The effect of single and fractionated doses of x rays on the effective proportion of hypoxic cells in C 3 H mouse mammary tumours

The changing paradigm of tumour response to irradiation

Tumours contain multiple different cell populations, including cells derived from the bone marrow as well as cancer-associated fibroblasts and various stromal populations including the vasculature. The microenvironment of the tumour cells plays a significant role in the response of the tumour to radiation treatment. Low levels of oxygen (hypoxia) caused by the poorly organized vasculature in tumours have long been known to affect radiation response; however, other aspects of the microenvironment may also play important roles. This article reviews some of the old literature concerning tumour response to irradiation and relates this to current concepts about the role of the tumour microenvironment in tumour response to radiation treatment. Included in the discussion are the role of cancer stem cells, radiation damage to the vasculature and the potential for radiation to enhance immune activity against tumour cells. Radiation treatment can cause a significant influx of bone marrow-derived cell populations into both normal tissues and tumours. Potential roles of such cells may include enhancing vascular recovery as well as modulating immune reactivity.

Reoxygenation after single irradiation in rodent tumors of different types and sizes

PURPOSE

To investigate the variation of reoxygenation patterns after single irradiation in murine tumors of different types and sizes.

METHODS AND MATERIALS

Whole-body single irradiation of 13 to 15 Gy was delivered to 10 mm RIF1 tumors of C3H/He mice, 22 mm SCCVII tumors of C3H/He mice, and 16 mm EMT6 tumors of Balb/c mice. Thereafter, changes in the hypoxic fraction with time were determined by the paired survival curve method. The data were compared with the results we had ++previously obtained with 10 mm SCCVII and 10 mm EMT6 tumors.

RESULTS

The hypoxic fraction at 1 h after the priming irradiation was 26% for 10 mm RIF1 tumors, 48% for 10 mm SCCVII tumors, and 100% for 10 mm EMT6 tumors. Thus, RIF1 and SCCVII tumors, both of which have few necrotic areas, showed rapid reoxygenation, whereas EMT6 tumors, which have large necrotic areas, reoxygenated slowly. Although the hypoxic fraction returned to the pretreatment level within 72 h in 10 mm SCCVII and 10 mm EMT6 tumors, it did not in 10 mm RIF1 tumors. In contrast, the patterns of reoxygenation were similar between 22 mm and 10 mm SCCVII tumors and between 16 mm and 10 mm EMT6 tumors.

CONCLUSION

The three tumors showed different patterns of reoxygenation. Tumors that have a low proportion of necrosis may reoxygenate rapidly. However, tumor size appeared to have less influence on the pattern of reoxygenation.

Restoration of tumor oxygenation after cytotoxic therapy by a perflubron emulsion/carbogen breathing

Female, Fisher 344 rats bearing 13762 mammary carcinoma implanted subcutaneously in a hind limb were treated with standard therapeutic single doses of antitumor treatments of several types including: 1) antitumor alkylating agents (cisplatin, cyclophosphamide); 2) natural products (adriamycin, taxol and etoposide); 3) antimetabolites (5-flourouracil); 4) hypoxic cell selective agents (mitomycin C, SR-4233) as well as 5) fractionated radiation therapy (3 Gray daily for 5 days). The oxygen levels in the tumors were measured in the absence of treatment and 24 hrs. after treatment using an Eppendorf p02 histograph. Fifty- to sixty-points were measured per tumor and 8-10 tumors comprised each group. The tumors were more hypoxic post treatment with every anticancer drug or radiation. The percent of p02 readings < or = 5 mmHg in the untreated tumors ranged from 85% (x-rays) to 59% (etoposide). Administration of the perflubron emulsion (8 ml/kg) and carbogen breathing (95% O2/5% CO2) increased the oxygenation of the tumors such that the percent of pO2 readings < or = 5 mmHg was 32% in the untreated controls and ranged from 27% (x-rays) to 56% (adria) in the treated tumors. These results indicate that administration of a perflubron emulsion/carbogen can increase the oxygen content of tumors when hypoxia is the result of cytotoxic therapy.

