Amelioration of both early and late radiation-induced damage to pig skin by essential fatty acids

Biomolecular Analysis of Beta Dose-Dependent Cutaneous Radiation Injury in a Porcine Model

While cutaneous radiation injury (CRI) is generally referenced as a consequence of a nuclear attack, it can also be caused by less dangerous events such as the use of dirty bombs, industrial radiological accidents, or accidental overexposure of beta (β) particle or gamma (γ) radiation sources in medical procedures. Although the gross clinical consequences of these injuries have been well documented, relatively little is known about the molecular changes underlying the progression of pathology. Here we describe a porcine model of cutaneous radiation injury after skin was exposed to strontium-90 b particle at doses of 16-42 Gy and characterize the anatomical and molecular changes over 70 days. The results show that irradiated sites displayed dosedependent increases in erythema and moist desquamation that peaked between days 35 and 42. Dose-dependent histopathological changes were observed, with higher doses exhibiting increased inflammation and epidermal hyperplasia beyond day 35. Furthermore, immunohistochemistry showed that exposure to 37 Gy β-particle radiation decreased epidermal cell proliferation and desmosomal junction proteins at day 70, suggesting compromised epidermal integrity. Metabolomic analysis of biopsies revealed dose- and time-dependent changes as high as 252-fold in several metabolites not previously linked to CRI. These alterations were seen in pathways reflecting protein degradation, oxidative stress, eicosanoid production, collagen matrix remodeling, mitochondrial stress, cell membrane composition and vascular disruption. Taken together, these data show that exposure to high doses of β particle damaged the molecular processes underlying skin integrity to a greater extent and for a longer period of time than has been shown previously. These findings further understanding of radiation-induced skin injury and serve as a foundation for the development and testing of potential therapeutics to treat CRI.

ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context

This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.

Amelioration of radiation-induced skin injury by adenovirus-mediated heme oxygenase-1 (HO-1) overexpression in rats

Objective

Radiation-induced skin injury remains a serious concern for radiation therapy. Heme oxygenase-1 (HO-1), the rate-limiting enzyme in heme catabolism, has been reported to have potential antioxidant and anti-apoptotic properties. However, the role of HO-1 in radiation-induced skin damage remains unclear. This study aims to elucidate the effects of HO-1 on radiation-induced skin injury in rats.

Methods

A control adenovirus (Ad-EGFP) and a recombinant adenovirus (Ad-HO1-EGFP) were constructed. Rats were irradiated to the buttock skin with a single dose of 45 Gy followed by a subcutaneous injection of PBS, 5 × 10⁹ genomic copies of Ad-EGFP or Ad-HO1-EGFP (n = 8). After treatment, the skin MDA concentration, SOD activity and apoptosis were measured. The expression of antioxidant and pro-apoptotic genes was determined by RT-PCR and real-time PCR. Skin reactions were measured at regular intervals using the semi-quantitative skin injury score.

Results

Subcutaneous injection of Ad-HO1-EGFP infected both epidermal and dermal cells and could spread to the surrounding regions. Radiation exposure upregulated the transcription of the antioxidant enzyme genes, including SOD-1, GPx2 and endogenous HO-1. HO-1 overexpression decreased lipid peroxidation and inhibited the induction of ROS scavenging proteins. Moreover, HO-1 exerted an anti-apoptotic effect by suppressing FAS and FASL expression. Subcutaneous injection of Ad-HO1-EGFP demonstrated significant improvement in radiation-induced skin injury.

Conclusions

The present study provides evidences for the protective role of HO-1 in alleviating radiation-induced skin damage in rats, which is helpful for the development of therapy for radiation-induced skin injury.

Novel approaches to radiotherapy-induced skin reactions: A literature review

Patients undergoing radiotherapy treatment will receive some degree of skin damage. Internationally there are many preventative and treatment options recommended, with varying degrees of evidence of success. This review explores the possible benefits of various plant-based treatments within the context of other novel treatments. The evidence suggests that using a hydrophilic substance such as Aloe vera gel or vegetable oil that is high in essential fatty acids, is as effective as mild steroid creams such as 1% hydrocortisone in reducing the severity of reactions. Additionally with plant-based treatments there does not appear to be side effects such as may occur with steroids. There remains great scope for further studies either replicating some of these current studies or exploring other options such as the use of essential oils or other herbal extracts.

