The Inherent Cellular Sensitivity to 62·5 MeV(p→Be+)Neutrons of Human Cells Differing in Photon Sensitivity

Variations in the RBE for cell killing along the depth-dose profile of a modulated proton therapy beam

Considerable evidence now exists to show that that the relative biological effectiveness (RBE) changes considerably along the proton depth-dose distribution, with progressively higher RBE values at the distal part of the modulated, or spread out Bragg peak (SOBP) and in the distal dose fall-off (DDF). However, the highly variable nature of the existing studies (with regards to cell lines, and to the physical properties and dosimetry of the various proton beams) precludes any consensus regarding the RBE weighting factor at any position in the depth-dose profile. We have thus conducted a systematic study on the variation in RBE for cell killing for two clinical modulated proton beams at Indiana University and have determined the relationship between the RBE and the dose-averaged linear energy transfer (LETd) of the protons at various positions along the depth-dose profiles. Clonogenic assays were performed on human Hep2 laryngeal cancer cells and V79 cells at various positions along the SOBPs of beams with incident energies of 87 and 200 MeV. There was a marked variation in the radiosensitivity of both cell lines along the SOBP depth-dose profile of the 87 MeV proton beam. Using Hep2 cells, the D(0.1) isoeffect dose RBE values (normalized against (60)Co) were 1.46 at the middle of SOBP, 2.1 at the distal end of the SOBP and 2.3 in the DDF. For V79 cells, the D(0.1) isoeffect RBE for the 87 MEV beam were 1.23 for the proximal end of the SOBP: 1.46 for the distal SOBP and 1.78 for the DDF. Similar D(0.1) isoeffect RBE values were found for Hep2 cells irradiated at various positions along the depth-dose profile of the 200 MeV beam. Our experimentally derived RBE values were significantly correlated (P = 0.001) with the mean LETd of the protons at the various depths, which confirmed that proton RBE is highly dependent on LETd. These in vitro data suggest that the RBE of the proton beam at certain depths is greater than 1.1, a value currently used in most treatment planning algorithms. Thus, the potential for increased cell killing and normal tissue damage in the distal regions of the proton SOBP may be greater than originally thought.

The apparent increase in the {beta}-parameter of the linear quadratic model with increased linear energy transfer during fast neutron irradiation

The issue of whether the beta-parameter of the linear quadratic model changes with linear energy transfer (LET) remains controversial. Retrospective analysis of UK fast neutron experimental data using human cell lines at Clatterbridge shows that the beta-parameter of the linear quadratic model probably does increase with LET during neutron irradiation. For cells without a deficiency in DNA damage repair and for experiments in which beta-parameter estimates were considered to be unreliably low, a provisional relationship of beta(H) = 1.82 beta(L) was found (where the suffixes refer to high and low LET exposures, respectively). This implies that radicalbeta increases by around 1.35 in the specific case of 62.5 MeV neutrons relative to 4 MeV X-rays. Increments in the beta-parameter with LET influence the relative biological effect (RBE), especially at high doses per fraction. Large fractions are being used in experimental carbon ion therapy, in which broadly similar RBE values to fast neutrons are found. These interesting findings after fast neutron exposure need to be studied further for applications in charged particle beam therapy using light ions, which is presently undergoing a worldwide expansion.

Micronucleus response of human glioblastoma and neuroblastoma cells toward low-LET photon and high-LET p(66)/Be neutron irradiation

