The immunobiology of low-dose total-body irradiation: more questions than answers

Low-dose total body irradiation enhances systemic anti-tumor immunity induced by local cryotherapy

BACKGROUND

Strategies that restore the immune system's ability to recognize malignant cells have yielded clinical benefits but only in some patients. Tumor cells survive cryotherapy and produce a vast amount of antigens to trigger innate and adaptive responses. However, because tumor cells have developed immune escape mechanisms, cryotherapy alone may not be enough to induce a significant immune response.

METHODS

The mice were randomly divided into four groups: Group A: low-dose total body irradiation combined with cryotherapy (L-TBI+cryo); Group B: cryotherapy (cryo); Group C: low-dose total body irradiation(L-TBI); Group D: control group (Control). The tumor growth, recurrence, and survival time of mice in each group were compared and the effects of different treatments on systemic anti-tumor immunity were explored.

RESULTS

L-TBI in conjunction with cryotherapy can effectively control tumor regrowth, inhibit tumor lung metastasis, extend the survival time of mice, and stimulate a long-term protective anti-tumor immune response to resist the re-challenge of tumor cells. The anti-tumor mechanism of this combination therapy may be related to the stimulation of inflammatory factors IFN-γ and IL-2, as well as an increase in immune effector cells (CD8+ T cells) and a decrease in immunosuppressive cells (MDSC, Treg cells) in the spleen or tumor tissue.

CONCLUSIONS

We present unique treatment options for enhancing the immune response caused by cryotherapy, pointing to the way forward for cancer treatment.

Effect of triple therapy with low-dose total body irradiation and hypo-fractionated radiation plus anti-programmed cell death protein 1 blockade on abscopal antitumor immune responses in breast cancer

Immunostimulatory effects of radiotherapy can be synergistically augmented with immune checkpoint blockade to act both on irradiated tumor lesions and distant, non-irradiated tumor sites. Our hypothesis was that low-dose total body irradiation (L-TBI) combined with hypo-fractionated radiotherapy (H-RT) and anti-programmed cell death protein 1 (aPD-1) checkpoint blockade would enhance the systemic immune response. We tested the efficacy of this triple therapy (L-TBI + H-RT + aPD-1) in BALB/c mice with bilateral breast cancer xenografts. The L-TBI dose was 0.1 Gy. The primary tumor was treated with H-RT (8 Gy × 3). The PD-1 monoclonal antibody was injected intraperitoneally, and the secondary tumors not receiving H-RT were monitored for response. The triple therapy significantly delayed both primary and secondary tumor growths, improved survival rates, and reduced the number of lung metastasis lesions. It increased the activated dendritic and CD8⁺ T cell populations and reduced the infiltration of myeloid-derived suppressor cells in the secondary tumor microenvironment relative to other groups. Thus, L-TBI could be a potential therapeutic modality, and when combined with H-RT and aPD-1, the therapeutic effect could be enhanced significantly.

Hematological Changes Following Low Dose Radiation Therapy and Comparison to Current Standard of Care Cancer Treatments

Cancer is the second leading cause of mortality worldwide accounting for almost 10 million deaths in 2020. Current standard of care treatment varies depending on the type and stage of disease, but commonly includes surgery, chemotherapy, and/or radiation therapy. There is evidence that whole- and half-body exposure to low dose ionizing radiation can also be an effective therapeutic due to its stimulation of anti-cancer immunity. One of the limiting factors for past clinical trials using low dose radiation therapy has been adverse hematological events. However, similar hematological changes are also frequently reported following standard of care treatments in oncology. This review summarizes the effects of various cancer therapies on hematologic toxicity through the evaluation of complete blood count reports. The reviewed literature elucidates hematological trends in patients undergoing chemotherapy, and both high and low dose radiation therapy. In general, high dose radiation and chemotherapy can result in widespread changes in blood counts, with the most severe effects related to leukopenia. Overall, compared to standard of care treatments, low dose radiation results in similar, yet more mild hematological changes. Taken together, hematological toxicities should not be a limiting factor in the applicability of low dose radiation as a cancer therapeutic.

Bridging Radiotherapy to Immunotherapy: The IFN-JAK-STAT Axis

The unprecedented successes of immunotherapies (IOs) including immune checkpoint blockers (ICBs) and adoptive T-cell therapy (ACT) in patients with late-stage cancer provide proof-of-principle evidence that harnessing the immune system, in particular T cells, can be an effective approach to eradicate cancer. This instills strong interests in understanding the immunomodulatory effects of radiotherapy (RT), an area that was actually investigated more than a century ago but had been largely ignored for many decades. With the "newly" discovered immunogenic responses from RT, numerous endeavors have been undertaken to combine RT with IOs, in order to bolster anti-tumor immunity. However, the underlying mechanisms are not well defined, which is a subject of much investigation. We therefore conducted a systematic literature search on the molecular underpinnings of RT-induced immunomodulation and IOs, which identified the IFN-JAK-STAT pathway as a major regulator. Our further analysis of relevant studies revealed that the signaling strength and duration of this pathway in response to RT and IOs may determine eventual immunological outcomes. We propose that strategic targeting of this axis can boost the immunostimulatory effects of RT and radiosensitizing effects of IOs, thereby promoting the efficacy of combination therapy of RT and IOs.

Effect of low-dose total-body radiotherapy on immune microenvironment

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LTBI (low-dose total-body irradiation) can change the immune microenvironment of tumor.

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LTBI (low-dose total-body irradiation) can regulate a variety of signal pathways (such as nuclear factor-κ B, p38 / MAPK, c-jun), thereby enhancing the expression and function of immune cells in the body, and it may even change the immune microenvironment of human body through an unknown signal pathway, such as enhancing the connection between PD-1 and PD-L1 and promoting the low expression of CTLA4.

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LTBI (low-dose total-body irradiation) can stably stimulate the immune function of cancer patients.

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LTBI (low-dose total-body irradiation) can be widely used as a new comprehensive anti-tumor therapy.