Enhanced radiosensitivity of rat autochthonous mammary tumors by dietary docosahexaenoic acid

Dietary docosahexaenoic acid (DHA), which integrates into tumor cell membranes, has been reported to enhance the efficacy against tumors of cytotoxic drugs that induce reactive oxygen species (ROS). Because ionizing radiation also generate ROS, we initiated a study to determine whether dietary DHA might sensitize mammary tumors to irradiation. Mammary tumors were induced by N-methylnitrosourea (NMU) in Sprague-Dawley rats. The optimal dose of radiation to examine the effect of DHA on tumor response to irradiation was determined to be 18 grays (Gy) using a 4-6 MeV electron beam (according to the depth of the target volume) delivered in a single fraction from a linear accelerator. Two groups of rats were fed a basal diet containing 7% of a mixture of peanut and rapeseed oils enriched with 8% of an oil containing either a low (palm oil) or high (DHASCO oil containing 40% DHA) DHA content. DHA group was equally subdivided into 2 groups without or with addition of vitamin E (100 IU/kg diet). Irradiation was carried out when the first tumor in each rat reached 1.5 cm2 and subsequent change in tumor size was documented over time. DHA level in adipose tissue, taken as a biomarker, was higher in the DHA supplemented group compared to the control group. Vitamin E level in liver, the best storage for this compound, was higher in the vitamin E supplemented DHA group compared to the DHA group. Tumor size decreased by 60% at 12 days after irradiation in the DHA group vs. 31% in the control group (p = 0.03) and 36% in the DHA plus vitamin E group. Therefore, dietary DHA sensitized mammary tumors to radiation. The addition of vitamin E inhibited the beneficial effect of DHA, suggesting that this effect might be mediated by oxidative damage to the peroxidizable lipids.

Pharmacological intervention to prevent or ameliorate chronic radiation injuries

Until the 1990s, chronic radiation-induced normal-tissue injury was viewed as being due solely to the delayed mitotic death of parenchymal or vascular cells; these injuries were held to be inevitable, progressive, and untreatable. It is now clear that parenchymal and vascular cells are active participants in the response to radiation injury rather than passive observers dying as they attempt to divide. This offers fundamentally new approaches to radiation injury because it allows for the possibility of pharmacological interventions directed at modulating steps in the cascade of events leading to expression of injury. Such interventions would be relevant to both cancer patients and victims of radiation accidents. Prophylaxis and treatment of chronic radiation injuries have been experimentally shown in multiple organ systems (eg, lung, kidney, soft tissue) and with fundamentally different pharmacological agents (eg, corticosteroids, angiotensin-converting enzyme inhibitors, pentoxifylline, superoxide dismutase). For the most part, this has been achieved using clinically relevant radiation and drug schedules and with agents that have already been approved for human use. Unfortunately, assessment of the utility of these agents for clinical use has been minimal, and there are no established mechanisms for any of the experimental or clinical successes. Clinical development of pharmacological approaches to modification of chronic radiation injuries could lead to significant improvement in survival and quality of life for radiotherapy patients and for victims of radiation accidents or nuclear terrorism.

Modification of doxorubicin-induced cardiotoxicity: effect of essential fatty acids and ICRF-187 (dexrazoxane)

The capacity of an oil, containing gamma-linolenic acid (GLA), to reduce the severity of doxorubicin-induced cardiotoxicity has been investigated in a rat model. Groups of 12-week-old, male, Sprague-Dawley rats were injected intravenously (i.v.) with single doses (3 mg/kg body weight) of doxorubicin (DOX). Daily for 1 week prior to DOX administration and for up to 20 weeks afterwards groups of rats received either an oil containing both GLA and linoleic acid (So-1100, Scotia Pharmaceuticals), at two dose levels, or an oil containing linoleic acid, but no GLA (So-1129) by oral gavage. Other groups of rats received water as a control. One of the groups of rats that received water also received i.v. ICRF-187 (60 mg/kg) 15 min prior to DOX. A group of animals acted as age-matched controls. The maximum reduction in body weight in the first 2 weeks after the administration of DOX. was used as a measure of acute toxicity. This was most severe in the group receiving a combination of DOX and ICRF-187 (5.6+/-0.43%). Animals receiving 2 ml of either So-1100 or So-1129 were the least affected ( approximately 2.5%). Measurements of cardiac volume output made at various intervals after DOX administration indicated a approximately 35% reduction in cardiac function in the control and So-1129 oil group after 20 weeks. The corresponding reduction in the groups receiving ICRF-187 and 2 ml of So-1100 was approximately 16%. The group receiving daily doses of 1 ml So-1100 showed an intermediate response. The death of an animal with signs of congestive cardiac failure occurred in 40% of the animals in the DOX only control (water) group. There were no deaths in the groups of rats receiving either ICRF-187 or pre- and post-administration of 2 ml of So-1100. It was concluded that an oil containing GLA (So-1100) has similar cardioprotective properties against DOX-induced cardiotoxicity as ICRF-187, but with less general toxicity in this rat model.

