Age and sex effects across the blood proteome after ionizing radiation exposure can bias biomarker screening and risk assessment.

Molecular biomarkers of ionizing radiation (IR) exposure are a promising new tool in various disciplines: they can give necessary information for adaptive treatment planning in cancer radiotherapy, enable risk projection for radiation-induced survivorship diseases, or facilitate triage and intervention in radiation hazard events. However, radiation biomarker discovery has not yet resolved the most basic features of personalized medicine: age and sex. To overcome this critical bias in biomarker identification, we quantitated age and sex effects and assessed their relevance in the radiation response across the blood proteome. We used high-throughput mass spectrometry on blood plasma collected 24 h after 0.5 Gy total body irradiation (15 MV nominal photon energy) from male and female C57BL/6 N mice at juvenile (7-weeks-old) or adult (18-weeks-old) age. We also assessed sex and strain effects using juvenile male and female BALB/c nude mice. We showed that age and sex created significant effects in the proteomic response regarding both extent and functional quality of IR-induced responses. Furthermore, we found that age and sex effects appeared non-linear and were often end-point specific. Overall, age contributed more to differences in the proteomic response than sex, most notably in immune responses, oxidative stress, and apoptotic cell death. Interestingly, sex effects were pronounced for DNA damage and repair pathways and associated cellular outcome (pro-survival vs. pro-apoptotic). Only one protein (AHSP) was identified as a potential general biomarker candidate across age and sex, while GMNN, REG3B, and SNCA indicated some response similarity across age. This low yield advocated that unisex or uniage biomarker screening approaches are not feasible. In conclusion, age- and sex-specific screening approaches should be implemented as standard protocol to ensure robustness and diagnostic power of biomarker candidates. Bias-free molecular biomarkers are a necessary progression towards personalized medicine and integral for advanced adaptive cancer radiotherapy and risk assessment.

Increased therapeutic effect on medullary thyroid cancer using a combination of radiation and tyrosine kinase inhibitors.

Since patients with medullary thyroid cancer (MTC) often have metastatic disease at the time of diagnosis, the development of efficient systemic treatment options for MTC is important. Vandetanib and cabozantinib are two tyrosine kinase inhibitors (TKIs) that were recently approved by FDA and EMA for systemic treatment of metastatic MTC. Additionally, since MTC is of a neuroendocrine tumour type, treatment with radiolabelled somatostatin analogues (e.g. 177Lu-octreotate) is a valid option for patients with MTC. The aim of this study was to investigate the potentially increased therapeutic effect of combining radiation therapy with these TKIs for treatment of MTC in a mouse model. Nude mice carrying patient-derived MTC tumours (GOT2) were treated with external beam radiotherapy (EBRT) and/or one of the two TKIs vandetanib or cabozantinib. The tumour volume was determined and compared with that of mock-treated controls. The treatment doses were chosen to give a moderate effect as monotherapy to be able to detect any increased therapeutic effect from the combination therapy. At the end of follow-up, tumours were processed for immunohistochemical (IHC) analyses. The animals in the combination therapy groups showed the largest reduction in tumour volume and the longest time to tumour progression. Two weeks after start of treatment, the tumour volume for these mice was reduced by about 70-75% compared with controls. Furthermore, also EBRT and TKI monotherapy resulted in a clear anti-tumour effect with a reduced tumour growth compared with controls. The results show that an increased therapeutic effect could be achieved when irradiation is combined with TKIs for treatment of MTC. Future studies should evaluate the potential of using 177Lu-octreotate therapy in combination with TKIs in patients.

Reference dose determination in 60Co and high-energy radiotherapy photon beams by using Farmer-type cylindrical ionization chambers - an experimental investigation.

