Re-irradiation of mouse kidneys: a comparison of re-treatment tolerance after single and fractionated partial tolerance doses

Pre-clinical evaluation of biomarkers for the early detection of nephrotoxicity following alpha-particle radioligand therapy

PURPOSE

Cancer treatment with alpha-emitter-based radioligand therapies (α-RLTs) demonstrates promising tumor responses. Radiolabeled peptides are filtered through glomeruli, followed by potential reabsorption of a fraction by proximal tubules, which may cause acute kidney injury (AKI) and chronic kidney disease (CKD). Because tubular cells are considered the primary site of radiopeptides' renal reabsorption and potential injury, the current use of kidney biomarkers of glomerular functional loss limits the evaluation of possible nephrotoxicity and its early detection. This study aimed to investigate whether urinary secretion of tubular injury biomarkers could be used as an additional non-invasive sensitive diagnostic tool to identify unrecognizable tubular damage and risk of long-term α-RLT nephrotoxicity.

METHODS

A bifunctional cyclic peptide, melanocortin 1 ligand (MC1L), labeled with [203Pb]Pb-MC1L, was used for [212Pb]Pb-MC1L biodistribution and absorbed dose measurements in CD-1 Elite mice. Mice were treated with [212Pb]Pb-MC1L in a dose-escalation study up to levels of radioactivity intended to induce kidney injury. The approach enabled prospective kidney functional and injury biomarker evaluation and late kidney histological analysis to validate these biomarkers.

RESULTS

Biodistribution analysis identified [212Pb]Pb-MC1L reabsorption in kidneys with a dose deposition of 2.8, 8.9, and 20 Gy for 0.9, 3.0, and 6.7 MBq injected [212Pb]Pb-MC1L doses, respectively. As expected, mice receiving 6.7 MBq had significant weight loss and CKD evidence based on serum creatinine, cystatin C, and kidney histological alterations 28 weeks after treatment. A dose-dependent urinary neutrophil gelatinase-associated lipocalin (NGAL, tubular injury biomarker) urinary excretion the day after [212Pb]Pb-MC1L treatment highly correlated with the severity of late tubulointerstitial injury and histological findings.

CONCLUSION

Urine NGAL secretion could be a potential early diagnostic tool to identify unrecognized tubular damage and predict long-term α-RLT-related nephrotoxicity.

Pre-clinical Evaluation of Biomarkers for Early Detection of Nephrotoxicity Following Alpha-particle Radioligand Therapy

Purpose

Cancer treatment with alpha-emitter-based radioligand therapies (α-RLTs) demonstrates promising tumor responses. Radiolabeled peptides are filtered through glomeruli, followed by potential reabsorption of a fraction by proximal tubules, which may cause acute kidney injury (AKI) and chronic kidney disease (CKD). Because tubular cells are considered the primary site of radiopeptides' renal reabsorption and potential injury, the current use of kidney biomarkers of glomerular functional loss limits the evaluation of possible nephrotoxicity and its early detection. This study aimed to investigate whether urinary secretion of tubular injury biomarkers could be used as additional non-invasive sensitive diagnostic tool to identify unrecognizable tubular damage and risk of long-term α-RLTs nephrotoxicity.

Methods

A bifunctional cyclic peptide, melanocortin ligand-1(MC1L), labeled with [ 203 Pb]Pb-MC1L, was used for [ 212 Pb]Pb-MC1L biodistribution and absorbed dose measurements in CD-1 Elite mice. Mice were treated with [ 212 Pb]Pb-MC1L in a dose escalation study up to levels of radioactivity intended to induce kidney injury. The approach enabled prospective kidney functional and injury biomarker evaluation and late kidney histological analysis to validate these biomarkers.

Results

Biodistribution analysis identified [ 212 Pb]Pb-MC1L reabsorption in kidneys with a dose deposition of 2.8, 8.9, and 20 Gy for 0.9, 3.0, and 6.7 MBq injected [ 212 Pb]Pb-MC1L doses, respectively. As expected, mice receiving 6.7 MBq had significant weight loss and CKD evidence based on serum creatinine, cystatin C, and kidney histological alterations 28 weeks after treatment. A dose-dependent urinary Neutrophil gelatinase-associated lipocalin (NGAL, tubular injury biomarker) urinary excretion the day after [ 212 Pb]Pb-MC1L treatment highly correlated with the severity of late tubulointerstitial injury and histological findings.