The history of low-dose total-body irradiation (LTBI) as a means of radiotherapy for treating malignant tumors can be traced back to the 1920s. Despite this very low total dose, LTBI can induce long-term remissions. Tumor cells are known to change and maintain their own survival and development conditions through autocrine and paracrine signaling. LTBI can change the tumor microenvironment, enhance the infiltration of activated T cells, and trigger inflammatory processes. LTBI-mediated immune response can exert systemic long-term anti-tumor effects, and can induce tumor regression at the primary site and metastatic sites. With a continuous improvement in the anti-tumor immune microenvironment in the field of tumor therapy, LTBI provides more choices to comprehensively treat of tumors. The present study aimed to explore the experimental research mechanism of LTBI and immune microenvironment, and discuss the difficulties and development prospects of applying LTBI to tumor treatment.

Low-dose radiation therapy for coronavirus disease-2019 pneumonia: Is it time to look beyond apprehensions?

Coronavirus disease-2019 (COVID-19) has become a global health crisis. Mortality associated with COVID-19 is characterized mainly by acute respiratory distress syndrome (ARDS), sepsis, pneumonia, and respiratory failure. The pathogenesis of the disease is known to be associated with pro-inflammatory processes after virus infection. Hence, various therapeutic strategies are being developed to control the inflammation and cytokine storm in COVID-19 patients. Recently, low-dose radiation therapy (LDRT) has been suggested for the treatment of pneumonia/ADRS in COVID-19 patients through irradiation of lungs by gamma/X-ray. In this direction, a few clinical trials have also been initiated. However, a few recent publications have raised some concerns regarding LDRT, especially about possibilities of activation/aggressiveness of virus (severe acute respiratory syndrome coronavirus 2 in case of COVID-19), lung injury and risk of second cancer after low-dose therapy. The present manuscript is an attempt to analyze these apprehensions based on cited references and other available literature, including some from our laboratory. At this point, LDRT may be not the first line of therapy. However, based on existing anti-inflammatory evidence of LDRT, it needs encouragement as an adjuvant therapy and for more multi-centric clinical trials. In addition, it would be worth combining LDRT with other anti-inflammatory therapies, which would open avenues for multi-modal therapy of pneumonia/ARDS in COVID-19 patients. The mode of irradiation (local lung irradiation or whole-body irradiation) and the window period after infection of the virus, need to be optimized using suitable animal studies for effective clinical outcomes of LDRT. However, considering ample evidence, it is time to look beyond the apprehensions if a low dose of radiation could be exploited for better management of COVID-19 patients.

Implementation of total body photon irradiation as part of an institutional bone marrow transplant program for the treatment of canine lymphoma and leukemias

A total body irradiation (TBI) protocol was developed to support a bone marrow transplant (BMT) program for the treatment of canine hematologic malignancies. The purpose of this prospective study is to describe implementation of the protocol and resultant dosimetry. Nongraphic manual treatment planning using 6 MV photons, isocentric delivery, 40 × 40 cm field size, wall-mounted lasers to verify positioning, a lucite beam spoiler (without use of bolus material), a dose rate of 8.75 cGy/min at patient isocenter, and a source-to-axis distance of 338 cm were used for TBI. A monitor unit calculation formula was derived using ion chamber measurements and a solid water phantom. Five thermoluminescent dosimeters (TLDs) were used at various anatomic locations in each of four cadaver dogs, to verify fidelity of the monitor unit formula prior to clinical implementation. In vivo dosimetric data were then collected with five TLDs at various anatomic locations in six patients treated with TBI. A total dose of 10 Gy divided into two 5 Gy fractions was delivered approximately 16 h apart, immediately followed by autologous stem cell transplant. The mean difference between prescribed and delivered doses ranged from 99% to 109% for various sites in cadavers, and from 83% to 121% in clinical patients. The mean total body dose in cadavers and clinical patients when whole body dose was estimated by averaging doses measured by variably placed TLDs ranged from 98% to 108% and 93% to 102% of the prescribed dose, respectively, which was considered acceptable. This protocol could be used for institutional implementation of TBI.

Immunological mechanism of low-dose priming radiation resistance in walker-256 tumor model mice

The aim of the present study was to investigate whether low-dose priming radiation induces antitumor immunity that can be augmented by the modulation of natural killer (NK) cell and cytokine activity using a mouse tumor model. Walker-256 cells were injected into the right flank of male BALB/c mice. At 7 days after inoculation, mice were divided into three groups, including group 1,2,3. In group 1 the mice were without radiation, in group 2 the mice were received 2 Gy radiation only, and in group 3 the mice were radiated with a priming dose of 75 mGy followed by 2 Gy radiation after 24 h. On day 21 following the radiation, the tumors were removed and the tumor index (tumor weight as a percentage of body weight) was calculated. At 1, 7, 14 and 21 days following the 2 Gy radiation, mouse splenocytes were isolated to analyze the NK activity and measure the production of the cytokines interleukin-1β, interferon-γ and tumor necrosis factor-α by ELISA. Apoptosis was also measured by flow cytometry. The results demonstrated that priming radiation significantly delayed the tumor growth and prolonged the median survival time to 38 days compared with the 31-day survival in the 2 Gy radiation group. The percentage of apoptotic cells was significantly higher in the mice that received 75 mGy + 2 Gy radiation compared with that in the mice that received 2 Gy alone; by contrast, mice that were not irradiated exhibited a relatively low level of apoptosis. The primed mice had a higher level of NK activity as compared with the mice exposed to 2 Gy radiation only or mice that were not irradiated. Furthermore, cytokine expression remained at a higher level in mice receiving priming dose of radiation compared that in the mice receiving only 2 Gy radiation. In conclusion, the results indicated that low-dose priming X-ray radiation may enhance the NK activity and the levels of cytokines, and that the immune response serves an important role in anticancer therapy, including radiotherapy.