Ionization chamber dosimetry is predominantly used for determination of the absorbed dose to water in 60Co and high-energy radiotherapy photon beams. The most widespread ionization chambers employed for absolute or reference dose determinations in reference conditions are the Farmer-type cylindrical ionization chambers. The Farmer-type ionization chambers have a variety of constructions and materials and their responses vary in the radiation beam. Clinical accelerators, in addition to conventional photon beams with flattening-filter, can also deliver flattening-filter-free (FFF) photon beams. The responses of five different Farmer-type cylindrical ionization chambers were experimentally examined with reference to absorbed dose determination in reference conditions when using the International Atomic Energy Agency (IAEA) - American Association of Physicists in Medicine (AAPM) Technical Reports Series no. 483 (TRS-483) and the IAEA TRS-398 dosimetry protocol in the present investigation. The irradiations were performed using 60Co and megavoltage photon beams with 6 MV, 15 MV, 6 MV FFF and 10 MV FFF nominal photon energies. The chamber calibrations were performed at different Secondary Standard Dosimetry Laboratories and are traceable to primary standards at different Primary Standard Dosimetry Laboratories. The chambers were also cross-calibrated at our laboratory using 60Co γ-beam. The variation found in the data regarding the reference dose determination using the various Farmer-type chambers in the photon beams employed was about 1% at maximum. Thus, the selection of the ionization chamber in reference dose determinations may affect the outcomes. The differences in the absorbed dose values were similar in the conventional as well as in the FFF photon beams. For the FFF photon beams the absorbed dose computations were performed using the IAEA-AAPM TRS-483 dosimetry protocol. Two of the ionization chambers used had identical construction but different central electrodes, i.e. graphite versus aluminium. The results obtained using these two chambers show that, in the photon beams examined, the employed correction for the central electrode (p cel ) regarding these two chambers is associated with an inaccuracy which is larger than the calculated uncertainty for this correction. The outcomes found in the present experimental investigation using the various ionization chambers also indicate possible inaccuracy in the employed beam quality correction factors (k Q ) and imply the need for a revision of these factors.

Gemcitabine potentiates the anti-tumour effect of radiation on medullary thyroid cancer.

Patients with medullary thyroid cancer (MTC) are often diagnosed with spread tumour disease and the development of better systemic treatment options for these patients is important. Treatment with the radiolabelled somatostatin analogue 177Lu-octreotate is already a promising option but can be optimised. For example, combination treatment with another substance could increase the effect on tumour tissue. Gemcitabine is a nucleoside analogue that has been shown to sensitise tumour cells to radiation. The aim of this study was to investigate potentially additive or synergistic effects of combining radiation with gemcitabine for treatment of MTC. Nude mice transplanted with patient-derived MTC tumours (GOT2) were divided into groups and treated with radiation and/or gemcitabine. Radiation treatment was given as 177Lu-octreotate or external beam radiotherapy (EBRT). The volume of treated and untreated tumours was followed. The absorbed dose and amount of gemcitabine were chosen to give moderate tumour volume reduction when given as monotherapy to enable detection of increased effects from combination treatment. After follow-up, the mice were killed and tumours were immunohistochemically (IHC) analysed. Overall, the animals that received a combination of EBRT and gemcitabine showed the largest reduction in tumour volume. Monotherapy with EBRT or gemcitabine also resulted in a clear detrimental effect on tumour volume, while the animals that received 177Lu-octreotate monotherapy showed similar response as the untreated animals. The GOT2 tumour was confirmed in the IHC analyses by markers for MTC. The IHC analyses also revealed that the proliferative activity of tumour cells was similar in all tumours, but indicated that fibrotic tissue was more common after EBRT and/or gemcitabine treatment. The results indicate that an additive, or even synergistic, effect may be achieved by combining radiation with gemcitabine for treatment of MTC. Future studies should be performed to evaluate the full potential of combining 177Lu-octreotate with gemcitabine in patients.

Long-term mucosal injury and repair in a murine model of pelvic radiotherapy.

Chronic intestinal injury after pelvic radiotherapy affects countless cancer survivors worldwide. A comprehensive understanding of the long-term injury dynamics is prevented in available animal models. With linear accelerators that are used to treat cancer in patients, we irradiated a small volume encompassing the colorectum in mice with four fractions of 8 Gy per fraction. We then determined the long-term dynamics of mucosal injury, repair, and the duration of inflammation. We show that crypt fission, not cell proliferation, is the main long-term mechanism for rescuing crypt density after irradiation, and provides a potentially wide window for clinical interventions. Persisting macrophage aggregations indicate a chronic mucosal inflammation. A better understanding as to how crypt fission is triggered and why it fails to repair fully the mucosa may help restore bowel health after pelvic radiotherapy. Moreover, anti-inflammatory interventions, even if implemented long after completed radiotherapy, could promote bowel health in pelvic cancer survivors.

177Lu-octreotate therapy for neuroendocrine tumours is enhanced by Hsp90 inhibition.

