Contrasting Dose-rate Effects of γ-irradiation on Rat Salivary Gland Function

Proton FLASH Radiotherapy Ameliorates Radiation-induced Salivary Gland Dysfunction and Oral Mucositis and Increases Survival in a Mouse Model of Head and Neck Cancer

Head and neck cancer radiotherapy often damages salivary glands and oral mucosa, severely negatively impacting patients' quality of life. The ability of FLASH proton radiotherapy (F-PRT) to decrease normal tissue toxicity while maintaining tumor control compared with standard proton radiotherapy (S-PRT) has been previously demonstrated for several tissues. However, its potential in ameliorating radiation-induced salivary gland dysfunction and oral mucositis and controlling orthotopic head and neck tumor growth has not been reported. The head and neck area of C57BL/6 mice was irradiated with a single dose of radiotherapy (ranging from 14-18 Gy) or a fractionated dose of 8 Gy × 3 of F-PRT (128 Gy/second) or S-PRT (0.95 Gy/second). Following irradiation, the mice were studied for radiation-induced xerostomia by measuring their salivary flow. Oral mucositis was analyzed by histopathologic examination. To determine the ability of F-PRT to control orthotopic head and neck tumors, tongue tumors were generated in the mice and then irradiated with either F-PRT or S-PRT. Mice treated with either a single dose or fractionated dose of F-PRT showed significantly improved survival than those irradiated with S-PRT. F-PRT-treated mice showed improvement in their salivary flow. S-PRT-irradiated mice demonstrated increased fibrosis in their tongue epithelium. F-PRT significantly increased the overall survival of the mice with orthotopic tumors compared with the S-PRT-treated mice. The demonstration that F-PRT decreases radiation-induced normal tissue toxicity without compromising tumor control, suggests that this modality could be useful for the clinical management of patients with head and neck cancer.

The salivary glands as a dose limiting organ of PSMA- targeted radionuclide therapy: A review of the lessons learnt so far

At present, prostate cancer remains the second most occurring cancer in men, in Europe. Treatment efficacy for therapy of advanced metastatic disease, and metastatic castration-resistant prostate cancer in particular is limited. Prostate-specific membrane antigen (PSMA) is a promising therapeutic target in prostate cancer, seeing the high amount of overexpression on prostate cancer cells. Clinical investigation of PSMA-targeted radionuclide therapy has shown good clinical efficacy. However, adverse effects are observed of which salivary gland hypofunction and xerostomia are among the most prominent. Salivary gland toxicity is currently the dose-limiting side effect for PSMA-targeted radionuclide therapy, and more specifically for PSMA-targeted alpha therapy. To date, mechanisms underlying the salivary gland uptake of PSMA-targeting compounds and the subsequent damage to the salivary glands remain largely unknown. Furthermore, preventive strategies for salivary gland uptake or strategies for treatment of salivary gland toxicity are needed. This review focuses on the current knowledge on uptake mechanisms of PSMA-targeting compounds in the salivary glands and the research performed to investigate different strategies to prevent or treat salivary gland toxicity.

Mouth-Watering Results: Clinical Need, Current Approaches, and Future Directions for Salivary Gland Regeneration

Permanent damage to the salivary glands and resulting hyposalivation and xerostomia have a substantial impact on patient health, quality of life, and healthcare costs. Currently, patients rely on lifelong treatments that alleviate the symptoms, but no long-term restorative solutions exist. Recent advances in adult stem cell enrichment and transplantation, bioengineering, and gene transfer have proved successful in rescuing salivary gland function in a number of animal models that reflect human diseases and that result in hyposalivation and xerostomia. By overcoming the limitations of stem cell transplants and better understanding the mechanisms of cellular plasticity in the adult salivary gland, such studies provide encouraging evidence that a regenerative strategy for patients will be available in the near future.

Concise Review: A Critical Evaluation of Criteria Used to Define Salivary Gland Stem Cells

In the effort to develop cell-based therapies to treat salivary gland dysfunction, many different populations of cells in the adult salivary glands have been proposed as stem cells. These cell populations vary, depending on the assay used, and are often nonoverlapping, leading to the conclusion that salivary glands harbor multiple stem cells. The goal of this review is to critically appraise the assays and properties used to identify stem cells in the adult salivary gland, and to consider the caveats of each. Re-evaluation of the defining criteria may help to reconcile the many potential stem cell populations described in the salivary gland, in order to increase comparability between studies and build consensus in the field. Stem Cells 2019;37:1144-1150.