Cancer immunotherapy: how low-level ionizing radiation can play a key role

The cancer immunoediting hypothesis assumes that the immune system guards the host against the incipient cancer, but also "edits" the immunogenicity of surviving neoplastic cells and supports remodeling of tumor microenvironment towards an immunosuppressive and pro-neoplastic state. Local irradiation of tumors during standard radiotherapy, by killing neoplastic cells and generating inflammation, stimulates anti-cancer immunity and/or partially reverses cancer-promoting immunosuppression. These effects are induced by moderate (0.1-2.0 Gy) or high (>2 Gy) doses of ionizing radiation which can also harm normal tissues, impede immune functions, and increase the risk of secondary neoplasms. In contrast, such complications do not occur with exposures to low doses (≤0.1 Gy for acute irradiation or ≤0.1 mGy/min dose rate for chronic exposures) of low-LET ionizing radiation. Furthermore, considerable evidence indicates that such low-level radiation (LLR) exposures retard the development of neoplasms in humans and experimental animals. Here, we review immunosuppressive mechanisms induced by growing tumors as well as immunomodulatory effects of LLR evidently or likely associated with cancer-inhibiting outcomes of such exposures. We also offer suggestions how LLR may restore and/or stimulate effective anti-tumor immunity during the more advanced stages of carcinogenesis. We postulate that, based on epidemiological and experimental data amassed over the last few decades, whole- or half-body irradiations with LLR should be systematically examined for its potential to be a viable immunotherapeutic treatment option for patients with systemic cancer.

NORMAL TISSUE REACTIONS TO CHRONIC RADIATION EXPOSURE IN MAN

This paper presents an overview of radiobiological dependences governing the occurrence of tissue (organ) reactions that determine the outcomes of chronic exposure to low-LET ionizing radiation (IR) in humans. The mechanisms involved in the development of tissue reactions (TRs) to long-term exposures to IR and radioadaptation are considered. The overview describes the reactions of the haematopoietic, immune, nervous, reproductive and endocrine systems, lungs, skin and crystalline lens to chronic radiation exposure, which are of fundamental importance in view of radiation protection. It is shown that the individual's physiological tissue (organ) reserve, and also that induced by radiation exposure at low-dose rates are of great significance in the context of TR development.

Radiation-hormesis phenotypes, the related mechanisms and implications for disease prevention and therapy

Humans are continuously exposed to ionizing radiation throughout life from natural sources that include cosmic, solar, and terrestrial. Much harsher natural radiation and chemical environments existed during our planet's early years. Mammals survived the harsher environments via evolutionarily-conserved gifts ̶ a continuously evolving system of stress-induced natural protective measures (i.e., activated natural protection [ANP]). The current protective system is differentially activated by stochastic (i.e., variable) low-radiation-dose thresholds and when optimally activated in mammals includes antioxidants, DNA damage repair, p53-related apoptosis of severely-damaged cells, reactive-oxygen-species (ROS)/reactive-nitrogen-species (RNS)- and cytokine-regulated auxiliary apoptosis that selectively removes aberrant cells (e.g., precancerous cells), suppression of disease promoting inflammation, and immunity against cancer cells. The intercellular-signaling-based protective system is regulated at least in part via epigenetic reprogramming of adaptive-response genes. When the system is optimally activated, it protects against cancer and some other diseases, thereby leading to hormetic phenotypes (e.g., reduced disease incidence to below the baseline level; reduced pain from inflammation-related problems). Here, some expressed radiation hormesis phenotypes and related mechanisms are discussed along with their implications for disease prevention and therapy.

Defining molecular signature of pro-immunogenic radiotherapy targets in human prostate cancer cells

To understand the impact of clinically relevant radiation therapy (RT) on tumor immune gene expression and to utilize the changes that occur during treatment to improve cancer treatment outcome, we examined how immune response genes are modulated in prostate cancer cells of varying p53 status. LNCaP (p53 wild-type), PC3 (p53 null) and DU145 (p53 mutant) cells received a 10 Gy single dose or 1 Gy × 10 multifractionated radiation dose to simulate hypofractionated and conventionally fractionated prostate radiotherapy. Total RNA was isolated 24 h after multifractionated radiation treatment and single-dose treatments and subjected to microarray analysis and later validated by RT-PCR. RT-PCR was utilized to identify total-dose inflection points for significantly upregulated genes in response to multifractionated radiation therapy. Radiation-induced damage-associated molecular pattern molecules (DAMPs) and cytokine analyses were performed using bioluminescence and ELISA. Multifractionated doses activated immune response genes more robustly than single-dose treatment, with a relatively larger number of immune genes upregulated in PC3 compared to DU145 and LNCaP cells. The inflection point of multifractionated radiation-induced immune genes in PC3 cells was observed in the range of 8-10 Gy total radiation dose. Although both multifractionated and single-dose radiation-induced proinflammatory DAMPs and positively modulated the cytokine environment, the changes were of higher magnitude with multifractionated therapy. The findings of this study together with the gene expression data suggest that cells subjected to multifractionated radiation treatment would promote productive immune cell-tumor cell interactions.

Alteration of cytokine profiles in uranium miners exposed to long-term low dose ionizing radiation

Objective. The aim of the study is to estimate the immune function through cytokine profiles in sera of uranium mines. Methods. Antibody arrays were used to detect 50 cytokines in sera of uranium miners. Miners who had continuously worked underground for <5 years were treated as control group and those who worked for ⩾5 years as experimental group. Results. Of 28 measurable cytokines, the release of IL-1α, IL-1RI, IL-15, IL-3, and IP-10 were significantly upregulated in the experimental group, and no cytokine was found significantly downregulated. Other proinflammatory cytokines such as IFN-γ, IL-10, IL-6, and TNFα levels were slightly upregulated in the experimental group. With adjustment to age, BMI, and cigarette smoking, IL-1α and IL-3 levels increased significantly with underground time. Conclusion. Alteration of cytokine profiles in this study may indicate persistent inflammatory responses in uranium miners exposed to long-term low doses radiation.

Different responses of tumor and normal cells to low-dose radiation

AIM OF THE STUDY

We demonstrated stimulation of both erythrocyte immune function and superoxide dismutase activity in tumor-bearing mice in response to whole-body 75 mGy X-rays. In addition, we enhanced the chemotherapeutic effect by exposing tumor-bearing mice to low-dose radiation (LDR). This study aims to investigate the different responses of tumor cells and normal cells to LDR.

MATERIAL AND METHODS

Survival fraction, micronucleus frequency, and cell cycle of Lewis cells and primary human fibroblast AG01522 cells were measured. S180 sarcoma cells were implanted in mice, and tumor sizes were measured in vivo.