The identification of photon resistant tumors that are sensitive to neutrons is still an unresolved problem, and no radiobiological criteria have been developed that could help the selection of patients for neutron therapy. The micronucleus (MN) assay has been evaluated for this purpose in a panel of human glioblastoma and neuroblastoma cell lines spanning a wide range of photon sensitivities defined by mean inactivation doses ([Latin capital letter D with macron above][gamma]) of 1.25-3.21 Gy. We show that the relative biologic effectiveness (RBE) of the p(66)/Be neutrons is significantly correlated with inherent photon sensitivity (r = 0.89, p < 0.01), indicating that the panel of cell lines used is suitable to study the differential biologic response to neutrons and photons. We find that p(66)/Be neutrons are 1.43 to 5.29 times more effective per unit dose in inducing micronuclei than 60Co [gamma]-rays. Surprisingly, cells that are inherently photon resistant tend to show a higher yield of micronuclei following exposure to either photons or neutrons, but no significant correlation could be demonstrated. However, RBE values based on micronucleus yield were found to strongly correlate with RBE values derived from cell survival data (r = 0.91, p < 0.01). It is concluded that although micronucleus yield does not reflect intrinsic sensitivity to either photons or neutrons, the strong correlation between RBE calculated from micronucleus formation and RBE derived from cell survival demonstrates that the micronucleus endpoint has a potential for detecting photon resistant cells that show increased sensitivity to neutrons.

Biological factors influencing the RBE of neutrons: implications for their past, present and future use in radiotherapy

The recent resurgence of interest in fast-neutron therapy, particularly for the treatment of prostate cancer, warrants a review of the original radiobiological basis for this modality and the evolution of these concepts that resulted from subsequent experimentation with the fast-neutron beams used for randomized clinical trials. It is clear from current radiobiological knowledge that some of the postulates that formed the mechanistic basis for past clinical trials were incorrect. Such discrepancies, along with the inherent physical disadvantages of neutron beams in terms of collimation and intensity modulation, may partially account for the lack of therapeutic benefit observed in many randomized clinical trials. Moreover, it is equally apparent that indiscriminate prescription of fast-neutron therapy is likely to lead to an adverse clinical outcome in a proportion of patients. Hence any renewed efforts to establish a niche for this modality in clinical radiation oncology will necessitate the development of a triage system that can discriminate those patients who might benefit from fast-neutron therapy from those who might be harmed by it. In the future, fast-neutron therapy might be prescribed based upon the relative status of appropriate molecular parameters that have a differential impact upon radiosensitivity to photons compared to fast neutrons.

A comparison of the potential therapeutic gain of p(66)/Be neutrons and d(14)/Be neutrons

PURPOSE

To determine the relationship between photon sensitivity and neutron sensitivity and between neutron RBE and photon resistance for two neutron modalities (with mean energies of 6 and 29 MeV) using human tumor cell lines spanning a wide range of radiosensitivities, the principal objective being whether or not a neutron advantage can be demonstrated.

METHODS AND MATERIALS

Eleven human tumor cell lines with mean photon inactivation doses of 1.65-4. 35 Gy were irradiated with 0-5.0 Gy of p(66)/Be neutrons (mean energy of 29 MeV) at Faure, S.A. and the same plating was irradiated on the same day with 0-10.0 Gy of Cobalt-gamma-rays. Twelve human tumor cell lines, many of which were identical with the above selection, and spanning mean photon inactivation doses of 1.75-4.08 Gy, were irradiated with 0-4 Gy of d(14)/Be neutrons (mean energy of 6 MeV) and with 0-10 Gy of 240 kVp X-rays at the Essen Klinikum. Cell survival was determined by the clonogenic assay, and data were fitted to the linear quadratic equation.

RESULTS

1. Using the mean inactivation dose, a significant correlation was found to exist between neutron sensitivity and photon sensitivity. However, this correlation was more pronounced in the Faure beam (r(2) = 0.89, p </= 0.0001) than in the Essen beam (r(2) = 0.65, p = 0.0027). 2. No significant relationship could be established between neutron RBE and photon resistance for both modalities (p = 0.69 and p = 0.07, respectively). 3. Using alpha-coefficients as a criterion, the neutron sensitivity for the Faure beam correlated with photon sensitivity (p = 0.001), but this did not apply to the Essen beam (p = 0.27). 4. The neutron RBE for the Essen beam derived from alpha-coefficients showed a steep increase with photon resistance (p = 0.003). In the Faure beam there was no increase of RBE with photon resistance (p = 0.494).