Radiation inhibits salivary gland function by promoting STIM1 cleavage by caspase-3 and loss of SOCE through a TRPM2-dependent pathway

Store-operated Ca²⁺ entry (SOCE) is critical for salivary gland fluid secretion. We report that radiation treatment caused persistent salivary gland dysfunction by activating a TRPM2-dependent mitochondrial pathway, leading to caspase-3-mediated cleavage of stromal interaction molecule 1 (STIM1) and loss of SOCE. After irradiation, acinar cells from the submandibular glands of TRPM2^+/+ , but not those from TRPM2^-/- mice, displayed an increase in the concentrations of mitochondrial Ca²⁺ and reactive oxygen species, a decrease in mitochondrial membrane potential, and activation of caspase-3, which was associated with a sustained decrease in STIM1 abundance and attenuation of SOCE. In a salivary gland cell line, silencing the mitochondrial Ca²⁺ uniporter or caspase-3 or treatment with inhibitors of TRPM2 or caspase-3 prevented irradiation-induced loss of STIM1 and SOCE. Expression of exogenous STIM1 in the salivary glands of irradiated mice increased SOCE and fluid secretion. We suggest that targeting the mechanisms underlying the loss of STIM1 would be a potentially useful approach for preserving salivary gland function after radiation therapy.

Calcium signalling in salivary gland physiology and dysfunction

Studies over the past four decades have established that Ca(2+) is a critical factor in control of salivary gland function and have led to identification of the critical components of this process. The major ion transport mechanisms and ion channels that are involved in fluid secretion have also been established. The key event in activation of fluid secretion is an increase in [Ca(2+) ]i triggered by inositol 1,4,5-trisphosphate (IP3 )-induced release of Ca(2+) from ER via the IP3 receptor (IP3 R). IP3 Rs determine the site of initiation and the pattern of the [Ca(2+) ]i signal in the cell. However, Ca(2+) entry into the cell is required to sustain the elevation of [Ca(2+) ]i and fluid secretion and is mediated by the store-operated Ca(2+) entry (SOCE) mechanism. Orai1, TRPC1, TRPC3 and STIM1 have been identified as critical components of SOCE in these cells. Cells finely tune the generation and amplification of [Ca(2+) ]i signals for regulation of cell function. An important emerging area is the concept that unregulated [Ca(2+) ]i signals in cells can directly cause cell damage, dysfunction and disease. Alternatively, aberrant [Ca(2+) ]i signals can also amplify and increase the rates of cell damage. Such defects in Ca(2+) signalling have been described in salivary glands in conjunction with radiation-induced loss of salivary gland function as well as in the salivary defects associated with the autoimmune exocrinopathy Sjögren's syndrome. Such defects have been associated with altered function or expression of key Ca(2+) signalling components, such as STIM proteins and TRP channels. These studies offer new avenues for examining the mechanisms underlying the disease and development of novel clinical targets and therapeutic strategies.

Effects of dose rates on radiation-induced replenishment of intestinal stem cells determined by Lgr5 lineage tracing

An understanding of the dynamics of intestinal Lgr5(+) stem cells is important for elucidating the mechanism of colonic cancer development. We previously established a method for evaluating Lgr5(+) stem cells by tamoxifen-dependent Lgr5-lineage tracing and showed that high-dose-rate radiation stimulated replenishment of colonic stem cells. In this study, we evaluated the effects of low-dose-rate radiation on stem cell maintenance. Tamoxifen (4OHT)-injected Lgr5-EGFP-IRES-Cre(ERT2) × ROSA-LSL-LacZ mice were used, LacZ-labeled colonic crypts were enumerated, and the loss of LacZ(+) crypts under low-dose-rate radiation was estimated. After 4OHT treatment, the number of LacZ-labeled Lgr5(+) stem cells was higher in the colon of infant mice than in adult mice. The percentage of LacZ-labeled crypts in infant mice rapidly decreased after 4OHT treatment. However, the percentage of labeled crypts plateaued at ∼2% at 4 weeks post-treatment and remained unchanged for up to 7 months. Thus, it will be advantageous to evaluate the long-term effects of low-dose-rate radiation. Next, we determined the percentages of LacZ-labeled crypts irradiated with 1 Gy administered at different dose rates. As reported in our previous study, mice exposed to high-dose-rate radiation (30 Gy/h) showed a marked replenishment (P = 0.04). However, mice exposed to low-dose-rate radiation (0.003 Gy/h) did not exhibit accelerated stem-cell replenishment (P = 0.47). These findings suggest the percentage of labeled crypts can serve as a useful indicator of the effects of dose rate on the stem cell pool.