Conclusion

urine NGAL secretion could be a potential early diagnostic tool to identify unrecognized tubular damage and predict long-term α-RLT-related nephrotoxicity.

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

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

Re-treatment after full-course radiotherapy: is it a viable option?

Re-irradiation of previously treated areas may become necessary for recurrent cancer, new primary tumours (common in head and neck cancer patients), or nodal and metastatic disease. Factors that should be taken into account in the decision to re-treat include: 1) previously treated volume (how much overlap is there with new treatment fields) and dose fractionation schedule; 2) which critical tissues or organs are at risk; 3) how much time has elapsed since first treatment; 4) whether there are any practical alternatives to re-irradiation? Rapidly proliferating tissues generally recover well from the initial radiotherapy and will tolerate re-irradiation to almost full doses. Some slowly proliferating tissues are also capable of partial proliferative and functional recovery, although this takes several months and some residual damage remains. Preclinical data demonstrate that re-irradiation with reduced doses is possible in lung and spinal cord after intervals of 3-6 months. Other slowly proliferating organs, e.g. the kidneys, do not appear to be capable of recovery, even after low, subtolerance doses. The largest clinical experience of re-irradiation is for head and neck cancers. A review of this literature reveals that the most frequent normal tissue complication seen is trismus (lockjaw), which occurs in 16 to 30% of re-treated cases, with lower incidences of soft tissue or bone necrosis and fibrosis. Myelitis is rarely reported, even in the re-treatment situation. In general the highest incidence of local control for the lowest incidence of serious complications is achieved for combinations of external beam and brachytherapy, and for small, well-differentiated, new primary tumours rather than recurrent disease. Re-treatment with total doses < 55 Gy gives very poor local control rates. Re-treatment schedules with curative intent require a high re-treatment dose, which is accompanied by an increased risk of normal tissue damage. To minimize serious complications, re-irradiation schedules require the best possible treatment planning (conformal therapy where possible). Hyperfractionation or a combination of external beam and brachytherapy could also be beneficial.

The influence of dose per fraction on the pathogenesis of radiation nephropathy

Both kidneys of male Wistar rats were irradiated with either a 10-Gy single dose or 26 Gy at a rate of 2 Gy per fraction per day. Serum blood urea nitrogen (BUN), creatinine and blood haematocrit levels were assessed prior to radiotherapy and at intervals of 8 weeks thereafter. A subset of animals from each dose group were killed at 4, 8, 16 and 24 weeks and both kidneys of each animal were examined by electron microscopy. In both dose groups a significant increase in BUN and creatinine levels, together with a decrease in haematocrit level, was observed at 16 weeks, and this was followed by an apparent improvement at 24 weeks. There was no statistical difference in these responses between the two groups. The morphological changes in both dose groups were essentially similar, but differed in severity. At 4 weeks after irradiation glomerular and proximal tubular injury were observed in both groups. A marked increase of glomerular and tubular injury in the 10-Gy dose group, without any apparent progression in the 26-Gy dose group, was detected at 8 weeks. By 16 weeks a noticeable improvement in both tubular and glomerular lesions (especially in the 10-Gy dose group) was observed. No apparent difference from the 16th week of evaluation was found at 24 weeks. These findings indicate that there is some recovery in kidney after irradiation, but the extent of the recovery process is somewhat limited.

