Radiological and Nuclear Terrorism: The Oncologic Emergency Response

Public concern about the possibility of terrorism involving radiological materials has grown rapidly since the September 11, 2001 terrorist attacks on New York City, the Pentagon, and Pennsylvania. Such concern is driven by the widespread availability of radiological materials and the intentions of malfeasants and organizations around the world to do harm to others. In contrast to nuclear materials, radiological materials are ubiquitous and are found in most cities throughout the country at academic institutions, hospitals, and many businesses and industrial settings. In contrast, nuclear materials are difficult to access because of their rarity and the security of the settings in which they are found. A radiological or nuclear incident of any kind will require prompt assessment of the location and nature of the incident, activation of mass casualty response systems, followed by immediate consultation of hematology, health and medical physics, and nuclear medicine personnel. Radiation-induced injuries and illnesses are typically delayed. Successful assessment and management of individuals with acute radiation syndrome (ARS), including the hematopoietic subsyndrome (HS), is required to support management of injuries resulting from a high radiation dose, including injuries to the gastrointestinal and neurovascular systems. Administration of cytokines within 24 h of exposure shortens the period of granulocytopenia and is strongly recommended by subject matter experts in the management of the HS. Hematopoietic stem cell transplantation after failure of a 2–3 week trial of cytokines has been clearly documented and is weakly recommended in selected individuals with the HS. Administration of prophylactic and therapeutic broad-spectrum antimicrobials (including antibacterial, antiviral, and antifungal agents) is recommended and should be guided by recommendations of the Infectious Diseases Society of America for management of febrile neutropenia. This article provides an overview for clinicians who are called upon in a radiological and/or nuclear incident to manage individuals with ARS and other radiation-related illnesses.