RESULTS

In response to LDR exposure in vitro, a stimulating effect was observed in AG01522 cells but not in Lewis cells. Low-dose radiation did not cause an adaptive response in the Lewis cell cycle. Lack of an LDR-induced radioadaptive response in tumor cells was observed in tumor-bearing mouse models. Furthermore, a higher apoptotic effect and lower expression of the anti-apoptosis gene Bcl-2 were found in tumor cells of tumor-bearing mice exposed to D1 + D2 than those in tumor cells of tumor-bearing mice exposed to D2 alone.

CONCLUSIONS

Different responses of tumor cells and normal cells to LDR were found. Low-dose radiation was found to stimulate the growth of normal cells but not of tumor cells in vitro and in vivo, which is a very important and clinically relevant phenomenon.

Effect of low doses of low-let radiation on the innate anti-tumor reactions in radioresistant and radiosensitive mice

BALB/c and C57BL/6 mice differ in their Th1/Th2 lymphocyte and M1/M2 macrophage phenotypes, radiosensitivity, and post-irradiation tumor incidence. In this study we evaluated the effects of repeated low-level exposures to X-rays on the development of artificial tumor colonies in the lungs of animals from the two strains and cytotoxic activities of natural killer (NK) cells and macrophages obtained from these mice. After ten daily irradiations of BALB/c or C57BL/6 mice with 0.01, 0.02, and 0.1 Gy X-rays NK cell-enriched splenocytes collected from the animals demonstrated significant and comparable up-regulation of their anti-tumor cytotoxic function. Likewise, peritoneal macrophages collected from the two irradiated strains of mice exhibited the similarly stimulated cytotoxicities against susceptible tumor cells and produced significantly more nitric oxide. These results were accompanied by the significantly reduced numbers of the neoplastic colonies induced in the lungs by intravenous injection of syngeneic tumor cells. The obtained results indicate that ten low-level irradiations with X-rays stimulate the generally similar anti-tumor reactions in BALB/c and C57BL/6 mice.

Effects of ionizing radiation on the immune system with special emphasis on the interaction of dendritic and T cells

Dendritic cells (DCs), as professional antigen-presenting cells, are members of the innate immune system and function as key players during the induction phase of adaptive immune responses. Uptake, processing, and presentation of antigens direct the outcome toward either tolerance or immunity. The cells of the immune system are among the most highly radiosensitive cells in the body. For high doses of ionizing radiation (HD-IR) both immune-suppressive effects after whole body irradiation and possible immune activation during tumor therapy were observed. On the other hand, the effects of low doses of ionizing radiation (LD-IR) on the immune system are controversial and seem to show high variability among different individuals and species. There are reports revealing that protracted LD-IR can result in radioresistance. But immune-suppressive effects of chronic LD-IR are also reported, including the killing or sensitizing of certain cell types. This article shall review the current knowledge of radiation-induced effects on the immune system, paying special attention to the interaction of DCs and T cells.

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

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

Tumor-infiltrating myeloid cells induce tumor cell resistance to cytotoxic T cells in mice

Cancer immunotherapeutic approaches induce tumor-specific immune responses, in particular CTL responses, in many patients treated. However, such approaches are clinically beneficial to only a few patients. We set out to investigate one possible explanation for the failure of CTLs to eliminate tumors, specifically, the concept that this failure is not dependent on inhibition of T cell function. In a previous study, we found that in mice, myeloid-derived suppressor cells (MDSCs) are a source of the free radical peroxynitrite (PNT). Here, we show that pre-treatment of mouse and human tumor cells with PNT or with MDSCs inhibits binding of processed peptides to tumor cell-associated MHC, and as a result, tumor cells become resistant to antigen-specific CTLs. This effect was abrogated in MDSCs treated with a PNT inhibitor. In a mouse model of tumor-associated inflammation in which the antitumor effects of antigen-specific CTLs are eradicated by expression of IL-1β in the tumor cells, we determined that therapeutic failure was not caused by more profound suppression of CTLs by IL-1β-expressing tumors than tumors not expressing this proinflammatory cytokine. Rather, therapeutic failure was a result of the presence of PNT. Clinical relevance for these data was suggested by the observation that myeloid cells were the predominant source of PNT in human lung, pancreatic, and breast cancer samples. Our data therefore suggest what we believe to be a novel mechanism of MDSC-mediated tumor cell resistance to CTLs.

After the bomb drops: a new look at radiation-induced multiple organ dysfunction syndrome (MODS)

PURPOSE

There is increasing concern that, since the Cold War era, there has been little progress regarding the availability of medical countermeasures in the event of either a radiological or nuclear incident. Fortunately, since much is known about the acute consequences that are likely to be experienced by an exposed population, the probability of survival from the immediate hematological crises after total body irradiation (TBI) has improved in recent years. Therefore focus has begun to shift towards later down-stream effects, seen in such organs as the gastrointestinal tract (GI), skin, and lung. However, the mechanisms underlying therapy-related normal tissue late effects, resulting from localised irradiation, have remained somewhat elusive and even less is known about the development of the delayed syndrome seen in the context of whole body exposures, when it is likely that systemic perturbations may alter tissue microenvironments and homeostasis.

CONCLUSIONS

The sequence of organ failures observed after near-lethal TBI doses are similar in many ways to that of multiple organ dysfunction syndrome (MODS), leading to multiple organ failure (MOF). In this review, we compare the mechanistic pathways that underlie both MODS and delayed normal tissue effects since these may impact on strategies to identify radiation countermeasures.

Different radiosensitivity of CD4(+)CD25(+) regulatory T cells and effector T cells to low dose gamma irradiation in vitro

PURPOSE

To determine the radiosensitivity difference of human Cluster of Differentiation (CD)4(+)CD25(+) regulatory T cells (Treg) and effector T cells to low dose gamma ray and elucidate the underlying mechanisms in vitro.

MATERIALS AND METHODS

Blood samples were collected from five health subjects and five patients with advanced hepatocellular carcinoma (HCC). Treg and CD4(+)CD25⁻ T cells were selected using magnetic microbeads. The proliferative profiles, cytokine secretion, and differential expressions of apoptosis-related proteins in Treg and CD4(+)CD25⁻ T cells were compared using [³H]-thymidine incorporation, Luminex assay and flow cytometry when treated with various low doses of γ-ray.