Loss of TRPM2 function protects against irradiation-induced salivary gland dysfunction

Xerostomia as a result of salivary gland damage is a permanent and debilitating side effect of radiotherapy for head and neck cancers. Effective treatments for protecting, or restoring, salivary gland function are not available. Here we report that irradiation treatment leads to activation of the calcium-permeable channel, transient potential melastatin-like 2 (TRPM2), via stimulation of poly-ADP-ribose polymerase. Importantly, irradiation induced an irreversible loss of salivary gland fluid secretion in TRPM2+/+ mice while a transient loss was seen in TRPM2-/- mice with >60% recovery by 30 days after irradiation. Treatment of TRPM2+/+ mice with the free radical scavenger Tempol or the PARP1 inhibitor 3-aminobenzamide attenuated irradiation-induced activation of TRPM2 and induced significant recovery of salivary fluid secretion. Furthermore, TPL (4-hydroxy-2,2,6,6-tetramethylpiperidine-N-oxyl) induced complete recovery of function in irradiated TRPM2-/- mice. These novel data demonstrate that TRPM2 is activated by irradiation, via PARP1 activation, and contributes to irreversible loss of salivary gland function.

Pro-apoptotic gene knockdown mediated by nanocomplexed siRNA reduces radiation damage in primary salivary gland cultures

A critical issue in the management of head and neck tumors is radioprotection of the salivary glands. We have investigated whether siRNA-mediated gene knock down of pro-apoptotic mediators can reduce radiation-induced cellular apoptosis in salivary gland cells in vitro. We used novel, pH-responsive nanoparticles to deliver functionally active siRNAs into cultures of salivary gland cells. The nanoparticle molecules are comprised of cationic micelles that electrostatically interact with the siRNA, protecting it from nuclease attack, and also include pH-responsive endosomolytic constituents that promote release of the siRNA into the target cell cytoplasm. Transfection controls with Cy3-tagged siRNA/nanoparticle complexes showed efficiently internalized siRNAs in more than 70% of the submandibular gland cells. We found that introduction of siRNAs specifically targeting the Pkcδ or Bax genes significantly blocked the induction of these pro-apoptotic proteins that normally occurs after radiation in cultured salivary gland cells. Furthermore, the level of cell death from subsequent radiation, as measured by caspase-3, TUNEL, and mitochondrial disruption assays, was significantly decreased. Thus, we have successfully demonstrated that the siRNA/nanoparticle-mediated knock down of pro-apoptotic genes can prevent radiation-induced damage in submandibular gland primary cell cultures.

The impact of dose on parotid salivary recovery in head and neck cancer patients treated with radiation therapy

PURPOSE

A common side effect experienced by head and neck cancer patients after radiation therapy (RT) is impairment of the parotid glands' ability to produce saliva. Our purpose is to investigate the relationship between radiation dose and saliva changes in the 2 years after treatment.

METHODS AND MATERIALS

The study population includes 142 patients treated with conformal or intensity-modulated radiotherapy. Saliva flow rates from 266 parotid glands are measured before and 1, 3, 6, 12, 18, and 24 months after treatment. Measurements are collected separately from each gland under both stimulated and unstimulated conditions. Bayesian nonlinear hierarchical models were developed and fit to the data.

RESULTS

Parotids receiving higher radiation produce less saliva. The largest reduction is at 1-3 months after RT followed by gradual recovery. When mean doses are lower (e.g., <25 Gy), the model-predicted average stimulated saliva recovers to pretreatment levels at 12 months and exceeds it at 18 and 24 months. For higher doses (e.g., >30 Gy), the stimulated saliva does not return to original levels after 2 years. Without stimulation, at 24 months, the predicted saliva is 86% of pretreatment levels for 25 Gy and <31% for >40 Gy. We do not find evidence to support that the overproduction of stimulated saliva at 18 and 24 months after low dose in 1 parotid gland is the result of low saliva production from the other parotid gland.

CONCLUSIONS

Saliva production is affected significantly by radiation, but with doses <25-30 Gy, recovery is substantial and returns to pretreatment levels 2 years after RT.

Radioprotective effect of amifostine on parotid gland functioning is region dependent

PURPOSE

To investigation the protective ability of amifostine during partial irradiation of the rat parotid gland.

METHODS AND MATERIALS

Single-dose X-ray irradiation was performed by use of collimators with conformal radiation portals for either the 100% volume (15 Gy) or the 50% cranial/caudal partial parotid gland volumes (30 Gy). Amifostine was administered intraperitoneally at a dose of 250 mg per kg body weight, 25 minutes before irradiation. Saliva flow rates, gland weights, and the tissues of the individual lobes were investigated up to 1 year after treatment.

RESULTS

A clear protective effect of amifostine was found against loss of saliva flow, the altered appearance of gross morphology, loss of gland weight, and histopathologic changes for the 100% volume gland irradiations and for the 50% volume cranial irradiations but not for the 50% volume caudal irradiations.

CONCLUSIONS

The protective ability of amifostine is strongly dependent on the irradiated glandular region and observed for later damage only. The major effect of the drug seems to be the prevention of volume effects caused by secondary damage that occurs in shielded parts of the gland. The results of the present study show that understanding of the anatomy and physiology of organs that are to be spared is necessary to ensure optimal preservation of function.