Reduced oxygenation in a rat mammary carcinoma after chemo- or radiation therapy and reoxygenation with perflubron emulsion/carbogen breathing

Rat 13672 mammary carcinoma tumors were grown subcutaneously in the hind legs of female Fischer 344 rats to a volume of about 1 cm3. Tumor oxygenation was measured using an Eppendorf PO2 histograph. Tumor oxygen measurements were made under four conditions: (a) normal air breathing, (b) carbogen breathing, (c) after intravenous administration of a perflubron emulsion (8 ml/kg) with air breathing and (d) after intravenous administration of a perflubron emulsion (8 ml/kg) with carbogen breathing. Tumor oxygenation was examined without treatment or 24 h and 48 h after treatment with cyclophosphamide (300 mg/kg, i.p.) or cisplatin (8 mg/kg, i.p.] or after the fifth dose of a daily regimen of 3-Gy irradiation (5 x 3 Gy). Under normal air-breathing conditions 49% of the tumor had a PO2 < or = 670 Pa (5 mm Hg). The degree of hypoxia in the tumors increased after each treatment such that 24 h after treatment 65%-85% of the oxygen readings were < or = 670 Pa and 48 h after treatment 60%-74% of the oxygen readings were < or = 670 Pa. Administration of the perflubron emulsion/carbogen atmosphere increased the oxygen content of the tumors both without treatment and after each of the treatments. A knowledge of tumor oxygen content over the course of treatment and the ability to increase tumor oxygen should allow for the development of more rational treatment combinations and better treatment outcomes.

Combination of perfluorochemical emulsions and carbogen breathing with cancer chemotherapy

Over the past ten years several laboratories have explored the use of perfluorochemical emulsions (PFCE) and carbogen (95% O2/5% CO2; C) or oxygen breathing as an adjuvant to radiation therapy and/or chemotherapy in solid tumor model systems. The rationale for the use of PFCE and C or oxygen breathing in this therapeutic setting is that solid tumor masses contain areas of hypoxia which are therapeutically resistant. Since x-rays and many chemotherapeutic agents require oxygen to be maximally cytotoxic and most normal tissues are well-oxygenated, the additional oxygen put in circulation by the PFCE/C should not increase the normal tissue toxicities produced by the various therapies. Several anticancer agents are dependent on oxygen to be cytotoxic, these drugs such as the iron-chelating peptide bleomycin are enhanced in antitumor activity by the co-administration of a PFCE/C. The antitumor alkylating agents especially cyclophosphamide, BCNU and melphalan show increased tumor cell killing without a concomitant increase in bone marrow toxicity when administered with PFCE/C. Enhanced activity was also observed when topoisomerase II inhibitors such as adriamycin and etoposide were co-administered with PFCE/C. Positive effects, although smaller, were observed when antimetabolites such as 5-fluorouracil and methotrexate were co-administered with PFCE/C.

Variations of the hypoxic fraction in the SCC VII tumors after single dose and during fractionated radiation therapy: assessment without anesthesia or physical restraint of mice

Variations of the hypoxic fraction (HF) after single dose (13 Gy or 4 Gy) and during fractionated (5 fractions of 4 Gy, 1 or 2 fractions per day) radiation therapy were studied in SCC VII tumors implanted subcutaneously in the hind legs of C3H/He/Jms mice using the paired survival curve method. Whole-body irradiation was delivered to tumor-bearing mice without anesthesia or physical restraint, because both are known to increase the HF artificially. The HF decreased after a single 13 Gy dose in a biphasic fashion: extremely rapidly within 1 hr and comparatively slowly during the following 12-72 hr. On the other hand, nearly no fall of HF was observed in 24 hr following a single 4 Gy dose. Also, reoxygenation was found to occur more rapidly in the interfraction period as the number of fractions of 4 Gy increased irrespective of differences of interfraction time. However, the HF just before each radiation fraction was significantly higher than the pretreatment level for both fractionated regimens. Thus, the reoxygenation patterns observed after single low and high doses of irradiation were different from each other, and reoxygenation in each interfraction period did not always proceed in a similar manner to that after single low dose irradiation. Reoxygenation was facilitated as fractionated radiation therapy proceeded, but it was not sufficient for the HF to remain at a level comparable to that before irradiation.

