Low Dose-rate Studies Research Articles

PSOR6 Presentation Time: 11:55 AM: A Scoping Review of Immune Changes After Prostate Brachytherapy

<h3>Purpose</h3> Prostate brachytherapy (BT), with either low-dose-rate (LDR) or high-dose-rate (HDR), delivers a highly conformal and heterogeneous dose, allowing for dose escalation beyond external beam radiotherapy (EBRT). Whether this different dose deposition results in opportunistic biological changes that could be harnessed to improve outcomes is not well studied. Given the increasing interest in incorporating immunotherapy into prostate cancer treatment, we sought to investigate the impact of prostate BT on the immune system. <h3>Materials Methods</h3> A scoping review was performed using PubMed and Scopus for papers published between 2011-2021. Search terms used were "brachytherapy" AND "immune" AND "prostate". A total of 62 records were identified. After review, 6 studies were identified for review that included information an immune assessment on patient samples (tissue and/or blood) after prostate BT. <h3>Results</h3> 2 LDR studies (N=68) evaluated changes in the peripheral blood following I-125 BT monotherapy. Both studies demonstrated significant increases in peripheral CD3+ T cells and CD4+ T cells post-BT. However, increased circulating CD8+ T cells were observed in only one study. One study also demonstrated significant increases in Treg subsets up to 150 days post-treatment, which may be compensatory to increased cytotoxic T cell titers. 4 HDR studies (N=37) were identified (HDR fraction sizes 10-15 Gy), and all were done in combination with EBRT. Androgen deprivation therapy was included, for select patients, and one study included nivolumab. Three looked at changes in tissue immune infiltrates seen in post-BT biopsies and 1 looked at changes in both tissue and blood. The largest study (N=24) showed a single 10 Gy fraction of HDR converted 80% of "cold" tumors into an "intermediate" or "hot" state, based on a tumor inflammation signature, when comparing a pre-BT biopsy to a biopsy done prior to HDR fraction 2. In another study (N=6) a significant correlation between increased pathologic response (no tumor in ≥ 4/6 cores) and increased CD4+ and CD8+ T cells in prostate tissue as well as CD4+ T cells in the blood was seen (p values not reported). Tumor infiltrating lymphocyte recruitment may be context dependent given a case report demonstrated decreased T cell infiltration post BT+EBRT. Finally, in a separate study (N=6), peripheral blood analysis demonstrated increased CD8+ T cells with an activated phenotype, decreased CD4+/CD8+ T ratio, decreased CD4+ helper T cells, and increased CD4+PD1+ cells at 3 months post-treatment when compared to baseline levels EBRT. Patients with PSA<0.02 at 3 months were also more likely to have increased CD4+ PD1+ T cells. <h3>Conclusion</h3> Both LDR and HDR BT can invoke an immune activating phenotype in prostate cancer; however, changes in immunosuppressive cells are also seen. Additional data is needed to understand how to better promote synergy between these changes and improving clinical outcomes.

Developmental, Morphological and Physiological Traits in Plants Exposed for Five Generations to Chronic Low-Level Ionising Radiation.

The effects of ionising radiation (IR) on plants are important for environmental protection but also in agriculture, horticulture, space science, and plant stress biology. Much current understanding of the effects of IR on plants derives from acute high-dose studies but exposure to IR in the environment frequently occurs at chronic low dose rates. Chronic low dose-rate studies have primarily been field based and examined genetic or cytogenetic endpoints. Here we report research that investigated developmental, morphological and physiological effects of IR on Arabidopsis thaliana grown over 7 generations and exposed for five generations to chronic low doses of either 137Cs (at a dose rate of c. 40 μGy/h from β/γ emissions) or 10 μM CdCl2. In some generations there were significant differences between treatments in the timing of key developmental phases and in leaf area or symmetry but there were, on the basis of the chosen endpoints, no long-term effects of the different treatments. Occasional measurements also detected no effects on root growth, seed germination rates or redox poise but in the generation in which it was measured exposure to IR did decrease DNA-methylation significantly. The results are consistent with the suggestion that chronic exposure to c. 40 μGy/h can have some effects on some traits but that this does not affect function across multiple generations at the population level. This is explained by the redundancy and/or degeneracy between biological levels of organization in plants that produces a relatively loose association between genotype and phenotype. The importance of this explanation to understanding plant responses to stressors such as IR is discussed. We suggest that the data reported here provide increased confidence in the Derived Consideration Reference Levels (DCRLs) recommended by the International Commission for Radiological Protection (ICRP) by providing data from controlled conditions and helping to contextualize effects reported from field studies. The differing sensitivity of plants to IR is not well understood and further investigation of it would likely improve the use of DCRLs for radiological protection.

