X-Ray Microscopy and X-Ray Microanalysis

Purpose : The treatment of thoracic malignancies is frequently limited by the ’tolerance? of normal lung tissue. In order to learn more about the factors that influence lung tolerance an animal model that closely mimics the clinical exposure situation is required. The lungs of pigs are similar to those of man in a variety of ways and the animal?s size permits the irradiation of partial tissue volumes comparable with those used clinically; very rarely in man is the whole lung irradiated. In this report, the available data for the effects of irradiation on pig lung are reviewed as they relate to the key issues in radiotherapy. Results : The dose–effect relationships for exposure to single doses indicate that for a significant impairment in both early and late lung function and for the histological detection of fibrosis, the dose-related changes in pig and man are similar. Studies with dose-fractionation using X-rays indicate a large dependence of the iso-effective dose on fraction number and fraction size, and the parameters obtained were not significantly influenced by the time of assessment after irradiation. A simple power–law function fitted the whole data set better than the linear–quadratic model, with a fraction number exponent (N) of 0.44 +/- 0.06 for treatments given in 1–30 fractions. The alpha/beta values ranged from 0.6 to 4.86 Gy, tending to increase with the length of the followup period; however; the majority of these alpha/beta values were not significantly different from zero at the 5% level. Studies of the effect of changes in the volume of lung tissue irradiated indicated the need for care in the use of the terms ’tolerance? and ’isoeffective? dose. Doses that were iso-effective for the severity of regional damage were not matched by those for total lung function. The same level of damage in a small volume compared with a large volume had less effect, i.e. was better tolerated in terms of changes in total lung function. Conclusion : Iso-effective doses in pig and humans are lower than those for the more common laboratory animal species. This observation may be related to the differences in anatomical structure of the lungs in the different species.     

The relative biological effectiveness of fractionated doses of fast neutrons (42 MeVd----Be) for normal tissues in the pig. IV. Effects on renal function

The effects of fractionated doses of fast neutrons (42 MeVd----Be) on the radiation response of the pig kidney have been assessed and compared with those observed after X irradiation. Following X irradiation there was a marked increase in the total dose at which renal function was preserved with decreasing fraction size. The rate of this increase was dependent on the overall treatment time; for fractionated irradiation given over 18 or 39 days the exponents related to fraction number, N, were 0.36 +/- 0.03 and 0.48 +/- 0.003, respectively. In contrast, there was no significant change in the iso-effect dose for renal injury following fractionated irradiation with fast neutrons where there was also little effect of varying the overall treatment time. Analysing these data by means of the linear-quadratic (LQ) model, using both an Fe-plot and the Tucker test, gave alpha/beta ratios of 2.42 +/- 0.06 Gy and 2.99 +/- 0.16 Gy, respectively, for X-ray doses given in 18 days. For fractionated doses of X rays given in 39 days the alpha/beta ratios were 0.40 +/- 0.01 Gy and 0.47 +/- 0.02 Gy, respectively. The alpha/beta ratios for renal tissue following fast neutron irradiation obtained by the two methods were also similar, i.e. 15.00 +/- 0.60 Gy and 15.72 +/- 3.76 Gy, respectively. The pronounced fractionation effect seen with X irradiation, particularly for doses administered over 39 days as opposed to 18 days, coupled with the absence of any such effect with fast neutrons, resulted in a marked increase in relative biological effectiveness (RBE) with decreasing X-ray dose/fraction. The slopes of the resulting regression lines were -0.73 +/- 0.05 and -0.33 +/- 0.02, respectively. The lack of dose sparing associated with fractionation, or variation of the overall treatment time for fast neutron irradiation, suggests that doses administered to tumours adjacent to the kidney can be given as a few relatively large dose/fractions in a short overall treatment time without an increased risk of complications related to renal tissue. This may be of therapeutic advantage in the treatment of rapidly proliferating tumours where dose may be wasted using more conventional protracted fractionated irradiation schedules.     