The influence of intravesical photodynamic therapy on subsequent bladder irradiation tolerance

The aim of this project was to measure the irradiation tolerance of normal (non tumour bearing) mouse bladder after previous intravesical photodynamic therapy (PDT). Illumination with a range of light doses at 24 h after Photofrin was used as the initial PDT treatment and irradiation with a range of X-ray doses was given at 12 or 24 weeks after the initial therapy. Functional bladder damage was assessed from changes in micturition frequency (tested regularly for a follow-up period of 53 weeks after irradiation) and from cystometry measurements of the bladder at 53-56 weeks. PDT alone caused a marked increase in micturition frequency, with (partial) recovery by the time of irradiation. Irradiation alone caused a modest, transient acute response within 5 weeks and a progressive, permanent late response starting from about 25 weeks depending on X-ray dose. A reduced bladder capacity was also evident at 53-56 weeks after 20 Gy X-rays and after PDT alone. Irradiation after previous intravesical PDT caused an acute reaction similar to X-rays alone, but there was a much earlier expression of late functional bladder damage. The final level of damage prior to sacrifice at 53-56 weeks, was not significantly greater than after X-rays alone. These results suggest that irradiation after previous whole bladder PDT, for refractory bladder tumours, may lead to an increased risk of persistent increases in micturition frequency and reduced bladder capacity, beginning at very early times after irradiation.

Radiation tolerance of normal mouse bladders after intravesical chemotherapy

The aim of this study was to compare functional damage in normal mouse bladder after various initial intravesical therapies and to investigate tolerance to subsequent irradiation. Six consecutive weekly intravesical instillations of Mitomycin C (MMC) or doxorubicin (DOX) were used as the initial therapy. Irradiation with single doses of 10-25 Gy (X-rays) was given at 4 or 12 weeks after intravesical treatment. Functional bladder damage was assessed from changes in the micturition frequency, expressed as frequency index (FI, number of urination events/ml urine in a 24-h test period) and from cystometry measurements of bladder volume at 52-56 weeks. Irradiation alone caused a temporary acute response (increased FI) within the first 4 weeks and a progressive late response starting from 15 to 37 weeks, depending on the radiation dose. A reduced bladder capacity was also evident at 52-56 weeks after 25 Gy. Intravesical MMC or DOX caused a 3-fold increase in FI during intravesical therapy with recovery to control levels within 2-3 weeks after cessation of treatment. Irradiation 4 weeks after MMC, or 4 or 12 weeks after DOX resulted in acute responses very similar to irradiation alone. There was no difference in time of onset or extent of late bladder damage when irradiation was given after DOX, compared with irradiation alone as assessed from repeated measurements of FI or cystometry at 52-56 weeks. In contrast, irradiation 12 weeks after MMC led to a decrease in acute radiation response compared with X-rays alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Loss of reirradiation tolerance in the kidney with increasing time after single or fractionated partial tolerance doses

The aim was to determine the influence of initial dose and dose per fractionation on retreatment tolerance of the kidney. Mouse kidney was bilaterally irradiated with various single or fractionated X-ray doses equivalent to about 12-70% of a defined response dose. The mice were retreated with a range of single doses after 2 or 26 weeks. The development of functional kidney damage was followed by monthly testing of clearance of 51CrEDTA until the animals expressed overt renal dysfunction (maximum follow-up 70 weeks after retreatment). Reirradiation tolerance was assessed by probit analysis and Kaplan-Meier actuarial estimates of the incidence of a defined level of renal damage at 40 weeks after retreatment. Doses required to give a 50% incidence of damage (RD50) were compared for animals that had received previous single dose or fractionated irradiations, or that were previously unirradiated. Multivariate analysis of time to expression of renal damage (latency) was also done using the Cox Proportional Hazards model. Results demonstrated that previous irradiation always compromised retreatment tolerance, even for intervals of 26 weeks after initial treatments with < 20% full response dose. Reirradiation tolerance was inversely related to the initial dose and tolerance decreased significantly with increasing interval between treatments, suggesting progression rather than recovery from the initial damage. Linear-quadratic analysis of the data for reirradiation at 26 weeks after partial-response doses gave an alpha/beta = 1.4 Gy. This was significantly lower than the alpha/beta = 3.3 Gy obtained for initial treatments alone (no retreatment), indicating a larger fractionation-sparing effect for the retreatment situation.