Normal tissue radiobiology: from the laboratory to the clinic

This manuscript is in four parts, presenting the four talks given in a symposium on normal tissue radiobiology. The first part addresses the general concept of the role of parenchymal cell radiosensitivity vs. other factors, highlighting research over the last decade that has altered our understanding of factors underlying normal tissue response. The other three parts expand on specific themes raised in the first part dealing in particular with (1) modifications of fibroblast response to irradiation in relation to the induction of tissue fibrosis, (2) the use of the linear-quadratic equation to model the potential benefits of using different means (both physical and biologic) of modifying normal tissue response, and (3) the specific role of the growth factor TFG-beta1 in normal tissue response to irradiation. The symposium highlights the complexities of the radiobiology of late normal tissue responses, yet provides evidence and ideas about how the clinical problem of such responses may be modified or alleviated.

[Radiation-induced superficial fibrosis and TGF-alpha 1]

Radiation-induced fibrosis is a late sequela of both therapeutic and accidental irradiations, which has been described in various tissues, including the lung, liver, kidney and skin. This review presents different aspects of superficial radiation-induced fibrosis, such as clinical observations, histological changes, cellular and molecular regulations, and medical management. Recent evidence on the critical role played by TGF-beta 1 in the initiation, development and persistence of fibrosis are discussed, as well as the possibility that this cytokine may constitute a specific target for antifibrotic agents.

TGF-beta1 and radiation fibrosis: a master switch and a specific therapeutic target?

Radiation fibrosis is a frequent sequel of therapeutic or accidental radiation overexposure in normal human tissues. One of the main fundamental problems yet unsolved in fibrotic tissues is the origin of the chronic activation of myofibroblasts within these tissues. It has been postulated that this chronic activation results from a continuous production of activating factors. In this context, fibrosis could be defined as a wound where continuous signals for tissue repair are emitted. Cytokines and growth factors probably play a central role in this process. Among them, transforming growth factor-beta1 (TGF-beta1) is considered as a master switch for the fibrotic program. This review discusses recent evidence on the critical role played by TGF-beta in the initiation, development, and persistence of radiation fibrosis. It summarizes the results concerning this factor after irradiation of various tissues and cells, with an emphasis on superficial fibrosis, including skin and subcutaneous tissues. Finally, recent data concerning the treatment of established fibrotic disorders of various etiology are presented, as well as the possible mechanisms involved in fibrosis regression, which show that the TGF-beta pathway may constitute a specific target for antifibrotic agents.

Toxicity antagonists in head and neck cancer

Clinical trials of altered fractionation and concurrent chemoradiation regimens have better elucidated the limits of both acute and late normal tissue toxicities in the head and neck. Acute effects on mucosal epithelium represent the principal barrier to intensification of radiation or chemoradiation schedules. Late soft tissue injury and organ dysfunction limit efforts to escalate radiation total dose. New insights into the cellular and molecular mechanisms of injury repair allow new strategies in the management and prevention of treatment-related toxicity. Toxicity antagonists are agents that directly interfere with the mechanism of toxicity or modulate the normal tissue response to injury. This article reviews 10 agents under development. Not only could such interventions reduce treatment-related morbidity, but they may also allow treatment intensification in advanced disease.

[New approach to conservative therapy of radiation injuries]

PURPOSE

The improvement of tumor control rates and improved survival times of radiotherapy patients result in an increasing importance of radiation side effects in normal tissues.

METHODS

Possibilities for the modulation of normal tissue reaction by stimulation of tissue regeneration, or by interference with general pathogenetic pathways which are not specific for radiation damage, are illustrated by a number of examples.

RESULTS AND CONCLUSIONS

Increasing knowledge about the pathogenesis of normal tissue radiation responses are expected to significantly improve the efficacy of prophylactic means and possibilities for conservative management of side effects of radiation therapy. Novel approaches may be developed if the so-called "humoral radiation pathology" is taken into consideration in addition to the cellular effects of radiation.