Repair in mouse lung for up to 20 fractions of X rays or neutrons

Local irradiation of the mouse thorax followed by the measurement of lung damage up to 17 months after irradiation has been carried out with up to 20 fractions of 3 MeV neutrons or of 240 kV X rays. Doses per fraction down to 0.28 and 1.5 Gy respectively were used. Repair capacity and RBE values were assessed by measuring breathing rate and lethality at monthly intervals up to 17 months. Only a small sparing of neutron damage was found. Sparing with X rays continued to increase as the size of each fraction was decreased, and was the main influence on the RBE values. The single-dose RBE was approximately 1.8, increasing to approximately 5 at the lowest dose per fraction measured. Dose-response curves derived for each fraction were well fitted by the formula alpha d + beta d2 where the repair parameter alpha/beta has values of 2-4 Gy after X irradiation. A slight fall of alpha/beta with time after X irradiation was observed, from about 4 Gy for pneumonitis to about 2 Gy for late fibrosis. This was significant for lethality but not for the increase of breathing rate. With neutrons the value of alpha was much higher than with X rays and a trend of increasing value of alpha at later times after irradiation was seen. Use of the linear quadratic dose-response formula predicts a continuing increase in the sparing of X-ray damage in lung as doses per fraction are decreased below those used here, and a limiting low-dose RBE of about 7.     

Volume and dose–response effects for severe symptomatic pneumonitis after fractionated irradiation of canine lung

Purpose : To study the dose-related incidence of severe symptomatic pneumonitis following fractionated irradiation applied to three different volumes of lung in normal beagle dogs. Materials and methods : A three-dimensional treatment planning system was used to design mediastinal fields of increasing width to irradiate 33%, 67% or 100% of both lungs combined in 128 normal beagle dogs. Total doses, ranging from 27 to 72 Gy, were delivered in 1.5Gy fractions over 6 weeks. Results : No dogs irradiated to 33% of their total lung volume developed severe symptomatic pneumonitis. In the 67% volume group, logistic fit of the data showed a dose–response curve with a 50% probability of developing severe symptomatic pneumonitis (ED50) after a total dose of 56.0 Gy (52.2–66.0 Gy, 95% confidence interval, CI). The more clinically relevant ED 5 for the first 6 months after irradiation of 67% of the lung was 48.1 Gy (18.5–52.0 Gy, 95% CI). The ED 50 and ED 5 values after irradiation of the whole lung (100%) were 44.1 Gy (41.2–53.5 Gy, 95% CI) and 39.1 Gy (8.8–41.8 Gy, 95% CI) respectively. Conclusion : Severe symptomatic pneumonitis proved to be a very informative volume-effect endpoint, clearly demonstrating that irradiated lung volume is a critical parameter to be considered in assigning thoracic radiotherapy treatment parameters. Volume effects in lung are dependent on the compensatory capacity of the nonirradiated lung. Underlying pathophysiology of irradiated tissue, as well as decreased compensatory capacity of nonirradiated tissue may have a strong effect on the dose-volume response.     

Volume and dose-response effects for severe symptomatic pneumonitis after fractionated irradiation of canine lung

PURPOSE: To study the dose-related incidence of severe symptomatic pneumonitis following fractionated irradiation applied to three different volumes of lung in normal beagle dogs. MATERIALS AND METHODS: A three-dimensional treatment planning system was used to design mediastinal fields of increasing width to irradiate 33%, 67% or 100% of both lungs combined in 128 normal beagle dogs. Total doses, ranging from 27 to 72 Gy, were delivered in 1.5 Gy fractions over 6 weeks. RESULTS: No dogs irradiated to 33% of their total lung volume developed severe symptomatic pneumonitis. In the 67% volume group, logistic fit of the data showed a dose-response curve with a 50% probability of developing severe symptomatic pneumonitis (ED50) after a total dose of 56.0 Gy (52.2-66.0 Gy, 95% confidence interval, CI). The more clinically relevant ED5 for the first 6 months after irradiation of 67% of the lung was 48.1 Gy (18.5-52.0 Gy, 95% CI). The ED50 and ED5 values after irradiation of the whole lung (100%) were 44.1 Gy (41.2-53.5Gy, 95% CI) and 39.1 Gy (8.8-41.8 Gy, 95% CI) respectively. CONCLUSION: Severe symptomatic pneumonitis proved to be a very informative volume-effect endpoint, clearly demonstrating that irradiated lung volume is a critical parameter to be considered in assigning thoracic radiotherapy treatment parameters. Volume effects in lung are dependent on the compensatory capacity of the nonirradiated lung. Underlying pathophysiology of irradiated tissue, as well as decreased compensatory capacity of nonirradiated tissue may have a strong effect on the dose-volume response.     

