Effects of radiation on the mouse lung and potential induction of radiation pneumonitis

Cytokines and radiation-induced pulmonary injuries

Radiation therapy is one of the most common treatment strategies for thorax malignancies. One of the considerable limitations of this therapy is its toxicity to normal tissue. The lung is the major dose-limiting organ for radiotherapy. That is because ionizing radiation produces reactive oxygen species that induce lesions, and not only is tumor tissue damaged, but overwhelming inflammatory lung damage can occur in the alveolar epithelium and capillary endothelium. This damage may result in radiation-induced pneumonitis and/or fibrosis. While describing the lung response to irradiation generally, the main focus of this review is on cytokines and their roles and functions within the individual stages. We discuss the relationship between radiation and cytokines and their direct and indirect effects on the formation and development of radiation injuries. Although this topic has been intensively studied and discussed for years, we still do not completely understand the roles of cytokines. Experimental data on cytokine involvement are fragmented across a large number of experimental studies; hence, the need for this review of the current knowledge. Cytokines are considered not only as molecular factors involved in the signaling network in pathological processes, but also for their diagnostic potential. A concentrated effort has been made to identify the significant immune system proteins showing positive correlation between serum levels and tissue damages. Elucidating the correlations between the extent and nature of radiation-induced pulmonary injuries and the levels of one or more key cytokines that initiate and control those damages may improve the efficacy of radiotherapy in cancer treatment and ultimately the well-being of patients.

Pulmonary Effects of Antineoplastic Therapy

Pulmonary toxicity is common after cancer therapy and can result from all therapeutic modalities. The consequential decrease in lung function ranges in severity from subclinical to life-threatening or even fatal and can manifest in the acute setting or many years after completion of therapy. Radiation effects are due to direct insult to the pulmonary parenchyma and, for younger children, impaired thoracic musculoskeletal development. Radiation pneumonitis can occur in the acute/subacute setting, as well as fibrosis with comprised gas exchange as a late effect of direct lung irradiation; thoracic wall malformation can cause restriction of function as a chronic sequela. The pulmonary effects of cytotoxic drugs usually present as acute effects, but there is the potential for significant late morbidity and mortality. Of course, surgical interventions can also cause both acute and/or late pulmonary effects as well, depending on the specific procedure. Although treatment approaches for the management of pediatric cancers are continually adapted to provide optimal therapy while minimizing toxicities, to a varying degree all therapies have the potential for both acute and late pulmonary toxicity. Of note, the cumulative incidence of pulmonary complications rises with increasing time since diagnosis, which suggests that adult survivors of childhood cancer require lifelong monitoring and management of potential new-onset pulmonary morbidity as they age. Knowledge of cytotoxic therapies and an understanding of lung physiology and how it may be altered by therapy facilitate appropriate clinical care and monitoring of long-term survivors.

Partial volume rat lung irradiation: an evaluation of early DNA damage

PURPOSE

1. To investigate early DNA damage induced in rat lung cells following single-dose, partial-volume irradiation (lung base and lung apex). 2. To determine the variation in DNA damage in different lung regions. 3. To investigate the possible mechanisms associated with early DNA damage after lung irradiation.

METHODS AND MATERIALS

The whole lung or the upper or lower half of the entire lung of Sprague-Dawley rats was exposed to 10 Gy 60Co gamma rays. The animals were sacrificed at various times up to 42 h after irradiation. A trypsin-digested lung cell suspension was prepared and cells that attached to slides in the initial 24-h period were then grown in the presence of culture medium with cytochalasin-B for a further 72 h. Radiation-induced DNA damage was quantified in the cells (primarily fibroblasts) from both irradiated and unirradiated lung regions by using a well-characterized micronucleus assay.