Secondary radiation damage as the main cause for unexpected volume effects: a histopathologic study of the parotid gland

PURPOSE

To elucidate with a histopathological study the mechanism of region-dependent volume effects in the partly irradiated parotid gland of the rat.

METHODS AND MATERIALS

Wistar rats were locally X-irradiated with collimators with conformal radiation portals for 100% volume and 50% cranial/caudal partial volumes. Single doses up to 40 Gy were applied. Parotid saliva samples were collected, and the three lobes of the parotid gland were examined individually on the macro- and micromorphologic level up to 1 year after irradiation.

RESULTS

Dose-dependent loss of gland weight was observed 1 year after total or partial X-irradiation. Weight loss of the glands correlated very well with loss of secretory function. Irradiating the cranial 50% volume (implicating a shielded lateral lobe) resulted in substantially more damage in terms of weight loss and loss of secretory function than 50% caudal irradiation (shielding the ventral and dorsal lobe). Histologic examinations of the glands 1 year after irradiation revealed that the shielded lateral lobe was severely affected, in contrast to the shielded ventral and dorsal lobes. Time studies showed that irradiation of the cranial 50% volume caused late development of secondary damage in the shielded lateral lobe, becoming manifest between 240 and 360 days after irradiation. The possible clinical significance of this finding is discussed.

CONCLUSION

It is concluded that the observed region-dependent volume effect for late function loss in the rat parotid gland after partial irradiation is mainly caused by secondary events in the shielded lateral lobe. The most probable first step (primary radiation event) in the development of this secondary damage is radiation exposure to the hilus region (located between the ventral and dorsal lobe). By injuring major excretory ducts and supply routes for blood and nerves in this area, the facility system necessary for proper functioning of the nonexposed lateral lobe is seriously affected. The unexpected volume effect in the rat might have consequences for treatment strategies in radiotherapy, implicating not only salivary glands but also other organs with a seemingly homogeneous distribution of radiosensitive elements, a situation wherein volume effects have not been anticipated up to now.

On the mechanism of salivary gland radiosensitivity

PURPOSE

To contribute to the understanding of the enigmatic radiosensitivity of the salivary glands by analysis of appropriate literature, especially with respect to mechanisms of action of early radiation damage, and to supply information on the possibilities of amelioration of radiation damage to the salivary glands after radiotherapy of head-and-neck cancer.

METHODS AND MATERIALS

Selected published data on the mechanism of salivary gland radiosensitivity and radioprotection were studied and analyzed.

RESULTS

From a classical point of view, the salivary glands should not respond as rapidly to radiation as they appear to do. Next to the suggestion of massive apoptosis, the leakage of granules and subsequent lysis of acinar cells was suggested to be responsible for the acute radiation-induced function loss of the salivary glands. The main problem with these hypotheses is that recently performed assays show no cell loss during the first days after irradiation, while saliva flow is dramatically diminished. The water secretion is selectively hampered during the first days after single-dose irradiation. Literature is discussed that shows that the compromised cells suffer selective radiation damage to the plasma membrane, disturbing signal transduction primarily affecting watery secretion. Although the cellular composition of the submandibular gland and the parotid gland are different, the damage response is very alike. The acute radiation-induced function loss in both salivary glands can be ameliorated by prophylactic treatment with specific receptor agonists.

CONCLUSIONS

The most probable mechanism of action, explaining the enigmatic high radiosensitivity for early effects, is selective radiation damage to the plasma membrane of the secretory cells, disturbing muscarinic receptor stimulated watery secretion. Later damage is mainly due to classical mitotic cell death of progenitor cells, leading to a hampered replacement capacity of the gland for secretory cells, but is also caused by damage to the extracellular environment, preventing proper cell functioning.

Defects in muscarinic receptor-coupled signal transduction in isolated parotid gland cells after in vivo irradiation: evidence for a non-DNA target of radiation

Radiation-induced dysfunction of normal tissue, an unwanted side effect of radiotherapeutic treatment of cancer, is usually considered to be caused by impaired loss of cell renewal due to sterilisation of stem cells. This implies that the onset of normal tissue damage is usually determined by tissue turnover rate. Salivary glands are a clear exception to this rule: they have slow turnover rates (>60 days), yet develop radiation-induced dysfunction within hours to days. We showed that this could not be explained by a hypersensitivity to radiation-induced apoptosis or necrosis of the differentiated cells. In fact, salivary cells are still capable of amylase secretion shortly after irradiation while at the same time water secretion seems specifically and severely impaired. Here, we demonstrate that salivary gland cells isolated after in vivo irradiation are impaired in their ability to mobilise calcium from intracellular stores (Ca2+ i), the driving force for water secretion, after exposure to muscarinic acetylcholine receptor agonists. Using radioligand-receptor-binding assays it is shown that radiation caused no changes in receptor density, receptor affinity nor in receptor-G-protein coupling. However, muscarinic acetylcholine agonist-induced activation of protein kinase C alpha (PKCalpha), measured as translocation to the plasma membrane, was severely affected in irradiated cells. Also, the phorbol ester PMA could no longer induce PKCalpha translocation in irradiated cells. Our data hence indicate that irradiation specifically interferes with PKCalpha association with membranes, leading to impairment of intracellular signalling. To the best of our knowledge, these data for the first time suggest that, the cells' capacity to respond to a receptor agonist is impaired after irradiation.