Modulation of the cell kinetics of pig skin by the topical application of evening primrose oil or Lioxasol

The daily topical application of two compounds, a cream containing 10% evening primrose oil (EPO) and Lioxasol (a compound used clinically to treat radiation burns), resulted in increased cell proliferative activity in the skin of female Large White pigs. The effect was most pronounced in the case of the EPO based cream, and was comparable in magnitude with that observed in a previous study on pig skin using orally administered EPO. There was an increase in the size of the rete pegs in the epidermis by 6 weeks after the start of application of the EPO cream. However, this did not translate into an increase in the total thickness of the viable epidermis (excluding the stratum corneum) due to a reduction in the density of rete pegs, from 2 weeks after treatment. Lioxasol had no overall effect on the size of the rete pegs. The labelling index (LI) of cells in the basal layer of the epidermis of pigs receiving a daily topical application of EPO increased progressively with time from the start of application. The LI was maximal (17.9 +/- 2.4%) at the end of the observation period (8 weeks) at which time it was a factor of approximately 2 higher than in the basal layer prior to treatment. A considerably less marked increase in the LI of the basal layer was seen after the application of Lioxasol. The overall increase was approximately 20%, relative to the LI in the untreated epidermis. Labelled cell nuclei were also counted in the papillary dermis. After the application of the EPO cream, no significant increase in the number of labelled cells was observed until week 8, at which time values were approximately twice those in untreated skin. In Lioxasol treated skin the effect on the numbers of labelled cells in the papillary dermis was more immediate, with a approximately 60% increase at 2 weeks. This enhanced level of labelling was maintained until the end of the observation period of 10 weeks. Studies on the cell kinetics of the skin using the alcohol component of the Lioxasol preparation suggested that alcohol rather than Lioxasol was the most significant ingredient. It was concluded that the EPO cream merited further evaluation as a potential modulator of skin response to ionizing radiation.

Dietary effect of a symmetrical triacylglycerol, 1,3-biseicosapentaenoyl-2-gamma-linolenoyl glycerol, on fatty acid composition of guinea pigs

The dietary effect of 1,3-biseicosapentaenoyl-2-gamma-linolenoyl glycerol (STG) on the fatty acid composition of guinea pigs was examined and compared with that of an eicosapentaenoic acid ethyl ester (EPA-E) and of a soybean oil (SBO) diet. In terms of content of plasma lipid, EPA-E had a greater hypolipidemic effect than STG. On the other hand, in terms of EPA incorporation, contents of EPA in liver lipid were almost the same in the STG and EPA-E groups. Considering that the amount of EPA administered in the EPA-E group was almost 1.5 times that of the STG group, EPA may be absorbed more effectively as the glycerol ester than as the ethyl ester in guinea pigs. In all the tissue lipids, the STG group had a higher unsaturation index (UI) than the EPA-E group even though there is a lower UI in the STG diet than the EPA-E diet. These results suggest that greater amounts of desaturase products as a whole were synthesized in the STG group than in the other two groups. The dihomo-gamma-linolenic acid/arachidonic acid (DGLA/AA) ratio in plasma total lipids in the STG group was 3.5 times that of SBO group, and the DGLA/AA ratio in the EPA-E group was half that of the SBO group. In liver lipid, the ratios of DGLA/AA and EPA/AA in the STG group were 0.687 and 0.488 (phosphatidylcholine fraction) and 0.237 and 0.752 (phosphatidylethanolamine fraction), respectively. The ratio of DGLA/AA as well as the high EPA/AA ratio obtained in the present study with the STG diet may lead to physiological alterations, including enhanced synthesis of 1- and 3-series eicosanoids.

[The therapeutic management of radiogenic oral mucositis]

BACKGROUND

Acute reactions of oral mucosa are a frequent side effect of radiotherapy, which often necessitates interruption of the treatment. Marked proliferation of tumor stem cells during treatment interruptions may occur in squamous cell carcinomata, which represent the majority of tumors in the head and neck area. Hence a fatal consequence of treatment breaks may be a significant decrease in tumor cure rates. Furthermore, marked acute responses frequently result in increased late sequelae ("consequential damage"). Therefore, amelioration of the mucosal response aiming at avoiding treatment breaks and at reduction of late reactions could definitely increase the therapeutic success of radiation treatment.

PATIENTS AND METHOD

Various possibilities for the therapeutic management of radiation-induced oral mucositis with a symptomatic or radio- and epithelial biological background are summarized and presented systematically.

RESULTS

A variety of prophylactic and therapeutic methods have been proposed for the management of acute radiation reactions of the oral mucosa. Frequently, their efficacy has been established for chemotherapy or in combination with other immunosuppressive treatments. Hence, systematical rather than local effects have to be considered.

CONCLUSIONS

In general, prophylaxis of oral mucositis is mainly based on dental restoration or edentation, in combination with frequent oral hygienic measures after the meals and with antiseptic mouthwashes. Intensive personal care is recommended. The necessity of a percutaneous endoscopic gastrostoma is dependent on the status of the patient and on size and localization of the treatment area, i.e. the impairment of food uptake which is to be expected. Therapeutic intervention is restricted to local or systemic treatment of pain and local application of antimycotics and antibiotics.

