•A kinetic model is proposed to explain normal tissue sparing by FLASH irradiation.•The model takes into consideration and solves 9 differential rate equations, based on published values of the rate ...constants of free radical and enzymatic reactions involving reactive oxygen species in a cellular context.•For different doses, dose-rates and oxygen concentrations, the area-under-the-curve (AUC) drawn from the time-dependent evolution of peroxyl radical intermediates ROO., correlates the normal tissue complications (NTCP) determined from the outcomes of published FLASH studies.
FLASH radiotherapy, a technique based on delivering large doses in a single fraction at the micro/millisecond timescale, spares normal tissues from late radiation-induced toxicity, in an oxygen-dependent process, whilst keeping full anti-tumor efficiency. We present a theoretical model taking into account the kinetics of formation and decay of reactive oxygen species, in particular of organic peroxyl radicals ROO. formed by addition of O2 to primary carbon-centred radicals R. and known to play a major role at the origin radio-induced complications.
The model focuses on the time-dependent evolution of radiolytic products in living matter exposed to continuous irradiation at dose-rates in the range 10-3-107Gy·s-1. The 9 differential rate equations resulting from the radiolytic and enzymatic reactions network were solved using the published values of these reactions rate constants in a cellular environment.
The model suggests a correlation between the area-under-the-curve of time-evolving ROO. and the probability of normal tissue complications. The model does not lend weight to the hypothesis of transient oxygen depletion as a main determinant of FLASH but rather suggests a major role of radical–radical recombination.
The model gives support to the reduction of ROO. lifetime as the main root of FLASH and compares favorably with published experimental results. We conclude that any process - in this case radical recombination - that shortens the lifetime or limits the radiolytic yield of ROO. is likely to protect normoxic tissues against the deleterious effects of radiation.
Radiobiology of the FLASH effect Friedl, Anna A.; Prise, Kevin M.; Butterworth, Karl T. ...
Medical physics (Lancaster),
March 2022, Letnik:
49, Številka:
3
Journal Article
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Radiation exposures at ultrahigh dose rates (UHDRs) at several orders of magnitude greater than in current clinical radiotherapy (RT) have been shown to manifest differential radiobiological ...responses compared to conventional (CONV) dose rates. This has led to studies investigating the application of UHDR for therapeutic advantage (FLASH‐RT) that have gained significant interest since the initial discovery in 2014 that demonstrated reduced lung toxicity with equivalent levels of tumor control compared with conventional dose‐rate RT. Many subsequent studies have demonstrated the potential protective role of FLASH‐RT in normal tissues, yet the underlying molecular and cellular mechanisms of the FLASH effect remain to be fully elucidated. Here, we summarize the current evidence of the FLASH effect and review FLASH‐RT studies performed in preclinical models of normal tissue response. To critically examine the underlying biological mechanisms of responses to UHDR radiation exposures, we evaluate in vitro studies performed with normal and tumor cells. Differential responses to UHDR versus CONV irradiation recurrently involve reduced inflammatory processes and differential expression of pro‐ and anti‐inflammatory genes. In addition, frequently reduced levels of DNA damage or misrepair products are seen after UHDR irradiation. So far, it is not clear what signal elicits these differential responses, but there are indications for involvement of reactive species. Different susceptibility to FLASH effects observed between normal and tumor cells may result from altered metabolic and detoxification pathways and/or repair pathways used by tumor cells. We summarize the current theories that may explain the FLASH effect and highlight important research questions that are key to a better mechanistic understanding and, thus, the future implementation of FLASH‐RT in the clinic.
Previous studies using FLASH radiotherapy (RT) in mice showed a marked increase of the differential effect between normal tissue and tumors. To stimulate clinical transfer, we evaluated whether this ...effect could also occur in higher mammals.
Pig skin was used to investigate a potential difference in toxicity between irradiation delivered at an ultrahigh dose rate called "FLASH-RT" and irradiation delivered at a conventional dose rate called "Conv-RT." A clinical, phase I, single-dose escalation trial (25-41 Gy) was performed in 6 cat patients with locally advanced T2/T3N0M0 squamous cell carcinoma of the nasal planum to determine the maximal tolerated dose and progression-free survival (PFS) of single-dose FLASH-RT.
Using, respectively, depilation and fibronecrosis as acute and late endpoints, a protective effect of FLASH-RT was observed (≥20% dose-equivalent difference vs. Conv-RT). Three cats experienced no acute toxicity, whereas 3 exhibited moderate/mild transient mucositis, and all cats had depilation. With a median follow-up of 13.5 months, the PFS at 16 months was 84%.
Our results confirmed the potential advantage of FLASH-RT and provide a strong rationale for further evaluating FLASH-RT in human patients.