Three-dimensional dose distribution for partial irradiation of rat parotid glands with 200kV X-rays

PURPOSE

To investigate dose distributions in partial-volume irradiation experiments in small experimental animals, in particular the parotid gland of rat.

MATERIALS AND METHODS

High-resolution magnetic resonance imaging images were made that provided the outlines of the parotid glands, which were used to design collimators with conformal radiation ports for 100 and 50% cranial/caudal partial-volume irradiation. A protocol for absolute dosimetry was designed and relative dose measurements were performed. From the three-dimensional topographical data and the three-dimensional dose distribution, dose-volume histograms were determined.

RESULTS

The standard uncertainty of absorbed entrance dose was within 3%. Radiochromic film, thermoluminescence dosemeters and ionization chamber dose measurements revealed that the relative doses measured were in good agreement. The 20-80% penumbra of the beam across the 50% field edge was only 0.4 mm at a 6 mm depth. The gradient of the percentage depth dose from the skin of the rat to a depth of 12 mm was 1.5% mm(-1). The absorbed doses in the cranial 50% and the caudal 50% partial volumes were comparable. This finding was reflected in the calculated dose-volume histograms of the different regions, which were similar. The dose in the shielded area between the left and right ports was about 14% of the dose near the centres of the beams.

CONCLUSION

The designed set-up showed that irradiation of small volumes could be performed with high accuracy allowing the study of differences in radiation damage. Similar doses were given to the 50% cranial and 50% caudal gland volumes and, therefore, a possible difference in radiosensitivity in these volumes was not a dose effect. The approach used was also applicable for the irradiation of small volumes of other tissues.

Oral sequelae of head and neck radiotherapy

In addition to anti-tumor effects, ionizing radiation causes damage in normal tissues located in the radiation portals. Oral complications of radiotherapy in the head and neck region are the result of the deleterious effects of radiation on, e.g., salivary glands, oral mucosa, bone, dentition, masticatory musculature, and temporomandibular joints. The clinical consequences of radiotherapy include mucositis, hyposalivation, taste loss, osteoradionecrosis, radiation caries, and trismus. Mucositis and taste loss are reversible consequences that usually subside early post-irradiation, while hyposalivation is normally irreversible. Furthermore, the risk of developing radiation caries and osteoradionecrosis is a life-long threat. All these consequences form a heavy burden for the patients and have a tremendous impact on their quality of life during and after radiotherapy. In this review, the radiation-induced changes in healthy oral tissues and the resulting clinical consequences are discussed.

The enigmatic mechanism of irradiation-induced damage to the major salivary glands

Irradiation is a central treatment modality administered for head and neck malignancies. Its major and most devastating side-effect is an induced damage to the major salivary glands. This article aims at suggesting a comprehensive explanation for the underlying mechanism of this damage, which has been considered as enigmatic throughout the 90 years since it was first described in 1911. The mechanism suggested is based on the considerable literature concerning this enigma in rat salivary glands. According to this proposed mechanism, the irradiation results in a sublethal DNA damage, which manifests and becomes lethal at a delayed phase. Thus, when the acinar progenitor cells are going through a reproductive phase when parenchymal replenishment is required, they die. The injurious agents, which result in this delayed reproductive cell death, appear to be highly redox-active transition metal ions, such as iron and copper. These metal ions, which seem to be associated with secretion granules, are not necessarily contained within the granules as previously suggested, but rather are probably located at sites more proximal to the DNA.

