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Kaul D, Ehret F, Roohani S, Jendrach M, Buthut M, Acker G, Anwar M, Zips D, Heppner F, Prüss H. Radiation Therapy in Alzheimer's Disease: A Systematic Review. Int J Radiat Oncol Biol Phys 2024; 119:23-41. [PMID: 38042449 DOI: 10.1016/j.ijrobp.2023.11.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/11/2023] [Accepted: 11/19/2023] [Indexed: 12/04/2023]
Abstract
PURPOSE Pathophysiological hallmarks of Alzheimer's disease (AD) include extracellular amyloid plaques and intracellular neurofibrillary tangles. Recent studies also demonstrated a role of neuroinflammation in the progression of the disease. Clinical trials and animal studies using low-dose radiation therapy (LDRT) have shown therapeutic potential for AD. This systematic review summarizes the current evidence on the use of LDRT for the treatment of AD, outlines potential mechanisms of action, and discusses current challenges in the planning of future trials. METHODS AND MATERIALS A systematic review of human and animal studies as well as registered clinical trials describing outcomes for RT in the treatment of AD was conducted. We followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles published until July 1, 2023, were included. RESULTS The initial search yielded 993 articles. After the removal of duplicates and ineligible publications, a total of 16 (12 animal, 4 human) studies were included. Various dose regimens were utilized in both animal and human trials. The results revealed that LDRT reduced the number of amyloid plaques and neurofibrillary tangles, and it has a role in the regulation of genes and protein expression involved in the pathological progression of AD. LDRT has demonstrated reduced astro- and microgliosis, anti-inflammatory and neuroprotective effects, and an alleviation of symptoms of cognitive deficits in animal models. Most studies in humans suggested improvements in cognition and behavior. None of the trials or studies described significant (>grade 2) toxicity. CONCLUSIONS Preclinical studies, animal studies, and early clinical trials in humans have shown a promising role for LDRT in the treatment of AD pathologies, although the underlying mechanisms are yet to be fully explored. Phase I/II/III trials are needed to assess the long-term safety, efficacy, and optimal treatment parameters of LDRT in AD treatment.
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Affiliation(s)
- David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Felix Ehret
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Berlin, Germany
| | - Siyer Roohani
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Berlin, Germany
| | - Marina Jendrach
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maria Buthut
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Güliz Acker
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Muneeba Anwar
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Frank Heppner
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
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2
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Jithoo A, Penny TR, Pham Y, Sutherland AE, Smith MJ, Petraki M, Fahey MC, Jenkin G, Malhotra A, Miller SL, McDonald CA. The Temporal Relationship between Blood-Brain Barrier Integrity and Microglial Response following Neonatal Hypoxia Ischemia. Cells 2024; 13:660. [PMID: 38667275 PMCID: PMC11049639 DOI: 10.3390/cells13080660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Blood-brain barrier (BBB) dysfunction and neuroinflammation are key mechanisms of brain injury. We performed a time-course study following neonatal hypoxia-ischemia (HI) to characterize these events. HI brain injury was induced in postnatal day 10 rats by single carotid artery ligation followed by hypoxia (8% oxygen, 90 min). At 6, 12, 24, and 72 h (h) post-HI, brains were collected to assess neuropathology and BBB dysfunction. A significant breakdown of the BBB was observed in the HI injury group compared to the sham group from 6 h in the cortex and hippocampus (p < 0.001), including a significant increase in albumin extravasation (p < 0.0033) and decrease in basal lamina integrity and tight-junction proteins. There was a decrease in resting microglia (p < 0.0001) transitioning to an intermediate state from as early as 6 h post-HI, with the intermediate microglia peaking at 12 h (p < 0.0001), which significantly correlated to the peak of microbleeds. Neonatal HI insult leads to significant brain injury over the first 72 h that is mediated by BBB disruption within 6 h and a transitioning state of the resident microglia. Key BBB events coincide with the appearance of the intermediate microglial state and this relationship warrants further research and may be a key target for therapeutic intervention.
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Affiliation(s)
- Arya Jithoo
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Tayla R. Penny
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Amy E. Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Madeleine J. Smith
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Maria Petraki
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
| | - Michael C. Fahey
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia;
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Atul Malhotra
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia;
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Courtney A. McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia; (A.J.); (T.R.P.); (Y.P.); (A.E.S.); (M.J.S.); (G.J.); (A.M.); (S.L.M.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
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Zhou S, Ding X, Zhang Y, Liu Y, Wang X, Guo Y, Zhang J, Liu X, Gong G, Su Y, Wang L, Zhao M, Hu M. Evaluation of specific RBE in different cells of hippocampus under high-dose proton irradiation in rats. Sci Rep 2024; 14:8193. [PMID: 38589544 PMCID: PMC11001863 DOI: 10.1038/s41598-024-58831-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024] Open
Abstract
The study aimed to determine the specific relative biological effectiveness (RBE) of various cells in the hippocampus following proton irradiation. Sixty Sprague-Dawley rats were randomly allocated to 5 groups receiving 20 or 30 Gy of proton or photon irradiation. Pathomorphological neuronal damage in the hippocampus was assessed using Hematoxylin-eosin (HE) staining. The expression level of NeuN, Nestin, Caspase-3, Olig2, CD68 and CD45 were determined by immunohistochemistry (IHC). The RBE range established by comparing the effects of proton and photon irradiation at equivalent biological outcomes. Proton20Gy induced more severe damage to neurons than photon20Gy, but showed no difference compared to photon30Gy. The RBE of neuron was determined to be 1.65. Similarly, both proton20Gy and proton30Gy resulted in more inhibition of oligodendrocytes and activation of microglia in the hippocampal regions than photon20Gy and photon30Gy. However, the expression of Olig2 was higher and CD68 was lower in the proton20Gy group than in the photon30Gy group. The RBE of oligodendrocyte and microglia was estimated to be between 1.1 to 1.65. For neural stem cells (NSCs) and immune cells, there were no significant difference in the expression of Nestin and CD45 between proton and photon irradiation (both 20 and 30 Gy). Therefore, the RBE for NSCs and immune cell was determined to be 1.1. These findings highlight the varying RBE values of different cells in the hippocampus in vivo. Moreover, the actual RBE of the hippocampus may be higher than 1.1, suggesting that using as RBE value of 1.1 in clinical practice may underestimate the toxicities induced by proton radiation.
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Affiliation(s)
- Shengying Zhou
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261053, Shandong, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China
| | - Xingchen Ding
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China
| | - Yiyuan Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China
| | - Yuanyuan Liu
- Department of Pathology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China
| | - Xiaowen Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China
- Shandong University cancer center, Jinan, 250100, Shandong, China
| | - Yujiao Guo
- Affiliated Hospital of Jining Medical College, Jining, 272067, Shandong, China
| | | | - Xiao Liu
- 960 Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Jinan, 250031, Shandong, China
| | - Guanzhong Gong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China
| | - Ya Su
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China
| | - Lizhen Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China
| | - Miaoqing Zhao
- Department of Pathology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.
| | - Man Hu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, NO.440 Ji Yan Road, Jinan, 250117, Shandong, China.
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4
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Strohm AO, Johnston C, Hernady E, Marples B, O'Banion MK, Majewska AK. Cranial irradiation disrupts homeostatic microglial dynamic behavior. J Neuroinflammation 2024; 21:82. [PMID: 38570852 PMCID: PMC10993621 DOI: 10.1186/s12974-024-03073-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/22/2024] [Indexed: 04/05/2024] Open
Abstract
Cranial irradiation causes cognitive deficits that are in part mediated by microglia, the resident immune cells of the brain. Microglia are highly reactive, exhibiting changes in shape and morphology depending on the function they are performing. Additionally, microglia processes make dynamic, physical contacts with different components of their environment to monitor the functional state of the brain and promote plasticity. Though evidence suggests radiation perturbs homeostatic microglia functions, it is unknown how cranial irradiation impacts the dynamic behavior of microglia over time. Here, we paired in vivo two-photon microscopy with a transgenic mouse model that labels cortical microglia to follow these cells and determine how they change over time in cranial irradiated mice and their control littermates. We show that a single dose of 10 Gy cranial irradiation disrupts homeostatic cortical microglia dynamics during a 1-month time course. We found a lasting loss of microglial cells following cranial irradiation, coupled with a modest dysregulation of microglial soma displacement at earlier timepoints. The homogeneous distribution of microglia was maintained, suggesting microglia rearrange themselves to account for cell loss and maintain territorial organization following cranial irradiation. Furthermore, we found cranial irradiation reduced microglia coverage of the parenchyma and their surveillance capacity, without overtly changing morphology. Our results demonstrate that a single dose of radiation can induce changes in microglial behavior and function that could influence neurological health. These results set the foundation for future work examining how cranial irradiation impacts complex cellular dynamics in the brain which could contribute to the manifestation of cognitive deficits.