The relative biological effectiveness of fractionated doses of fast neutrons (42 MeVd----Be) for normal tissues. III. Effects on lung function

The effect of single and fractionated doses of fast neutrons (42 MeVd----Be) on the early and late radiation responses of the pig lung have been assessed by the measurement of changes in lung function using a 133Xe washout technique. The results obtained for irradiation schedules with fast neutrons have been compared with those after photon irradiation. There was no statistically significant difference between the values for the relative biological effectiveness (RBE) for the early and late radiation response of the lung. The RBE of the neutron beam increased with decreasing size of dose/fraction with an upper limit value of 4.39 +/- 0.94 for infinitely small X-ray doses per fraction.     

Serial histopathological changes in irradiated guinea pig lung receiving conventional fractionated and hyperfractionated irradiation.

PURPOSE: To determine serial histopathological differences in guinea pig lungs receiving the same total dose as clinically used between conventional fractionated and hyperfractionated irradiation. METHODS AND MATERIALS: The guinea pigs received 80 Gy in 40 daily fractions of 2 Gy each (conventional fractionation), 80 Gy in 80 fractions of 1 Gy each twice a day (hyperfractionation), 81 Gy in 27 daily fractions of 3 Gy each (conventional fractionation), or 81 Gy in 54 fractions of 1.5 Gy each twice a day (hyperfractionation). We evaluated the histopathological changes of irradiated guinea pig lungs at 1, 2, 3, 6, 9, and 12 months after irradiation. RESULTS: The guinea pig lungs that received 81 Gy in 27 daily fractions showed histopathological changes of inflammation including formation of lymph follicles after 6 months. The lungs which received 81 Gy in 54 fractions showed similar but slightly less pronounced changes than those that received 81 Gy in 27 daily fractions. The guinea pig lungs of other groups showed no histopathological changes during the observation period. CONCLUSION: In hyperfractionated irradiation the damage to the guinea pig lung is quantitatively less than that occurring as a result of conventional fractionated irradiation of the same total dose.     

Rapid induction of cytokine gene expression in the lung after single and fractionated doses of radiation

Purpose: To investigate cytokine gene expression in the lung after single and fractionated doses of radiation, and to investigate the effect of steroids and the genetic background. Materials and methods: Expression of cytokine genes (mTNF-alpha, mIL-1alpha, mIL-1beta, mIL-2, mIL-3, mIL-4, mIL-5, mIL-6, mIFNgamma) in the lungs of C3H/HeJ and C57BL/6J mice was measured by RNase protection assay at different times after various doses of radiation. The effects of dexamethasone and fractionated radiation treatment on gene expression were also studied. Results: IL-1beta was the major cytokine induced in the lungs of C3H/HeJ mice within the first day after thoracic irradiation. Radiation doses as low as 1Gy were effective. Responses to 20Gy irradiation peaked within 4-8h and subsided by 24h. With the exception of IL-1alpha and TNF-alpha, the other cytokines that were investigated had undetectable pre-treatment mRNA levels and were not radiation inducible. Similar responses were seen in C57BL/6J mice, although TNF-alpha was induced and there were some quantitative differences. Pre-treatment of C3H/HeJ mice with dexamethasone reduced basal and induced IL-1 levels, but complete inhibition was not achieved. Dexamethasone was also effective if given immediately after irradiation. Fractionated daily doses of radiation (4Gy/day) helped to maintain cytokine gene expression for a longer period. Conclusions: Inflammatory genes are rapidly induced in the lung by irradiation. This response cannot be readily abolished by steroid pre-treatment. Fractionated treatment schedules help to perpetuate the response.     