Reoxygenation in a rat rhabdomyosarcoma tumor following X-irradiation

The paired survival curve technique was used to characterize the rate at which the fraction of hypoxic cells in rat rhabdomyosarcoma R-1 tumors returns to the preirradiation value of 37% following a single dose of 225-kVp X rays. Tumors were administered a conditioning x-ray dose of 15-Gy, followed at 0, 3, 6, 12, 24, or 48 hr by a 5-Gy, 10-Gy, or 15-Gy dose of X rays under air-breathing conditions or under hypoxic conditions produced by nitrogen-gas asphyxiation 5 min prior to irradiation. Cellular surviving fractions were determined by the tumor excision assay following in vivo irradiation. From the ratio of the survival fractions measured for tumor cells from air-breathing and hypoxic animals, the fraction of hypoxic cells was determined as a function of time postirradiation. These results indicated that immediately following a 15-Gy dose of X rays, essentially 100% of the viable cells remaining were hypoxic. The tumors reoxygenated rapidly, returning to the preirradiation level of 37% during the first 6 hr postirradiation.

Hypoxia and reoxygenation in human melanoma xenografts

Tumor hypoxia and reoxygenation pattern following single dose (10.0 Gy) and fractionated (7 fractions of 2.0 Gy, 1 fraction per day) irradiation were studied in five human melanoma xenograft lines using the paired survival curve method. The hypoxic fractions differed significantly among the melanoma lines; they were found to be 6 +/- 3% (E.E.), 22 +/- 8% (E.F.), 31 +/- 11% (G.E.), 45 +/- 17% (M.F.), and 15 +/- 5% (V.N.). There were no clear correlations between hypoxic fraction and tumor volume-doubling time or vascular density, suggesting that intrinsic cellular characteristics, for example, rate of oxygen consumption and ability to retain clonogenicity under hypoxic stress, also may play an important role for the magnitude of the hypoxic fractions in the melanomas. Reoxygenation was rapid and extensive in all melanoma lines; 12-24 hr after the single dose irradiation or the last fraction of the fractionated irradiation, the hypoxic fractions were similar to those in untreated tumors and stayed at that level up to at least 10 days after irradiation. The hypoxic fractions 1-10 days after irradiation tended to be higher after fractionated than after single dose irradiation, but the differences were not statistically significant. There was a positive correlation between the hypoxic fractions in untreated tumors and the hypoxic fractions after irradiation and reoxygenation, suggesting that it may be possible to predict radiation resistance caused by hypoxia from the hypoxic fractions in tumors before start of radiation therapy. However, hypoxia is probably not a major cause of failure in the radiation therapy of malignant melanoma.

Phosphorus-31 magnetic resonance spectroscopy and blood perfusion of the RIF-1 tumor following X-irradiation

Phosphorus-31 magnetic resonance spectra were obtained from the RIF-1 tumor in C3H mice before and up to 2 days after various doses of X rays. Parallel studies were performed to measure relative changes in tumor blood perfusion using [14C]iodo-antipyrine and changes in % tumor necrosis using Chalkley's method. Tumor ratios of phosphocreatine to inorganic phosphate (PCr/Pi) and nucleotide triphosphates to inorganic phosphate (NTP/Pi) as well as pH as measured by 31P-MRS increased significantly at most time points after irradiation with doses of 5, 10, and 20 Gy. Tumor blood perfusion was found to significantly improve after a dose of 20 Gy but not after a dose of 2 Gy. Percent tumor necrosis increased to about 3 times its control level at 1 day after a dose of 20 Gy and then declined to about twice its control value at 2 days. The magnitude of the changes in the 31P-MRS parameters makes it unlikely that any of them are entirely due to radiation-induced changes in the radiobiologically hypoxic fraction of these tumors. Changes in the necrotic fraction did not appear to influence the tumor spectra. However, the observed improvement in tumor blood perfusion may have resulted in an increase in oxidative phosphorylation of the whole tumor population as well as a clearance of inorganic phosphate and acid metabolites, so that 31P-MRS changes may indirectly reflect changes in tumor blood perfusion.