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Affiliation(s)
- Alexandra O Strohm
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Carl Johnston
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Eric Hernady
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Brian Marples
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - M Kerry O'Banion
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, 14642, USA
- Del Monte Institute for Neuroscience, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Ania K Majewska
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, 14642, USA.
- Del Monte Institute for Neuroscience, University of Rochester Medical Center, Rochester, NY, 14642, USA.
- Center for Visual Science, University of Rochester Medical Center, Rochester, NY, 14642, USA.
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Ahmed S, Ma N, Kawanokuchi J, Matsuoka K, Oikawa S, Kobayashi H, Hiraku Y, Murata M. Taurine reduces microglia activation in the brain of aged senescence-accelerated mice by increasing the level of TREM2. Sci Rep 2024; 14:7427. [PMID: 38548872 PMCID: PMC10978912 DOI: 10.1038/s41598-024-57973-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/23/2024] [Indexed: 04/01/2024] Open
Abstract
Alzheimer's disease (AD), a chronic neurodegenerative disorder, is the leading cause of dementia. Over-activated microglia is related to amyloid-beta (Aβ) and phosphorylated tau (phospho-tau) accumulation in the AD brain. Taurine is an amino acid with multiple physiological functions including anti-inflammatory effects, and has been reported to be neuroprotective in AD. However, the role of taurine in microglia-mediated AD remains unclear. Here, we examined the effects of taurine on the brains of senescence-accelerated mouse prone 8 (SAMP8) mice by comparing those administered 1% taurine water with those administered distilled water (DW). We observed increased levels of taurine and taurine transporter (TAUT) in the brains of the taurine-treated mice compared with those of control mice. Immunohistochemical and Western blot analyses revealed that taurine significantly reduced the number of activated microglia, levels of phospho-tau and Aβ deposit in the hippocampus and cortex. Triggering receptors expressed on myeloid cells-2 (TREM2) are known to protect against AD pathogenesis. Taurine upregulated TREM2 expression in the hippocampus and cortex. In conclusion, the present study suggests that taurine treatment may upregulate TREM2 to protect against microglia over-activation by decreasing the accumulation of phospho-tau and Aβ; providing an insight into a novel preventive strategy in AD.
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Affiliation(s)
- Sharif Ahmed
- Department of Environmental and Molecular Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
- Department of Environmental Health, University of Fukui School of Medical Sciences, Eiheiji, Fukui, Japan
| | - Ning Ma
- Graduate School of Health Science, Suzuka University of Medical Science, Suzuka, Mie, Japan
- Institute of Traditional Chinese Medicine, Suzuka University of Medical Science, Suzuka, Mie, Japan
- Department of Acupuncture and Moxibution Science, Faculty of Health Science, Suzuka University of Medical Science, Suzuka, Mie, Japan
| | - Jun Kawanokuchi
- Graduate School of Health Science, Suzuka University of Medical Science, Suzuka, Mie, Japan
- Institute of Traditional Chinese Medicine, Suzuka University of Medical Science, Suzuka, Mie, Japan
| | - Keiya Matsuoka
- Department of Acupuncture and Moxibution Science, Faculty of Health Science, Suzuka University of Medical Science, Suzuka, Mie, Japan
| | - Shinji Oikawa
- Department of Environmental and Molecular Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hatasu Kobayashi
- Department of Environmental and Molecular Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yusuke Hiraku
- Department of Environmental Health, University of Fukui School of Medical Sciences, Eiheiji, Fukui, Japan
| | - Mariko Murata
- Department of Environmental and Molecular Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
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Marino N, Bedeschi M, Vaccari ME, Cambiaghi M, Tesei A. Glitches in the brain: the dangerous relationship between radiotherapy and brain fog. Front Cell Neurosci 2024; 18:1328361. [PMID: 38515789 PMCID: PMC10956129 DOI: 10.3389/fncel.2024.1328361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024] Open
Abstract
Up to approximately 70% of cancer survivors report persistent deficits in memory, attention, speed of information processing, multi-tasking, and mental health functioning, a series of symptoms known as "brain fog." The severity and duration of such effects can vary depending on age, cancer type, and treatment regimens. In particular, every year, hundreds of thousands of patients worldwide undergo radiotherapy (RT) for primary brain tumors and brain metastases originating from extracranial tumors. Besides its potential benefits in the control of tumor progression, recent studies indicate that RT reprograms the brain tumor microenvironment inducing increased activation of microglia and astrocytes and a consequent general condition of neuroinflammation that in case it becomes chronic could lead to a cognitive decline. Furthermore, radiation can induce endothelium reticulum (ER) stress directly or indirectly by generating reactive oxygen species (ROS) activating compensatory survival signaling pathways in the RT-surviving fraction of healthy neuronal and glial cells. In particular, the anomalous accumulation of misfolding proteins in neuronal cells exposed to radiation as a consequence of excessive activation of unfolded protein response (UPR) could pave the way to neurodegenerative disorders. Moreover, exposure of cells to ionizing radiation was also shown to affect the normal proteasome activity, slowing the degradation rate of misfolded proteins, and further exacerbating ER-stress conditions. This compromises several neuronal functions, with neuronal accumulation of ubiquitinated proteins with a consequent switch from proteasome to immunoproteasome that increases neuroinflammation, a crucial risk factor for neurodegeneration. The etiology of brain fog remains elusive and can arise not only during treatment but can also persist for an extended period after the end of RT. In this review, we will focus on the molecular pathways triggered by radiation therapy affecting cognitive functions and potentially at the origin of so-called "brain fog" symptomatology, with the aim to define novel therapeutic strategies to preserve healthy brain tissue from cognitive decline.
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Affiliation(s)
- Noemi Marino
- Bioscience Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Martina Bedeschi
- Bioscience Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Melania Elettra Vaccari
- Bioscience Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Marco Cambiaghi
- Bioscience Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Anna Tesei
- Bioscience Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
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Ainslie AP, Klaver M, Voshart DC, Gerrits E, den Dunnen WFA, Eggen BJL, Bergink S, Barazzuol L. Glioblastoma and its treatment are associated with extensive accelerated brain aging. Aging Cell 2024; 23:e14066. [PMID: 38234228 DOI: 10.1111/acel.14066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024] Open
Abstract
Progressive neurocognitive dysfunction is the leading cause of a reduced quality of life in patients with primary brain tumors. Understanding how the human brain responds to cancer and its treatment is essential to improve the associated cognitive sequelae. In this study, we performed integrated transcriptomic and tissue analysis on postmortem normal-appearing non-tumor brain tissue from glioblastoma (GBM) patients that had received cancer treatments, region-matched brain tissue from unaffected control individuals and Alzheimer's disease (AD) patients. We show that normal-appearing non-tumor brain regions of patients with GBM display hallmarks of accelerated aging, in particular mitochondrial dysfunction, inflammation, and proteostasis deregulation. The extent and spatial pattern of this response decreased with distance from the tumor. Gene set enrichment analyses and a direct comparative analysis with an independent cohort of brain tissue samples from AD patients revealed a significant overlap in differentially expressed genes and a similar biological aging trajectory. Additionally, these responses were validated at the protein level showing the presence of increased lysosomal lipofuscin, phosphorylated microtubule-associated protein Tau, and oxidative DNA damage in normal-appearing brain areas of GBM patients. Overall, our data show that the brain of GBM patients undergoes accelerated aging and shared AD-like features, providing the basis for novel or repurposed therapeutic targets for managing brain tumor-related side effects.