Rapid induction of cytokine gene expression in the lung after single and fractionated doses of radiation

PURPOSE: To investigate cytokine gene expression in the lung after single and fractionated doses of radiation, and to investigate the effect of steroids and the genetic background. MATERIALS AND METHODS: Expression of cytokine genes (mTNF-alpha, mIL-1alpha, mIL-1beta, mIL-2, mIL-3, mIL-4, mIL-5, mIL-6, mIFN-gamma) in the lungs of C3H/HeJ and C57BL/6J mice was measured by RNase protection assay at different times after various doses of radiation. The effects of dexamethasone and fractionated radiation treatment on gene expression were also studied. RESULTS: IL-1beta was the major cytokine induced in the lungs of C3H/HeJ mice within the first day after thoracic irradiation. Radiation doses as low as 1 Gy were effective. Responses to 20 Gy irradiation peaked within 4-8h and subsided by 24 h. With the exception of IL-1alpha and TNF-alpha, the other cytokines that were investigated had undetectable pre-treatment mRNA levels and were not radiation inducible. Similar responses were seen in C57BL/6J mice, although TNF-alpha was induced and there were some quantitative differences. Pre-treatment of C3H/HeJ mice with dexamethasone reduced basal and induced IL-1 levels, but complete inhibition was not achieved. Dexamethasone was also effective if given immediately after irradiation. Fractionated daily doses of radiation (4 Gy/day) helped to maintain cytokine gene expression for a longer period. CONCLUSIONS: Inflammatory genes are rapidly induced in the lung by irradiation. This response cannot be readily abolished by steroid pre-treatment. Fractionated treatment schedules help to perpetuate the response.     

Lack of effect of small high-dose volumes on the dose–response relationship for the development of fibrosis in distant parts of the ipsilateral lung in mini-pigs

Purpose : Multi-field radiation therapy for intrathoracic tumours results in a heterogeneous dose distribution in lung tissue. This study investigated whether irradiation of small lung volumes with high fibrogenic doses affects the dose–response relationship for development of fibrosis in distant parts of the ipsilateral lung of mini-pigs. Materials and methods : The whole right lung of 26 ’Mini-Lewe? pigs was irradiated with homogeneous doses of between 25 Gy and 40 Gy given in five equal fractions using opposing anterior–posterior portals and a linear accelerator. Another 32 animals were irradiated with a constant dose of 35 Gy to a small house-shaped high-dose field (base 3.0 cm, height 4 cm) located 3 cm caudolateral to the right hilus, while the surrounding right lung received either no irradiation or homogeneous doses of between 20 Gy and 30 Gy. The radiation fields were simulated and port films were obtained for each of the 10 fields in all pigs. Fibrosis was quantified 9 months after irradiation by determination of the hydroxyproline (HP) content of the 32 high-dose volumes and in the lung apex and the basolateral lung of all 58 pigs. Based on the reference value for the HP-ratio, i.e. the HP-concentration of the right lung over the left lung, obtained in 12 unirradiated control animals, the experimental results were converted into quantal data for probit analysis, a responder being an animal with an HP-ratio > 1.33. Results : A dose–response relationship for the HP-ratio was obtained in the different lung sites and irradiation groups. For a given dose level the mean HP-ratios and response rates did not differ systematically between the lung apex and the basolateral lung. Probit analysis of the pooled data produced ED 50 values of 21.8 Gy (95% CI 12–37) for irradiation without a high-dose volume and 25.9 Gy (24–28) for irradiation with a high-dose volume. These values are not significantly different. The results from both irradiation groups could be well fitted by a common dose–response curve with an ED 50 value of 26.1 Gy. Unexpectedly, the response rates in the high-dose volume increased with increasing dose to the surrounding right lung. Analysis of the port films provided an explanation for this finding: inaccuracies in daily field positioning. When this error was corrected for by use of the mean dose to the high-dose volume, a dose–response curve with an ED 50 of 25.2 Gy (22–29) was determined for the high-dose volume. Conclusions : The results of the study indicate that the irradiation of a small lung volume with high fibrogenic doses does not affect the dose–response relationship for development of fibrosis in distant parts of the ipsilateral lung.     