177Lu-octreotate is an FDA-approved radionuclide therapy for patients with gastroenteropancreatic neuroendocrine tumours (NETs) expressing somatostatin receptors. The 177Lu-octreotate therapy has shown promising results in clinical trials by prolonging progression-free survival, but complete responses are still uncommon. The aim of this study was to improve the 177Lu-octreotate therapy by means of combination therapy. To identify radiosensitising inhibitors, two cell lines, GOT1 and P-STS, derived from small intestinal neuroendocrine tumours (SINETs), were screened with 1,224 inhibitors alone or in combination with external radiation. The screening revealed that inhibitors of Hsp90 can potentiate the tumour cell-killing effect of radiation in a synergistic fashion (GOT1; false discovery rate <3.2×10-11). The potential for Hsp90 inhibitor ganetespib to enhance the anti-tumour effect of 177Lu-octreotate in an in vivo setting was studied in the somatostatin receptor-expressing GOT1 xenograft model. The combination led to a larger decrease in tumour volume relative to monotherapies and the tumour-reducing effect was shown to be synergistic. Using patient-derived tumour cells from eight metastatic SINETs, we could show that ganetespib enhanced the effect of 177Lu-octreotate therapy for all investigated patient tumours. Levels of Hsp90 protein expression were evaluated in 767 SINETs from 379 patients. We found that Hsp90 expression was upregulated in tumour cells relative to tumour stroma in the vast majority of SINETs. We conclude that Hsp90 inhibitors enhance the tumour-killing effect of 177Lu-octreotate therapy synergistically in SINET tumour models and suggest that this potentially promising combination should be further evaluated.

A novel mouse model of radiation-induced cancer survivorship diseases of the gut.

A deeper understanding of the radiation-induced pathophysiological processes that develop in the gut is imperative to prevent, alleviate, or eliminate cancer survivorship diseases after radiotherapy to the pelvic area. Most rodent models of high-dose gastrointestinal radiation injury are limited by high mortality. We therefore established a model that allows for the delivering of radiation in fractions at high doses while maintaining long-term survival. Adult male C57/BL6 mice were exposed to small-field irradiation, restricted to 1.5 cm of the colorectum using a linear accelerator. Each mouse received 6 or 8 Gy, two times daily in 12-h intervals in two, three, or four fractions. Acute cell death was examined at 4.5 h postirradiation and histological changes at 6 wk postirradiation. Another group was given four fractions of 8 Gy and followed over time for development of visible symptoms. Irradiation caused immediate cell death, mainly limited to the colorectum. At 6 wk postirradiation, several crypts displayed signs of radiation-induced degeneration. The degenerating crypts were seen alongside crypts that appeared perfectly healthy. Crypt survival was reduced after the fourth fraction regardless of dose, whereas the number of macrophages increased. Angiogenesis was induced, likely as a compensatory mechanism for hypoxia. Four months postirradiation, mice began to show radiation-induced symptoms, and histological examination revealed an extensive crypt loss and fibrosis. Our model is uniquely suitable for studying the long-term trajectory and underlying mechanisms of radiation-induced gastrointestinal injury.NEW & NOTEWORTHY A novel mouse model for studying the long-term trajectory of radiation-induced gut injury. The method allows for the use of high doses and multiple fractions, with minor impact on animal health for at least 3 mo. Crypt loss and a slow progression of fibrosis is observed. Crypt degeneration is a process restricted to isolated crypts. Crypt degeneration is presented as a convenient proxy endpoint for long-term radiation-induced gut injury.

Non-targeted transcriptomic effects upon thyroid irradiation: similarity between in-field and out-of-field responses varies with tissue type.

Non-targeted effects can induce responses in tissues that have not been exposed to ionizing radiation. Despite their relevance for risk assessment, few studies have investigated these effects in vivo. In particular, these effects have not been studied in context with thyroid exposure, which can occur e.g. during irradiation of head and neck tumors. To determine the similarity between in-field and out-of-field responses in normal tissue, we used a partial body irradiation setup with female mice where the thyroid region, the thorax and abdomen, or all three regions were irradiated. After 24 h, transcriptional regulation in the kidney cortex, kidney medulla, liver, lungs, spleen, and thyroid was analyzed using microarray technology. Thyroid irradiation resulted in transcriptional regulation in the kidney medulla and liver that resembled regulation upon direct exposure of these tissues regarding both strength of response and associated biological function. The kidney cortex showed fewer similarities between the setups, while the lungs and spleen showed little similarity between in-field and out-of-field responses. Interestingly, effects were generally not found to be additive. Future studies are needed to identify the molecular mechanisms that mediate these systemic effects, so that they may be used as targets to minimize detrimental side effects in radiotherapy.

Alpha particle induced DNA damage and repair in normal cultured thyrocytes of different proliferation status.