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Affiliation(s)
- Anna P Ainslie
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- European Research Institute for the Biology of Ageing, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Myrthe Klaver
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- European Research Institute for the Biology of Ageing, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daniëlle C Voshart
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Emma Gerrits
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wilfred F A den Dunnen
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart J L Eggen
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Steven Bergink
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- University College Groningen, University of Groningen, Groningen, The Netherlands
| | - Lara Barazzuol
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Chen Z, Li Y, Rasheed M, Wang H, Lei R, Zhao T, Deng Y, Ma H. Corrigendum: Altered expression of inflammation-associated molecules in striatum: an implication for sensitivity to heavy ion radiations. Front Cell Neurosci 2024; 18:1356536. [PMID: 38440149 PMCID: PMC10911010 DOI: 10.3389/fncel.2024.1356536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/08/2024] [Indexed: 03/06/2024] Open
Abstract
[This corrects the article DOI: 10.3389/fncel.2023.1252958.].
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Affiliation(s)
- Zixuan Chen
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Yumeng Li
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Madiha Rasheed
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Hao Wang
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Runhong Lei
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Tuo Zhao
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Yulin Deng
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Hong Ma
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
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9
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Chen Z, Li Y, Rasheed M, Wang H, Lei R, Zhao T, Deng Y, Ma H. Altered expression of inflammation-associated molecules in striatum: an implication for sensitivity to heavy ion radiations. Front Cell Neurosci 2023; 17:1252958. [PMID: 38107411 PMCID: PMC10725200 DOI: 10.3389/fncel.2023.1252958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023] Open
Abstract
Background and objective Heavy ion radiation is one of the major hazards astronauts face during space expeditions, adversely affecting the central nervous system. Radiation causes severe damage to sensitive brain regions, especially the striatum, resulting in cognitive impairment and other physiological issues in astronauts. However, the intensity of brain damage and associated underlying molecular pathological mechanisms mediated by heavy ion radiation are still unknown. The present study is aimed to identify the damaging effect of heavy ion radiation on the striatum and associated underlying pathological mechanisms. Materials and methods Two parallel cohorts of rats were exposed to radiation in multiple doses and times. Cohort I was exposed to 15 Gy of 12C6+ ions radiation, whereas cohort II was exposed to 3.4 Gy and 8 Gy with 56Fe26+ ions irradiation. Physiological and behavioural tests were performed, followed by 18F-FDG-PET scans, transcriptomics analysis of the striatum, and in-vitro studies to verify the interconnection between immune cells and neurons. Results Both cohorts revealed more persistent striatum dysfunction than other brain regions under heavy ion radiation at multiple doses and time, exposed by physiological, behavioural, and 18F-FDG-PET scans. Transcriptomic analysis revealed that striatum dysfunction is linked with an abnormal immune system. In vitro studies demonstrated that radiation mediated diversified effects on different immune cells and sustained monocyte viability but inhibited its differentiation and migration, leading to chronic neuroinflammation in the striatum and might affect other associated brain regions. Conclusion Our findings suggest that striatum dysfunction under heavy ion radiation activates abnormal immune systems, leading to chronic neuroinflammation and neuronal injury.
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Affiliation(s)
- Zixuan Chen
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Yumeng Li
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Madiha Rasheed
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Hao Wang
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Runhong Lei
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Tuo Zhao
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Yulin Deng
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Hong Ma
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Medical Technology, Beijing Institute of Technology, Beijing, China
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10
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Hardy SJ, Finkelstein A, Milano MT, Schifitto G, Sun H, Holley K, Usuki K, Weber MT, Zheng D, Seplaki CL, Janelsins M. Association of Radiation Dose to the Amygdala-Orbitofrontal Network with Emotion Recognition Task Performance in Patients with Low-Grade and Benign Brain Tumors. Cancers (Basel) 2023; 15:5544. [PMID: 38067248 PMCID: PMC10705220 DOI: 10.3390/cancers15235544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Although data are limited, difficulty in social cognition occurs in up to 83% of patients with brain tumors. It is unknown whether cranial radiation therapy (RT) dose to the amygdala-orbitofrontal network can impact social cognition. METHODS We prospectively enrolled 51 patients with low-grade and benign brain tumors planned for cranial RT. We assessed longitudinal changes on an emotion recognition task (ERT) that measures the ability to recognize emotional states by displaying faces expressing six basic emotions and their association with the RT dose to the amygdala-orbitofrontal network. ERT outcomes included the median time to choose a response (ERTOMDRT) or correct response (ERTOMDCRT) and total correct responses (ERTHH). RESULTS The RT dose to the amygdala-orbitofrontal network was significantly associated with longer median response times on the ERT. Increases in median response times occurred at lower doses than decreases in total correct responses. The medial orbitofrontal cortex was the most important variable on regression trees predicting change in the ERTOMDCRT. DISCUSSION This is, to our knowledge, the first study to show that off-target RT dose to the amygdala-orbitofrontal network is associated with performance on a social cognition task, a facet of cognition that has previously not been mechanistically studied after cranial RT.
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Affiliation(s)
- Sara J. Hardy
- Department of Radiation Oncology, University of Rochester, Rochester, NY 14620, USA; (M.T.M.); (D.Z.); (M.J.)
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, USA;
| | - Alan Finkelstein
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14627, USA;
- Center for Advanced Brain Imaging and Neurophysiology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Michael T. Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY 14620, USA; (M.T.M.); (D.Z.); (M.J.)
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, USA;
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA;
| | - Hongying Sun
- Department of Surgery, Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY 14642, USA; (H.S.); (M.T.W.)
| | - Koren Holley
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA;
| | - Kenneth Usuki
- Department of Radiation Oncology, University of Rochester, Rochester, NY 14620, USA; (M.T.M.); (D.Z.); (M.J.)
| | - Miriam T. Weber
- Department of Surgery, Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY 14642, USA; (H.S.); (M.T.W.)
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Dandan Zheng
- Department of Radiation Oncology, University of Rochester, Rochester, NY 14620, USA; (M.T.M.); (D.Z.); (M.J.)
| | - Christopher L. Seplaki
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA;
- Office for Aging Research and Health Services, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Michelle Janelsins
- Department of Radiation Oncology, University of Rochester, Rochester, NY 14620, USA; (M.T.M.); (D.Z.); (M.J.)
- Department of Surgery, Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY 14642, USA; (H.S.); (M.T.W.)
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11
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Janssen P, De Pauw L, Mambretti M, Lara O, Walckiers J, Mackens L, Rooman I, Guillaume B, De Ridder M, Ates G, Massie A. Characterization of the long-term effects of lethal total body irradiation followed by bone marrow transplantation on the brain of C57BL/6 mice. Int J Radiat Biol 2023; 100:385-398. [PMID: 37976378 DOI: 10.1080/09553002.2023.2283092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Total body irradiation (TBI) followed by bone marrow transplantation (BMT) is used in pre-clinical research to generate mouse chimeras that allow to study the function of a protein specifically on immune cells. Adverse consequences of irradiation on the juvenile body and brain are well described and include general fatigue, neuroinflammation, neurodegeneration and cognitive impairment. Yet, the long-term consequences of TBI/BMT performed on healthy adult mice have been poorly investigated. MATERIAL AND METHODS We developed a robust protocol to achieve near complete bone marrow replacement in mice using 2x550cGy TBI and evaluated the impact of the procedure on their general health, mood disturbances, memory, brain atrophy, neurogenesis, neuroinflammation and blood-brain barrier (BBB) permeability 2 and/or 16 months post-BMT. RESULTS We found a persistent decrease in weight along with long-term impact on locomotion after TBI and BMT. Although the TBI/BMT procedure did not lead to anxiety- or depressive-like behavior 2- or 16-months post-BMT, long-term spatial memory of the irradiated mice was impaired. We also observed radiation-induced impaired neurogenesis and cortical microglia activation 2 months post-BMT. Moreover, higher levels of hippocampal IgG in aged BMT mice suggest an enhanced age-related increase in BBB permeability that could potentially contribute to the observed memory deficit. CONCLUSIONS Overall health of the mice did not seem to be majorly impacted by TBI followed by BMT during adulthood. Yet, TBI-induced alterations in the brain and behavior could lead to erroneous conclusions on the function of a protein on immune cells when comparing mouse chimeras with different genetic backgrounds that might display altered susceptibility to radiation-induced damage. Ultimately, the BMT model we here present could also be used to study the related long-term consequences of TBI and BMT seen in patients.