RESULTS

When the lungs were removed at 16-18 h after whole-lung irradiation, about 0.85 micronuclei (MN) per binucleate cell (BNC) were observed in the lung cells of the irradiated animals, compared to 0.02 MN/BNC in the lung cells of the controls. When only the lung base was irradiated, the frequency of micronuclei was 0.85 MN/BNC compared to 0.43 MN/BNC observed in cells from the irradiated lung apex. Of particular interest was the finding that the unirradiated lung apex also showed a large frequency of micronuclei (0.43 MN/BNC) after the irradiation of the lung base, whereas the unirradiated lung base showed only a marginal (approximately 2-fold) increase relative to the spontaneous frequency following irradiation of the lung apex. The changes in the frequency of micronuclei varied with the time at which the lungs were removed from the rats for early times, but had stabilized by 18 h after irradiation. Normal (unirradiated) cells grown in filtered or unfiltered conditioned media obtained from irradiated cell cultures showed an insignificant marginal increase in the number of micronuclei relative to the spontaneous frequency. Lung cells obtained from the lung base or the lung apex of healthy controls and irradiated separately in vitro showed no regional differences in the induction of micronuclei. Cells from the lungs of rats injected with superoxide dismutase, within 1 h prior to irradiation of the lung base, and processed 16-18 h after irradiation showed a reduction in the number of MN in the shielded lung apex, indicating the possible involvement of oxygen radicals.

CONCLUSIONS

These data indicate that cells in the lung base sustain more DNA damage than those in the lung apex when either region is irradiated; however, when the whole lung, is irradiated, the lung damage observed is similar in the two regions. Also, out-of-field effects are observed for the lung apex but not the lung base. Possible mechanisms include a clastogenic (chromosome damaging) factor produced in the plasma following irradiation and/or the production of oxygen radicals by activated lymphocytes/monocytes. The partial blocking of the DNA damage, observed in the unirradiated lung apex following irradiation of the lung base, by superoxide dismutase, suggests that oxygen radicals are involved in this out-of-field effect. These radicals are likely produced as a result of the induction of inflammatory cytokines, such as tumor necrosis factor (TNF) and interleukin-1 (IL-1) by the irradiation. The reason for the lack of an out-of-field effect in the lung base when the lung apex is irradiated is unknown, but may be due to the greater volume of lung irradiated in the lower lung field, because this is likely to affect the level of cytokines produced. Alternatively, it may reflect cytokines produced as a result of the partial liver irradiation that occurs with the lower lung field.

A perpetual cascade of cytokines postirradiation leads to pulmonary fibrosis

PURPOSE

Radiation-induced pulmonary reactions have classically been viewed as distinct phases--acute pneumonitis and, later, fibrosis--occurring at different times after irradiation and attributed to different target cell populations. We prefer to view these events as a continuum, with no clear distinction between the temporal sequence of the different pulmonary reactions; the progression is the result of an early activation of an inflammatory reaction, leading to the expression and maintenance of a cytokine cascade. In the current study, we have examined the temporal and spatial expression of cytokine and extracellular matrix messenger ribonucleic acid (mRNA) abundance in fibrosis-sensitive mice after thoracic irradiation.

METHODS AND MATERIALS

Radiation fibrosis-prone (C57BL/6) mice received thoracic irradiation of 5 and 12.5 Gy. At Day 1, and 1, 2, 8, 16, and 24 weeks after treatment, animals were killed and lung tissue processed for light microscopy and isolation of RNA. Expression of cytokine and extracellular matrix mRNA abundance was evaluated by slot-blot analysis and cellular localization by in situ hybridization and immunochemistry.

RESULTS

One of the cytokines responsible for the inflammatory phase (IL-1 alpha) is elevated at 2 weeks, returns to normal baseline values, then increases at 8 weeks, remaining elevated until 26 weeks when lung fibrosis appears. Transforming growth factor-beta (TGF beta), a proliferative cytokine, is elevated at 2 weeks, persists until 8 weeks, and then returns to baseline values. In parallel with the cytokine cascade, the fibrogenic markers for CI/CIII/IV (collagen genes) correlate by showing a similar early and then later elevation of activity. For instance, the collagen gene expression of CI/CIII is a biphasic response with an initial increase at 1-2 weeks that remits at 8 weeks, remains inactive from 8 to 16 weeks, and then becomes elevated at 6 months when collagen deposition is recognized histopathologically.

CONCLUSION

These studies clearly demonstrate the early and persistent elevation of cytokine production following pulmonary irradiation. The temporal relationship between the elevation of specific cytokines and the histological and biochemical evidence of fibrosis serves to illustrate the continuum of response, which, we believe, underlies pulmonary radiation reactions and supports the concept of a perpetual cascade of cytokines produced immediately after irradiation, prompting collagen genes to turn on, and persisting until the expression of late effects becomes apparent pathologically and clinically.