Hyperthermic enhancement of the antitumor effect of natural human tumor necrosis factor-alpha and -beta: an in vitro and in vivo study

A synergistic antitumor effect of natural human tumor necrosis factor-beta (TNF-beta) in combination with hyperthermia was found, in comparison with that of TNF-alpha, using an in vitro antiproliferative assay on a human colon cancer cell line (RPMI4788) and an in vivo tumor growth inhibition assay on Meth A sarcoma cells. In vitro combined treatment with TNF-beta (10,000 U/ml) and hyperthermia (at 43 degrees for 60 min) synergistically inhibited the proliferation of the cells. Combined effects of TNF-alpha or natural human interferon-alpha or -gamma (IFN-alpha, -gamma) and hyperthermia were also examined, and furthermore, the combinations of TNFs and IFNs were examined in combination with hyperthermia at 42 degrees; their antiproliferative effects were further augmented by hyperthermia. In vivo growth of Meth A sarcoma cells (5 x 10(5)), transplanted subcutaneously into BALB/c mice, was inhibited significantly (P less than 0.05) with the combination of TNF-alpha or -beta (2 x 10(5) U/mouse) and hyperthermia (at 43 degrees for 60 min) as compared to either a single intravenous injection of TNF-alpha or -beta alone or the hyperthermia alone. The influence of TNF-beta and hyperthermia on the cell cycle was examined. Flow cytometric analysis showed that RPMI4788 cells treated with TNF-alpha or -beta accumulated in the S phase of the cell cycle, and that hyperthermia (at 42 degrees for 60 min) alone had no influence on the cell cycle and did not augment the S phase accumulation of the cells treated with TNF-alpha or -beta.

Tumor hypoxia: its impact on cancer therapy

The presence of radiation resistant cells in solid human tumors is believed to be a major reason why radiotherapy fails to eradicate some such neoplasms. The presence of unperfused regions containing hypoxic cells may also contribute to resistance to some chemotherapeutic agents. This paper reviews the evidence that radiation resistant hypoxic cells exist in solid tumors, the assumptions and results of the methods used to detect hypoxic cells, and the causes and nature of tumor hypoxia. Evidence that radiation resistant hypoxic cells exist in the vast majority of transplanted rodent tumors and xenografted human tumors is direct and convincing, but problems with the current methodology make quantitative statements about the magnitude of the hypoxic fractions problematic. Evidence that radiation resistant hypoxic cells exist in human tumors is considerably more indirect than the evidence for their existence in transplanted tumors, but it is convincing. However, evidence that hypoxic cells are a significant cause of local failure after optimal clinical radiotherapy or chemotherapy regimens is limited and less definitive. The nature and causes of tumor hypoxia are not definitively known. In particular, it is not certain whether hypoxia is a chronic or a transient state, whether hypoxic cells are proliferating or quiescent, or whether hypoxic cells have the same repair capacity as aerobic cells. A number of new methods for assessing hypoxia are reviewed. While there are still problems with all of the new techniques, some of them have the potential of allowing the assessment of hypoxia in individual human tumors.

Anemia: a problem or an opportunity in radiotherapy?

Anemia may often become a problem in the treatment of the cancer patient. There are insufficient clinical data to assess the overall importance of anemia in radiotherapy, but there is clear evidence that uncorrected anemia is detrimental to local tumor control in some sites. There may be situations, however, when the transfused, previously anemic patient is at an advantage. These patients have shown a dramatically better response than non-anemic patients when radiotherapy for cancer of the cervix was given in hyperbaric oxygen. Animal experiments suggest that adaptive processes may be responsible for this effect. There is an important difference between acute and chronic anemia in their influence on the radiosensitivity of mouse tumors; while acute anemia consistently causes radioresistance, this effect is lost as the duration of the anemia prior to irradiation is prolonged. This would suggest that anemia per se should not cause tumor radioresistance in the chronically anemic patient. Blood transfusion in previously anemic animals has been shown to produce a markedly increased tumor radiosensitivity, but again this is only transient and sensitivity returns to normal when the interval between transfusion and irradiation is extended to 24 hrs. The mechanisms responsible for tumor adaptation to anemia and blood transfusion are not known, but there is evidence that changes in diffusion distances occur within tumors in response to alterations in oxygen availability and that changes in blood chemistry through the 2,3-DPG system may alter the release of oxygen to the tissues. These are complex processes and it remains to be determined what influence they have in the treatment of human cancer. However, the animal data suggest a clear benefit of blood transfusion to restore the hemoglobin level in radiotherapy, but they also emphasize the need to irradiate immediately so that adaptive mechanisms cannot erode the effect.

