Low-dose X-ray irradiation promotes fracture healing through up-regulation of vascular endothelial growth factor

Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis?

INTRODUCTION

Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed.

METHODS

We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes.

RESULTS

After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043).

CONCLUSION

Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.

0.5‑Gy X‑ray irradiation induces reorganization of cytoskeleton and differentiation of osteoblasts

Osteoblasts are sensitive to ionizing radiation. The small GTPase RhoA and its effector Rho-associated protein kinase (ROCK) are critical to several cellular functions, including cytoskeleton reorganization, cell survival, and cell differentiation. However, whether the RhoA/ROCK signaling pathway is involved in the regulation of osteoblast cytoskeleton reorganization and differentiation induced by low-dose X-ray irradiation remains to be determined. The aim of the present study was to investigate the role of the RhoA/ROCK signaling pathway in mediating differentiation of osteoblasts and reorganization of the cytoskeleton under low-dose X-ray irradiation. Osteoblasts were pretreated with the ROCK kinase-specific inhibitor (Y-27632) before exposure to low-dose X-ray irradiation. The changes of F-actin in MC3T3 cells were observed at different time points following X-ray irradiation. Cell Counting Kit-8 assay, alkaline phosphatase activity, Alizarin red staining and western blotting were used to detect the proliferation and differentiation of osteoblasts after 0.5-Gy X-ray irradiation. In the present study, low-dose X-ray irradiation promoted the expression of genes associated with the cytoskeleton reorganization. Indeed, the results showed that, 0.5-Gy X-ray irradiation can induce reorganization of cytoskeleton and promote differentiation of osteoblasts through the RhoA/ROCK signaling pathway. Additionally, inhibiting ROCK activity blocked low-dose X-ray irradiation-induced LIMK2 phosphorylation, stress fiber formation and cell differentiation. Thus, these results demonstrated the excitatory effects of low-dose X-ray irradiation on MC3T3-E1 cells, including reorganization of the cytoskeleton and differentiation of osteoblasts.

Effects of Localized X-Ray Irradiation on Peripheral Nerve Regeneration in Transected Sciatic Nerve in Rats

Low-dose radiation has been used in clinical and experimental models for the prevention of scarring and for fracture healing. There is evidence that low-dose radiation improves the hormesis of various cell types but little is known about its effects on peripheral nerve tissue. In this study, we investigated the beneficial effects of low-dose radiation on the regeneration of transectional peripheral nerve injury in an experimental rat model. Seventy-two male Sprague-Dawley rats received transection injury to the left sciatic nerves, and the nerves were subsequently sutured by epineurium end-to-end anastomosis to restore continuity. Animals were randomly assigned to one of two treatment groups (n = 36/group): 1 Gy X-ray irradiation or control (sham irradiation). Gait analysis, electrophysiological examination and morphological investigations were performed. In addition, Western blot and qRT-PCR were performed to determine the level of vascular endothelial growth factor (VEGF) and growth-associated protein-43 (GAP-43). Content of VEGF and GAP-43 in the regenerated sciatic nerve of the irradiated group was higher than the control group. At 4 to 12 weeks after surgery, the irradiated animals exhibited a significantly improved functional recovery relative to controls. At 12 weeks after surgery, amplitude and conduction velocity of the irradiated group were higher than the control group (P < 0.05). The number of nerve fibers, diameter of axons and morphological structure of the myelin sheath in the irradiated group were superior to those of the control group. These results suggest that low-dose radiation contributed to regeneration and functional recovery after transverse peripheral nerve injury by inducing increased production of VEGF and GAP-43, which promote the axonal regeneration and myelination.

The Effect of Perioperative Radiation Therapy on Spinal Bone Fusion Following Spine Tumor Surgery

Introduction

Perioperative irradiation is often combined with spine tumor surgery. Radiation is known to be detrimental to healing process of bone fusion. We tried to investigate bone fusion rate in spine tumor surgery cases with perioperative radiation therapy (RT) and to analyze significant factors affecting successful bone fusion.