Radiation epidemiology and health effects following low-level radiation exposure

Radiation epidemiology is the study of human disease following radiation exposure to populations. Epidemiologic studies of radiation-exposed populations have been conducted for nearly 100 years, starting with the radium dial painters in the 1920s and most recently with large-scale studies of radiation workers. As radiation epidemiology has become increasingly sophisticated it is used for setting radiation protection standards as well as to guide the compensation programmes in place for nuclear weapons workers, nuclear weapons test participants, and other occupationally exposed workers in the United States and elsewhere. It is known with high assurance that radiation effects at levels above 100–150 mGy can be detected as evidenced in multiple population studies conducted around the world. The challenge for radiation epidemiology is evaluating the effects at low doses, below about 100 mGy of low-linear energy transfer radiation, and assessing the risks following low dose-rate exposures over years. The weakness of radiation epidemiology in directly studying low dose and low dose-rate exposures is that the signal, i.e. the excess numbers of cancers associated with low-level radiation exposure, is so very small that it cannot be seen against the very high background occurrence of cancer in the population, i.e. a lifetime risk of incidence reaching up to about 38% (i.e. 1 in 3 persons will develop a cancer in their lifetime). Thus, extrapolation models are used for the management of risk at low doses and low dose rates, but having adequate information from low dose and low dose-rate studies would be highly desirable. An overview of recently conducted radiation epidemiologic studies which evaluate risk following low-level radiation exposures is presented. Future improvements in risk assessment for radiation protection may come from increasingly informative epidemiologic studies, combined with mechanistic radiobiologic understanding of adverse outcome pathways, with both incorporated into biologically based models.

Recent Epidemiologic Studies and the Linear No-Threshold Model For Radiation Protection-Considerations Regarding NCRP Commentary 27.

National Council on Radiation Protection and Measurements Commentary 27 examines recent epidemiologic data primarily from low-dose or low dose-rate studies of low linear-energy-transfer radiation and cancer to assess whether they support the linear no-threshold model as used in radiation protection. The commentary provides a critical review of low-dose or low dose-rate studies, most published within the last 10 y, that are applicable to current occupational, environmental, and medical radiation exposures. The strengths and weaknesses of the epidemiologic methods, dosimetry assessments, and statistical modeling of 29 epidemiologic studies of total solid cancer, leukemia, breast cancer, and thyroid cancer, as well as heritable effects and a few nonmalignant conditions, were evaluated. An appraisal of the degree to which the low-dose or low dose-rate studies supported a linear no-threshold model for radiation protection or on the contrary, demonstrated sufficient evidence that the linear no-threshold model is inappropriate for the purposes of radiation protection was also included. The review found that many, though not all, studies of solid cancer supported the continued use of the linear no-threshold model in radiation protection. Evaluations of the principal studies of leukemia and low-dose or low dose-rate radiation exposure also lent support for the linear no-threshold model as used in protection. Ischemic heart disease, a major type of cardiovascular disease, was examined briefly, but the results of recent studies were considered too weak or inconsistent to allow firm conclusions regarding support of the linear no-threshold model. It is acknowledged that the possible risks from very low doses of low linear-energy-transfer radiation are small and uncertain and that it may never be possible to prove or disprove the validity of the linear no-threshold assumption by epidemiologic means. Nonetheless, the preponderance of recent epidemiologic data on solid cancer is supportive of the continued use of the linear no-threshold model for the purposes of radiation protection. This conclusion is in accord with judgments by other national and international scientific committees, based on somewhat older data. Currently, no alternative dose-response relationship appears more pragmatic or prudent for radiation protection purposes than the linear no-threshold model.