RESULTS

A dose-dependent reduction of proliferation in response to irradiation which paralleled the induction of apoptosis existed in Treg and CD4(+)CD25⁻ T cells. Treg were more radiosensitive to low-dose irradiation (0.94 Gray [Gy]) than effector T cells. The interferon-γ (IFNγ) was significantly upregulated and interleukin 10 (IL-10) was significantly downregulated in irradiated Treg. An enhanced immune response to low dose gamma ray existed in the peripheral blood in patients with advanced HCC. Higher levels of active caspase-3, CD95, B cell lymphoma 2 (Bcl-2)-associated X protein (Bax) expression were observed in Treg compared to CD4(+)CD25⁻ T cells. In addition, gamma irradiation activated CD4(+)CD25⁻ T cells to express CD25.

CONCLUSIONS

These studies revealed that Treg were more radiosensitive than CD4(+)CD25⁻ T cells to low dose irradiation. Higher expressions of apoptosis-related proteins such as caspase-3, CD95 and Bax were observed in Treg when compared to CD4(+)CD25⁻ T cells. Our results suggest that treatment with low doses of gamma irradiation may be a viable strategy to enhance immune response in patients with advanced HCC.

Early hematopoiesis inhibition under chronic radiation exposure in humans

The major goal of this study was to identify and quantitatively describe the association between the characteristics of chronic (low-dose rate) exposure to (low LET) ionizing radiation and cellularity of peripheral blood cell lines. About 3,200 hemograms (i.e., spectra of blood counts) obtained over the years of maximal exposure to ionizing radiation (1950-1956) for inhabitants of the Techa River were used in analyses. The mean cumulative red bone marrow dose (with standard errors), calculated using Techa River Dosimetry System-2000, was 333.6 +/- 4.6 mGy (SD = 259.9 mGy, max = 1151 mGy) to the year 1956. The statistical approach included both empirical methods for estimating frequencies of cytopenic states of the investigated blood cell lines (e.g. neutrophile, platelets, erythrocyte, etc.), and regression methods, including generalized linear models and logistic regressions which allowed taking into account confounding factors (e.g., attained age, age at maximal exposure, presence of concomitant diseases, and demographic characteristics). The results of the analyses demonstrated hematopoiesis inhibition manifested by a decrease in peripheral blood cellularity and an increase in the frequency of cytopenia in all blood cell lines (leukocytes, including lymphocytes, monocytes, neutrophiles, as well as platelets and erythrocytes). The intensity of hematopoiesis inhibition in the period of maximal exposures is determined by the combined influence of the dose rate and cumulative dose. The contribution of specific confounding factors was quantified and shown to be much less important than dose characteristics. The best predictor among dose characteristics was identified for each blood cell line. A 2-fold increase in dose rate is assumed to be a characteristic of radiosensitivity and a quantitative characteristic of the effect.

Immunological mechanism of the low-dose radiation-induced suppression of cancer metastases in a mouse model

According to the doctrine underlying the current radiation protection regulations each, no matter how small, exposure to ionizing radiation may be carcinogenic. However, numerous epidemiological observations demonstrate that cancer incidence and/or mortality are not elevated among inhabitants of the high- versus low-natural-background radiation areas and homes. Results of our own and other authors' studies described in this paper bear testimony to the possibility that stimulation of the anti-neoplastic immune surveillance mediated by NK lymphocytes and activated macrophages explains, at least partially, the accumulating epidemiological and experimental evidence indicating that low-level exposures to the low-linear energy transfer (LET) radiation inhibit the development of spontaneous and artificial metastases in humans and laboratory animals, respectively. The results presented also suggest the possibility of using low-level X- and gamma-ray exposures to cure cancer and to prevent cancer metastases. For a broader perspective, the results presented may help towards relaxing the current radiation protection regulations, especially as they apply to diagnostic and therapeutic exposures of patients to the indicated forms of radiation.

A phase II trial of adjuvant low-dose total body irradiation in non-Hodgkin's lymphoma patients following standard CHOP

Because survival results achieved in aggressive NHL with the standard CHOP are not very satisfactory, we investigated adding adjuvant low-dose total body irradiation (LTBI) to standard CHOP in a phase II trial. Thirty-six patients were included between September 1999 and September 2001. All patients were in documented complete remission (CR) after the end of their standard CHOP. LTBI started 4-6 weeks following the last CHOP course and was given in two courses, each with 4 daily fractions of 0.2 Gy, separated by 2 weeks of rest. Patients with bulky disease received involved-field radiotherapy on initial bulky sites starting 4-6 weeks after the last LTBI fraction. Primary end points were disease-free survival (DFS) and overall survival (OS) and the secondary end point was toxicity. The toxicities of LTBI were temporary thrombocytopenia and leucopenia (requiring no transfusions or treatment with growth factors). The 3-year DFS was 61%+/-9% and the overall survival was 87+/-6%. Univariate analysis showed time to achieve CR, and whether the patient got LTBI-induced haematological toxicity to be 2 significant prognostic factors affecting DFS. The use of adjuvant LTBI in patients with aggressive NHL in CR after standard chemotherapy is a feasible, non-toxic treatment that is worthy of testing in a future phase III trial.

Low dose gamma-irradiation differentially modulates antioxidant defense in liver and lungs of Balb/c mice

PURPOSE

To evaluate the effect of low-dose (<50 cGy) whole body ?-irradiation on the antioxidant defense system in the liver and the lungs of mice at various post-irradiation intervals.

MATERIALS AND METHODS

Male Balb/c mice, 5 - 6 weeks of age, were divided into irradiated and non-irradiated groups. Whole body irradiation was done with gamma-rays from a (60)Co source at doses of 10, 25 and 50 cGy (48.78 cGy/min). Lipid peroxidation and antioxidant status were measured in the liver and the lungs at 4, 12 and 24 h after irradiation.

RESULTS

Lipid peroxidation increased by 1.38 and 2.0 fold in lung and liver respectively at 12 h after exposure to 25 cGy. Whole body exposure to 25 and 50 cGy significantly (p < 0.05) increased the hepatic reduced glutathione at 4 h. Reduced glutathione continued to rise until 12 h and returned to the basal level at 24 h, whereas in the lungs it remained elevated until 24 h at 10 and 25 cGy. Antioxidant enzymes activities for superoxide dismutase, catalase, glutathione peroxidase and glutathione reductase increased by 1.22, 1.13, 1.22 and 1.11 fold respectively (p < 0.05) in the liver at 4 h after exposure to 50 cGy and remained elevated at almost the same level up to 12 h after exposure. Surprisingly these antioxidant defense enzymes remained unaltered in the lung at the above radiation doses.