Usefulness of intensity-modulated radiation therapy for breast conserving radiation therapy: a three-dimensional treatment planning system comparison of irradiation methods

Until recently, conservative radiation therapy of breast cancer using a wedge-filter combined with rectangular tangential irradiation was widely carried out. This method of irradiation creates uniform dose distribution in the target, minimizing the radiation dose to the lung. However, this method of irradiation results in many cases in which the amount of dose in the irradiated area differs as a result of the shape and size of the breast. It is necessary to prevent excessive doses from reaching the lung. IMRT ensures a uniform dose to the target. Therefore, IMRT was examined because of the possibility that the normal tissue dose can be effectively utilized in cases of conservative radiation therapy of breast cancer by providing a minimum dose. To compare the irradiation of each method of rectangular tangential irradiation, an electronic compensator (ELC), and IMRT, which uses Dynamic MLC, we evaluated target dose uniformity, standard deviation, and target differential DVH in 13 examples. We evaluated the lung dose of the irradiated side (V(30), 30 Gy volume) of the lung to the volume of the lung on the irradiated side based on the report of Hernando.(6)) With this method of irradiation, irrespective of the difference in the shape and size of the target, dose uniformity with ELC was very good. IMRT can reduce the lung dose in comparison with the other irradiation methods. However, it is apt to cause a high-dose area in the irradiation field. In addition, it affects the target and the skin-extracting contour, and the dose to the skin surface declines. Although ELC cannot offer lung doses that are as low as those of IMRT, most of the 13 examples planned for cure with ELC showed rates of 22% of V(30) and below. In conservative radiation therapy of breast cancer, ELC is more effective than the rectangular tangential irradiation method and IMRT.     

Acute response of mouse kidney clonogens to fractionated irradiation in situ and then assayed in primary culture

Although the difference in sensitivity to the changes in dose fraction size between early-responding and late-responding tissues is well established, the underlying mechanisms in terms of target-cell responses are not yet clearly identified for any tissue. The radiosensitivity of mouse kidney cells after in situ single-dose, 2, 8, and 16 fraction X-irradiations was measured in primary culture using a clonogenic assay. The assay was made 12 h after single doses or 12 h after the last dose of the multifraction regimens. When analysed using the linear-quadratic model, as predicted the individual alpha components for all the different fractionation schedules were not significantly different, and the changes in the beta values were consistent with those expected on the basis of the reciprocal fraction numbers. When all four data sets were integrated to derive a common alpha/beta ratio, the result was 4.4 +/- 1.3 (1SE) Gy, or 2.8 +/- 0.9 Gy (a better fit) if the single-dose data set was excluded. These values fall into the range reported for kidney using assays of tissue function at long times after irradiation. Hence, it has been shown for the first time that the fractionation sensitivity of a late-responding organ is mimicked by that of a clonogenic cell population in that organ. The evidence also suggests that the time available prior to fixation of potentially lethal damage does not influence the low alpha/beta ratio observed for the kidney.     

Lack of effect of small high-dose volumes on the dose-response relationship for the development of fibrosis in distant parts of the ipsilateral lung in mini-pigs