Injury to the lung from cancer therapy: clinical syndromes, measurable endpoints, and potential scoring systems

Toxicity of the respiratory system is a common side effect and complication of anticancer therapy that can result in significant morbidity. The range of respiratory compromise can extend from acute lethal events to degrees of chronic pulmonary decompensation, manifesting years after the initial cancer therapy. This review examines the anatomic-histologic background of the lung and the normal functional anatomic unit. The pathophysiology of radiation and chemotherapy induced lung injury is discussed as well as the associated clinical syndromes. Radiation tolerance doses and volumes are assessed in addition to chemotherapy tolerance and risk factors and radiation-chemotherapy interactions. There are a variety of measurable endpoints for detection and screening. Because of the wide range of available quantitative tests, it would seem that the measurement of impaired lung function is possible. The development of staging systems for acute and late toxicity is discussed and a new staging system for Late Effects in Normal Tissues (LENT) is proposed.

Acceleration of fibrinolysis by ultrasound in a rabbit ear model of small vessel injury

High frequency ultrasound has been previously shown to accelerate fibrinolysis in vitro at intensities that are potentially applicable for noninvasive administration clinically. To extend these findings in vivo, we have investigated the effects of ultrasound on fibrinolysis induced by streptokinase in a rabbit model of small vessel injury. Full thickness puncture wounds were made in rabbit ears with a scalpel blade. The rabbits were rested for 2-3 hours after cessation of bleeding to allow maturation of hemostatic plugs. Saline or streptokinase was then infused intravenously, and ultrasound was applied to some lesions at 1 MHz with a 50% duty cycle at 1 W/cm2 net intensity. Ear lesions in rabbits treated with saline showed no bleeding after 30 minutes whether they were exposed to ultrasound or not. Streptokinase alone induced bleeding after 19.7 +/- 5.5 minutes. Application of ultrasound significantly reduced the time to bleeding in streptokinase treated rabbits to 7.5 +/- 3.9 minutes (p < .002). The times to bleeding with "sham" ultrasound (18.8 +/- 5.6 minutes) and heating of the ear (18.0 +/- 5.6 minutes) during streptokinase administration were not significantly different compared to streptokinase alone. Histologic examination revealed that application of ultrasound resulted in a mild increase in interstitial edema and accumulation of polymorphonuclear leukocytes but did not cause vascular or other tissue damage. We conclude that the noninvasive, percutaneous application of ultrasound significantly accelerated streptokinase-induced fibrinolysis in this rabbit model of small vessel injury.

Morphological correlates of fractionated radiation of the mouse lung: early and late effects

PURPOSE

The definition and quantitation of radiation-induced morphologic alterations in murine lungs is presented.

METHODS AND MATERIALS

The extent of injury to the lung, which is the dose-limiting organ in the thorax, may be reduced by fractionating the total radiation exposure to permit partial repair of radiation-induced damage between fraction administration and also to permit a larger total exposure to be administered. We previously reported that, following fractionated radiation exposures, as the dose/fraction decreases, the total dose to reach an isoeffect increases, with an alpha/beta ratio of 3.2 and 3.0 for breathing rates and lethality, respectively. In the present report, we provide comparative morphologic evaluation of the effects of weekly fractionated (three doses at one dose/week), daily fractionated (15 doses at 1/diem), and hyperfractionated (30 doses at 2/diem) radiation exposures. The doses administered within each group were uniform. To determine morphologic alterations, LAF1 mice were irradiated with 3, 15, and 30 fractions delivered in 19 days overall treatment time. In the hyperfractionation schedule, the two fractions per day were separated by a 6-h time interval. Total doses were as follows: 15-21 Gy for weekly fractionation, 30-41.5 Gy for daily fractionation, and 30-49.5 Gy for hyperfractionated schedules. Lung tissue, recovered either 24 or 72 weeks following the final exposure, was evaluated by transmission and scanning electron microscopy and light microscopy.

RESULTS

Using a series of morphologic parameters, a total dose of 15 Gy in the weekly treatment schedule was found to be equivalent to a total dose of 30 Gy in the daily fractionation schedule and 37 Gy in the hyperfractionated treatment regimen at 24 weeks postirradiation. Measured at 72 weeks postirradiation, total exposures of 15 Gy on the weekly fractionation regimen corresponded to total exposures of approximately 30 Gy in both the daily fractionated and hyperfractionated regimens. Morphological damage was not uniform throughout the exposed lung and tended to be concentrated in lobes or portions of lobes.