Early to late sparing of radiation damage to the parotid gland by adrenergic and muscarinic receptor agonists

Damage to salivary glands after radiotherapeutic treatment of head and neck tumours can severely impair the quality of life of the patients. In the current study we have investigated the early-to-late pathogenesis of the parotid gland after radiation. Also the ability to ameliorate the damage using pretreatment with adrenergic or muscarinic receptor agonists is studied. Rats were locally irradiated with or without i.p. pretreatment with phenylephrine (alpha-adrenoceptor agonist, 5 mg kg(-1)), isoproterenol (beta-adrenoceptor agonist, 5 mg kg(-1)), pilocarpine (4 mg kg(-1)), methacholine (3.75 mg kg(-1)) (muscarinic receptor agonists) or methacholine plus phenylephrine. Parotid salivary flow rate, amylase secretion, the number of cells and gland histology were monitored sequentially up to 240 days postirradiation. The effects were described in 4 distinct phases. The first phase (0-10 days) was characterised by a rapid decline in flow rate without changes in amylase secretion or acinar cell number. The second phase (10-60 days) consists of a decrease in amylase secretion and is paralleled by acinar cell loss. Flow rate, amylase secretion and acinar cell numbers do not change in the third phase (60-120 days). The fourth phase (120-240 days) is determined by a further deterioration of gland function but an increase in acinar cell number, albeit with poor tissue morphology. All drug pretreatments used could reduce radiation effects in phase I and II. The protective effects were lost during phase IV, with the exception of methacholine plus phenylephrine pretreatment. The latter combination of drugs ameliorated radiation-damage throughout the entire follow-up time. The data show that combined pre-irradiation stimulation of muscarinic acetylcholine receptors with methacholine plus alpha-adrenoceptors with phenylephrine can reduce both early and late damage, possibly involving the PLC/PIP2 second messenger pathways. This opens perspectives for the development of clinical applicable methods for long-term sparing of parotid glands subjected to radiotherapy of head and neck cancer patients.

Natural history and prevention of radiation injury

Radiation therapy for cancers of the head and neck can irreversibly damage the salivary glands. Xerostomia (subjective oral dryness) develops within the first week of therapy and is progressive, with devastating effects on the quality of life of the individual. The xerostomia does not correlate with the degree of salivary gland hypofunction. The mechanism of tissue injury in humans is still unclear, but much progress has been made with animal models. This paper reviews the natural history of radiation damage to human salivary glands and highlights the inter-individual variations in the responses to and recovery from therapeutic radiation. The degree of salivary gland damage is correlated to the dose of radiation delivered and the volume of gland included in the field of radiation. The molecular mechanism of acute radiation damage is not fully understood; however, long-term salivary gland dysfunction is associated with both loss of gland weight and loss of acinar cells. Various strategies have been used to prevent or alleviate the problem of salivary gland hypofunction following therapeutic radiation. This paper reviews the progress made to date and the possibilities for future interventions to prevent radiation damage.

Early radiation effects on muscarinic receptor-induced secretory responsiveness of the parotid gland in the freely moving rat

Although the salivary glands have a low rate of cell turnover, they are relatively radiosensitive. To study the possible mechanism behind this inherent radiosensitivity, a rat model was developed in which saliva can be collected after local irradiation of the parotid gland without the use of anesthetics or stressful handling. Saliva secretion was induced by the partial muscarinic receptor agonist pilocarpine (0.03-3 mg/kg) with or without pretreatment with the beta-adrenoceptor antagonist propranolol (2.5 mg/kg), or the full muscarinic receptor agonist methacholine (0.16-16 mg/min), and measured during 5 min per drug dose before and 1, 3, 6 and 10 days after irradiation. The maximal secretory response induced by pilocarpine plus propranolol was increased compared to that with pilocarpine alone but did not reach the level of methacholine-induced secretion, which was about five times higher. One day after irradiation a decrease in maximal pilocarpine-induced secretion was observed (-22%) using the same dose of pilocarpine that induces 50% of the maximal response (ED(50)), in both the absence and presence of propranolol, indicating that the receptor-drug interaction was not affected by the radiation at this time. The secretory response to methacholine 1 day after irradiation, however, was normal. At day 3 after irradiation, the maximal methacholine-induced secretion was also affected, whereas pilocarpine (+/-propranolol)-induced maximal secretion decreased further. At day 6 after irradiation, maximal secretory responses had declined to approximately 50% regardless of the agonist used, whereas ED(50) values were still unaffected. No net acinar cell loss was observed within the first 10 days after irradiation, and this therefore could not account for the loss in function. The results indicate that radiation does not affect cell number or receptor-drug interaction, but rather signal transduction, which eventually leads to the impaired response. We hypothesize that the early radiation effect, within 3 days, may be membrane damage affecting the receptor-G-protein signaltransfer. Later critical damage, however, is probably of a different nature and may be located in the second-messenger signal transduction pathway downstream from the G protein, not necessarily involving cellular membranes.

Dose, volume, and function relationships in parotid salivary glands following conformal and intensity-modulated irradiation of head and neck cancer

PURPOSE

To determine the relationships between the three-dimensional dose distributions in parotid glands and their saliva production, and to find the doses and irradiated volumes that permit preservation of the salivary flow following irradiation (RT).

