3. The method of profile scoring was used successfully to separate the component of change due to the underlying disease from the changes in the blood picture due to radiation. 61. 4. Detailed determinations of aminoaciduria were carried out for the entire study period. No significant trends in aminoaciduria could be determined either using the values in mg/ml for single specimens or by calculating the 24-hour levels. 5. Similar determinations for creatine and creatinine in urine were done using standard clinical laboratory methods. No significant increases in creatine excretion were found at these dose levels. 6. Serum electrophoresis did not show alteration in albumin or globulin fractions after treatment. 7. Immunoelectrophoretic studies using a bivalent goat antiserum for Beta 2A and Beta 2M globulins showed no changes in patients treated with radiation. In one patient receiving a single dose of nitrogen mustard, there was disappearance of these two globulins on the 6th day. These substances again were found in normal concentration on the 9th day. 8. The program for the coming years has been designed on the basis of the experiences reported above. In brief, the studies for each patient will bc altered as follows: a.Patients will be selected insofar as possible who have not had extensive previous radiation or chemical treatment. They need not have evidence of metastasis as long as the neoplasm is sufficiently far advanced to preclude a curative attempt by other means. 62. b. The radiation dose will be increased to 150-200 rad. About 15 patients will be studied at this dose range. c. Several additional patients will be studied with single doses of nitrogen mustard or other radiomimetic drug using O.4 mg/kilo. d. The same pre- and post-treatment study schedule will be given as before. e. The tests to be done for 9 days post-treatment include the following: (1) Urinary taurine for correlation with leukocyte count. (2) BAIBA in urine. (3) Kynurenic and xanthurenic acids. (4) Deoxycytidine. (5) Fragments of DNA in urine, uridylic acid, cytidylic acid, inosine, adenylic acid. (6) Xanthine and hypoxanthine in urine. (7) Urinary phosphate. (8) Glutathione. f. The tests to be done over a 30-day period include: (1) Routine electrophoresis. (2) Immunoelectrophoresis. (3) Quantitative precipitin studies (Dr. Luzzio). (4) Serum urea nitrogen and/or serum creatine once weekly. 63. (5) Urinalysis once weekly and as needed. (6) Routine hematology.