CONCLUSIONS

In the three fractionation regimens studied, there is progressive sparing of the lung with increased fractionation (i.e., weekly < daily < twice daily) during the pneumonitic stage (24 weeks postirradiation). Both daily and twice daily fractionations provide increased sparing over weekly fractionation during the fibrotic stages (72 weeks postirradiation), but were not markedly different from each other (i.e., weekly < daily = twice daily).

Morphological effects of pulsed ultrasound in the lung

We have previously described the induction of subcapsular hemorrhage in the murine lung by extracorporeal shock wave lithotripsy at exposures of 2 MPa (Hartman et al. 1990) and pulsed ultrasound (Child et al. 1990). Since extravasation of erythrocytes and alveolar flooding are prominent, we proposed to determine whether or not the injury was progressive, by continuing to develop following termination of exposure, and by localizing where the injury was developing. Mice were exposed to 10 microsecond impulses at 1.6 MPa for 3 min and sacrificed either immediately or 5 min following exposure. When observed with both light and transmission electron microscopy, there was no gradation in lung injury, with a sharp demarcation of the hemorrhagic area. Moreover, both type I pneumocytes and capillary endothelial cells were injured, causing direct continuities between vessel lumina and alveolar spaces. In the absence of extravasation, the tissue appeared normal. There was no evidence that injury increased in severity during the first 5 min after exposure.

Morphologic and functional characteristics of subpopulations of murine lung fibroblasts grown in vitro

Fibrotic development is a common response of the lung to toxic or deleterious insult. For example, the lung is the dose-limiting organ for irradiation of the thorax for primary or metastatic lesions, due in large part to latent fibrosis. The development of the fibrotic response reflects a cascade of cell-cell and cell-extracellular matrix interactions, the ultimate target of which is the fibroblast. There is increasing evidence of subpopulations of pulmonary fibroblasts, which may have differing roles in either the initiation or progression of fibrosis. Recently we described two fibroblast subpopulations from the murine lung, which differ in the presence or absence of the membrane antigen Thy-1 (Phipps et al., 1989). These Thy-1+ and Thy-1- subpopulations are stable and differ in certain functions, such as the production of cytokines and the display of Class II MHC antigens. To determine the morphologic development of the two subpopulations and their growth characteristics in vitro, cultures of the two cell subtypes were prepared for transmission and scanning electron microscopy at varying stages of growth. Thy-1+ fibroblasts are more spindle-shaped, contain intracellular lipid, exhibit abundant cell-cell contacts, and are capable of secreting large amounts of collagen and modest amounts of fibronectin. Thy-1- fibroblasts are more rounded and spread, contain no intracellular lipid droplets, possess more intracellular microfilaments and microtubules, and synthesize less collagen and more fibronectin than do Thy-1+ cells. There are no significant differences between the two subpopulations insofar as growth rates are concerned, but Thy-1+ fibroblasts possess an additional DNA peak during periods of early growth.

Electron microscopic identification and morphologic preservation of enriched populations of lung cells isolated by laser flow cytometry and cell sorting: a new technique

There is increasing need to verify the identities of cell subpopulations enriched by laser flow cytometry and fluorescence-activated cell sorting (FACS). When cell subpopulations isolated from whole organs or tissues have similar characteristics (e.g., size, granularity, staining), light, phase contrast or fluorescence microscopy may not provide sufficient resolution to identify isolated cells accurately and many flow cytometric parameters (e.g., viability, fluorescence) require the cells to be live at the point of analysis where the cell transects the laser beam. In some studies, cells identified by fluorescence microscopy as a highly enriched subpopulation were found by electron microscopy to contain significant populations of other cell types. A technique, fixation-in-flow (FIF), has been developed to increase ability to correlate morphological and laser analyses of cell subpopulations. Sheath fluid is replaced by fixative, permitting fixation to be initiated immediately after laser beam analysis of live cells. This new procedure yields improved cytoarchitectural preservation of recovered cell subpopulation(s) for evaluation by transmission or scanning electron microscopy. This report presents results from applying the methodology to identify more accurately cell subpopulations of the distal lung, specifically type II pneumocytes, Clara cells and pulmonary macrophages. A modification of this procedure was employed to isolate fibroblast subpopulations from murine lung fibroblasts grown in vitro and the procedure is being used to determine the responses of cultured fibroblasts to other permutations (e.g., X-irradiation, cytokines).

