Metabolic Changes in Humans Following Total Body Irradiation, 01 May 1963 - 29 February 1964

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METABOLIC CHANGES IN HUMANS FOLLOWING TOTAL BODY IFlRADLATION Defense Atomic Support Agency University of Cincinnati College of Medicine Cincinnati General Hospital

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pualified requemterm may obtain copie6 of t h i s report from DDC.

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These studies are designed to obtain information which is necessary to estimate combat effectiveness of troops and to develop methods of diagnosis. prognosis, prophylaxis and treatment of radiation injury. A t the present time parameters of active investigation are clinical findings, hematologic effects, profile scores, miscellaneous laboratory tests, deoxycytidine excretion i n the urine, xanthurenic acid excretion i n the urine, chromosome changes in leucocytes, immunologic studies and the use of autologous bone marrow. Six patients were given from 149r to 231r (100-150 rad) total body irrad - iation from aGobo source. vomiting with nausea lasting 48 hours. found 2 5 to 35 days after irradiation. Only one of the patients had prodromal nausea and The lowest hematologic values were Deoxycytidine was found i n increased amounts i n the urine from patients after total body irradiation. urine after 500r and 800r whole body irradiation than after lesser d o s e s . In rats much larger amounts were found in the Studies by Dr. Anthony Luzzio, U.S. A r m y Research Laboratory, Ft. Knox, Kentucky, indicate there may be a n immunologic post irradiation alteration in human gamma globulin antigenicity. Combat effectiveness would be relatively maintained with an exposure up to 200 rad, though a second exposure would result in significant troop ineffecAnimal experiments described herein were conducted according to the Principles of laboratory animal c a r e as promulgated by the National Society for Medical Research.

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TABLE OF CONTENTS 3. Selection of Subjects 4. Technique of Study 5. Analysis of Data 8. Hematology and Profile Scoring 10. Quantitative Precipitin Test Aims and Scope of the Project Proposals for Human Study Program LI Total Body Radiation Dosimetry IV Deoxycytidine Excretion in Humans V I Incidence of Endoreduplication P r e and Post Irradiation Observations Partition of Profile Scores Based on "Net Erythrocyte" Score Urinary Excretion of Deoxycytidine in Total Body F i g . 2 - 30Printout of Total White Count - No Previous Therapy, Low Dose

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This project was initiated in February 1960 and this report presents data accumulated from May 1. 1963 through February 29. 1964. The previous reports of November 1961 and April 1963 (DASA 1422) cover the data compiled prior to May 1963. Six additional padents have received from 149 r to 231 r (100-150 rad) total body irradiation in the period covered by this report. 2. AIMS AND SCOPE O F THE PROJECT These studies a r e designed t o obtain new information about the metabolic effects of total body and partial body irradiation so as to obtain a better understanding of these acute and subacute effects in human beings. This information i s necessary to provide knowledge of combat effectiveness of troops and to develop additional methods of diagnosis, prognosis, prophylaxis and treatment of At the present time parameters of active investigation are: 2. Hemograms and profile scores 3. Miscellaneous laboratory tests (serum urea nitrogen(SUN), blood cultures, C-Reactive Protein and bone marrow aspiration) 5. Xanthurenic acid i n urine 7. Quantitative precipitin test (Dr. Luzzio, U. S. Army Medical Deoxycytidine and other nucleosides in urine Chromosome changes i n white cells Research Laboratory, Ft. Knox, Kentucky)

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8. Levels of serum lipoproteins (Lt. Col. E.C. Knoblock. Walter Reed Army Institute of Research) 9. Use of autologous marrow Only patients with metastatic o r incurable neoplasms a r e eligible for stable hemogram a r e required. disease on the observed metabolic changes remains a problem. Patients who have solid tumors which might be radioresistant Relatively good nutritional status, normal renal function and a Interpretation of the effect of the underlying Patients who have bad no previous radiation o r chemotherapy a r e generally used though some patients so previously treated have been studied. It is possible to isolate the effect of previous radiation by such studies. 4. TECHNIQUE OF STUDY The design of the study is such that the patient serves as his own A pre-irradiation control period of one to two weeks i s utilized.control. ever,with the increased levels of radiation, the post-irradiation period has been extended to six o r eight weeks. Five observations are made i n the pre-irradiation period. Observations currently made are listed i n Table I. tained a t standard test times a s described by Thoma and Wald (See section on Analysis of Data). Post irradiation specimens are then obPatients have been studied on the Tumor Ward and the Metabolic Ward of the General Hospital. One bed on the Metabolic Ward has been allotted for