Small dose rate changes significantly affect the magnitude of cellular signaling in response to high LET exposure

Purpose: The purpose of this study was to determine whether small differences in dose rate influence cellular response following radiation exposure.Introduction: Astronauts will receive chronic low-dose exposure to charged particles during space travel. The heterogeneous mix of energetic heavy ions in the space radiation environment poses a major challenge to understanding the biological significance of these exposures. Estimating the relative risk for carcinogenesis from high LET (linear energy transfer) exposures and identifying ways to mitigate these risks are key to ensuring the future safety of astronauts. Several factors complicate the accurate modeling of cancer risk from these exposures. In addition to dose effects, the rate at which dose is delivered plays a key role in the biological consequences of high LET exposure. Low-dose rate studies thus far have assessed differences between acute doses of a couple of minutes in comparison with prolonged exposures that are delivered over the course of a day or longer. Our studies aim to understand if small differences in dose rate delivered between 0.5 and 2 min show any biological effect. In these studies, we have utilized ATM-mediated phosphorylation of ATF2 in response to radiation exposure as a tool to evaluate dose rate effects. As mammary tissues are radiation-sensitive and are of particular interest to NASA, our studies were carried with isogenic mammary epithelial and fibroblasts cells.Materials and methods: Normal human primary mammary epithelial and fibroblast cells were initiated 1 week prior to X-ray or Fe 1000 MeV/u exposure. Cells at ∼80% confluency on the day of irradiation were irradiated at room temperature. Cells were fixed and stained at early time points (0.5–24 h) following different dose exposures for flow cytometry analysis of phospho-ATF2 as described previously [ 1]. The mean fold induction of pATF2 fluorescence in cells in the G1 phase of cell cycle was determined relative to control samples.Results: Small dose rate changes, ∼2–2.5 fold change, resulted in obvious changes in the levels of phospho-signaling observed. The earliest time point (0.5 h) revealed the greatest effect from small dose rate changes, with most differences eliminated by 24 h post-exposure. Different cell types revealed differences in the effects observed with fibroblasts showing a greater induction with higher dose rate and epithelial cells showing a greater induction post-low-dose rate exposures. An example of the notable difference in phospho-protein induction observed in the fibroblast strain when even a minor difference in dose rate is used (2-2.5 fold) is shown in Fig. 1.Conclusion: The phospho-signaling profile for a key DNA damage-response protein, pATF2, was measured at both early and late (0.5–24 h) time points. Our studies reveal that even small dose rate changes show significant differences in terms of the levels of phospho-protein induction. Cell type is a major determinate in this effect, and could predict the late consequences of exposure. Fig. 1.Comparison of phospho ATF2 induction in a primary fibroblast line (184 Fb) upon exposure to a high dose rate (HDR) vs a low dose rate (LDR) of Fe 1000 MeV/u. A notable difference is observed at all doses even though the difference between dose rates is very minor (2-2.5 fold).

DEVELOPMENT AND CHARACTERIZATION OF A NOVEL VARIABLE LOW DOSE-RATE IRRADIATOR FOR IN VIVO MOUSE STUDIES

Radiation exposure of humans generally results in low doses delivered at low dose rate. Our limited knowledge of the biological effects of low dose radiation is mainly based on data from the atomic bomb Life Span Study (LSS) cohort. However, the total doses and dose rates in the LSS cohort are still higher than most environmental and occupational exposures in humans. Importantly, the dose rate is a critical determinant of health risks stemming from radiation exposure. Understanding the shape of the dose-rate response curve for different biological outcomes is thus crucial for projecting the biological hazard from radiation in different environmental and man-made conditions. A significant barrier to performing low dose-rate studies is the difficulty in creating radiation source configurations compatible with long-term cellular or animal experiments. In this study the design and characterization of a large area, I-based irradiator is described. The irradiator allows continuous long-term exposure of mice at variable dose rates and can be sited in standard animal care facilities. The dose rate is determined by the level of I activity added to a large NaOH-filled rectangular phantom. The desired dose rate is maintained at essentially constant levels by weekly additions of I to compensate for decay. Dosimetry results for long-term animal irradiation at targeted dose rates of 0.00021 and 0.0021 cGy min are presented.