Dose-fractionation sensitivity of mouse kidney clonogens measured using different interfraction intervals and postirradiation assay times

The fractionation sensitivity of kidney clonogenic epithelial cells (X-irradiation in vivo, assay in vitro) was quantified using the linear-quadratic model. The cells were assayed either immediately after the fractionation schedule or after a time delay in order to compare the relative amounts of dose sparing due to fractionation (conventionally sublethal damage repair) and to post-irradiation delay intervals before assay (conventionally potentially-lethal damage repair). As the delay before assay was increased, there was a tendency for both alpha and beta to decrease, and as a consequence the alpha/beta ratio stayed virtually unchanged (3.3-4.4 Gy) regardless of delay time before assay. No change in survival was observed from 12 h to 6 weeks after neutron irradiation (62 MeVp-->Be), suggesting that the change observed after X-rays was due to repair rather than repopulation. As the interfraction intervals in an 8-fraction X-irradiation schedule were increased in steps from 6 h to 5 days, there was improved survival, consistent with the presence of long-term repair. These studies provide further evidence for the potential importance of long-term repair in late reacting tissues not only during but also after multifraction irradiation schedules.

Re-irradiation tolerance in the rat spinal cord: influence of level of initial damage

The influence of the level of initial radiation damage on the long term recovery and re-irradiation tolerance in the rat spinal cord was investigated. Rats were irradiated with 0, 10, 20, 30 and 36 daily fractions of 2.15 Gy initially representing 0, 25, 50, 75 and 90% of cord tolerance. After an interval of 20 weeks, retreatments were given using graded single doses of X-ray. The end-point was paralysis of the forelimbs due to white matter necrosis. Latent times to paralysis were inversely proportional to the level of initial injury and retreatment doses. The retreatment ED50S were 19.0, 17.0, 15.7, 14.0 and 11.8 Gy for the control animals and animals irradiated initially with 10, 20, 30 and 36 fractions of 2.15 Gy respectively. Using the extrapolated response dose (ERD) concept, alpha/beta of 3.0 Gy, the retreatment ED50S in % ERD were 81, 70, 58 and 42% after initial doses of 25, 50, 75 and 90% ERD respectively. The level of initial injury appeared to influence the proportion of residual injury. For an initial injury of 25 and 90% of ERD, the respective residual injury was 74 and 65% of the initial damage; for an initial injury of 50 and 75% ERD, the residual injury decreased to 59 and 57% respectively. It is concluded that there was significant long-term recovery in the rat spinal cord, and that the level of initial radiation damage influenced both the retreatment tolerance and the time to expression of injury.

Fractionation sensitivity of the rat cervical spinal cord during radiation retreatment

Data concerning the fractionation sensitivity of normal tissues during radiation retreatment are limited. Experiments were performed to investigate whether the fractionation sensitivity of the rat cervical spinal cord is changed during retreatment 6 months after a first dose of 15 Gy, representing about half the biologically effective dose for induction of paresis. After a 6 months interval, the long-term recovery from the first treatment was about 45%. The fractionation sensitivity of the rat cervical spinal cord during reirradiation was not significantly different from the fractionation sensitivity of not previously irradiated control rats, with an alpha/beta ratio of 2.3 Gy in control rats and 1.9 Gy during reirradiation of the spinal cord. An additional observation from these experiments was the presence of incomplete repair after fractionated treatment with 2 fractions of 3 Gy per day with 10-h intervals.

A simple method for fitting curves to dose-effect data for functional damage

Dose-effect curves are used extensively to assess how tissues respond to radiation. One method of obtaining these is to fit a curve to the values of some measured effect plotted against dose using non-linear least-squares regression. This paper reports the use of a generalized (four-parameter) sigmoid equation fitted to all the individual data points, rather than to the mean values for each dose group, which eliminates the need to incorporate weighting of the data. The equation allows an analytical solution for values of isoeffect doses, which can be used, for example, to determine dose enhancement ratios, or equivalent remembered doses in top-up experiments. The regression approach can also determine both standard errors and 95% confidence limits on the mean predicted effect values from the fit to the data at all doses, and these define a uniform envelope of errors about the best-fit line, from which an error in an isoeffect dose can be assessed. This approach has been used to fit dose-effect data from a variety of normal tissues and tumours with highly satisfactory results.