PURPOSE: Multi-field radiation therapy for intrathoracic tumours results in a heterogeneous dose distribution in lung tissue. This study investigated whether irradiation of small lung volumes with high fibrogenic doses affects the dose-response relationship for development of fibrosis in distant parts of the ipsilateral lung of mini-pigs. MATERIALS AND METHODS: The whole right lung of 26 'Mini-Lewe' pigs was irradiated with homogeneous doses of between 25 Gy and 40 Gy given in five equal fractions using opposing anterior-posterior portals and a linear accelerator. Another 32 animals were irradiated with a constant dose of 35 Gy to a small house-shaped high-dose field (base 3.0 cm, height 4 cm) located 3 cm caudolateral to the right hilus, while the surrounding right lung received either no irradiation or homogeneous doses of between 20 Gy and 30 Gy. The radiation fields were simulated and port films were obtained for each of the 10 fields in all pigs. Fibrosis was quantified 9 months after irradiation by determination of the hydroxyproline (HP) content of the 32 high-dose volumes and in the lung apex and the basolateral lung of all 58 pigs. Based on the reference value for the HP-ratio, i.e. the HP-concentration of the right lung over the left lung, obtained in 12 unirradiated control animals, the experimental results were converted into quantal data for probit analysis, a responder being an animal with an HP-ratio > 1.33. RESULTS: A dose-response relationship for the HP-ratio was obtained in the different lung sites and irradiation groups. For a given dose level the mean HP-ratios and response rates did not differ systematically between the lung apex and the basolateral lung. Probit analysis of the pooled data produced ED50 values of 21.8 Gy (95% CI 12-37) for irradiation without a high-dose volume and 25.9 Gy (24-28) for irradiation with a high-dose volume. These values are not significantly different. The results from both irradiation groups could be well fitted by a common dose-response curve with an ED50 value of 26.1 Gy. Unexpectedly, the response rates in the high-dose volume increased with increasing dose to the surrounding right lung. Analysis of the port films provided an explanation for this finding: inaccuracies in daily field positioning. When this error was corrected for by use of the mean dose to the high-dose volume, a dose-response curve with an ED50 of 25.2 Gy (22-29) was determined for the high-dose volume. CONCLUSIONS: The results of the study indicate that the irradiation of a small lung volume with high fibrogenic doses does not affect the dose-response relationship for development of fibrosis in distant parts of the ipsilateral lung.     

Th2 cells as effectors in postirradiation pulmonary damage preceding fibrosis in the rat.

PURPOSE: Radiation-induced pneumonitis and subsequent pulmonary fibrosis are important dose-limiting complications of radiotherapy. Their pathogenesis is known only in part. T-lymphocytes comprise a significant part of the infiltrating cells but little is known about their role. The aim of this study was to define the function of T-lymphocytes during development of postirradiation pneumonitis and pulmonary fibrosis. MATERIALS AND METHODS: Rats received a unilateral lung irradiation of 20 Gy. Kinetics of T-lymphocytes isolated from irradiated and non-irradiated lungs were analysed. Subsequent CD4 depletion experiments were performed to affirm the importance of CD4+ T-cells in the development of lung fibrosis. Finally, the T helper-cell subtype of the T-lymphocytes was analysed by determining the cytokine mRNA by RT-PCR. RESULTS: A selective increase of CD4+ T-cells was observed peaking 4 weeks after irradiation in the irradiated lungs. When rats were depleted of these cells, the postirradiation thickening of parenchyma was significantly reduced as determined by morphometric analysis of lung tissue sections. In addition, it was found that IL-4 mRNA was selectively increased in the CD4+ T-cells isolated from irradiated lungs, which indicates a lymphocyte reactivity dominated by Th2 cells. CONCLUSION: The results suggest a critical role for Th2 CD4+ T-lymphocytes in the pathogenesis of radiation-induced pneumonitis preceding lung fibrosis.     

Bronchoalveolar lavage and interstitial cells have different roles in radiation-induced lung injury

PURPOSE: To determine the contribution of intra-alveolar cells as opposed to cells fixed in the interstitium in the development of radiation-induced lung injury. MATERIALS AND METHODS: C3H/HeN mice were irradiated to the thorax with various doses of radiation. The cellular composition and cytokine production were assessed in the two sites by histological staining and RNase protection assay. RESULTS: Following thoracic irradiation, there was an initial decrease in the number of bronchial alveolar lavage (BAL) cells that was followed after 2 months by a dose-dependent increase up to 4 months. Foamy Mac-1 positive macrophages were present early in the BAL populations, which also expressed the pro-inflammatory cytokines TNF-alpha, IL-1alpha and IL-1beta, but this response subsided by the time of onset of pneumonitis (3 months). In contrast, in whole lung tissue there was a steady increase in Mac-1 positive cells and increased expression of TNF-alpha, IL-1alpha and IL-1beta mRNAs to maximum levels at 3-4 months. CONCLUSIONS: These data indicate distinct temporal and spatial changes in pro-inflammatory cytokine gene expression in different cellular compartments of the irradiated lung. BAL cells became inflammatory early on, but interstitial cells became involved later and were probably more involved in contributing to the pneumonitis.     