METHODS AND MATERIALS

Eighty-eight patients with head and neck cancer irradiated with parotid-sparing conformal and multisegmental intensity modulation techniques between March 1994 and August 1997 participated in the study. The mean dose and the partial volumes receiving specified doses were determined for each gland from dose-volume histograms (DVHs). Nonstimulated and stimulated saliva flow rates were selectively measured from each parotid gland before RT and at 1, 3, 6, and 12 months after the completion of RT. The data were fit using a generalized linear model and the normal tissue complication probability (NTCP) model of Lyman-Kutcher. In the latter model, a "severe complication" was defined as salivary flow rate reduced to < or =25% pre-RT flow at 12 months.

RESULTS

Saliva flow rates data were available for 152 parotid glands. Glands receiving a mean dose below or equal to a threshold (24 Gy for the unstimulated and 26 Gy for the stimulated saliva) showed substantial preservation of the flow rates following RT and continued to improve over time (to median 76% and 114% of pre-RT for the unstimulated and stimulated flow rates, respectively, at 12 months). In contrast, most glands receiving a mean dose higher than the threshold produced little saliva with no recovery over time. The output was not found to decrease as mean dose increased, as long as the threshold dose was not reached. Similarly, partial volume thresholds were found: 67%, 45%, and 24% gland volumes receiving more than 15 Gy, 30 Gy, and 45 Gy, respectively. The partial volume thresholds correlated highly with the mean dose and did not add significantly to a model predicting the saliva flow rate from the mean dose and the time since RT. The NTCP model parameters were found to be TD50 (the tolerance dose for 50% complications rate for whole organ irradiated uniformly) = 28.4 Gy, n (volume dependence parameter) = 1, and m (the slope of the dose/response relationship) = 0.18. Clinical factors including age, gender, pre-RT surgery, chemotherapy, and certain medical conditions were not found to be significantly associated with the salivary flow rates. Medications (diuretics, antidepressants, and narcotics) were found to adversely affect the unstimulated but not the stimulated flow rates.

CONCLUSIONS

Dose/volume/function relationships in the parotid glands are characterized by dose and volume thresholds, steep dose/response relationships when the thresholds are reached, and a maximal volume dependence parameter in the NTCP model. A parotid gland mean dose of < or =26 Gy should be a planning goal if substantial sparing of the gland function is desired.

Protection against irradiation-induced damage to salivary glands by adrenergic agonist administration

PURPOSE

Irradiation [IR]-induced damage to major salivary glands is an entity first described at the beginning of our century, yet its underlying mechanism is still enigmatic. Exposure of the salivary glands to IR is often inevitable when delivering radiotherapy for malignancies of the head and neck region. Frequently, this results in rapidly developing, life-long severe xerostomia for which no adequate prevention or treatment is available. The purpose of this study was to examine the role of secretion granules in serous cells of the parotid (P) and submandibular (SM) glands as mediators in the IR-induced salivary damage. Functional parameters (flow rate and gland weight), and total body weight were examined at both early term (4 days) and extended term (2 months) post-IR in male Wistar rats exposed to 15 Gy of head and neck irradiation following stimulation for granule secretion (degranulation).

METHODS AND MATERIALS

At 4 days, it was demonstrated that IR reduced P flow rate, P gland weight, total body weight, and submandibular/sublingual gland weight by 89, 33, 30, and 32% (p < 0.01), respectively, while SM flow rate was not altered significantly. At 2 months, these parameters were reduced by 59, 37, 31, and 37%, respectively, and the SM flow rate was reduced by 39% (p < 0.01).

RESULTS

Pilocarpine, a muscarinsic agonist which, albeit its efficacy as a salivary watery secretion stimulator, causes only limited degranulation, did not protect significantly any of the reduced parameters at either term. In contrast, cyclocytidine, an adrenergic agonist that is a very potent salivary degranulating agent, protected the P against the weight loss at 4 days and 2 months, and against the flow rate reduction at 2 months. The P weight and flow rate were protected to the extent that their values were not significantly different than those of the nonirradiated controls. Cyclocytidine also partially protected against the body weight reduction at 2 months. Our results emphasize the importance of secretion granules as mediatory agents in IR-induced P damage, and more so at the extended term. The demonstrated protective role of adrenergic agonists against IR damage to the P may be of importance in the clinical setting.

Muscarinic receptor stimulation increases tolerance of rat salivary gland function to radiation damage

PURPOSE

To investigate if muscarinic receptor-stimulated activation of the PLC/PIP2 second messenger pathway prior to irradiation increases the radiotolerance of rat salivary gland.

MATERIALS AND METHODS

Rats were treated with pilocarpine, methacholine, reserpine, methacholine plus reserpine, or atropine prior to irradiation with a single dose of 15 Gy X-rays. Parotid and submandibular/sublingual saliva was collected 4 days before and 1-30 days after irradiation. Lag phase, flow rate, amylase secretion, and salivary sodium and potassium concentration were measured.