CONCLUSION

Radiobiological differences between high-energy and low-energy neutrons are particularly apparent in the dependence of the neutron RBE on photon sensitivity. The increase of RBE with photon resistance is more pronounced in the low-energy Essen neutrons than in the high-energy Faure neutrons. An RBE advantage is indicated for photon-resistant cell lines and this is particularly apparent in the low-dose range using alpha-coefficients as compared to the mean inactivation dose. The clinical application of low-energy neutrons may be more restricted because of poor penetration and lack of skin sparing. However, these neutrons discriminate better between photon-sensitive and photon-resistant cells giving an RBE range of 2-6 and a mean RBE of 4.1, than high-energy neutrons where the RBE range is 1.6-3.5 and the mean RBE is 2.4. From the radiobiological point of view it, therefore, appears that the clinical potential of low-energy neutrons is considerably underrated.

The influence of hypoxia on the relative sensitivity of human tumor cells to 62.5 MeV (p-->Be) fast neutrons and 4 MeV photons

Fast neutrons have been used in the clinical radiation therapy of tumors largely because of experimental evidence that their cytotoxic effects are much less dependent on oxygen levels than those of low-LET photons. The potential therapeutic advantage of fast neutrons based on hypoxia alone can be calculated as the "hypoxic gain factor", which is the ratio of the OERs for the fast-neutron compared to the photon beams. The hypoxic gain factor that is generally anticipated based on studies with established mammalian cell lines is about 1.6. However, surprisingly few studies have examined the influence of hypoxia on the fast-neutron radiosensitivity of human tumor cells of different histological types. For this reason, we have determined the OERs of five human tumor cell lines exposed to 62.5 MeV (p-->Be) cyclotron-generated fast neutrons or 4 MeV photons from a clinical linear accelerator. The OERs for four chemotherapy-naive cell lines, HT29/5, Hep2, HeLa and RT112, were invariably greater for photons than for neutrons, but all of these values were lower than expected on the basis of the previous literature. Despite their low OERs, these cell lines showed hypoxic gain factors that were within the range of 1.31-1.63, indicating that such effects cannot entirely explain the disappointing clinical results obtained with fast neutrons. In contrast, comparison of the surviving fractions at clinically relevant doses (1.6 Gy of neutrons and 2.0 Gy of photons) for these four tumor cell lines suggested that little benefit should result from neutron treatment. Only the cisplatin-resistant OAW42-CP line showed a significant hypoxic gain factor by this method of analysis. We conclude that, at the dose fractions used in clinical radiation therapy, there may not be a radiobiological precedent for higher local control rates after fast-neutron irradiation of hypoxic tumor cells.

Neutron and photon clonogenic survival curves of two chemotherapy resistant human intermediate-grade non-Hodgkin lymphoma cell lines

BACKGROUND

The potential role of neutron therapy in the management of intermediate-grade non-Hodgkin lymphoma (IGNHL) has not been examined because of the belief that the anticipated radiobiological effectiveness (RBE) would be uniformly very low.

PURPOSE

To determine the fast neutron RBE for two chemotherapy-resistant IGNHL cell lines.

METHODS AND MATERIALS

Conventional soft agar clonogenic survival curves following irradiation by 60Co and fast neutron were established for two IGNHL cell lines. These cell lines, WSU-DLCL2 and SK-DHL2B, were found in previous studies to be able to repair sublethal damage, and were also resistant to L-Pam and doxorubicin chemotherapy.

RESULTS

When the surviving fraction after 2 Gy photon was chosen as the biological endpoint, the RBE for WSU-DLCL2 and SK-DHL2B measured 3.34 and 3.06. Similarly, when 10% survival was considered, the RBE for these two cell lines measured 2.54 and 2.59. The RBE, as measured by the ratios alpha neutron/alpha photon, for WSU-DLCL2, SK-DHL2B cell lines are 6.67 and 5.65, respectively. These results indicate that the RBE for these IGNHL cell lines is higher than the average RBE for cell lines of other histological types.

CONCLUSION

Fast neutron irradiation may be of potential value in treating selected cases of IGNHL.