Serum markers for prediction of pulmonary radiation syndromes. Part I: Surfactant apoprotein

Detection of a biochemical marker indicating radiation lung injury prior to the onset of clinical pathologic events could prove valuable in patient management. An increased level of alveolar surfactant is one of the earliest detectable changes following lung irradiation, starting within hours of irradiation and persisting a maximum of 2-6 weeks. However, because broncho-alveolar lavage is impracticable and endothelial cell damage due to radiation results in changes in permeability of vessel wall with leakage of alveolar proteins into serum, identification of serum markers was sought. A series of experiments in rabbits are described that clearly demonstrate serum surfactant apoprotein is an accurate marker and predictor for later lethal radiation pneumonitis. At 3-7 days after graded single doses to lung, surfactant was found in the serum paralleling the dose response for lethality. Control studies with a physiologic agent such as terbutaline release alveolar surfactant, but no serum surfactant was detected. Monitoring serum surfactant could direct preventive intervention prior to clinicopathologic manifestation of pulmonary radiation syndromes.

Characterization of two major populations of lung fibroblasts: distinguishing morphology and discordant display of Thy 1 and class II MHC

We have determined that murine lung fibroblasts are divisible into two major subpopulations based on expression of Thy 1. Twenty-four to fifty-three percent of freshly isolated lung cells displayed Thy 1 and were separated using FACS into Thy 1+ and Thy 1- fractions for morphologic examination. Analysis by electron microscopy revealed that both the Thy 1+ and Thy 1- fractions contained fibroblasts. Freshly isolated lung cells cultured for 2 wk consisted of greater than 95% fibroblasts, with 28 to 49% displaying Thy 1. These cells were sorted by FACS into Thy 1+ and Thy 1- lines that maintained a stable phenotype over many weeks and that were used as a source to obtain stable fibroblast clones. Adherent pulmonary fibroblasts are not phagocytic and lack the markers of macrophages, dendritic cells, B lymphocytes, and T lymphocytes (with the exception of Thy 1). Interestingly, the Thy 1- fibroblasts spread more and contained a more extensive microfilament and microtubule network than did the spindly and often lipid-containing Thy 1+ population. Both populations of fibroblasts synthesized collagen. Class I MHC expression was very low on Thy 1+ and Thy 1- fibroblasts, but high levels were displayed after gamma-IFN treatment. Most exciting was the unexpected finding that only the Thy 1- lines and clones displayed class II MHC (Ia) in response to treatment with gamma-IFN. Moreover, only the Thy 1- fraction (gamma-IFN-treated) presented antigen to T lymphocyte clones, an observation that suggests that this subset of cells may be involved primarily in promoting chronic lung inflammation, which is associated with developing fibrosis. Thus, two populations of pulmonary fibroblasts exist, defined by the expression of Thy 1, distinguishing morphology, inducibility for Ia expression, and antigen-presenting function. It should now be possible, using these characteristics, to ascertain the role of pulmonary fibroblast subpopulations in developing fibrosis.

Cellular events in alveolitis and the evolution of pulmonary fibrosis

"Alveolitis", as opposed to "pneumonia" sensu strictiori, is a term used to denote diffuse inflammatory changes of the pulmonary parenchyma, excluding those that result from local bacterial, fungal or other extracellular microbial growth. The various types of alveolitis are classified according to their histological characteristics and range from "luminal phagocytic" or "mural lymphoplasmacellular" and "exudative" to "fibrosing" alveolitis. In this overview, various exogenous and endogenous causes of different types of alveolitis, and the cellular events in their pathogenesis are briefly discussed to illustrate the complex mechanisms involved. Particular emphasis is placed on the possible transition from diffuse exudative to fibrosing alveolitis. It appears that pulmonary fibrosis, which is usually patchy rather than truly diffuse, does not have a uniform pathogenesis. Besides the possibility of a certain degree of a diffuse fibrosis three major pathways are evident: (1) granulation tissue budding into alveolar lumina (luminal fibrosis) (2) exudate incorporation into alveolar walls (mural fibrosis) and--at least equally important--(3) so-called collapse (atelectatic) induration (obliterative-interseptal fibrosis), a process that has largely been neglected so far.