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Affiliation(s)
- P Janssen
- Laboratory of Neuro-Aging & Viro-Immunotherapy, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Laboratory of Medical and Molecular Oncology, Oncology Research Centre (ORC), VUB, Brussels, Belgium
| | - L De Pauw
- Laboratory of Neuro-Aging & Viro-Immunotherapy, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - M Mambretti
- Laboratory of Medical and Molecular Oncology, Oncology Research Centre (ORC), VUB, Brussels, Belgium
| | - O Lara
- Laboratory of Neuro-Aging & Viro-Immunotherapy, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Laboratory of Medical and Molecular Oncology, Oncology Research Centre (ORC), VUB, Brussels, Belgium
| | - J Walckiers
- Laboratory of Neuro-Aging & Viro-Immunotherapy, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - L Mackens
- Laboratory of Neuro-Aging & Viro-Immunotherapy, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - I Rooman
- Laboratory of Medical and Molecular Oncology, Oncology Research Centre (ORC), VUB, Brussels, Belgium
| | - B Guillaume
- Ludwig Institute for Cancer Research, Brussels, Belgium
- de Duve Institute, UCLouvain, Brussels, Belgium
- Centre hospitalier de Jolimont, Service de Biochimie Médicale, La Louvière, Belgium
| | - M De Ridder
- Department of Radiotherapy, UZ Brussel, VUB, Brussels, Belgium
| | - G Ates
- Laboratory of Neuro-Aging & Viro-Immunotherapy, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - A Massie
- Laboratory of Neuro-Aging & Viro-Immunotherapy, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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12
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Sorokina SS, Malkov AE, Rozanova OM, Smirnova EN, Shemyakov AE. Behavioral performance and microglial status in mice after moderate dose of proton irradiation. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2023; 62:497-509. [PMID: 37794305 DOI: 10.1007/s00411-023-01044-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
Cognitive impairment is a remote effect of gamma radiation treatment of malignancies. The major part of the studies on the effect of proton irradiation (a promising alternative in the treatment of radio-resistant tumors and tumors located close to critical organs) on the cognitive abilities of laboratory animals and their relation to morphological changes in the brain is rather contradictory. The aim of this study was to investigate cognitive functions and the dynamics of changes in morphological parameters of hippocampal microglial cells after 7.5 Gy of proton irradiation. Two months after the cranial irradiation, 8- to 9-week-old male SHK mice were tested for total activity, spatial learning, as well as long- and short-term hippocampus-dependent memory. To estimate the morphological parameters of microglia, brain slices of control and irradiated animals each with different time after proton irradiation (24 h, 7 days, 1 month) were stained for microglial marker Iba-1. No changes in behavior or deficits in short-term and long-term hippocampus-dependent memory were found, but an impairment of episodic memory was observed. A change in the morphology of hippocampal microglial cells, which is characteristic of the transition of cells to an activated state, was detected. One day after proton exposure in the brain tissue, a slight decrease in cell density was observed, which was restored to the control level by the 30th day after treatment. The results obtained may be promising with regard to the future use of using high doses of protons per fraction in the irradiation of tumors.
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Affiliation(s)
- S S Sorokina
- Laboratory of Isotope Investigations, Institute of Theoretical and Experimental Biophysics RAS, Pushchino, Moscow Region, Russia.
| | - A E Malkov
- Laboratory of Neurons Systematic Organization, Institute of Theoretical and Experimental Biophysics RAS, Pushchino, Moscow Region, Russia
| | - O M Rozanova
- Laboratory of Cell Engineering, Institute of Theoretical and Experimental Biophysics RAS, Pushchino, Moscow Region, Russia
| | - E N Smirnova
- Laboratory of Cell Engineering, Institute of Theoretical and Experimental Biophysics RAS, Pushchino, Moscow Region, Russia
| | - A E Shemyakov
- Theranostics and Nuclear Medicine Laboratory, Institute of Theoretical and Experimental Biophysics RAS, Pushchino, Moscow Region, Russia
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13
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Roggan MD, Kronenberg J, Wollert E, Hoffmann S, Nisar H, Konda B, Diegeler S, Liemersdorf C, Hellweg CE. Unraveling astrocyte behavior in the space brain: Radiation response of primary astrocytes. Front Public Health 2023; 11:1063250. [PMID: 37089489 PMCID: PMC10116417 DOI: 10.3389/fpubh.2023.1063250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/06/2023] [Indexed: 04/09/2023] Open
Abstract
IntroductionExposure to space conditions during crewed long-term exploration missions can cause several health risks for astronauts. Space radiation, isolation and microgravity are major limiting factors. The role of astrocytes in cognitive disturbances by space radiation is unknown. Astrocytes' response toward low linear energy transfer (LET) X-rays and high-LET carbon (12C) and iron (56Fe) ions was compared to reveal possible effects of space-relevant high-LET radiation. Since astronauts are exposed to ionizing radiation and microgravity during space missions, the effect of simulated microgravity on DNA damage induction and repair was investigated.MethodsPrimary murine cortical astrocytes were irradiated with different doses of X-rays, 12C and 56Fe ions at the heavy ion accelerator GSI. DNA damage and repair (γH2AX, 53BP1), cell proliferation (Ki-67), astrocytes' reactivity (GFAP) and NF-κB pathway activation (p65) were analyzed by immunofluorescence microscopy. Cell cycle progression was investigated by flow cytometry of DNA content. Gene expression changes after exposure to X- rays were investigated by mRNA-sequencing. RT-qPCR for several genes of interest was performed with RNA from X-rays- and heavy-ion-irradiated astrocytes: Cdkn1a, Cdkn2a, Gfap, Tnf, Il1β, Il6, and Tgfβ1. Levels of the pro inflammatory cytokine IL-6 were determined using ELISA. DNA damage response was investigated after exposure to X-rays followed by incubation on a 2D clinostat to simulate the conditions of microgravity.ResultsAstrocytes showed distinct responses toward the three different radiation qualities. Induction of radiation-induced DNA double strand breaks (DSBs) and the respective repair was dose-, LET- and time-dependent. Simulated microgravity had no significant influence on DNA DSB repair. Proliferation and cell cycle progression was not affected by radiation qualities examined in this study. Astrocytes expressed IL-6 and GFAP with constitutive NF-κB activity independent of radiation exposure. mRNA sequencing of X-irradiated astrocytes revealed downregulation of 66 genes involved in DNA damage response and repair, mitosis, proliferation and cell cycle regulation.DiscussionIn conclusion, primary murine astrocytes are DNA repair proficient irrespective of radiation quality. Only minor gene expression changes were observed after X-ray exposure and reactivity was not induced. Co-culture of astrocytes with microglial cells, brain organoids or organotypic brain slice culture experiments might reveal whether astrocytes show a more pronounced radiation response in more complex network architectures in the presence of other neuronal cell types.