The assessment of RBE effects using the concept of biologically effective dose

PURPOSE

To modify existing linear-quadratic (LQ) equations in order to take account of relative biological effectiveness (RBE) using the concept of biologically effective dose (BED).

METHODS AND MATERIALS

Clinically useful forms of the LQ model have been modified to incorporate RBE effects in such a way as to allow comparison between high- and low-LET (linear energy transfer) radiations in terms of similar biological dose units. The new parameter in the formulation is RBEM, the intrinsic (or maximum) RBE at zero dose. The principal assumption (following Kellerer and Rossi; ref. 1) is that high-LET radiation modifies the alpha-coefficient of damage while leaving the beta-coefficient unaltered.

RESULTS

The equations allow a quantitative estimation of how the apparent RBE will change with changes in dose/fraction or dose-rate and of how the magnitude and rate of change is governed by the low-LET alpha/beta ratio of the irradiated tissue. The modifications are applicable to all types of radiotherapy (fractionated, continuous low dose-rate, therapy with decaying sources, etc.). In cases where the normal tissue RBEM is greater than that for the tumor, the revised formulation helps explain why there will be situations where therapeutic index will be adversely affected by use of high-LET radiation. Such clinical advantages as have been observed are more likely to result from favorable geometrical sparing of critical normal tissues and/or the fact that slowly growing tumors may have alpha/beta values more typical of late-responding normal tissues.

CONCLUSIONS

The incorporation of RBE into existing LQ methodology allows quantitative assessment of clinical applications of high-LET radiations via an examination of the associated BEDs. On the basis of such assessments high-LET radiations are shown to confer few advantages.

RBE of fast neutrons for apoptosis in mouse thymocytes

We compared apoptosis in mouse thymocytes following exposure to low doses of high linear energy transfer (LET), 62.5-MeV (p-->Be+) fast neutrons and low LET, 4-MeV photons by flow cytometric analysis of hypodiploid cells. The incidence of apoptotic cell death rose steeply at very low radiation doses reaching a plateau of 3 Gy. Both the time course and the radiation dose-response curves were similar for high and low LET radiation modalities. The relative biological effectiveness (RBE) of 1.0 for apoptosis in the mouse thymocyte system contrasts with the much higher value typically seen in many classical systems of clonogenic cell survival and tissue response. This difference suggests that while radiation-induced apoptosis may contribute significantly to loss of susceptible cells at doses of < or = 2 Gy, it appears to have a questionable role in determining the relative intrinsic radiosensitivity of mammalian cells to high and low LET irradiation at clinically relevant levels of cell kill.

Irregular variations in radiation sensitivity when the linear energy transfer is increased

Seven cell lines were analyzed for clonogenic survival after irradiation with photons (60Co) or accelerated helium or nitrogen ions. The cell lines showed different sensitivity to photon radiation and most of the differences decreased after irradiation with helium ions with a linear energy transfer (LET) of about 40 keV/microns. However, all cell types had individual LET sensitization patterns and the mean relative biological effectiveness (RBE) at 10% survival ranged from 1.46 +/- 0.12 to 2.41 +/- 0.26 for the helium ions. This difference was significant and the differences increased further when higher survival levels were considered. There was only a weak tendency towards a relation between photon and helium ion sensitivity when the linear component of the survival curves, the alpha-values, were compared, and no relation at all for other parameters. It was not possible to predict the response to an increased LET from the photon responses obtained. Three of the cell lines were also irradiated with nitrogen ions with an LET of 125 keV/microns. These cells were, as expected, sensitized further and the average RBE at 10% survival was 3.67 +/- 0.67. However, one cell line was more resistant than the others in this case. Furthermore, the quadratic component of the survival curves, the beta values, were higher after irradiation with nitrogen than with helium ions. Thus, several irregular and unexpected results were seen when the LET was increased.