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One of the main limitations to anticancer radiotherapy lies in irreversible damage to healthy tissues located within the radiation field. "FLASH" irradiation at very high dose-rate is a new treatment ...modality that has been reported to specifically spare normal tissue from late radiation-induced toxicity in animal models and therefore could be a promising strategy to reduce treatment toxicity.
Lung responses to FLASH irradiation were investigated by qPCR, single-cell RNA sequencing (sc-RNA-Seq), and histologic methods during the acute wound healing phase as well as at late stages using C57BL/6J wild-type and Terc
mice exposed to bilateral thorax irradiation as well as human lung cells grown
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studies gave evidence of a reduced level of DNA damage and induced lethality at the advantage of FLASH. In mouse lung, sc-RNA-seq and the monitoring of proliferating cells revealed that FLASH minimized the induction of proinflammatory genes and reduced the proliferation of progenitor cells after injury. At late stages, FLASH-irradiated lungs presented less persistent DNA damage and senescent cells than after CONV exposure, suggesting a higher potential for lung regeneration with FLASH. Consistent with this hypothesis, the beneficial effect of FLASH was lost in Terc
mice harboring critically short telomeres and lack of telomerase activity.
The results suggest that, compared with conventional radiotherapy, FLASH minimizes DNA damage in normal cells, spares lung progenitor cells from excessive damage, and reduces the risk of replicative senescence.
In vitro studies suggested that sub-millisecond pulses of radiation elicit less genomic instability than continuous, protracted irradiation at the same total dose. To determine the potential of ...ultrahigh dose-rate irradiation in radiotherapy, we investigated lung fibrogenesis in C57BL/6J mice exposed either to short pulses (≤ 500 ms) of radiation delivered at ultrahigh dose rate (≥ 40 Gy/s, FLASH) or to conventional dose-rate irradiation (≤ 0.03 Gy/s, CONV) in single doses. The growth of human HBCx-12A and HEp-2 tumor xenografts in nude mice and syngeneic TC-1 Luc(+) orthotopic lung tumors in C57BL/6J mice was monitored under similar radiation conditions. CONV (15 Gy) triggered lung fibrosis associated with activation of the TGF-β (transforming growth factor-β) cascade, whereas no complications developed after doses of FLASH below 20 Gy for more than 36 weeks after irradiation. FLASH irradiation also spared normal smooth muscle and epithelial cells from acute radiation-induced apoptosis, which could be reinduced by administration of systemic TNF-α (tumor necrosis factor-α) before irradiation. In contrast, FLASH was as efficient as CONV in the repression of tumor growth. Together, these results suggest that FLASH radiotherapy might allow complete eradication of lung tumors and reduce the occurrence and severity of early and late complications affecting normal tissue.
Most anticancer radiation therapy facilities are based on linear electron accelerators with electron–photon conversion providing dose-rates in the range 0.03-0.40 Gy.s−1, and treatment plans usually ...involve daily fractions of 2 Gy cumulated for up to reaching a total dose close to the limit of tolerance of the normal tissues that surround tumors. We recently developed another methodology named “FLASH” that relies on very high dose-rate facilities and consists in delivering ≥ 10 Gy in a single microsecond pulse of relativistic electrons, or else in a limited number of pulses of 1-2 Gy each given in ≤ 100 ms temporal sequence. In mice FLASH was found to elicit a dramatic decrease of damage to normal tissues whilst keeping the anti-tumor efficiency unchanged. In the following we describe the methods used for beam monitoring in the FLASH mode with emphasis on techniques that provide proportional, time-resolved dosimetry of radiation at the submicrosecond time scale. These methods include measurement of the electron fluence, optically monitored chemical dosimeters in water, solid scintillation and Cerenkov light emission. An application to the calibration of Gafchromic™ films is described and the minimal requirements for dose monitoring in preclinical assays are discussed. Good repeatability and linearity of these techniques in a range of peak dose-rates from 2x102 to 4x107 Gy.s−1 and from 1 mGy to over 30 Gy per microsecond pulse have been obtained with an overall precision better than ± 2%.
•Time-resolved dosimetry at very high dose-rate.•Submicrosecond chemical dosimetry.•Optics-based dosimetric methods.•To prepare clinical applications of FLASH radiotherapy.
Radiation Induced Lung Injury (RILI) is one of the main limiting factors of thorax irradiation, which can induce acute pneumonitis as well as pulmonary fibrosis, the latter being a life-threatening ...condition. The order of cellular and molecular events in the progression towards fibrosis is key to the physiopathogenesis of the disease, yet their coordination in space and time remains largely unexplored. Here, we present an interactive murine single cell atlas of the lung response to irradiation, generated from C57BL6/J female mice. This tool opens the door for exploration of the spatio-temporal dynamics of the mechanisms that lead to radiation-induced pulmonary fibrosis. It depicts with unprecedented detail cell type-specific radiation-induced responses associated with either lung regeneration or the failure thereof. A better understanding of the mechanisms leading to lung fibrosis will help finding new therapeutic options that could improve patients' quality of life.