Sensitizers and radiation dose fractionation: results and interpretations

Misonidazole is generally regarded as having been a clinical failure as a radiation sensitizer. It is hoped that the newer sensitizers SR-2508 and Ro 03-8799 will give better results because single dose studies with animal tumors have indicated that these two drugs give higher enhancement ratios than misonidazole at clinically tolerated doses. Other factors may also have influenced the clinical efficacy of misonidazole, however, particularly reoxygenation during the course of the fractionated treatments. In this paper reoxygenation in animal tumors and experimental studies in which fractionated radiation doses have been combined with sensitizers are reviewed. It is concluded that, even for dose fractions of 2 Gy, reoxygenation may not completely eliminate the influence of hypoxic cells on tumor response, when large total doses are given. Problems associated with tumor heterogeneity are also discussed to highlight the desirability of selecting the most suitable patients for clinical studies. Poorly reoxygenating tumors, rapidly growing tumors and tumors in patients in whom oxygen delivery to tissue is compromised are those whose control is most likely to be improved by combining radiation sensitizers with conventional treatment. However effective sensitizers should also allow fractionation schedules to be modified, to achieve a therapeutic gain, by taking advantage of differences in repair or repopulation between the tumor and critical normal tissue, without having to consider possible detrimental effects on reoxygenation.

Tumor-to-tumor variability in the hypoxic fractions of experimental rodent tumors

Paired determinations of the radiation responses of normally-aerated and artificially hypoxic rodent tumors, performed to measure the hypoxic fractions of the tumors, were obtained from our own laboratories and from the literature. The data were reanalyzed to assess whether the variabilities in the radiation responses of the normally-aerated and artificially hypoxic tumors were similar. If there were large differences in the hypoxic fractions of individual tumors within the experiments, the variability in the data from aerobic tumors would be expected to be greater than the variability in the data from artificially hypoxic tumors (which should all be brought to uniform hypoxia and therefore uniform radioresistance). The analyses revealed the variability to be as great or greater for hypoxic tumors as for normally-aerated tumors. This finding suggests that factors other than tumor-to-tumor differences in oxygenation produce most of the variability in the radiation responses of individual tumors from an experimental tumor line.

Hypoxic fractions of solid tumors: experimental techniques, methods of analysis, and a survey of existing data

Hypoxic fractions are measured by indirect techniques, which compare the response of tumors to large single doses of radiation given under normal aeration and artificial hypoxia. This paper reviews hypoxic fraction measurements and measurement techniques, giving particular attention to the biological, technical, and statistical aspects of the assays; the implicit assumptions underlying the analyses; and the dependence of the determinations on the assay conditions and the tumor and host characteristics. The three major hypoxic fraction assay techniques (paired survival curve, clamped tumor control, and clamped growth delay) share common biological assumptions. They require that the survival curves of naturally and artificially hypoxic cells have the same slope and intercept. They assume that the majority of the cells are either fully oxic or fully hypoxic. They assume that the methods used to induce artificial hypoxia leave no oxygenated regions and that tumor cells rendered artificially hypoxic are no less viable than cells in normally-aerated tumors. The universal validity of these assumptions is questionable. Each technique uses additional special assumptions and each may measure a different population of hypoxic cells. This paper reviews 92 hypoxic fraction determinations in 42 tumor systems. Radiobiologically hypoxic cells appear to be present in the majority of macroscopic solid rodent tumors. The hypoxic fraction was found to increase as the tumor size increased from microscopic to macroscopic; the dependence of hypoxic fraction on tumor size at macroscopic sizes was less clear. The site of tumor implantation, the use of anesthesia, and certain host characteristics may influence the hypoxic fraction. The hypoxic fraction generally did not depend on the tumor growth rate, transplantation history, or histology. These findings indicate that hypoxic cells are a common feature of solid tumors in rodents and provide no evidence that hypoxic cells should not be present in human tumors.