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Affiliation(s)
- Marie Denise Roggan
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
| | - Jessica Kronenberg
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- Microgravity User Support Center (MUSC), German Aerospace Center (DLR), Cologne, Germany
| | - Esther Wollert
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
| | - Sven Hoffmann
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- Department of Gravitational Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
| | - Hasan Nisar
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- Department of Medical Sciences, Pakistan Institute of Engineering and Applied Sciences (PIEAS), Islamabad, Pakistan
| | - Bikash Konda
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
| | - Sebastian Diegeler
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, United States
| | - Christian Liemersdorf
- Department of Gravitational Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
| | - Christine E. Hellweg
- Department of Radiation Biology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- *Correspondence: Christine E. Hellweg
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14
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Hardy SJ, Finkelstein AJ, Tivarus M, Culakova E, Mohile N, Weber M, Lin E, Zhong J, Usuki K, Schifitto G, Milano M, Janelsins-Benton MC. Cognitive and neuroimaging outcomes in individuals with benign and low-grade brain tumours receiving radiotherapy: a protocol for a prospective cohort study. BMJ Open 2023; 13:e066458. [PMID: 36792323 PMCID: PMC9933762 DOI: 10.1136/bmjopen-2022-066458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/27/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Radiation-induced cognitive decline (RICD) occurs in 50%-90% of adult patients 6 months post-treatment. In patients with low-grade and benign tumours with long expected survival, this is of paramount importance. Despite advances in radiation therapy (RT) treatment delivery, better understanding of structures important for RICD is necessary to improve cognitive outcomes. We hypothesise that RT may affect network topology and microstructural integrity on MRI prior to any gross anatomical or apparent cognitive changes. In this longitudinal cohort study, we aim to determine the effects of RT on brain structural and functional integrity and cognition. METHODS AND ANALYSIS This study will enroll patients with benign and low-grade brain tumours receiving partial brain radiotherapy. Patients will receive either hypofractionated (>2 Gy/fraction) or conventionally fractionated (1.8-2 Gy/fraction) RT. All participants will be followed for 12 months, with MRIs conducted pre-RT and 6-month and 12 month post-RT, along with a battery of neurocognitive tests and questionnaires. The study was initiated in late 2018 and will continue enrolling through 2024 with final follow-ups completing in 2025. The neurocognitive battery assesses visual and verbal memory, attention, executive function, processing speed and emotional cognition. MRI protocols incorporate diffusion tensor imaging and resting state fMRI to assess structural connectivity and functional connectivity, respectively. We will estimate the association between radiation dose, imaging metrics and cognitive outcomes. ETHICS AND DISSEMINATION This study has been approved by the Research Subjects Review Board at the University of Rochester (STUDY00001512: Cognitive changes in patients receiving partial brain radiation). All results will be published in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT04390906.
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Affiliation(s)
- Sara J Hardy
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Alan J Finkelstein
- Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
- Center for Advanced Brain Imaging and Neurophysiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Madalina Tivarus
- Center for Advanced Brain Imaging and Neurophysiology, University of Rochester Medical Center, Rochester, New York, USA
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Culakova
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Nimish Mohile
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Miriam Weber
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York, USA
| | - Edward Lin
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Jianhui Zhong
- Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
- Center for Advanced Brain Imaging and Neurophysiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Kenneth Usuki
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Giovanni Schifitto
- Department of Neurology, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Michael Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - M C Janelsins-Benton
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, USA
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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15
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Layer JP, Layer K, Sarria GR, Röhner F, Dejonckheere CS, Friker LL, Zeyen T, Koch D, Scafa D, Leitzen C, Köksal M, Schmeel FC, Schäfer N, Landsberg J, Hölzel M, Herrlinger U, Schneider M, Giordano FA, Schmeel LC. Five-Fraction Stereotactic Radiotherapy for Brain Metastases-A Retrospective Analysis. Curr Oncol 2023; 30:1300-1313. [PMID: 36826062 PMCID: PMC9955428 DOI: 10.3390/curroncol30020101] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/10/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023] Open
Abstract
PURPOSE To determine the safety and outcome profile of five-fraction stereotactic radiotherapy (FSRT) for brain metastases (BM), either as a definitive or adjuvant treatment. METHODS We assessed clinical data of patients receiving five fractions of 7 Gy each (cumulative physical dose of 35 Gy) to BM or surgical cavities. The primary endpoints were toxicity and radiation necrosis (RN) rates. Secondary endpoints were 1-year cumulative local control rate (LCR) and estimated overall survival (OS). RESULTS A total of 36 eligible patients receiving FSRT to a total of 49 targets were identified and included. The median follow up was 9 (1.1-56.2) months. The median age was 64.5 (34-92) years, the median ECOG score was 1, and the median Diagnostic-Specific Graded Prognostic Assessment (DS-GPA) score was 2. Treatment was well tolerated and there were no grade 3 adverse events or higher. The overall RN rate was 14.3% and the median time to RN was 12.9 (1.8-23.8) months. RN occurrence was associated with immunotherapy, young age (≤45 years), and large PTV. The cumulative 1-year local control rate was 83.1% and the estimated median local progression free-survival was 18.8 months. The estimated median overall survival was 11 (1.1-56.2) months and significantly superior in those patients presenting with RN. CONCLUSIONS FSRT with 5 × 7 Gy represents a feasible, safe, and efficient fast track approach of intensified FSRT with acceptable LC and comparable RN rates for both the adjuvant and definitive RT settings.
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Affiliation(s)
- Julian P. Layer
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Gustavo R. Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Fred Röhner
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Cas S. Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Lea L. Friker
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Christina Leitzen
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | | | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Jennifer Landsberg
- Department of Dermatology, University Hospital Bonn, 53127 Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Frank A. Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Leonard Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Correspondence:
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16
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Region-Specific Effects of Fractionated Low-Dose Versus Single-Dose Radiation on Hippocampal Neurogenesis and Neuroinflammation. Cancers (Basel) 2022; 14:cancers14225477. [PMID: 36428572 PMCID: PMC9688466 DOI: 10.3390/cancers14225477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/24/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Despite technical advances in hippocampus-sparing radiotherapy, radiation-induced injury to neural stem cell compartments may affect neurocognitive functions. In pre-clinical mouse models with fractionated low-dose radiation (FLDR) and single-dose radiation (SDR), the accurate response to radiation-induced injury was analyzed in different hippocampal subregions. METHODS Adult and juvenile C57BL/6NCrl mice were exposed to FLDR (20 × 0.1 Gy, daily exposure from Monday to Friday for 4 weeks) or SDR (1 × 2 Gy). In addition, 72 h after the last exposure, neuroglia (astrocytes and microglia) and neuroprogenitor cells were characterized and quantified in the hippocampal cornu ammonis (CA) and dentate gyrus (DG) by immunofluorescence studies. RESULTS After analyzing different hippocampal subregions, it was observed that radiation responses varied between non-neurogenic CA, with no detectable inflammatory alterations, and neurogenic DG, characterized by impaired neurogenesis and subsequent neuroinflammation. Age-dependent differences in radiosensitivity appeared to depend on the varying proliferative potential of neural stem cell niches. Using the same overall dose for FLDR and SDR (2 Gy), both the cumulative dose over time and also the single dose fraction have decisive impacts on hippocampal damage. CONCLUSION Region-specific effects of radiation-induced hippocampal injury relies primarily on cell deaths of proliferating neuroprogenitors. Dose per fraction defines the extent of neuronal injury, and subsequently activated microglia and reactive astrocytes modulate dynamic processes of neuroinflammation. Thus, limiting both cumulative doses and dose fractions to hippocampal DG is an important issue of clinical radiotherapy to preserve neurocognitive functions.
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Erbani J, Boon M, Akkari L. Therapy-induced shaping of the glioblastoma microenvironment: Macrophages at play. Semin Cancer Biol 2022; 86:41-56. [PMID: 35569742 DOI: 10.1016/j.semcancer.2022.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 01/27/2023]
Abstract
The intricate cross-talks between tumor cells and their microenvironment play a key role in cancer progression and resistance to treatment. In recent years, targeting pro-tumorigenic components of the tumor microenvironment (TME) has emerged as a tantalizing strategy to improve the efficacy of standard-of-care (SOC) treatments, particularly for hard-to-treat cancers such as glioblastoma. In this review, we explore how the distinct microenvironmental niches characteristic of the glioblastoma TME shape response to therapy. In particular, we delve into the interplay between tumor-associated macrophages (TAM) and glioblastoma cells within angiogenic and hypoxic niches, and interrogate their dynamic co-evolution upon SOC therapies that fuels malignancy. Resolving the complexity of therapy-induced alterations in the glioblastoma TME and their impact on disease relapse is a stepping stone to identify targetable pro-tumorigenic pathways and TAM subsets, and may open the way to efficient combination therapies that will improve clinical outcomes.
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Affiliation(s)
- Johanna Erbani
- Division of Tumour Biology and Immunology, Oncode Institute, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Menno Boon
- Division of Tumour Biology and Immunology, Oncode Institute, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Leila Akkari
- Division of Tumour Biology and Immunology, Oncode Institute, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands.