Methods

Study cohort was 33 patients who underwent spinal tumor resection and bone graft surgery combined with perioperative RT. Their medical records and radiological data were analyzed retrospectively. The analyzed factors were surgical approach, location of bone graft (anterior vs. posterior), kind of graft (autologous graft vs. allograft), timing of RT (preoperative vs. postoperative), interval of RT from operation in cases of postoperative RT (within 1 month vs. after 1 month) radiation dose (above 38 Gy vs. below 38 Gy) and type of radiation therapy (conventional RT vs. stereotactic radiosurgery). The bone fusion was determined on computed tomography images.

Result

Bone fusion was identified in 19 cases (57%). The only significant factors to affect bony fusion was the kind of graft (75% in autograft vs. 41 in allograft, p=0.049). Other factors proved to be insignificant relating to postoperative bone fusion. Regarding time interval of RT and operation in cases of postoperative RT, the time interval was not significant (p=0.101).

Conclusion

Spinal fusion surgery which was combined with perioperative RT showed relatively low bone fusion rate (57%). For successful bone fusion, the selection of bone graft was the most important.

DNA-PKcs-SIN1 complexation mediates low-dose X-ray irradiation (LDI)-induced Akt activation and osteoblast differentiation

Low-dose irradiation (LDI) induces osteoblast differentiation, however the underlying mechanisms are not fully understood. In this study, we explored the potential role of DNA-dependent protein kinase catalytic subunit (DNA-PKcs)-Akt signaling in LDI-induced osteoblast differentiation. We confirmed that LDI promoted mouse calvarial osteoblast differentiation, which was detected by increased alkaline phosphatase (ALP) activity as well as mRNA expression of type I collagen (Col I) and runt-related transcription factor 2 (Runx2). In mouse osteoblasts, LDI (1Gy) induced phosphorylation of DNA-PKcs and Akt (mainly at Ser-473). The kinase inhibitors against DNA-PKcs (NU-7026 and NU-7441) or Akt (LY294002, perifosine and MK-2206), as well as partial depletion of DNA-PKcs or Akt1 by targeted-shRNA, dramatically inhibited LDI-induced Akt activation and mouse osteoblast differentiation. Further, siRNA-knockdown of SIN1, a key component of mTOR complex 2 (mTORC2), also inhibited LDI-induced Akt Ser-473 phosphorylation as well as ALP activity increase and Col I/Runx2 expression in mouse osteoblasts. Co-immunoprecipitation (Co-IP) assay results demonstrated that LDI-induced DNA-PKcs-SIN1 complexation, which was inhibited by NU-7441 or SIN1 siRNA-knockdown in mouse osteoblasts. In summary, our data suggest that DNA-PKcs-SIN1 complexation-mediated Akt activation (Ser-473 phosphorylation) is required for mouse osteoblast differentiation.

Low level irradiation in mice can lead to enhanced trabecular bone morphology

Charged particle radiation such as iron ions and their secondary fragmentation products are of particular concern to the skeleton due to their high charge and energy deposition. However, little is known about the long-term effects of these particles on trabecular and cortical bone morphology when applied at relatively low levels. We hypothesized that even a 4.4 cGy dose of a complex secondary iron ion radiation field will compromise skeletal quantity and architecture in adult mice. One year after radiation exposure and compared to age-matched controls, 4.4 cGy irradiated mice had 51 % more trabecular bone, 56 % greater trabecular bone volume fraction, 16 % greater trabecular number, and 17 % less trabecular separation in the distal metaphysis of the femur. Similar to the metaphysis, trabecular bone of the distal femoral epiphysis in 4.4 cGy mice had 33 % more trabecular bone, 31 % greater trabecular bone volume fraction, and a 33 % smaller structural model index. Cortical bone morphology, whole bone mechanical properties, and lower leg muscle mass were unaffected. When compared to two additional groups, irradiated at either 8.9 or 17.8 cGy, a (negative) dose response relationship was observed for trabecular bone in the metaphysis but not in the epiphysis. In contrast to our original hypothesis, these data indicated that a secondary field of low-level, high-linear energy transfer iron radiation may cause long-term augmentation, rather than deterioration, of trabecular bone in the femoral metaphysis and epiphysis of mice.