A Chernobyl Child's Journey through Radiation
Katie N. Copeland
University of Alabama at Birmingham
Chernobyl was a very important event in history that affected many people in many areas. The nuclear power plant exploded in Russia, and the resulting fallout spread over many countries, even throughout Europe. The accident happened over two decades ago, but is still well known. Some victims acquired leukemia, some thyroid cancer, and the list goes on. One patient who resided in the Ukraine at age two during the explosion acquired a rare high grade synovial sarcoma of the chest wall. She has been fighting the battle since she was exposed to the radiation more than twenty years ago. The battle has been bicontinental and has contained many modalities of treatment. She developed an abundance of metastases throughout her thoracic cavity. This case study follows the brave radiation journey of this young woman, which includes consultation, simulation, treatment planning, and treatment delivery.
The chosen patient is a 26 year old female of slim build and shy nature who has fought a long, heroic battle with cancer since a very young age after being exposed to radiation from the Chernobyl accident. Chernobyl was a completely preventable accident that has still not had closure with the public. It is dubbed the “worst nuclear power accident in history,” and its affects are still being felt today.1 The accident occurred in the Ukraine in 1986 as a result of a flawed Soviet nuclear power plant accident. The accident is blamed on incompetent personnel who were testing the strength of the turbines after a major power outage. The machine began overheating and during its automatic shut down, it malfunctioned. The cover blew off of the reactor and two separate explosions of fission products, fuel, and graphite were blown out. These particles are known as “fall out.” The graphite burned for nine days, and the combination of all of these products released an unhealthy amount of radiation into the atmosphere.2 Some of these particles were spread through the Ukraine, Belarus, Russia, and even to some parts of Europe. It is estimated that the radiation reached up to 20,000 mSv on the first day of the explosion.2 It is thought that up to five million people were exposed to this radiation, and it has caused the largest amount of cancer incidences from a single incident ever.3 There is an undeniable link to thyroid cancer, lung cancer, leukemia, and a number of other cancers. In many ways, this ordeal is still trying to be resolved, as several countries remain in debt from the accident, and a number of people are dealing with the resulting cancers and diseases. The plant was eventually shut down.1
The patient grew up 200 miles from the Chernobyl incident and was outside playing in the rain with her sister when the fall out occurred (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.). Some cancers have a very long latent period, meaning they grow slowly and take a long time to form. While many people thought they were unaffected by the incident, it was found in later years that they were sick. Sadly enough, a tumor formed and was detected in this patient 17 years after the incident. She started seeing symptoms at 19 years of age, and had surgery soon after to debulk the tumor. Radiation therapy cancer treatment followed the surgery, and she received a 25 Gy dose of ionizing radiation in 2003 in Ukraine and a second dose of 30 Gy two years later (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.). There was a problem in locating her medical records in the Ukraine, so there is no legal documentation of these treatments; American doctors have nothing to rely on except word of the patient.
The patient’s sister moved to the United States after marrying an American, and the patient chose to follow her to the United States to seek further treatment in 2007. Since her previous medical records were not found, it is hard to know what her primary diagnosis was, so the doctors chose to focus on her future treatments and try their best to be cautious of the surrounding tissues and the tumor, while still increasing the overall dose to the tumor. Here in the U.S., she was diagnosed with a 7 by 6 centimeter mass, diagnosed as a high grade synovial sarcoma of the anterior chest wall (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.).