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18
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Jaylet T, Quintens R, Benotmane MA, Luukkonen J, Tanaka IB, Ibanez C, Durand C, Sachana M, Azimzadeh O, Adam-Guillermin C, Tollefsen KE, Laurent O, Audouze K, Armant O. Development of an Adverse Outcome Pathway for radiation-induced microcephaly via expert consultation and machine learning. Int J Radiat Biol 2022; 98:1752-1762. [PMID: 35947014 DOI: 10.1080/09553002.2022.2110312] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Brain development during embryogenesis and in early postnatal life is particularly complex and involves the interplay of many cellular processes and molecular mechanisms, making it extremely vulnerable to exogenous insults, including ionizing radiation (IR). Microcephaly is one of the most frequent neurodevelopmental abnormalities that is characterized by small brain size, and is often associated with intellectual deficiency. Decades of research span from epidemiological data on in utero exposure of the A-bomb survivors, to studies on animal and cellular models that allowed deciphering the most prominent molecular mechanisms leading to microcephaly. The Adverse Outcome Pathway (AOP) framework is used to organize, evaluate and portray the scientific knowledge of toxicological effects spanning different biological levels of organizations, from the initial interaction with molecular targets to the occurrence of a disease or adversity. In the present study, the framework was used in an attempt to organize the current scientific knowledge on microcephaly progression in the context of ionizing radiation (IR) exposure. This work was performed by a group of experts formed during a recent workshop organized jointly by the Multidisciplinary European Low Dose Initiative (MELODI) and the European Radioecology Alliance (ALLIANCE) associations to present the AOP approach and tools. Here we report on the development of a putative AOP for congenital microcephaly resulting from IR exposure based on discussions of the working group and we emphasize the use of a novel machine-learning approach to assist in the screening of the available literature to develop AOPs. CONCLUSION The expert consultation led to the identification of crucial biological events for the progression of microcephaly upon exposure to IR, and highlighted current knowledge gaps. The machine learning approach was successfully used to screen the existing knowledge and helped to rapidly screen the body of evidence and in particular the epidemiological data. This systematic review approach also ensured that the analysis was sufficiently comprehensive to identify the most relevant data and facilitate rapid and consistent AOP development. We anticipate that as machine learning approaches become more user-friendly through easy-to-use web interface, this would allow AOP development to become more efficient and less time consuming.
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Affiliation(s)
- Thomas Jaylet
- Université Paris Cité, T3S, Inserm UMRS 1124, Paris, France
| | - Roel Quintens
- Radiobiology Unit, Belgian Nuclear Research Centre, SCK-CEN, Mol, Belgium
| | | | - Jukka Luukkonen
- University of Eastern Finland, Kuopio Campus, Department of Environmental and Biological Sciences, P.O. Box 1627, FI-70211 Kuopio, Finland
| | - Ignacia Braga Tanaka
- Department of Radiobiology, Institute for Environmental Sciences, 1-7 lenomae, Obuchi, Rokkasho-mura, Kamikita-gun, Aomori 039-3212, Japan
| | - Chrystelle Ibanez
- PSE-SANTE/SESANE/LRTOX Institut de Radioprotection et de Sûreté Nucléaire (IRSN), F-92262, Fontenay-aux-Roses, France
| | - Christelle Durand
- PSE-SANTE/SESANE/LRTOX Institut de Radioprotection et de Sûreté Nucléaire (IRSN), F-92262, Fontenay-aux-Roses, France
| | - Magdalini Sachana
- Organisation for Economic Co-operation and Development (OECD), Environment Health and Safety Division, 75775 CEDEX 16 Paris, France
| | - Omid Azimzadeh
- Federal Office for Radiation Protection (Bfs), Section Radiation Biology, 85764 Neuherberg, Germany
| | - Christelle Adam-Guillermin
- PSE-SANTE/SDOS/LMDN, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Cadarache, 13115 Saint-Paul-Lez-Durance, France
| | - Knut Erik Tollefsen
- Norwegian Institute for Water Research (NIVA), Økernveien 94, N-0579, Oslo, Norway.,Norwegian University of Life Sciences (NMBU), Post box 5003, N-1432 Ås, Norway.,Centre for Environmental Radioactivity, Norwegian University of Life Sciences (NMBU), Post box 5003, N-1432 Ås, Norway
| | - Olivier Laurent
- PSE-SANTE/SESANE/LEPID, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), F-92262, Fontenay-aux-Roses, France
| | - Karine Audouze
- Université Paris Cité, T3S, Inserm UMRS 1124, Paris, France
| | - Olivier Armant
- PSE-ENV/SRTE/LECO, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Cadarache, 13115 Saint-Paul-Lez-Durance, France
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19
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Klippel Zanona Q, Alves Marconi G, de Sá Couto Pereira N, Lazzarotto G, Luiza Ferreira Donatti A, Antonio Cortes de Oliveira J, Garcia-Cairasco N, Elisa Calcagnotto M. Absence-like seizures, cortical oscillations abnormalities and decreased anxiety-like behavior in Wistar Audiogenic Rats with cortical microgyria. Neuroscience 2022; 500:26-40. [DOI: 10.1016/j.neuroscience.2022.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/25/2022] [Accepted: 07/29/2022] [Indexed: 10/16/2022]
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20
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Lehrer EJ, Jones BM, Dickstein DR, Green S, Germano IM, Palmer JD, Laack N, Brown PD, Gondi V, Wefel JS, Sheehan JP, Trifiletti DM. The Cognitive Effects of Radiotherapy for Brain Metastases. Front Oncol 2022; 12:893264. [PMID: 35847842 PMCID: PMC9279690 DOI: 10.3389/fonc.2022.893264] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/27/2022] [Indexed: 12/24/2022] Open
Abstract
Brain metastases are the most common intracranial neoplasm and are seen in upwards of 10-30% of patients with cancer. For decades, whole brain radiation therapy (WBRT) was the mainstay of treatment in these patients. While WBRT is associated with excellent rates of intracranial tumor control, studies have demonstrated a lack of survival benefit, and WBRT is associated with higher rates of cognitive deterioration and detrimental effects on quality of life. In recent years, strategies to mitigate this risk, such as the incorporation of memantine and hippocampal avoidance have been employed with improved results. Furthermore, stereotactic radiosurgery (SRS) has emerged as an appealing treatment option over the last decade in the management of brain metastases and is associated with superior cognitive preservation and quality of life when compared to WBRT. This review article evaluates the pathogenesis and impact of cranial irradiation on cognition in patients with brain metastases, as well as current and future risk mitigation techniques.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Brianna M. Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daniel R. Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Isabelle M. Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Nadia Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL, United States
| | - Jeffrey S. Wefel
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: Daniel M. Trifiletti,
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21
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Iqubal A, Iqubal MK, Sharma S, Wasim M, Alfaleh MA, Md S, Baboota S, Ali J, Haque SE. Pathogenic mechanisms and therapeutic promise of phytochemicals and nanocarriers based drug delivery against radiotherapy-induced neurotoxic manifestations. Drug Deliv 2022; 29:1492-1511. [PMID: 35543534 PMCID: PMC9103628 DOI: 10.1080/10717544.2022.2064562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Radiotherapy is one of the extensively used therapeutic modalities in glioblastoma and other types of cancers. Radiotherapy is either used as a first-line approach or combined with pharmacotherapy or surgery to manage and treat cancer. Although the use of radiotherapy significantly increased the survival time of patients, but its use has been reported with marked neuroinflammation and cognitive dysfunction that eventually reduced the quality of life of patients. Based on the preclinical and clinical investigations, the profound role of increased oxidative stress, nuclear translocation of NF-kB, production of proinflammatory cytokines such as TNF-α, IL-6, IL-β, increased level of MMPs, increased apoptosis, reduced angiogenesis, neurogenesis, and histological aberrations in CA1, CA2, CA3 and DG region of the hippocampus have been reported. Various pharmacotherapeutic drugs are being used as an adjuvant to counteract this neurotoxic manifestation. Still, most of these drugs suffer from systemic adverse effect, causes interference to ongoing chemotherapy, and exhibit pharmacokinetic limitations in crossing the blood-brain barrier. Therefore, various phytoconstituents, their nano carrier-based drug delivery systems and miRNAs have been explored to overcome the aforementioned limitations. The present review is focused on the mechanism and evidence of radiotherapy-induced neuroinflammation and cognitive dysfunction, pathological and molecular changes in the brain homeostasis, available adjuvants, their limitations. Additionally, the potential role and mechanism of neuroprotection of various nanocarrier based natural products and miRNAs have been discussed.