CONCLUSIONS

Low-dose whole body gamma-irradiation differentially modulates the antioxidant defense system in the liver and lungs of mice. The induction of endogenous glutathione, immediately after exposure to low-dose -irradiation, may be beneficial in protecting the cells from reactive oxygen species (ROS) induced oxidative stress.

Exacerbation of autoimmune thyroiditis by a single low dose of whole-body irradiation in non-obese diabetic-H2h4 mice

PURPOSE

To evaluate how irradiation affects thyroid autoimmunity in mouse models of Hashimoto's thyroiditis and Graves' hyperthyroidism.

MATERIALS AND METHODS

Non-obese diabetic (NOD)-H2(h4) mice spontaneously develop anti-thyroglobulin (Tg) antibodies and thyroiditis when supplied with sodium iodine (NaI) in the drinking water. BALB/c mice develop anti-thyrotropin receptor (TSHR) antibodies and hyperthyroidism following immunization with adenovirus expressing TSHR (Ad-TSHR). Mice were irradiated as follows: A single whole-body irradiation with 0.05, 0.5 or 3 Gy one week before or after the beginning of NaI or immunization with Ad-TSHR, fractionated whole-body irradiations with 0.05 Gy twice a week or 0.5 Gy once a week from one week before NaI or Ad-TSHR immunization, or a single regional irradiation to the thyroid gland with 0.5 Gy one week before NaI. The effect of a single irradiation with 0.05, 0.5 or 3 Gy on splenocytes was also evaluated.

RESULTS

A single whole-body irradiation with 0.5 Gy one week before NaI exacerbated thyroiditis and increased anti-Tg antibody titers in NOD-H2(h4) mice. In contrast, any irradiation protocols employed did not affect incidence of hyperthyroidism or anti-TSHR antibody titers in BALB/c mice. High-dose irradiation increased the relative ratios of effector T cells to regulatory T cells (an indication of enhanced immune status) but kills most of T cells.

CONCLUSIONS

These results indicate that a single whole-body low-dose irradiation with 0.5 Gy exacerbates thyroiditis in NOD-H2(h4) mice, data consistent with some clinical evidence for increased incidence of thyroid autoimmunity by environmental irradiation.

Production of cytokines by peritoneal macrophages and splenocytes after exposures of mice to low doses of X-rays

We have shown previously that irradiations of mice with 0.1 or 0.2 Gy of X-rays stimulate anti-tumour cytotoxic activities of peritoneal macrophages and splenocytes enriched for NK lymphocytes and suppress the development of pulmonary tumour colonies. The up-regulated cytotoxicities were related to the production of nitric oxide by macrophages, and perforin and Fas ligand by the splenocytes, but specific blockade of these pathways did not totally suppress the effector cell-mediated cytolysis of the tumour target. Hence, other factors such as cytotoxic/cytostatic cytokines might have been produced by the effector cells. To test this possibility peritoneal macrophages and splenocytes were isolated from BALB/c mice which had been either once or tentimes whole body-irradiated with the total doses of 0.1 and 0.2 Gy of X-rays and assayed for the levels of IL-1beta, IL-2, IL-12, IFN-gamma and TNF-alpha in the incubation medium using the respective ELISA kits. The results demonstrate that both single and multiple exposures to the two low doses of X-rays significantly stimulate secretion of IL-1beta, TNF-alpha and IL-12 by macrophages and IL-2 and IFN-gamma by splenocytes, but the kinetics and magnitude of the induced changes in the production of these cytokines differ between the two irradiation protocols.

Regulation of CD20 expression by radiation-induced changes in intracellular redox status

Increasing the levels of CD20 expression in cells that harbor low CD20 levels may enhance their responsiveness to CD20-specific antibody therapies. Here, we examined the regulation of CD20 expression after treatment with 0.5-2.0 Gy X-irradiation and hydrogen peroxide (H(2)O(2)), in the presence or absence of known antioxidants, in the Burkitt lymphoma cell lines Daudi and Raji. Irradiation of cells enhanced cell-surface CD20 expression; the kinetics and extent of this change were cell-type specific and time-dependent. The kinetics of reactive oxygen species generation and changes in mitochondrial membrane potential after irradiation were also correlated with changes in CD20 expression. Raji and Daudi cells treated with H(2)O(2) showed a 2-to 2.5-fold increase in CD20 expression at 12 and 20 h, respectively. Buthionine sulfoximine, which depletes glutathione, also increased surface CD20, whereas antioxidants, such as PEG-catalase, PEG-SOD, vitamin C, and amifostine, decreased CD20 expression induced by radiation or H(2)O(2). The antioxidant-mediated decrease in CD20 expression induced by radiation or H(2)O(2) suggests a mechanism involving redox regulation. These results demonstrate the critical role of radiation-induced oxidative stress in CD20 expression and may have implications for defining and improving the efficacy of CD20-targeted antibody therapy and radioimmunotherapy.

Identification of differentially expressed genes in human lymphoblastoid cells exposed to irradiation and suppression of radiation-induced apoptosis with antisense oligonucleotides against caspase-4

To identify candidate genes in response to ionizing radiation (IR) and discover new targets for basic research and radiation protection, whole human genome bioarrays were used to examine gene expression profiles in human lymphoblastoid AHH-1 cells exposed to IR. The results were confirmed by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR). In addition, the effects of ionizing radiation on cell growth, cell cycles and apoptosis were also examined. The microarray analysis revealed a set of IR responsive genes, including 906 genes at 4 hours and 789 genes at 24 hours after exposure to 5 Gy IR. The processes of cell cycles, apoptosis, signal transduction, and DNA repair involved a high percentage of IR responsive genes, among which, caspase-4 was most strongly induced by irradiation. Consistent with this, downregulation of caspase-4 expression by antisense oligonucleotides significantly increased cell viability and protected cells from undergoing apoptosis induced by IR. Taken together, the results suggested that caspase-4 plays an important role in radiation-induced apoptosis.