The development of innovative approaches that would reduce the sensitivity of healthy tissues to irradiation while maintaining the efficacy of the treatment on the tumor is of crucial importance for ...the progress of the efficacy of radiotherapy. Recent methodological developments and innovations, such as scanned beams, ultra-high dose rates, and very high-energy electrons, which may be simultaneously available on new accelerators, would allow for possible radiobiological advantages of very short pulses of ultra-high dose rate (FLASH) therapy for radiation therapy to be considered. In particular, very high-energy electron (VHEE) radiotherapy, in the energy range of 100 to 250 MeV, first proposed in the 2000s, would be particularly interesting both from a ballistic and biological point of view for the establishment of this new type of irradiation technique. In this review, we examine and summarize the current knowledge on VHEE radiotherapy and provide a synthesis of the studies that have been published on various experimental and simulation works. We will also consider the potential for VHEE therapy to be translated into clinical contexts.
Treatment planning in proton therapy uses a generic value for the relative biological efficiency (RBE) of 1.1 throughout the spread-out Bragg peak (SOBP) generated. In this article, we report on the ...variation of the RBE with depth in the SOBP of the 76- and 201-MeV proton beams used for treatment at the Institut Curie Proton Therapy Center in Orsay.
The RBE (relative to (137)Cs γ-rays) of the two modulated proton beams at three positions in the SOBP was determined in two human tumor cells using as endpoints clonogenic cell survival and the incidence of DNA double-strand breaks (DSBs) as measured by pulse-field gel electrophoresis without and with enzymatic treatment to reveal clustered lesions.
The RBE for induced cell killing by the 76-MeV beam increased with depth in the SOBP. However for the 201-MeV protons, it was close to that for (137)Cs γ-rays and did not vary significantly. The incidence of DSBs and clustered lesions was higher for protons than for (137)Cs γ-rays, but did not depend on the proton energy or the position in the SOBP.
Until now, little attention has been paid to the variation of RBE with depth in the SOBP as a function of the nominal energy of the primary proton beam and the molecular nature of the DNA damage. The RBE increase in the 76-MeV SOBP implies that the tumor tissues at the distal end receives a higher biologically equivalent dose than at the proximal end, despite a homogeneous physical dose. This is not the case for the 201-MeV energy beam. The precise determination of the effects of incident beam energy, modulation, and depth in tissues on the linear energy transfer-RBE relationship is essential for treatment planning.
Purpose: The electron linac ElectronFlash installed at Institut Curie (Orsay, France) is entirely dedicated to FLASH irradiation for radiobiological and pre-clinical studies. The system was designed ...to deliver an ultra-high-dose rate per pulse (UHDR) (above 106 Gy/s) and a very high average dose rate at different energies and pulse durations. A campaign of tests and measurements was performed to obtain a full reliable characterizations of the electron beam and of the delivered dose, which are necessary to the radiobiological experiments. Methods: A Faraday cup was used to measure the electron charges in a single RF pulse. The percentage depth dose (PDD) and the transverse dose profiles, at the energies of 5 MeV and 7 MeV, were evaluated employing Gafchromic films EBT-XD for two Poly-methylmethacrylate (PMMA) applicators with irradiation sizes of 30 mm and 120 mm, normally used for in vivo and in vitro experiments, respectively. The results were compared with Monte Carlo (MC) simulations. Results: The measurements were performed during a period of a few months in which the experimental set up was adapted and tuned in order to characterize the electron beam parameters and the values of delivered doses before the radiobiological experiments. The measurements showed that the dose parameters, obtained at the energy of 5 MeV and 7 MeV with different applicators, fulfill the FLASH regime, with a maximum value of an average dose rate of 4750 Gy/s, a maximum dose per pulse of 19 Gy and an instantaneous dose rate up to 4.75 ×106 Gy/s. By means of the PMMA applicators, a very good flatness of the dose profiles was obtained at the cost of a reduced total current. The flatness of the large field is reliable and reproducible in radiobiological experiments. The measured PDD and dose profiles are in good agreement with Monte Carlo simulations with more than 95% of the gamma-index under the thresholds of 3 mm/3%. Conclusions: The results show that the system can provide UHDR pulses totally satisfying the FLASH requirements with very good performances in terms of beam profile flatness for any size of the fields. The monitoring of electron beams and the measurement of the dose parameters played an important role in the in vivo and in vitro irradiation experiments performed at the Institut Curie laboratory.
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