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Affiliation(s)
- Ashif Iqubal
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Mohammad Kashif Iqubal
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India.,Product Development Department, Sentiss Research Centre, Sentiss Pharma Pvt Ltd, Gurugram, India
| | - Sumit Sharma
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Mohd Wasim
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Mohamed A Alfaleh
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Shadab Md
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Center of Excellence for Drug Research & Pharmaceutical Industries, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sanjula Baboota
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Javed Ali
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Syed Ehtaishamul Haque
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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22
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Targeting nanoparticles to malignant tumors. Biochim Biophys Acta Rev Cancer 2022; 1877:188703. [DOI: 10.1016/j.bbcan.2022.188703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/01/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
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23
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Allen BD, Limoli CL. Breaking barriers: Neurodegenerative repercussions of radiotherapy induced damage on the blood-brain and blood-tumor barrier. Free Radic Biol Med 2022; 178:189-201. [PMID: 34875340 PMCID: PMC8925982 DOI: 10.1016/j.freeradbiomed.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/20/2021] [Accepted: 12/02/2021] [Indexed: 02/07/2023]
Abstract
Exposure to radiation during the treatment of CNS tumors leads to detrimental damage of the blood brain barrier (BBB) in normal tissue. Effects are characterized by leakage of the vasculature which exposes the brain to a host of neurotoxic agents potentially leading to white matter necrosis, parenchymal calcification, and an increased chance of stroke. Vasculature of the blood tumor barrier (BTB) is irregular leading to poorly perfused and hypoxic tissue throughout the tumor that becomes resistant to radiation. While current clinical applications of cranial radiotherapy use dose fractionation to reduce normal tissue damage, these treatments still cause significant alterations to the cells that make up the neurovascular unit of the BBB and BTB. Damage to the vasculature manifests as reduction in tight junction proteins, alterations to membrane transporters, impaired cell signaling, apoptosis, and cellular senescence. While radiotherapy treatments are detrimental to normal tissue, adapting combined strategies with radiation targeted to damage the BTB could aid in drug delivery. Understanding differences between the BBB and the BTB may provide valuable insight allowing clinicians to improve treatment outcomes. Leveraging this information should allow advances in the development of therapeutic modalities that will protect the normal tissue while simultaneously improving CNS tumor treatments.
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Affiliation(s)
- Barrett D Allen
- Department of Radiation Oncology, University of California, Irvine, CA, 92697, USA
| | - Charles L Limoli
- Department of Radiation Oncology, University of California, Irvine, CA, 92697, USA.
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24
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Antonelli F, Casciati A, Belles M, Serra N, Linares-Vidal MV, Marino C, Mancuso M, Pazzaglia S. Long-Term Effects of Ionizing Radiation on the Hippocampus: Linking Effects of the Sonic Hedgehog Pathway Activation with Radiation Response. Int J Mol Sci 2021; 22:ijms222212605. [PMID: 34830484 PMCID: PMC8624704 DOI: 10.3390/ijms222212605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/04/2021] [Accepted: 11/17/2021] [Indexed: 12/29/2022] Open
Abstract
Radiation therapy represents one of the primary treatment modalities for primary and metastatic brain tumors. Although recent advances in radiation techniques, that allow the delivery of higher radiation doses to the target volume, reduce the toxicity to normal tissues, long-term neurocognitive decline is still a detrimental factor significantly affecting quality of life, particularly in pediatric patients. This imposes the need for the development of prevention strategies. Based on recent evidence, showing that manipulation of the Shh pathway carries therapeutic potential for brain repair and functional recovery after injury, here we evaluate how radiation-induced hippocampal alterations are modulated by the constitutive activation of the Shh signaling pathway in Patched 1 heterozygous mice (Ptch1+/-). Our results show, for the first time, an overall protective effect of constitutive Shh pathway activation on hippocampal radiation injury. This activation, through modulation of the proneural gene network, leads to a long-term reduction of hippocampal deficits in the stem cell and new neuron compartments and to the mitigation of radio-induced astrogliosis, despite some behavioral alterations still being detected in Ptch1+/- mice. A better understanding of the pathogenic mechanisms responsible for the neural decline following irradiation is essential for identifying prevention measures to contain the harmful consequences of irradiation. Our data have important translational implications as they suggest a role for Shh pathway manipulation to provide the therapeutic possibility of improving brain repair and functional recovery after radio-induced injury.
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Affiliation(s)
- Francesca Antonelli
- Division of Health Protection Technologies, Italian National Agency for New Technologies, Energy and Sustainable Economic Development (ENEA), 00123 Rome, Italy; (A.C.); (C.M.); (M.M.)
- Correspondence: (F.A.); (S.P.)
| | - Arianna Casciati
- Division of Health Protection Technologies, Italian National Agency for New Technologies, Energy and Sustainable Economic Development (ENEA), 00123 Rome, Italy; (A.C.); (C.M.); (M.M.)
| | - Montserrat Belles
- Physiology Unit, School of Medicine, Rovira I Virgili University (URV), 43007 Reus, Spain; (M.B.); (N.S.); (M.V.L.-V.)
| | - Noemi Serra
- Physiology Unit, School of Medicine, Rovira I Virgili University (URV), 43007 Reus, Spain; (M.B.); (N.S.); (M.V.L.-V.)
| | - Maria Victoria Linares-Vidal
- Physiology Unit, School of Medicine, Rovira I Virgili University (URV), 43007 Reus, Spain; (M.B.); (N.S.); (M.V.L.-V.)
| | - Carmela Marino
- Division of Health Protection Technologies, Italian National Agency for New Technologies, Energy and Sustainable Economic Development (ENEA), 00123 Rome, Italy; (A.C.); (C.M.); (M.M.)
| | - Mariateresa Mancuso
- Division of Health Protection Technologies, Italian National Agency for New Technologies, Energy and Sustainable Economic Development (ENEA), 00123 Rome, Italy; (A.C.); (C.M.); (M.M.)
| | - Simonetta Pazzaglia
- Division of Health Protection Technologies, Italian National Agency for New Technologies, Energy and Sustainable Economic Development (ENEA), 00123 Rome, Italy; (A.C.); (C.M.); (M.M.)
- Correspondence: (F.A.); (S.P.)
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25
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Zhou W, Hu M, Hu J, Du Z, Su Q, Xiang Z. Luteolin Suppresses Microglia Neuroinflammatory Responses and Relieves Inflammation-Induced Cognitive Impairments. Neurotox Res 2021; 39:1800-1811. [PMID: 34655374 DOI: 10.1007/s12640-021-00426-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 12/13/2022]
Abstract
Microglia-mediated neuroinflammation in response to injurious self and non-self-stimuli exerts detrimental effects on neurons, which may lead to cognitive impairment. Luteolin, a typical kind of natural flavonoid in honeysuckle, chrysanthemum, and Herba Schizonepetae, is widely recognized to be anti-inflammatory and antioxidant against peripheral inflammation. However, its protective effect against inflammation-induced cognitive impairment is currently unknown. In this paper, we investigated the relief potential of luteolin against lipopolysaccharide (LPS)-induced cognitive impairment and neuroinflammation and its possible anti-inflammatory mechanisms in lipopolysaccharide-stimulated BV2 microglia cells. In this study, luteolin ameliorated LPS-induced cognitive impairments, indicated by behavioral performance of neuroinflammatory model mice in Morris water maze tests. Protein analyses and histological examination also revealed protective effect of luteolin against neuronal damage, through inhibiting overproduction of inflammatory cytokines in both hippocampus and cortex of mice. We also observed luteolin in vitro significantly suppressed the levels of pro-inflammatory cytokines, such as tumor necrosis factor alpha (TNF-α) and interleukin-1 β (IL-1β), and inflammatory mediators like nitric oxide. Taken together, these results demonstrated luteolin was effective in alleviating cognitive impairment and limited neuronal damage via inhibiting the release of inflammatory mediators, suggesting luteolin is potential for further therapeutic research of neuroinflammation-related neurodegenerative diseases.