Low dose radiation increased the therapeutic efficacy of cyclophosphamide on S(180) sarcoma bearing mice

We examined whether low dose radiation (LDR) exposure (75 mGy) could increase the therapeutic efficacy of cyclophosphamide (CTX) by comparing the effects of tumor suppression, tumor cell apoptosis, cell cycle and proliferation of bone marrow in vivo. Kunming mice implanted with S(180) sarcoma cells were given 75 mGy whole body gamma-ray radiation exposure and CTX (300 mg/kg) by intraperitoneal injection 36 hours after LDR. Proliferation of bone marrow and tumor cells was analyzed by flow cytometry. Cytochrome c leakage from the tumor was measured by Western-blot. We discovered that tumor growth was significantly reduced in the group exposed to CTX add to LDR. The apoptosis of tumor cells increased significantly after LDR. The tumor cells were arrested in G(1) phase in the groups treated with CTX and CTX + LDR, but cell cycle was more significantly arrested in mice exposed to LDR followed by CTX than in mice exposed only to LDR or CTX chemotherapy. Concentration of bone marrow cells and proliferation index in CTX + LDR mice were higher than those in the untreated mice. LDR or CTX + LDR could induce greater cytochrome c levels and caspase-3 activity in tumors. These results suggest that low dose radiation can enhance the anti-tumor effect of the chemotherapy agent CTX markedly. Furthermore, LDR significantly protects hematopoetic function of the bone marrow, which is of practical significance on adjuvant chemotherapy.

Investigation of alloreactive NK cells in mixed lymphocyte reactions using paraformaldehyde-silenced target cells

Mixed lymphocyte reactions (MLRs) remain central to the characterization of cellular allo-interactions. Here we show that irradiation, as used to 'silence' a given cell-population in unidirectional ('one-way') MLRs, is unable to abolish cytokine-production even at doses much higher than usually applied. By contrast, using target cells silenced via a formaldehyde-based fixation-protocol, we demonstrate feasibility to detect - in a true one-way reaction - secretion of IFNgamma by alloreactive NK cells. This simple, fixation-based protocol provides an accurate, robust and time-efficient means for assessing alloreactivity, avoiding cytokine-production by the MLR stimulator cells.

Sparsely ionizing diagnostic and natural background radiations are likely preventing cancer and other genomic-instability-associated diseases

Routine diagnostic X-rays (e.g., chest X-rays, mammograms, computed tomography scans) and routine diagnostic nuclear medicine procedures using sparsely ionizing radiation forms (e.g., beta and gamma radiations) stimulate the removal of precancerous neo-plastically transformed and other genomically unstable cells from the body (medical radiation hormesis). The indicated radiation hormesis arises because radiation doses above an individual-specific stochastic threshold activate a system of cooperative protective processes that include high-fidelity DNA repair/apoptosis (presumed p53 related), an auxiliary apoptosis process (PAM process) that is presumed p53-independent, and stimulated immunity. These forms of induced protection are called adapted protection because they are associated with the radiation adaptive response. Diagnostic X-ray sources, other sources of sparsely ionizing radiation used in nuclear medicine diagnostic procedures, as well as radioisotope-labeled immunoglobulins could be used in conjunction with apoptosis-sensitizing agents (e.g., the natural phenolic compound resveratrol) in curing existing cancer via low-dose fractionated or low-dose, low-dose-rate therapy (therapeutic radiation hormesis). Evidence is provided to support the existence of both therapeutic (curing existing cancer) and medical (cancer prevention) radiation hormesis. Evidence is also provided demonstrating that exposure to environmental sparsely ionizing radiations, such as gamma rays, protect from cancer occurrence and the occurrence of other diseases via inducing adapted protection (environmental radiation hormesis).

Radiobiological basis of low-dose irradiation in prevention and therapy of cancer

Antimutagenic DNA damage-control is the central component of the homeostatic control essential for survival. Over eons of time, this complex DNA damage-control system evolved to control the vast number of DNA alterations produced by reactive oxygen species (ROS), generated principally by leakage of free radicals from mitochondrial metabolism of oxygen. Aging, mortality and cancer mortality are generally accepted to be associated with stem cell accumulation of permanent alterations of DNA, i.e., the accumulation of mutations. In a young adult, living in a low LET background of 0.1 cGy/y, the antimutagenic system of prevention, repair and removal of DNA alterations reduces about one million DNA alterations/cell/d to about one mutation/cell/d. DNA alterations from background radiation produce about one additional mutation per 10 million cells/d. As mutations accumulate and gradually degrade the antimutagenic system, aging progresses at an increasing rate, mortality increases correspondingly, and cancer increases at about the fourth power of age. During the past three decades, genomic, cellular, animal and human data have shown that low-dose ionizing radiation, including acute doses up to 30 cGy, stimulates each component of the homeostatic antimutagenic control system of antioxidant prevention, enzymatic repair, and immunologic and apoptotic removal of DNA alterations. On the other hand, high-dose ionizing radiation suppresses each of these antimutagenic protective components. Populations living in high background radiation areas and nuclear workers with increased radiation exposure show lower mortality and decreased cancer mortality than the corresponding populations living in low background radiation areas and nuclear workers without increased radiation exposure. Both studies of cancer in animals and clinical trials of patients with cancer also show, with high statistical confidence, the beneficial effects of low-dose radiation.

Enhanced cytotoxic activity of macrophages and suppressed tumor metastases in mice irradiated with low doses of X- rays

We showed in our previous report that a single exposure of mice to 0.1 or 0.2 Gy X-rays led to the significant inhibition of the development of artificial tumor metastases in the lungs and that the effect was related to the enhanced activity of natural killer cells. In the present study, a possible involvement of cytotoxic macrophages in the anti-metastatic effect of the low-level X-ray exposures was investigated. We now demonstrate that irradiation of mice with either of the two low doses of X-rays significantly stimulates the macrophage-mediated cytolysis of the susceptible tumor targets and that the effect coincides with the enhanced production of nitric oxide in the collected effector cells. We also show that suppression of the in vivo function of macrophages by carrageenan eliminates the inhibitory effect of the two low doses of X-rays on the development of pulmonary tumor colonies as well as significantly suppresses the macrophage-mediated cytotoxicity and nitric oxide production. Finally, aminoguanidine added to the culture medium of the assayed macrophages not only shuts down the nitric oxide synthesis in these cells but also significantly suppresses their cytolytic activity. Overall, the obtained results indicate that inhibition of the tumor metastases by a single exposure of mice to 0.1 or 0.2 Gy X-rays results, to a large extent, from the radiation-induced stimulation of the cytocidal activity of macrophages which secrete enhanced amounts of nitric oxide.