Quantitative clinical radiobiology of early and late lung reactions

Purpose : To quantify the response of human lung to a course of fractionated radiotherapy based on a literature review of published clinical data. Materials and methods : Quantitative clinical radiobiology is concerned with the estimation of parameters that describe the clinical outcome of radiotherapy as a function of patient and treatment characteristics. Here, parameters describing the steepness of the dose–response curve, the response to a change in dose per fraction and to a change in overall treatment time for early and late lung injury are compiled based on published clinical studies. Results : Two phases of lung injury are seen, radiation pneumonitis and lung fibrosis. The first signs of early lung changes are seen almost immediately after irradiation. This reaction peaks after 5 to 6 months, and settles partially before 9–10 months. Around that time, the late changes become manifest and these are stable in most cases. There is an important distinction between lung injury and radiotherapy-related morbidity, as even severe changes in a small volume may not give rise to any clinical symptoms. Many assays have been developed for lung damage, and these highlight various clinical and biological aspects of lung damage. Here, the literature on steepness of dose–response curves and fractionation sensitivity is reviewed and quantified by the alpha/beta ratio of the linear-quadratic model for both radiation pneumonitis and lung fibrosis. For the early phase a significant time factor exists. Current best estimates for these radiobiological parameters are derived. Other external factors affecting these estimates are briefly discussed. Conclusions : Quantitative estimates of radiobiological characteristics of human lung are available for the pneumonitis phase where the fractionation sensitivity is in the same range as for most late-responding normal tissues. Short intensive schedules may also bear an added risk for pneumonitis as the dose recovered per day is around 0.5 Gy. For the later phase of lung fibrosis, the estimates are fewer and generally less precise. It is clear though, that the alpha/beta ratio is low, possibly 2–3 Gy. No time factor has been demonstrated for the late reaction. Due to the considerable physiological reserve capacity in the normal human lung, the relationship between damage and morbidity depends strongly on the lung volume affected. It therefore seems likely that for small volumes irradiated to high doses, the dose-limiting complications may not be due to restriction of lung function, but rather to haemorrhage and formation of fistulae.     

Quantitative clinical radiobiology of early and late lung reactions

PURPOSE: To quantify the response of human lung to a course of fractionated radiotherapy based on a literature review of published clinical data. MATERIALS AND METHODS: Quantitative clinical radiobiology is concerned with the estimation of parameters that describe the clinical outcome of radiotherapy as a function of patient and treatment characteristics. Here, parameters describing the steepness of the dose-response curve, the response to a change in dose per fraction and to a change in overall treatment time for early and late lung injury are compiled based on published clinical studies. RESULTS: Two phases of lung injury are seen, radiation pneumonitis and lung fibrosis. The first signs of early lung changes are seen almost immediately after irradiation. This reaction peaks after 5 to 6 months, and settles partially before 9-10 months. Around that time, the late changes become manifest and these are stable in most cases. There is an important distinction between lung injury and radiotherapy-related morbidity, as even severe changes in a small volume may not give rise to any clinical symptoms. Many assays have been developed for lung damage, and these highlight various clinical and biological aspects of lung damage. Here, the literature on steepness of dose-response curves and fractionation sensitivity is reviewed and quantified by the alpha/beta ratio of the linear-quadratic model for both radiation pneumonitis and lung fibrosis. For the early phase a significant time factor exists. Current best estimates for these radiobiological parameters are derived. Other external factors affecting these estimates are briefly discussed. CONCLUSIONS: Quantitative estimates of radiobiological characteristics of human lung are available for the pneumonitis phase where the fractionation sensitivity is in the same range as for most late-responding normal tissues. Short intensive schedules may also bear an added risk for pneumonitis as the dose recovered per day is around 0.5 Gy. For the later phase of lung fibrosis, the estimates are fewer and generally less precise. It is clear though, that the alpha/beta ratio is low, possibly 2-3 Gy. No time factor has been demonstrated for the late reaction. Due to the considerable physiological reserve capacity in the normal human lung, the relationship between damage and morbidity depends strongly on the lung volume affected. It therefore seems likely that for small volumes irradiated to high doses, the dose-limiting complications may not be due to restriction of lung function, but rather to haemorrhage and formation of fistulae.     