RESULTS

Pretreatment with pilocarpine or methacholine resulted in an improvement of all measured functions of both glands. Pretreatment with reserpine had no effect on parotid gland function. Reserpine plus methacholine did not increase parotid gland function when compared with methacholine alone, indicating a purely muscarinic receptor stimulation as the initiator for the induced radioprotection. Pretreatment protective effects on submandibular gland function of reserpine plus methacholine were additive, indicating cooperation of muscarinic and alpha-adrenergic receptors. Atropine pretreatment slightly increased the radiation induced loss of salivary gland function.

CONCLUSIONS

Preirradiation activation of PLC/PIP2 second messenger pathway through stimulation of muscarinic receptors reduces the salivary gland radiosensitivity. The observed protection of salivary gland function may be of a secondary nature, implicating a cell conditioning after receptor stimulation of the PLC/PIP2 pathway.

Recent developments in the radiobiology of cellular membranes

We have reviewed the literature on cellular membrane radiobiology over the last ten years and, in particular, report on the development of rapid techniques used to identify damage soon after irradiation. It is clear that damage can now be quantified after low doses, and further refinements can be expected. From the work summarised, it would appear that changes to membranes at low doses may occur soon after damage to other important macromolecules by intercommunicating processes. We believe that there now exists a variety of rapid methods of measuring deposition of damage in vital macromolecules, such as cellular membranes and DNA, which can give a fuller picture of the overall effects of radiation and lead to predictions of eventual cellular mortality.

The early changes in salivary gland function during and after radiotherapy given for head and neck cancer

The salivary gland function of 47 patients treated by radical radiotherapy (CHART or conventionally fractionated treatment) for head and neck cancer has been studied before, during and for up to 12 weeks from the start of treatment. Pronounced falls in salivary flow and pH are seen once radiotherapy has commenced, particularly when both parotid glands are included in the treatment volume. The initial rate of reduction in flow reflects the rate of delivery of treatment. The parotid glands show the greatest sensitivity to radiotherapy compared with the other salivary glands and reduction in salivary flow is dependent on both dose and the proportion of the gland included in the treatment volume. These early changes in salivary gland function are as marked for patients receiving either CHART or conventionally fractionated treatment, so differing from the late changes which have been shown to be less evident after CHART.

Fractionated irradiation and late changes in rat parotid gland: effects on the number of acinar cells, potassium efflux, and amylase secretion

Irradiation of head- and neck cancer commonly results in oral dryness and discomfort for the patients due to salivary gland damage. The exact mechanisms behind the inherent radiosensitivity of salivary glands remain to be elucidated. In the present study, we used different in vitro secretory models and quantitative morphological characterization of rat parotid gland following fractionated unilateral irradiation to one gland on a 5-day fraction schedule (Monday-Friday) with 6 MV photons (total dose 30, 35, 40 and 45 Gy) or a two-fractions regimens in 5 days (Monday and Friday) with total dose of 24 and 32 Gy. The contralateral shielded gland served as control, and parallel analyses of irradiated and control glands were performed 180 days following the last irradiation treatment. The relative noradrenaline stimulated electrolyte secretion (86rubidium tracer for potassium) was decreased in the irradiated compared with control glands. The noradrenaline-stimulated exocytotic amylase release was not significantly affected by irradiation, but the gland content of amylase was decreased dose-dependently. The quantitative morphological analysis revealed a dose-dependent decline in the number of acinar cells, whereas the other parenchymal cells (intercalated, striated- and excretory duct cells) were unaffected by the irradiation compared with control glands.

Changes in serum and salivary amylase during radiotherapy for head and neck cancer: a comparison of conventionally fractionated radiotherapy with CHART

The changes in serum amylase that occur when radiotherapy is given in the treatment of head and neck cancer has been studied in 41 patients, 29 treated by CHART and 12 by conventionally fractionated radiotherapy. The peak rise in serum amylase following the start of treatment is seen earlier and is greater in the patients receiving continuous hyperfractionated accelerated radiotherapy (CHART). The serum amylase returns to normal earlier in the CHART patients so that the area under the curve is the same for both groups. The difference probably reflects the more rapid delivery of treatment to the patients receiving CHART. A close correlation between the peak rise in serum amylase and the amount of parotid tissue in the treatment volume is demonstrated. For six patients the total amount of amylase secreted by the parotid gland during CHART was measured and found to decline rapidly within a few days of the start of radiotherapy. The rise in serum amylase that results from the irradiation of salivary tissue provides a unique biochemical measure of an early radiation effect in a normal tissue. This probably reflects the interphase cell death of serous salivary cells. Although these immediate changes are of considerable interest they may not relate to the late effects of radiation on salivary gland function.