The potential benefit from a perfect radiosensitizer and its dependence on reoxygenation

The potential benefit of a perfect radiosensitizer has been assessed by computing the sensitization ratios that would be observed in a mixed population of oxic and hypoxic cells if different reoxygenation rates existed. The sensitizer has been assumed to be as effective as oxygen, completely non-toxic and freely diffusible to all hypoxic cells within the tumour. The calculations have been made for several different clinical fractionation regimes, namely 30, 20, 9 or 6 fractions, all with the same ret dose (NSD = 1700 rets). These calculations have allowed us to deduce how large the observed sensitization would be for differing rates of reoxygenation and for the different fractionation schemes. The size of the extrapolation number is seen to be an important parameter in these calculations. They have allowed us to indicate how much reoxygenation would be needed to abolish the benefit from (and hence the need for) a perfect radiosensitizer.

Radiosensitivity of Nall human melanoma transplanted into nude mice: repair, reoxygenation and dose fractionation

Split and fractionated gamma-rays experimental have been performed on a human melanoma transplanted into nude mice using an in vitro colony assay. Repair of potentially lethal observed after a single dose of 20 Gy was found to no longer occur when 7 daily doses of 2.5 Gy were administered. In split-dose experiments, the increase in survival level probably can not be explained by repair of sublethal damage. When a single high dose of radiation is administered a certain reoxygenation is observed; however there is no reoxygenation when low radiation doses are delivered daily.

The effect of recovery from potentially lethal damage on the determination of reoxygenation in a murine tumour

The pattern of reoxygenation in the murine anaplastic MT tumour was investigated using the established method of determining the hypoxic fraction, at intervals after a priming X-ray dose, from test doses given either to unclamped or clamped-off tumours. Little reoxygenation was apparent whilst the tumour was increasing in size for 12--72 hours after a single dose of 20.3 Gy, but extensive reoxygenation was evident whilst the tumour was shrinking at nine days after a dose of 50 Gy. However, the degree of reoxygenation may have been underestimated, especially after the smaller priming dose. This is because only the chronically hypoxic cells in this tumour have the ability to recover from potentially lethal damage (PLD) and so are more radioresistant than cells rendered acutely hypoxic by clamping. Because of this, even when tumours are clamped off during irradiation, the resulting survival curve is biphasic and the apparent effect of the clamp becomes a function of the X-ray dose used. The larger the dose, the smaller the observed effect of the clamp, so the greater the apparent hypoxic fraction and hence the smaller the apparent degree of reoxygenation.

Hypoxic cell sensitisers in radiotherapy

Solid tumours contain poorly oxygenated cells, and these are disproportionately resistant to therapeutic radiation. Several methods of overcoming this problem have been used clinically, including the administration of hyperbaric oxygen during irradiation, radiotherapy with heavy nuclear particles such as neutrons from cyclotrons, optimum size and spacing of multiple doses of conventional radiation, and, most recently, chemical radiosensitisers. These radiosensitisers mimic the sensitising effect of oxygen and are active only against hypoxic cells. They do not, therefore, increase radiation response in well-oxygenated normal tissues. They are not rapidly metabollised and so can penetrate further than oxygen from the vascular capillaries and effectively reach the hypoxic cells in the tumour. Some of these drugs are of considerable clinical promise. The results of in vitro and in vivo studies with radiosensitisers are summarised and preliminary clinical work is described.

Biological properties and response to x-rays of first-generation transplants of spontaneous mammary carcinomas in C3H mice

First-generation transplants of spontaneous mouse mammary carcinomas have been used extensively for radiobiological investigations of fractionated irradiation schedules, r.b.e. of fast neutrons and effectiveness of radiosensitizers, as reported elsewhere. The present work investigates the growth characteristics of the tumours; the criteria for the choice of end-points used in the definition of 'local control' of irradiated tumours; the reason for a decrease of 30 per cent in X-ray dose required to control tumours in females as compared with male mice; the proportion of hypoxic cells and its variation with time (reoxygenation) after a single dose of 1500 rad of X-rays; and the repair capacity of tumour cells within 24 hours after a substantial first dose of X-rays. Evidence is presented that the male-female difference was due to a higher proportion of hypoxic cells in tumours in male than in female mice. The repair of sub-lethal injury in tumour cells made hypoxic was slightly less than in skin made hypoxic but not significantly so. In the two-dose experiments on clamped tumours, no evidence of induced synchrony was found.