Childhood exposure to ionizing radiation increases the risk of developing thyroid cancer later in life and this is suggested to be due to higher proliferation of the young thyroid. The interest of using high-LET alpha particles from Astatine-211 ((211)At), concentrated in the thyroid by the same mechanism as (131)I [1], in cancer treatment has increased during recent years because of its high efficiency in inducing biological damage and beneficial dose distribution when compared to low-LET radiation. Most knowledge of the DNA damage response in thyroid is from studies using low-LET irradiation and much less is known of high-LET irradiation. In this paper we investigated the DNA damage response and biological consequences to photons from Cobolt-60 ((60)Co) and alpha particles from (211)At in normal primary thyrocytes of different cell cycle status. For both radiation qualities the intensity levels of γH2AX decreased during the first 24h in both cycling and stationary cultures and complete repair was seen in all cultures but cycling cells exposed to (211)At. Compared to stationary cells alpha particles were more harmful for cycling cultures, an effect also seen at the pChk2 levels. Increasing ratios of micronuclei per cell nuclei were seen up to 1Gy (211)At. We found that primary thyrocytes were much more sensitive to alpha particle exposure compared with low-LET photons. Calculations of the relative biological effectiveness yielded higher RBE for cycling cells compared with stationary cultures at a modest level of damage, clearly demonstrating that cell cycle status influences the relative effectiveness of alpha particles.

The effect of air cavity size in cylindrical ionization chambers on the measurements in high-energy radiotherapy photon beams--an experimental study.

The present investigation is a continuation of a previous study on the effect of the diameter of the air cavity in cylindrical ionization chambers on perturbation correction factors. Measurements were made using high-energy radiotherapy photon beams (4, 6 and 15 MV) in a water phantom. Two different pairs of cylindrical ionization chambers were used. The chambers in each pair had identical materials and construction but different air cavity diameters. The same methods were employed as in our previous investigation. The diameter of the air cavity in cylindrical ionization chambers influences the mass ionization (the measured ionization expressed per unit mass of air in the chamber air cavity) at the depth where the maximum ionization is observed and a normalization at this depth is therefore not correct. The corrections obtained at depths of 50 and 100 mm in the phantom showed that the air cavity diameter in cylindrical ionization chambers has a greater effect on the perturbation effects than the photon beam quality. The corrections found at depths of 50 and 100 mm are smaller than those currently used in dosimetry protocols.

Experimental investigation of the effect of air cavity size in cylindrical ionization chambers on the measurements in 6°Co radiotherapy beams.

In the late 1970s, Johansson et al (1978 Int. Symp. National and International Standardization of Radiation Dosimetry (Atlanta 1977) vol 2 (Vienna: IAEA) pp 243-70) reported experimentally determined displacement correction factors (p(dis)) for cylindrical ionization chamber dosimetry in 6°Co and high-energy photon beams. These p(dis) factors have been implemented and are currently in use in a number of dosimetry protocols. However, the accuracy of these factors has recently been questioned by Wang and Rogers (2009a Phys. Med. Biol. 54 1609-20), who performed Monte Carlo simulations of the experiments performed by Johansson et al. They reported that the inaccuracy of the p(dis) factors originated from the normalization procedure used by Johansson et al. In their experiments, Johansson et al normalized the measured depth-ionization curves at the depth of maximum ionization for each of the different ionization chambers. In this study, we experimentally investigated the effect of air cavity size of cylindrical ionization chambers in a PMMA phantom and 6°Co γ-beam. Two different pairs of air-filled cylindrical ionization chambers were used. The chambers in each pair had identical construction and materials but different air cavity volume (diameter). A 20 MeV electron beam was utilized to determine the ratio of the mass of air in the cavity of the two chambers in each pair. This ratio of the mass of air in each pair was then used to compare the ratios of the ionizations obtained at different depths in the PMMA phantom and 6°Co γ-beam using the two pairs of chambers. The diameter of the air cavity of cylindrical ionization chambers influences both the depth at which the maximum ionization is observed and the ionization per unit mass of air at this depth. The correction determined at depths of 50 mm and 100 mm is smaller than the correction currently used in many dosimetry protocols. The results presented here agree with the findings of Wang and Rogers' Monte Carlo simulations and show that the normalization procedure employed by Johansson et al is not correct.

Unique gene expression patterns indicate microglial contribution to neural stem cell recovery following irradiation.

Ionizing radiation results in damage to neural stem cells and reduced neurogenesis. The aim of the present study was to determine intrinsic and extrinsic factors that influence neural stem cell survival following irradiation, using qPCR. Gene expression of hippocampal and SVZ neurospheres were analyzed following irradiation, and results demonstrated that irradiated hippocampal and SVZ stem cells displayed similar gene expression profiles for intrinsic genes. Irradiated microglia (extrinsic factor) isolated from the SVZ exhibited increased gene expression of growth factors involved in stem cell maintenance, proliferation, and survival. However, microglial genes in the irradiated hippocampus responded less favorably with respect to stem cell recovery. This might explain the superior recovery of SVZ compared to hippocampal stem cells following in vivo irradiation. In addition, our results show that a combination of growth factors, which were upregulated in SVZ microglia, increased the proliferation and decreased cell death of irradiated neurospheres in vitro.