Derivation of the optimum dose per fraction from the linear quadratic model

The linear quadratic equation for fractionated radiotherapy has already been adapted to include a time factor for tumour repopulation: loge cell kill (E) is given as a function of dose per fraction (d), number of fractions (n), overall treatment time (T) and the clonogen doubling time (Tp). By incorporating a normal tissue isoeffect and replacing the relationship between T and n by a function f, the equation for E can be rewritten as a more complex function of d. In this form, E and d are continuous variables so that the dose per fraction (d') required to produce maximum values of E for isoeffective late normal tissue effects can be found by differential calculus. The derived equation takes the form (beta kTp-alpha Tp)d2 + 1.386fd + 0.693fk = 0 and when solved for d provides a direct estimation of the optimum dose per fraction. Where normal tissue sparing is possible and the tumour dose z is related to the normal tissue dose d, the optimum dose per fraction z' can be found by solving the equation (beta kTp-alpha gTp)z2 + 1.386fgz + 0.693fk = 0 The results show that a critical minimum dose per fraction is required to counteract rapid tumour clonogen repopulation in both conventional and accelerated radiotherapy. The calculus method is reasonably accurate for larger fraction numbers, when clonogen doubling times are 3.5 days or longer and for conventional radiotherapy given 5 days per week. The model is even more accurate for accelerated hyperfractionated radiotherapy providing that there is complete repair between successive fractions. Where greater normal tissue sparing is possible, as with focal teletherapy methods and brachytherapy, higher tumour doses per fraction can be used to increase further the tumour cell kill without exceeding normal tissue tolerance. These predicted doses per fraction are consistent with clinical experience when the given constraints in terms of frequency of treatment are considered. The model described can be used for tumours in which repopulation occurs at a constant rate throughout treatment. For tumours in which accelerated repopulation occurs, the optimum dose per fraction can be separately calculated for the initial phase of slow repopulation (for which very small doses per fraction are optimal) and also for the second phase of rapid repopulation (for which either accelerated hyperfractionated treatments or hypofractionated focal methods of treatment would be appropriate). The limitations of the model are fully discussed including the need for accurate radiobiological predictive assays. In the future such assays of pre-treatment doubling times and tumour cell radiosensitivities could be used to determine reasonable ranges for the optimum dose per fraction in experimental tumours and subsequently in clinical trails. This approach could produce major improvements in the therapeutic potential of radiotherapy.

Identification of human in vitro cell lines with greater intrinsic cellular radiosensitivity to 62.5 MeV (p-->Be+) neutrons than 4 MeV photons

PURPOSE

To identify human in vitro cell lines with a high relative cellular sensitivity to fast neutrons as compared to photons and to examine their relationship to intrinsic photon radiosensitivity and cellular proliferation kinetics.

METHODS AND MATERIALS

The clonogenic cell survival following exposure to low LET, 4 MeV photons or, high LET, 62.5 MeV (p-->Be+) fast neutrons and the cell kinetic parameters of 30 human in vitro cell lines, covering a wide range of histologies, were analyzed alone and with previously published data of Fertil and Malaise. The relative survival at 1.6 Gy of neutrons (SF1.6) compared to 2 Gy of photons (SF2) (the doses per fractions used in the Clatterbridge fast neutron studies) and the cell kinetic parameters of the 30 cell lines were also compared. The relative lethality of 62.5 MeV fast neutrons was assessed by comparing the ratio alpha neutrons/alpha photons to alpha photons or SF1.6 neutrons/SF2 photons to SF2 photons. Cellular proliferation kinetics were measured by flow cytometry following BrdU incorporation and the relationship of cellular proliferation to relative neutron lethality was measured by comparing the alpha neutron/alpha photon ratio to the labelling index (LI), potential doubling (Tpot) and ploidy.

RESULTS

The majority of cell survival curves obtained following exposure to 62.5 MeV fast neutrons were curvilinear with beta values of similar order to those obtained with low LET 4 MeV photons. Comparison of alpha values for neutrons and photons revealed a relatively neutron sensitive subset of 9 out of 30 in vitro cell lines. This subset was not, however, distinguishable when 1.6 Gy of neutrons was compared to 2 Gy of photons. There was no correlation between cell survival with neutrons or photons and the cell kinetic parameters Tpot or LI or with DNA ploidy.