The ultrastructure of epithelial cells of the distal lung

This review has focused on the structural and functional characteristics of those epithelial cells that line the walls of the lower respiratory bronchioles, alveolar ducts, and alveoli. In all, five cells types were considered: Clara cells, types I, II, and III pneumocytes, and alveolar macrophages. In addition, a very brief mention of the structure and influence of the basement membrane in alveolar development and repair was included, as well as a brief review of the role of epithelial cells in response to selected deleterious influences. No attempt was made to extend this review to cover the structure and functions of the epithelial lining of the conducting portions of the respiratory system, or the exciting and expanding complexities and interrelationships of the septal stroma. Since the volume of literature encircling this subject has virtually exploded during the last 15 years, it becomes almost impossible to review all reports. However, attempts were made to be selective in citations. Insofar as future developments are concerned, much remains to be understood concerning (1) the responses of all cell types to cytotoxic influences, including their respective abilities to repair induced damage, (2) cell-cell and cell-extracellular matrix relationships in response to injury, (3) the uniqueness of the basement membrane in the lung in controlling permeability and gaseous exchange, (4) the role(s) of alveolar macrophages in response to injury and their relationships to the septal macrophage population, (5) the aberrations in the respective cell types that can give rise to neoplastic growth, and (6) the role of the immune system in responding to the general defense of the lung. Indeed much has been learned in the past 2 decades, and it is expected that a review of this sort 1 or 2 decades hence will elucidate many of the functions and structural modifications of the lung.

Use of steroids to suppress vascular response to radiation

A quantitative measure of the vascular permeability surface area product (PS) for albumin has been made using a double isotope technique. PS was significantly elevated in irradiated rat lung, heart, skin, and muscle, between 19 and 26 days following 18 or 25 Gray thorax irradiation. Administration of dexamethasone from 2 days before irradiation through the day of measurement suppressed the expected increase in PS in lung, heart, and muscle, but not in skin. Shorter periods of steroid administration were not as effective in suppressing this response to radiation exposure. Increased vascular permeability following radiation may be an essential element in the development of radiation fibrosis. We hypothesize that the ability to suppress this response could result in a long term reduction in the incidence of fibrosis.

Predictive biochemical assays for late radiation effects

Surfactant precursors or other products of Type II pneumocytes have the potential to be the first biochemical marker for late radiation effects. This is particularly clinically important in the combined modality era because of the frequent occurrence of pneumonitis and pulmonary fibrosis secondary to radiation or chemotherapy. Accordingly, correlative studies have been pursued with the Type II pneumocyte as a beginning point to understand the complex pathophysiology of radiation pneumonitis and fibrosis. From our ultrastructural and biochemical studies, it is evident that Type II pneumocytes are an early target of radiation and the release of surfactant into the alveolus shortly after exposure persists for days and weeks. Through the use of lavaging techniques, alveolar surfactant has been elevated after pulmonary irradiation. In three murine strains and in the rabbit, there is a strong correlation with surfactant release at 7 and/or 28 days in vivo with later lethality in months. In vitro studies using cultures of type II pneumocytes also demonstrate dose response and tolerance factors that are comparable to the in vivo small and large animal diagnostic models. New markers are being developed to serve as a predictive index for later lethal pneumonopathies. With the development of these techniques, the search for early biochemical markers in man have been undertaken. Through the use of biochemical, histological, and ultrastructural techniques, a causal relationship between radiation effects on type II pneumocytes, pulmonary cells, endothelial cells of blood vessels, and their roles in the production of pneumonitis and fibrosis will evolve.

Surfactant release as an early measure of radiation pneumonitis

The immediate release of surfactant into lung alveoli following irradiation has been studied as a potential indicator for the later development of radiation pneumonitis. Utilizing single dose radiation exposure to the whole thorax in male LAF1/J mice, steep dose response curves for lavaged alveolar surfactant were identified at 7 and 28 days after exposure. Seven days after irradiation there was no elevation with doses up to and including 12 Gy; above this dose a detectable increase occurred. At 28 days the surfactant recovered by lavage was elevated compared to the levels seen at day 7 for all doses; doses greater than 12 Gy produced surfactant values significantly greater than those found in mice treated with 12 Gy or less. The radiation pulmonary lethality dose response curve assessed four months later indicated an LD50 value of approximately 13 Gy. The early biochemical effect and the later radiation pneumonitis lethalities therefore closely coincided. The evidence strongly indicates that alveolar surfactant release uncovered hours to days after radiation exposure may be an early biochemical marker that predicts for subsequent pneumonitis radiation injury.