LOW-DOSE RADIATION EPIDEMIOLOGY STUDIES: STATUS AND ISSUES

Although the Japanese atomic bomb study and radiotherapy studies have clearly documented cancer risks from high-dose radiation exposures, radiation risk assessment groups have long recognized that protracted or low exposures to low-linear energy transfer radiations are key radiation protection concerns because these are far more common than high-exposure scenarios. Epidemiologic studies of human populations with low-dose or low dose-rate exposures are one approach to addressing those concerns. A number of large studies of radiation workers (Chernobyl clean-up workers, U.S. and Chinese radiological technologists, and the 15-country worker study) or of persons exposed to environmental radiation at moderate to low levels (residents near Techa River, Semipalatinsk, Chernobyl, or nuclear facilities) have been conducted. A variety of studies of medical radiation exposures (multiple-fluoroscopy, diagnostic (131)I, scatter radiation doses from radiotherapy, etc.) also are of interest. Key results from these studies are summarized and compared with risk estimates from the Japanese atomic bomb study. Ideally, one would like the low-dose and low dose-rate studies to guide radiation risk estimation regarding the shape of the dose-response curve, DDREF (dose and dose-rate effectiveness factor), and risk at low doses. However, the degree to which low-dose studies can do so is subject to various limitations, especially those pertaining to dosimetric uncertainties and limited statistical power. The identification of individuals who are particularly susceptible to radiation cancer induction also is of high interest in terms of occupational and medical radiation protection. Several examples of studies of radiation-related cancer susceptibility are discussed, but none thus far have clearly identified radiation-susceptible genotypes.

Conditions for the equivalence of continuous to pulsed low dose rate brachytherapy

Low dose rate interstitial brachytherapy is extremely useful for those tumors that are accessible for an implant, while the introduction of remote afterloaders has eliminated exposure to nursing personnel. Currently, such machines require an inventory of many sources which are loaded into catheters implanted in the tumor and kept in place during treatment. A significant simplification of such machines would be possible in a pulsed mode, with a single source moving under computer control through the catheters. Assuming that the treatment time and average dose rate are kept unchanged, the question addressed is to find those combinations of radiation pulse widths and frequencies that would be functionally equivalent to a continuous irradiation. The linear-quadratic formalism was used to reanalyze published low dose-rate studies on cells of human origin to obtain 36 parameter sets (α, β, T 1 2 , where T 1 2 is the half time for sublethal damage repair. These data are consistent with those for human tumors. For each parameter set, those combinations of pulse width and frequency were calculated that would yield a functionally equivalent cell survival. For a regimen of 30 Gy in 60 hr, a pulse width of 10 min with a period between pulses of 1 hr would be appropriate for all the cell lines considered. Similar results were found for other possible time/dose combinations. For late effects, a 1-hr period between 10-min pulses might produce up to a 2% increase in late-effect probability, which is probably acceptable for the small volumes irradiated in interstitial brachytherapy.

Response of cells of human origin, normal and malignant, to acute and low dose rate irradiation

Dose response curves were obtained for normal human fibroblasts and for several cell lines derived from human tumors, including melanomas and an osteosarcoma. Most of the tumor lines are similar in radiosensitivity to the normal fibroblasts, except for the melanoma lines, which are significantly more resistant. The two melanoma lines differ, one being much more radioresistant than the other. Potentially lethal damage repair (PLDR) has been studied in these cell lines as well. The extent of PLDR does not appear to correlate with radioresistance; for example, the most resistant melanoma line shows very little repair of PLD. In addition, the normal fibroblasts repair PLD at least as well as any of the tumor derived lines, which casts doubts on the wisdom of introducing into clinical practice inhibitors of PLD until a clear differential between normal tissues and tumors has been demonstrated in vivo. Low dose-rate studies with normal human fibroblasts indicate a smaller dose-rate effect than for most established cell lines of rodent origin. Indeed, in the human cells studied, the effect of sublethal damage repair is quantitatively similar to the repair of potentially lethal damage. Dose response curves for acute and protracted exposures have been obtained for cells derived from patients with cancer-prone syndromes including ataxia telangiectasin (AT) and Bloom's syndrome. Both cell tines are much more radiosensitive than normal human fibroblasts; the AT cells show a dose-rate effect, while Bloom's syndrome cells do not.