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i During the pre-irradiation period, the patient's records are reviewed by the physicians to be certain that the contribution of the underlying disease can be evaluated. One or two sham irradiations a r e given to permit accurate dosimetry and obtain cooperation by the patient. possible subjective reactions resulting from the treatment. nurses, technicians and ward personnel are instructed not to discuss postThere is no discussion of irradiation symptoms o r reactions with the patient. Collection of data continues essentially according to the plan of Thoma and Wald (J. Occup. Med. k420-447, 1959) and described i n section 3 of Medical Aspects of Radiation Accidents, E.L. Saenger, ed., U.S. Government Printing AU data a r e recorded on score sheets and then transferred to IBM Thus all information together with the appropriate machine programscards. is available for analysis by other centers o r interested individuals. Profile scoring i s used to estimate the effect of previous irradiation The method is described i n Appendix B of DASA 1422. The methods of dosimetry remains the s a m e as i n the report of April 1963. The dosimetry for the patients is given i n Table II: Six additional patients have been studied since the l a s t report. They received from 149 to 231r of total body radiation (total midline dose inair without a phantom). Clinical summaries are attached to this report as Appendix A. Patient #032 received only sham because of a low white count and hypoplastic

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marrow when checked in the pre-radiation period. due to progression of her disease. One (#031) of the patients irradiated had radiation to her uterus thirtyfour years prior to total body irradiation. One patient (X030) had received a piperazine derivative (A8103 - Abbott) eight months before total body radiation. The four other patients were untreated. Only one of the patients had prodromal symptoms of nausea and vomiti n g with persistence of nausea to 4 8 hours after a dose of 227 r (150 rad). had received no previous therapy. As h a s been seen before, there appeared to be increased lassitude. Quantitation of this observation w i l l require specific procedures for performance 8. HEMATOLOGY AND PROFILE SCORING The presence of a "plateau" o r "peak" in the white blood cell count has continued to be observed. until about the twentieth day. between the twenty-fifth and thirty-fifth day after radiation. It is noted at approximately ten days and continues The lowest hematologic values are observed Mild lymphocytopenia w a s seen on the treatment day. Occasional giant polymorphonuclear granulocytes were seen in two patients. Profile scoring was continued i n the same manner a s described in the Summary Report of April, 1963. Appendix B. radiation score and total continued to be of value i n ascribing the importance of radiation i n precipitating demise. In this group of patients "net erythrocyte" acore did not introduce significant change froma score based on the hematocrit. Delineation of disease score, Table LU summarized the data based on

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Four additional patients have been evaluated in regard to urinary excretion of deoxycytidine (dCT). This substance was found i n increased yields i n the post radiation phase f o r periods up to 48 hours, (See Table N). It i s apparent from the first six patients that we have not a s yet demonstrated a dose effect relationship. difficulties with the technical procedure although it may be due to effect of concomitant disease. Because of the wide confidence limits noted i n several of our concurrent r a t experiments we suspect that the problem i s a technical The lack of such a relationship probably represents Four patients who have not received radiation but who had other illnesses have been studied for urinary dCT excretion. thermal burn, fracture, infection and cancer. None showed dCT. human so f a r studied who has shown urinary dCT is patient #030 who had received chemotherapy with A 8103 (Abbott) about 8 months p r i o r to irradiation. The observation that dCT is not excreted i n at least a few other disease states indicates that its excretion may atleast be relatively specific for radiation. These conditions included Some experiments have been carried out using the Wistar rat. Groups of 12 male rats were exposed a t doses of 0. 200, 500 and 800 rad. Rats excrete some dCT normally and pre-radiation levels ranged 0 f 100 The rats exposed a t 500 r a d showed an increase over those receiving 200 rad. There was no significant difference between dCT levels at 500 and 800 rad. All r a t s showed an increase in deoxycytidine excretion post radiation.