Identification of radiation response genes and proteins from mouse pulmonary tissues after high-dose per fraction irradiation of limited lung volumes

Purpose: The molecular effects of focal exposure of limited lung volumes to high-dose per fraction irradiation (HDFR) such as stereotactic body radiotherapy (SBRT) have not been fully characterized. In this study, we used such an irradiation system and identified the genes and proteins after HDFR to mouse lung, similar to those associated with human therapy.

Methods and materials: High focal radiation (90?Gy) was applied to a 3-mm volume of the left lung of C57BL6 mice using a small-animal stereotactic irradiator. As well as histological examination for lungs, a cDNA micro array using irradiated lung tissues and a protein array of sera were performed until 4 weeks after irradiation, and radiation-responsive genes and proteins were identified. For comparison, the long-term effects (12 months) of 20?Gy radiation wide-field dose to the left lung were also investigated.

Results: The genes ermap, epb4.2, cd200r3 (up regulation) and krt15, hoxc4, gdf2, cst9, cidec, and bnc1 (down-regulation) and the proteins of AIF, laminin, bNOS, HSP27, β-amyloid (upregulation), and calponin (downregulation) were identified as being responsive to 90?Gy HDFR. The gdf2, cst9, and cidec genes also responded to 20?Gy, suggesting that they are universal responsive genes in irradiated lungs. No universal proteins were identified in both 90?Gy and 20?Gy. Calponin, which was downregulated in protein antibody array analysis, showed a similar pattern in microarray data, suggesting a possible HDFR responsive serum biomarker that reflects gene alteration of irradiated lung tissue. These genes and proteins also responded to the lower doses of 20?Gy and 50?Gy HDFR.

Conclusions: These results suggest that identified candidate genes and proteins are HDFR-specifically expressed in lung damage induced by HDFR relevant to SBRT in humans.     

Early retardation of 99mTc-DTPA radioaerosol transalveolar clearance in irradiated canine lung.

The alteration of 99mTc-labeled diethylenetriaminepentaacetic acid (DTPA) transalveolar clearance in an initial phase of radiation lung injury was experimentally investigated. METHODS: Fourteen dogs were irradiated to the hemithorax with a single dose of 20 Gy. A DTPA radioaerosol study was performed before irradiation and on day 12 after irradiation. On day 14, the DTPA study was repeated again, with seven animals undergoing the study after inhalation of an aerosolized synthetic surfactant. The penetration index (P.I.) and clearance half-time (T(1/2)) of DTPA were measured in each lung. To evaluate the changes in lung surfactant after irradiation, alveolar lipids were stained in the resected lungs (n = 14), and the amounts of alveolar surfactant phospholipid and protein were measured by a bronchoalveolar lavage study in another six irradiated dogs. RESULTS: In all of the 14 irradiated animals, DTPA radioaerosol distributed uniformly throughout the lungs without significant changes in P.I. The T(1/2) values in irradiated lungs were significantly prolonged compared with the matched baseline values and those in nonirradiated lungs (P < 0.05 and 0.001, respectively). The aerosolized synthetic surfactant retarded the DTPA clearance both in the irradiated and in the nonirradiated lungs (P < 0.001) without significant changes in P.I. The histologic and bronchoalveolar lavage studies revealed an increase of alveolar surfactant materials in the irradiated lungs without substantial histologic changes in the alveolar structures. CONCLUSION: DTPA transalveolar clearance was retarded soon after irradiation. Increased alveolar surfactant may be partly responsible for this retarded DTPA clearance because the aerosolized synthetic surfactant also prolonged the clearance in nonirradiated lungs. A DTPA clearance test is sensitive for the early detection of radiation lung injury and seems helpful for clarifying the association of epithelial integrity changes and lung surfactant in radiation lung injury.