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Affiliation(s)
- Wei Zhou
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, 100 Waihuanxi Road, Guangzhou, 510006, PR China
| | - Mengmeng Hu
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, 100 Waihuanxi Road, Guangzhou, 510006, PR China
| | - Jingrong Hu
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, 100 Waihuanxi Road, Guangzhou, 510006, PR China
| | - Zhiyun Du
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, 100 Waihuanxi Road, Guangzhou, 510006, PR China
| | - Qing Su
- School of Computers, Guangdong University of Technology, 100 Waihuanxi Road, Guangzhou, 510006, PR China.
| | - Zhangmin Xiang
- Guangdong Provincial Key Laboratory of Emergency Test for Dangerous Chemicals, Guangdong Institute of Analysis, Guangzhou, 510070, PR China.
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26
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Under-recognized toxicities of cranial irradiation. Cancer Radiother 2021; 25:713-722. [PMID: 34274224 DOI: 10.1016/j.canrad.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 11/23/2022]
Abstract
Cranial irradiation of primary or metastatic lesions is frequent, historically with 3D-conformal radiation therapy and now with stereotactic radiosurgery and intensity modulation. Evolution of radiotherapy technique is concomitant to systemic treatment evolution permitting long time survival. Thus, physicians have to face underestimated toxicities on long-survivor patients and unknown toxicities from combination of cranial radiotherapy to new therapeutics as targeted therapies and immunotherapies. This article proposes to develop these toxicities, without being exhaustive, to allow a better apprehension of cranial irradiation in current context.
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27
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Schmal Z, Hammer B, Müller A, Rübe CE. Fractionated Low-Dose Radiation Induces Long-Lasting Inflammatory Responses in the Hippocampal Stem Cell Niche. Int J Radiat Oncol Biol Phys 2021; 111:1262-1275. [PMID: 34280471 DOI: 10.1016/j.ijrobp.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Despite major technical advances in hippocampus-sparing radiation therapy, radiation-induced injury to the neural stem cell compartment may affect neurocognitive functions. In the brain, glial cells modulate neuronal functions and are major mediators of neuroinflammation. In a preclinical mouse model with fractionated low-dose radiation (LDR), the complex response to radiation-induced injury was analyzed in the hippocampal stem cell compartment over a period of 6 months. METHODS AND MATERIALS Adult and juvenile C57BL/6NCrl mice were exposed to low doses of ionizing radiation (IR; 20 fractions of 0.1 Gy, for up to 4 weeks) daily. At 72 hours and 1, 3, and 6 months after fractionated LDR, magnetic resonance imaging (9.4 T) was conducted to detect structural and functional abnormalities in the hippocampal region. Using immunofluorescence and histologic studies, neuroglia cells (astrocytes, microglia, oligodendrocytes) were quantified and neuroinflammatory responses were characterized in the hippocampal dentate gyrus. Using in vivo bromodeoxyuridine labeling, the cell fate of newly generated progenitor cells was tracked in the subgranular zone of the dentate gyrus during fractionated LDR. RESULTS Low doses of IR induced long-lasting inflammatory responses with local increases of activated microglia and reactive astrocytes, which were most pronounced in the juvenile hippocampus within the first months after LDR. Glial activation with the consequent release of proinflammatory mediators increased local blood flow and vascular permeability in the hippocampal region. Cell fate mapping of progenitors located in the subgranular zone revealed a transient shift from neurogenesis to gliogenesis. CONCLUSIONS Glial cell activation and transient neuroinflammation may reflect radiation-induced neuronal damage in the hippocampal stem cell niche. The increased proliferative capacity of the developing brain may explain the enhanced hippocampal radiosensitivity, with stronger inflammatory reactions in the juvenile hippocampus. Thus, limiting the radiation dose to the hippocampal region is an important issue of clinical radiation therapy at all ages to preserve neurocognitive functions.
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Affiliation(s)
| | | | - Andreas Müller
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
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28
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Constanzo J, Faget J, Ursino C, Badie C, Pouget JP. Radiation-Induced Immunity and Toxicities: The Versatility of the cGAS-STING Pathway. Front Immunol 2021; 12:680503. [PMID: 34079557 PMCID: PMC8165314 DOI: 10.3389/fimmu.2021.680503] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/26/2021] [Indexed: 12/20/2022] Open
Abstract
In the past decade, radiation therapy (RT) entered the era of personalized medicine, following the striking improvements in radiation delivery and treatment planning optimization, and in the understanding of the cancer response, including the immunological response. The next challenge is to identify the optimal radiation regimen(s) to induce a clinically relevant anti-tumor immunity response. Organs at risks and the tumor microenvironment (e.g. endothelial cells, macrophages and fibroblasts) often limit the radiation regimen effects due to adverse toxicities. Here, we reviewed how RT can modulate the immune response involved in the tumor control and side effects associated with inflammatory processes. Moreover, we discussed the versatile roles of tumor microenvironment components during RT, how the innate immune sensing of RT-induced genotoxicity, through the cGAS-STING pathway, might link the anti-tumor immune response, radiation-induced necrosis and radiation-induced fibrosis, and how a better understanding of the switch between favorable and deleterious events might help to define innovative approaches to increase RT benefits in patients with cancer.
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Affiliation(s)
- Julie Constanzo
- IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Institut régional du Cancer de Montpellier, Montpellier, France
| | - Julien Faget
- IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Institut régional du Cancer de Montpellier, Montpellier, France
| | - Chiara Ursino
- IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Institut régional du Cancer de Montpellier, Montpellier, France
| | - Christophe Badie
- Cancer Mechanisms and Biomarkers Group, Radiation Effects Department, Centre for Radiation, Chemical & Environmental Hazards Public Health England Chilton, Didcot, United Kingdom
| | - Jean-Pierre Pouget
- IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Institut régional du Cancer de Montpellier, Montpellier, France
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Buizza G, Zampini MA, Riva G, Molinelli S, Fontana G, Imparato S, Ciocca M, Iannalfi A, Orlandi E, Baroni G, Paganelli C. Investigating DWI changes in white matter of meningioma patients treated with proton therapy. Phys Med 2021; 84:72-79. [PMID: 33872972 DOI: 10.1016/j.ejmp.2021.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/08/2021] [Accepted: 03/23/2021] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To evaluate changes in diffusion and perfusion-related properties of white matter (WM) induced by proton therapy, which is capable of a greater dose sparing to organs at risk with respect to conventional X-ray radiotherapy, and to eventually expose early manifestations of delayed neuro-toxicities. METHODS Apparent diffusion coefficient (ADC) and IVIM parameters (D, D* and f) were estimated from diffusion-weighted MRI (DWI) in 46 patients affected by meningioma and treated with proton therapy. The impact on changes in diffusion and perfusion-related WM properties of dose and time, as well as the influence of demographic and pre-treatment clinical information, were investigated through linear mixed-effects models. RESULTS Decreasing trends in ADC and D were found for WM regions hit by medium-high (30-40 Gy(RBE)) and high (>40 Gy(RBE)) doses, which are compatible with diffusion restriction due to radiation-induced cellular injury. Significant influence of dose and time on median ADC changes were observed. Also, D* showed a significant dependency on dose, whereas f consistently showed no dependency on dose and time. Age, gender and surgery extent were also found to affect changes in ADC. CONCLUSIONS These results overall agree with those from studies conducted on cohorts of mixed proton and X-ray radiotherapy patients. Future work should focus on relating our findings with clinical information of co-morbidities and thus exploiting such or more advanced imaging data to build normal tissue complication probability models to better integrate clinical and dose information.
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Affiliation(s)
- Giulia Buizza
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy.
| | - Marco Andrea Zampini
- MR Solutions Ltd., Ashbourne House, Old Portsmouth Rd., Guildford, United Kingdom.
| | - Giulia Riva
- Clinical Department, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Silvia Molinelli
- Medical Physics Unit, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Giulia Fontana
- Clinical Bioengineering Unit, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Sara Imparato
- Radiology Unit, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Mario Ciocca
- Medical Physics Unit, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Alberto Iannalfi
- Clinical Department, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Ester Orlandi
- Clinical Department, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Guido Baroni
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy; Clinical Bioengineering Unit, National Center of Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy.
| | - Chiara Paganelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy.
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