CONCLUSIONS

The use of in vitro assays of neutron and photon radiosensitivity irrespective of cell kinetic parameters allows identification of neutron sensitive cell populations when the ratio of the alpha values for neutrons and photons is compared to the reciprocal of the alpha photon value. This relationship is not apparent when fractions of 2 Gy of photons are compared to 1.6 Gy of neutrons. Whether or not this identification can be borne out in fractionated regimes in the clinic remains to be proved.

The relative cellular radiosensitivity of 30 human in vitro cell lines of different histological type to high LET 62.5 MeV (p-->Be+) fast neutrons and 4 MeV photons

It has been suggested that fast neutron therapy may have a role in the treatment of those tumours which lie within the most photon-resistant histological categories. A clinical radiobiological study by Battermann et al., however, did not support this hypothesis (Battermann, J.J. et al., Eur. J. Cancer 17: 539-548, 1981). Similarly, in a comparison of the intrinsic cellular radiosensitivity of 20 human in vitro cell lines with 4 MeV photons and 62.5 MeV (p-->Be+) neutrons, there was no correlation between RBE and photon sensitivity. However, because the range of histological cell types in this in vitro study did not include sufficient representatives of the most sensitive and resistant histological categories, it was not possible to examine the relationship between histology and the relative efficacy of fast neutrons compared with photons. The intrinsic radiosensitivity of a further 10 human in vitro cell lines has thus been measured and the results of all 30 cell lines used in a comparison of the relationship between relative neutron sensitivity and histology. These results together with those obtained by reanalysis of published data from a clinical study of the RBE of pulmonary metastases by Battermann et al. suggest that in the clinical situation, photon-resistant histology per se may not be a sufficient criterion for the choice of high LET irradiation and emphasize the need for predictive assays for individual tumours.

In vitro studies of intrinsic cellular radiosensitivity following 4 MeV photons or 62.5 MeV (p-->Be+) neutrons. Potential implications for high LET therapy

Recent studies of the intrinsic cellular sensitivity of 30 human in vitro cell lines to 4 MeV photons and 62.5 MeV (p-->Be+) neutrons have identified relatively neutron sensitive cell lines with high alpha values within the more resistant end of the photon radiation response range. Here we present data comparing the surviving fraction at 2 Gy of photons (SF2) to the surviving fractions at 1.6, 0.85 and 0.6 Gy of neutrons respectively (SF1.6 SF0.85 and SF0.6). With the ratio SF2/SF1.6 a negative trend can be seen between the probability of a preferential response to neutrons and relative photon resistance. With a ratio of SF2/SF0.6, however, a highly significant benefit for 62.5 MeV neutrons can be seen in the more photon resistant lines. We suggest further clinical studies to explore the potential relevance of these in vitro findings to the clinical situation should be undertaken.

The differential induction of collateral resistance to 62.5 MeV (p-->Be+) neutrons and 4 MeV photons by exposure to cis-platinum

PURPOSE

To determine the relative sensitivity to cis-platinum, 4 MeV photons and 62.5 MeV (p-->Be+) neutrons in five human tumor cell lines, and their cis-platinum resistant variants.

METHODS AND MATERIALS

The degree of cross-resistance of five human in-vitro cell lines to photons or fast neutrons was analysed for both cisplatinum-sensitive and resistant variants.

RESULTS

The development of acquired cis-platinum resistance conferred collateral resistance to 62.5 MeV (p--Be+) neutrons in all five cell lines, but did not consistently decrease the photon sensitivity of these same cells.

CONCLUSION

The reduction in photon and neutron sensitivity following the development of acquired cis-platinum resistance may possibly be regulated by different mechanisms. The reduction in neutron sensitivity was primarily due to a 1.3-1.7 fold reduction in the magnitude of the initial slope (alpha), which was independent of the degree of platinum resistance induced, suggesting a non-stochiometric relationship between the mechanisms responsible for acquired cis-platinum, and 62.5 MeV (p-->Be+) neutron resistance.