Sarcomas are cancers in body tissues, such as muscle, fat, and blood vessels. This patient formed a tumor in her synovial tissue, which is the tissue that lines cavities of joints. Synovial sarcoma is a very rare, slow growing, soft tissue sarcoma. These tumors can spread easily. They account for only five to ten percent of new soft tissue sarcomas each year, and the median age is 26.5 years old, which happened to be the age of this patient.4 It is linked to genetic factors, occurs mostly in young people, and favors men more than women. It is most commonly found as a mass, which can limit range of motion and cause numbness. Synovial sarcoma is generally treated with surgery and radiation therapy, as was this case.4 It usually presents in the knees or arms, but this patient's tumor was in her thorax, on her chest wall. Though rare, this type of cancer can form on the chest wall because of the pleura surrounding the lung cavities.5
The chosen patient's high grade synovial sarcoma of the anterior chest wall was labeled stage IV and multiply recurrent. Lung, mediastinal, pleural, pericardial and diaphragmatic metastases were also found, and they all were surgically excised. This is an unbelievable amount of metastases that, when totaled, means her whole thoracic cavity was bombarded with cancer cells. After the removal of her metastasis, she was given 4 cycles of chemotherapy for a systemic affect since the cancer was spreading so recklessly (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.).
Focus of this study will be placed on the radiation therapy part of her treatment. The steps of radiation therapy are simulation, treatment planning, and the actual treatment. Simulation is perhaps the most important part of the radiation therapy process because reproducibility must be accomplished. Reproducibility allows the tumor to be treated in the exact way every time, which maximizes the effects of the treatment.6 Simulation is where the patient is set up and scanned the way they will be treated on the actual machines. This patient was simulated using computed tomography. CT simulation involves an actual CT scanner, which takes only a short amount of time and gives a contour of both the patients’ body and a contour of the individual organs. This information is very useful in the treatment planning process, and is far more accurate and easier than conventional simulations.6
A typical CT simulation follows these steps: first, accessory treatment devices are made and the patient is placed in them, reference marks are made, the patient is scanned, and the scan is sent to the virtual simulation station. Having a virtual simulation station is an advantage over conventional simulations, because since the scan is on the computers, the patient may leave while the plan is created.6
In this particular case, after giving consent, the patient was simulated with chest, abdomen, and pelvic CT parameters. When setting up the CT, the lasers were placed on the medial end of the clavicle for the superior border and the pubic symphasis for the inferior border. She needed a large scan to check for metastases and localize the tumor and all surrounding normal tissues. The protocol procedure for a tumor in this general area was used, with her arms overhead, laying supine and head first. A vak-lok body fix was created for her. A vak-lok body mold is made by vacuuming the air out of the mold, allowing it to conform to its surroundings, which makes it very useful for immobilization. A body fix was chosen because the tumor was in the core of her body, and it is critical that her body and spine be lined up the same way every day. The best way to line up a spine is in a body fix because it immobilizes both the upper and lower parts of the body. After getting her body mold made and set up, the patient was given 100 mL of Isovue 370 intravenous contrast by an injector (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.). The injector releases the correct amount of contrast into the body at the right time for the scan. The 100 mL was based on the fact that she is a small person with a small frame. Larger patients call for more contrast (Larkin T. Oral communication. University of Alabama at Birmingham. June 2009.).
In the virtual work station, automatic parameters were set for an upper chest and lower abdomen CT scan. The critical structures include spinal cord, kidneys, heart, and lung, which are all of the main organs in her treatment field (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.). The tolerance doses for these structures are 45 Gy, 18 Gy, 45 Gy, and 30 Gy, respectively.7 These structures must be monitored throughout the treatment process because damage to them can cause vast side effects and a decreased quality of life. For example, if her spinal cord was overdosed, she could potentially be paralyzed, and while her cancer could be gone, she would be in a wheel chair the rest of her life. She was simulated with gating, but not treated with it. Gating means that during the treatment, the breathing cycle is tracked, and radiation is only given during a certain part of the cycle, when the tumor is in a specific place. With gating, a very large number of slices are taken, to be as specific as possible in knowing the behavior and position of the tumor. In her case, 2856 slices were taken, and they were 2.5 mm each (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.). However, because of the patient’s petite size and shallow breathing, gating did not seem to be necessary during her treatment. After the simulation, every detail is documented in the patient’s chart under “Patient Set-up” so that for each treatment, she is set up the same way and the correct area is irradiated. On the first day of treatment, the therapists follow the set up instructions, shift the table, and mark the patient for the isocenter (Larkin T. Oral communication. University of Alabama at Birmingham. June 2009.). Treatment should be smooth from this day forward.