The effect of azelastine on acute radiation dermatitis in mice models

PURPOSE

In our previous report we described the clinical value of azelastine, an oral antiallergic agent, as an inhibitor of radiation dermatitis. Here we studied the effect of azelastine on normal skin and tumor size after irradiation in a mouse model.

METHODS AND MATERIALS

The modifying effects of azelastine on both the degree of radiation dermatitis and antitumoral effect of radiation therapy were investigated in the normal skin as well as in SCC VII tumors of C3H/He mice. The right hind legs, with or without tumors, were irradiated with 20-60 Gy at 0.62 Gy/min. Azelastine was administered via the mouse chow, and acute skin reactions and tumor growth curves were compared between the azelastine and control groups.

RESULTS

The acute skin reactions of the azelastine group were significantly less prominent than those of the control group (p < 0.01). At a dose of 40 Gy the dose modification factors were 1.19-1.25. The tumor growth curves of the azelastine and control groups were almost identical, indicating that the treatment response of irradiation was not affected by administration of azelastine.

CONCLUSIONS

Application of azelastine reduces the degree of acute radiation dermatitis without affecting the antitumoral effect of radiation therapy.

Polyunsaturated fatty acids increase the sensitivity of 36B10 rat astrocytoma cells to radiation-induced cell kill

Polyunsaturated fatty acids (PUFA) such as gamma-linolenic acid (GLA, 18:3n-6), eicosapentaenoic acid (EPA, 20:5n-3), and docosahexaenoic acid (DHA, 22:6n-3) have been shown to be cytotoxic to tumor cells. The objective of this work was to study the effects of PUFA on the radiation response of a 36B10 rat astrocytoma cell line. Supplementation of the astrocytoma cells with 15-45 microM GLA, EPA, or DHA produced marked changes in the fatty acid profiles of their phospholipids and neutral lipids. The methylene bridge index of these lipids increased significantly. These PUFA also exerted cytotoxic effects, as determined using the clonogenic cell survival assay. While GLA and DHA produced a moderate cell-killing effect, EPA was extremely cytotoxic, especially at a concentration of 45 microM. The monounsaturated oleic acid (OA, 18:1n-9) did not affect cell survival. Further, all three PUFA, and particularly GLA, increased the radiation-induced cell kill; OA did not enhance the effect of radiation. alpha-Tocopherol acetate blocked the enhanced radiation sensitivity of GLA- and DHA-supplemented cells. In conclusion, GLA, EPA, and DHA supplementation prior to, during, and after irradiation can enhance the radiation-induced cytotoxicity of rat astrocytoma cells. GLA and DHA supplementation post-irradiation also enhanced the radiation response of the 36B10 cells. Because GLA maximally increases the radioresponsiveness of a rat astrocytoma, this PUFA might prove useful in increasing the therapeutic efficacy of radiation in the treatment of certain gliomas.

Trophic effects of essential fatty acids on pig skin

The daily oral administration of 3 ml of two oils (So-5407 and So-1129) containing essential fatty acids (EFAs) for 16 weeks resulted in a transient increase in cell proliferative activity in the skin of female Large White pigs. The So-5407 oil contained 7% gamma-linolenic acid (GLA) whereas So-1129 was an oil of similar composition, but with no GLA. Hyperplasia of the epidermis was observed after the administration of both oils, and this was characterized by an increase in the size of the rete pegs. The maximum effect occurred at 4 weeks after the start of oil administration, at which time the number of viable cell layers had increased by a factor of approximately 1.5, and mean epidermal thickness (excluding the stratum corneum) was approximately 40% greater than that of the epidermis prior to oil administration. There was a marked increase in the labelling index (LI) of the basal cell layer of the epidermis in pigs receiving So-5407. Maximum LIs were quantified at 4 weeks after the start of administration and were 18.8 +/- 1.3% and 13.1 +/- 1.7% for pigs receiving So-5407 and So-1129, respectively. After this time the LI declined progressively and had returned to values within normal limits (P > 0.1) by 8 weeks after the start of administration of both oils. A similar pattern of change in the LI was seen in the follicular epithelium, although the peak values at 4 weeks after the start of oil administration of 12.2 +/- 1.8% and 10.8 +/- 0.9 for the groups receiving So-5407 and So-1129, respectively, were lower than in the epidermis. Labelled cells were also counted in the papillary dermis and maximum values were again seen at 4 weeks after the start of oil administration. Of the two oils, So-1129 had the greatest effect, with the number of labelled cells in the papillary dermis being a factor of three to four-fold higher than in skin prior to oil administration, between 2 and 12 weeks after the start of administration.