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-Laboratory techniques f o r dCT analysis i n urine have been quite tedious 12. and have not a s yet reached the desired degree of accuracy. The entire procedure is being re-evaluated to develop a method by which l a r g e r numbers of specimens can be assayed i n shorter times. 10. QUANTITATIVE PRECIPITIN TEST Serum from our patients has been stored and sent to Dr. Anthony J. Luzzio of the U.S. A r m y Medical Research Laboratory, Ft. Knox, Kentucky. The serum has been examined for radiation altered human s e r u m gamma Serum Gamma Globulin, Serum from several patients showed a bimodal post irradiation increase in this serum gamma globulin as a result of i n vivo irradiation. . The Serologic Specificity of Radiation Altered Human The Journal of Immunology, 90:224, Feb., 1963). These data suggest an alteration in antigenicity of human Observation of peripheral blood chromosome cultures has continued. A finding of particular interest has been the observation of endoreduplication. This phenomenon has been observed i n eleven patients with cancer and i n one studied i n detail (Table VI). occurrence seems to be a radiation effect. this obeervation is associated with irradiation o r the presence of malignancy. Additional studies are being carried on i n controls and patients with malignancy to evaluate further the role of irradiation. It h a s been seen before and after irradiation. Four patients have been In at l e a s t one patient increased incidenee of this At this time it i s not clear whether

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Computer analysis of the hematologic data on the f i r s t twenty-nine patients has started. The patients have been divided into four groups: 1) Those receiving 100 r a d o r less total body irradiation who have not had previous irradiation; 2 ) those receiving 100 r a d o r less total body irradiation who have had previous irradiation; 3) those receiving more than 100 rad of total body irradiation who have not had previous irradiation; and 4) those receiving more than 100 rad of total body irradiation who have had previous irradiation. Printouts of each group and of the combined groups for each parameter were constructed with the abscissa in days post irradiation. On the ordinate the means of the pre-irradiation values were standardized at unity (1). Therefore all post irradiation values were related to the mean of the pre-irradiation observations (Fig. 2 is a representative printout). A fall in hemoglobin, hematocrit and reticulocytes in patients who received more than 100 rad total body irradiation was observed. seemed to influence the immediate lymphocyte fall and l a t e r decrease in monocytes of the high dose patients. creased in all groups but to a greater extent i n patients given more than 100 rad w h o had received previous irradiation. Total white cells in the peripheral blood de13. PROPOSALS FOR HUMAN STUDY PROGRAM W e propose to continue observing clinical and hematologic effects of irradiation with a Co-60 unit at arate of approximately 5.4 r / min at 282 cm. Exposures will be total and partial body, bilateral and unilateral. Storage and

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reinfusion of autologous bone marrow will be accomplished in the facility which The determination of urinary excretion of deoxycytidine. chromosome changes and iaununologic alterations will. continue. vestigations of performance testing will be made. Preliminary discussions regarding studies in volunteers will be instituted. These will, of necessity, require considerable perspicacity and contemplation. However, it is our hope such a program wiU be feasible. a) Clinical and hematological observations of cobalt 60 irradiation a t dose rates of 5.4 rfmin at 282 cm. will continue. Exposures will be given to the whole body, partial body (upper and lower portions and unilateral). Facilities for storage and reinfusion of bone marrow are just which marrow storage will be carried out on subjects. storage and reinfusion i s to protect subjects who receive doses in excess of 150 radin the event of bone marrow failure. Trials on cadavers will be made for the next four months after The purpose of marrow W e hope t o utilize doses between b) Deoxycytidine studies - The a s s a y of urinary deoxycytidine will be re-evaluated so as to simplify the techniques as discussed above. The most interesting aspect of dCT is the mechanism 2f urinary studies with C-14 labeled and tritiated materials a r e planned. 1) Clearance from blood 2) Determination of the existence of arenal threshold 3) Meaaurement of a respiratory component of C-14 In o r d e r to attempt to clarify this problem further the following

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These experiments will not, of course, answer the question posed i previously a s to whether dCT is produced because of interference with : synthesis o r because of increased breakdown of nuclear DNA. But until the metabolism of dCT is better understood in the human being, the elucidation of this problem by the administration of labeled precursors of dCT cannot Initially the method of breath analysis for d402 using the Carey vibrating reed electrometer will be undertaken with C14 labeled glucose and glycine in order to develop the methodology at a lower COSL. The initial labeled dCT will be labeled i n the 2 position of the pyrimidine ring. Subsequently uniformly labeled tritiated material will be used. These studies will be carried out i n patients other than those receiving whole body ! irradiation. Later studies i n succeeding years envision the administration …