Change in blood chemistry may explain higher toxicity of total body irradiation for bone marrow transplantation

Total body irradiation (TBI) is a well established conditioning regimen for patients who had undergone bone marrow transplantation. TBI not only offers a slightly significant survival advantage over Busulphan-based conditioning regimens but also lower toxicity profile. However the biological process after TBI seems rather different than conventional routine partial body irradiation. Not only the tolerance doses but also time to occurrence of the organ toxicities show a variation. It has been shown that there are alterations in trace element content in kidney after TBI in addition to cytokines and redox-active metal composition of blood. Acute phase proteins also have been shown to rise after irradiation. Considering all these evidences we suggest that TBI changes the blood content of trace elements, acute phase response proteins with probably many other inflammatory proteins and cytokines within the blood and this change in blood content may sensitize the organs to radiation.

Potential neuroprotective effect of low dose whole-body γ-irradiation against 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced dopaminergic toxicity in C57 mice

Low dose whole-body gamma-irradiation is recently reported to confer neuroprotection against optic nerve crush and contusive spinal cord injury. Here, we extended the study and investigated whether the pretreatment of a single low dose whole-body gamma-irradiation may have a preventive effect in MPTP-induced model of PD. One week after the last MPTP treatment, HPLC determination of striatal dopamine and immunostaining for tyrosine hydroxylase (TH), CD11b and GFAP to detect dopamine neurons and associated glial reaction in the substantia nigra pars compacta (SNpc) were performed. MPTP treatment reduced striatal DA levels significantly; nigral TH immunoreactivity was reduced to a lower extent; robust gliosis was also observed in SNpc. We found that 3.5 Gy irradiation but not 5.5 Gy restores the level of DA and its metabolites decreased by MPTP. However, there was no difference in the number of TH positive neurons between 3.5 Gy irradiated and saline treated mice after MPTP treatment. Irradiation also did not have obvious influence on microgliosis and astroglial reaction induced by MPTP treatment. In conclusion, the results presented here demonstrated that low dose whole-body gamma-irradiation renders neuroprotection against MPTP-mediated damage of striatal dopaminergic nerve fibers, though it does not seem to influence the MPTP-induced reduction of SNpc dopaminergic neurons and associated glial responses.

A phase II trial of low-dose total body irradiation and subcutaneous interleukin-2 in metastatic melanoma

BACKGROUND AND PURPOSE

Our own experimental data suggests a therapeutic synergism between low-dose total body irradiation (LTBI) and interleukin-2 (IL-2).

PATIENTS AND METHODS

Forty-five patients received a maximum of 2 cycles of high dose subcutaneous (s.c.) IL-2 and LTBI. One treatment cycle included 5 weeks treatment followed by 2 weeks break and composed of a single radiation fraction 0.1 Gy on days 1, 8, 22 and 30 and IL-2: 18 MU x 2 daily s.c. on days 2 to 5 and days 16-19 as well as 9 MU x 2 daily s.c. on days 9-12 and 31-34. In 17 patients, flow cytometric analyses of the various subpopulations of immune cells were done on blood samples before the first LTBI fraction and 24h after LTBI as well as after the first week of treatment.

RESULTS

Two patients (4.4%) had a partial response (PR) and 13 patients (29%) had stable disease (SD). The duration of the partial remission and stable disease did not exceed 3 months. The median overall survival was 5.8 months (95% CI, 4-8 months). Thirty-four of the 58 treatment cycles (74%) were given in 100% of the intended dose without modification or delay. The dose was modified in 15 cycles (26%) because of progression (6), liver toxicity (3), CNS toxicity (2), thrombocytopenia (1), lung morbidity (1) and itching (1). There were no treatment-related deaths. Flowcytometry data showed a significant increase in the percentage of cells carrying the beta chain of IL-2 receptor (CD122+), a significant increase in the percentage of NK cells (CD56+ cells) as well as a significant reduction in the percentage of B cells (CD20+) and monocytes (CD14+).

CONCLUSIONS

This LTBI and IL-2 regimen was well tolerated, however it cannot be recommended because of its low clinical efficacy. No indication of increased efficacy or altered toxicity was seen using LTBI.

Effective palliation by low dose local radiotherapy for recurrent and/or chemotherapy refractory non-follicular lymphoma patients

In this work, we have studied the response rates and duration of response after low-dose (4 Gy) involved field radiotherapy (LD-IF-RT) in relapsed or chemotherapy refractory indolent and aggressive lymphoma patients. 71 patients (177 symptomatic sites) received LD-IF-RT consisting of 39 males and 32 females with a median age of 69 years (range 43-93). Patients included were those with small lymphocytic lymphoma/chronic lymphocytic leukaemia (n=23), marginal zone lymphoma, nodal type (n=18), mantle cell lymphoma (n=17), and diffuse large B-cell lymphoma (n=13). Bulky disease (5 cm) was present in 73% of all patients. A median of two prior chemotherapy regimens (range 0-10) preceded LD-IF-RT. Median time since diagnosis was 31 months (range 1-216 months). Time to (local) progression was calculated according to the Kaplan-Meier method. Differences in response rates were compared using the chi2-test. The results showed that overall response rate was 87%; complete remission (CR) was reached in 34 patients (48%) and a partial remission (PR) in 28 patients (39%). Stable disease (SD) was maintained in nine patients (13%). The median time to progression (TP) was 12 months and the median time to local progression (TLP) was 22 months. The 34 CR patients showed a median TP of 16 months and a median TLP of 23 months. None of the factors studied (age, sex, lymphoma subtype, radiotherapy regimen, number of prior regimens or time since diagnosis, number of positive sites or largest lymphoma diameter) were found to relate to response. At time of death 70% of patients were without in-field progression after LD-IF-RT. It appears that LD-IF-RT is a valuable asset in the management of relapsed disease in both indolent and aggressive lymphoma and should be considered to palliate symptoms in patients with recurrent and/or chemotherapy refractory disease.