During the treatment planning process, the dosimetrists take the CT scans and build the best plan for the tumor, including the highest dose to the tumor while minimizing the dose to the surrounding critical structures. After being under-irradiated twice before, it was important to increase the dose to try to get a higher, more therapeutic dose to the tumor. Physicians decided to treat this patient b.i.d., or "twice a day." When a patient is treated twice a day, a six hour interval must separate the treatments to allow the body time to recover from the individual doses. The patient came in daily around 8:00 AM and 3:30 PM. Because the tumor was so superficial and large, it was decided that a 5 mm “solid water” bolus would be placed over the mass on both sides of her body, to increase skin sparing and make the dose more uniform across the field (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.).
Everything about every part of the simulation, treatment planning, and treatment processes is documented. Correct documentation is important in repositioning and reproducibility, to get the maximum effect of the treatment. There are technical charges and professional charges for billing. Technical charges are charged by the hospital, and professional charges are charged directly by the physician.6 This patient was billed under the technical component, as a complex isodose plan because of the extra time her very crucial, sensitive plan took (Patient chart. The Kirklin Clinic at Acton Road. Birmingham, AL. 2009.). Her vak-lok body mold was billed as complex. To bill for treatment, when the patient is closed out after treatment, the billing program automatically pops on the screen, and if the treatment goes as normally, all of the parameters will be checked and simply click "Bill All" (Larkin T. Oral communication. University of Alabama at Birmingham. June 2009.).
As one can see, this is a very delicate and unique radiation therapy case. Sometimes people are aware of risks they are taking to acquire cancer, such as smoking cigarettes, but other times, the risk is out of one’s control. This patient is a fine example of an innocent bystander who has been battling a rare synovial sarcoma from the mistakes of nuclear plant workers in Chernobyl. When the nuclear reactor exploded, numerous people were affected, and she is just one of the many people who are still suffering from that 1986 accident. She sought treatment twice in the Ukraine for her condition, but it was not ample. After inquiring American physicians, it was decided that she would continue treatment in the U.S. While surgery and chemotherapy were included in her treatment regimen, radiation therapy also played a large role. While the simulation was complex, it was necessary. This allows the same area to get treated every time, and in doing so, the tumor gets the correct dose of radiation. She was given personalized accessories and immobilization devices to aid in treating the tumor, and her treatment finished smoothly. This is a brave and courageous young lady who has been through a tremendous amount of treatment and hardship, and as a future radiation therapist, it is our job to treat these patients and give them hope for as long as we can.
1. The Chernobyl Nuclear Accident. Kiev City Guide. 2008. Available at: http://kievukraine.info/chernobyl_facts.htm. Accessed July 2, 2009.
2. Chernobyl Accident. World Nuclear Association website. April 2009. Available at: http://www.world-nuclear.org/info/chernobyl/inf07.htm. Accessed July 1, 2009.
3. Chernobyl's cancer world record. BBC News World Edition. Available at: http://news.bbc.co.uk/2/hi/health/1615299.stm. Accessed July 14, 2009.
4. Synovial Sarcoma: Questions and Answers. National Cancer Institute website. 2005. Available at: http://www.cancer.gov/cancertopics/factsheet/Sites-Types/synovial. Accessed July 1, 2009.
5. Hung JJ, Chou TY, Sun CH, Liu JS, Hsu WH. Primary Synovial Sarcoma of the Posterior Chest Wall. The Annals of Thoracic Surgery. June 2008; 85: 2120-2122. Available at: linkinghub.elsevier.com/retrieve/pii/S0003497508000076. Accessed July 14, 2009.
6. Washington C, Leaver D. Principles and Practices of Radiation Therapy. St. Louis, Missouri: Mosby Inc; 2004.
7. Radiation Oncology/Toxicology/Emami. Wikibooks website. May 2009. Available at: http://en.wikibooks.org/wiki/Radiation_Oncology/Toxicity/Emami. Accessed July 1, 2009.