Básica

Radiobiologia Basica
• Reoxygenation
• Redistribution
• Repair
• Repopulation (or Regeneration)
• Radiosensitivity
Isabel Bravo 1
Isabel Bravo 2
Isabel Bravo 3
FASES DA ACÇÃO DA RADIAÇÃO
Fase física: a radiação produz moléculas ionizadas 10 -18 seg
Fase fisico-química: produção de radicais livres 10-13 seg
Fase química: interacção das espécies reactivas com meio 10-6 seg
Fase biológica: resposta sequencial do organismo aos
Produtos químicos da irradiação. Desde 10-6

até vários anos.
Isabel Bravo 4
Isabel Bravo 5
Pathophysiology of radiation damage
Isabel Bravo 6
Pathophysiology of radiation damage

• half-time of repair
• long (1 – several hours)

✓ skin, kidney, spinal cord
• intermediate (30-60 min)

✓colon, lung
• shortest (< 30 min)

✓jejunal mucosa
• interfraction interval: > 8 hours to avoid late

toxicity due to incomplete repair
Isabel Bravo 7
Normal tissue tolerance

• we have radiation damage to cells
• SSB, DSB and other DNA lesions
• we have multiple repair-mechanisms
• fast, intermediate, slow
• we have different kinds of cell-death
• reproductive (mitotic), apoptotic, G1-arrest
• How can we use this knowledge to predict

radiosensititvity?
Isabel Bravo 8
Isabel Bravo 9
LINEAR ENERGY TRANSFER Radiobiologia Basica
Separation of ion clusters in relation to LOW LET

size of biological target Radiation
gamma rays
deep therapy
X-rays
soft X-rays
alpha-particle
LET is average energy (dE) imparted by excitation

and Ionization events caused by a charged particle HIGH LET
traveling a set distance (dl) - LET = dE/dl (keV/ m) Radiation
Isabel Bravo 10
Tipo celular Propriedades Exemplos Sensibilidade
Eritroblastos
Divisões regulares. Células da cripta
I- Vegetativas
Sem diferenciação intestinal e Muita alta
intermitóticas
germinativas da
epiderme
Divisões regulares.
II- Intermitóticas em Alguma
mielócitos Média alta
diferenciação diferenciação entre
divisões
Células do tecido
conjuntivo Média
Não se dividem
III- Pós-mitóticas regularmente.
Hepáticas Média baixa
reversíveis Variavelmente
diferenciadas.
Poucas divisões. Musculares
IV- Pós-mitóticas
Altamente Muito baixa
fixas Nervosas
diferenciadas.
Isabel Bravo 11
Isabel Bravo 12
Isabel Bravo 13
X- or -radiation is sparsely ionizing; most damage can be repaired
4 nm
Repairable Sublethal Damage
2 nm
Isabel Bravo 14
Radiobiology: normal tissues

• Sparing of normal tissues is essential for good
therapeutic outcome
• The radiobiology of normal tissues may be even
more complex as the one of tumours:
– different organs respond differently
– there is a response of a cell organization not
just of a single cell
– repair of damage is in general more important
Isabel Bravo 15
Isabel Bravo 16
Different tissue types

• Serial organs (e.g. • Parallel organs (e.g.
spine) lung)
Isabel Bravo 17
Different tissue types

• Serial organs (e.g. • Parallel organs (e.g.
spine) lung)
Effect of radiation on the organ is different

Isabel Bravo 18
• Tissues with a serial organization (e.g., spinal

cord) have little or no functional reserve,
and the risk of developing a complication is
less dependent on volume irradiated than
for tissues with a parallel organization.
• The risk of complication is strongly influenced

• by high-dose regions and hot spots.
Isabel Bravo 19
Volume effects
• The more normal tissue is irradiated in
parallel organs
the more chance that a whole organ fails
• The greater the volume the smaller the
dose should be
• In serial organs even a small volume
irradiated beyond a threshold can lead to
whole organ failure (e.g. spinal cord)
Isabel Bravo 20
Normal tissue tolerance
The tolerance doses is critically dependent on:

• the total dose
• the fractionation schedule
• the volume of normal tissue irradiated
• TD 5/5 = 5% probability of severe sequelae in 5
years
• TD 50/5= 50% probability of severe sequelae in 5
years
Isabel Bravo 21
What are these tolerance doses?
Isabel Bravo 22
4Rs OF DOSE FRACTIONATION
These are radiobiological mechanisms that impact the response

to a fractionated course of radiation therapy
• Repair of sublethal damage

– spares late responding normal tissue preferentially
• Redistribution of cells in the cell cycle
– increases acute and tumor damage, no effect on late responding normal tissue
• Repopulation
– spares acute responding normal tissue, no effect on late effects,
– danger of tumor repopulation
• Reoxygenation
– increases tumor damage, no effect in normal tissues
Isabel Bravo 23
Relevance of Radiobiology to Clinical Fractionation Protocols
Conventional treatment:
Tumors are generally irradiated with 2Gy dose per fraction delivered daily to a
more or less homogeneous field over a 6 week time period to a specified total
dose
The purpose of conventional dose fractionation is to increase dose to the tumor

while PRESERVING NORMAL TISSUE FUNCTION
• Deviating from conventional fractionation protocol impacts outcome
• How do you know what dose to give; for example if you want to change dose per fraction
or time? Radiobiological modeling provide the guidelines. It uses
– Radiobiological principles derived from preclinical data
– Radiobiological parameters derived from clinical altered fractionation protocols
• hyperfractionation, accelerated fractionation, some hypofractionation schedules
The number of non-homogeneous treatment plans (IMRT) and extreme hypofractionated

treatments are increasing. Do existing models cope?
Isabel Bravo 24
Radiobiology allows the optimization of a

radiotherapy schedule for individual patients in
regards to:
• Total dose and number of fractions
• Overall time of the radiotherapy course
• Tumour control probability (TCP) and normal

tissue complication probability (NTCP)
Isabel Bravo 25
Radiobiological models
• Many models exist
• Based on clinical experience, cell experiments or
mathematics
• One of the simplest and most used is the so called

“linear quadratic” or “alpha/beta” model developed
and modified by Thames, Withers, Dale, Fowler and
many others.
Isabel Bravo 26
LQ Model
• α Lethal cell kill
• β Sub-lethal damage
Isabel Bravo 27
It is hypothesized that the lethal lesions are large double
strand breaks with Multiply Damaged Sites (MDS) that
can not be repaired. They are more likely to occur at the
4 nm end of a track
Unrepairable Multiply Damaged Site
Single lethal hit

2 nm Also known as  - type killing
Isabel Bravo 28
At high dose, intertrack repairable Sublethal
Damage may Accumulate forming unrepairable,
lethal MDS
Also known as  - type killing

Isabel Bravo 29
Isabel Bravo 30
Linear Quadratic model

single-hit injury (e –αD)
= exponential curve
(linear in half-log cell surv. curve)
• multi-hit (cumulative)
injury (e –βD2)
= continuously bending curve
related by a coefficient “ β“
to the square of the dose
• α/β = dose, at which single

and multi-hit mechanisms
contribute equally to cell killing
Isabel Bravo 31
The linear quadratic model

1
0 2 4 6 8 10
Probability of cell survival
0.1
0.01
cell kill (low a/b)

cell kill (high a/b)
0.001
Dose (Gy)
Isabel Bravo 32
The linear quadratic model

1
0 2 4 6 8 10
Alpha determines
initial slope
0.1
Beta determines
0.01 curvature
cell kill (low a/b)
0.001
Dose (Gy)
Isabel Bravo 33
.
•The slope of an isoeffect curve
changes with size of dose per
fraction depending on tissue type
• Acute responding tissues have

flatter curves than do late
responding tissues
•  measures the sensitivity of

tumor or tissue to fractionation i.e. it
predicts how total dose for a given effect
will change when you change the size of
dose fraction
Isabel Bravo 34
α/β ratios
• Large α/β ratios • Small α/β ratio
• α/β = 10 to 20 • α/β = 2
– Early or acute reacting – Late reacting tissues,
tissues e.g. spinal cord
– Most tumours – prostate cancer
– breast
cancer
Isabel Bravo 35
Sensitivity of Tissue to Dose
Fractionation can be estimated by the
 ratio
Isabel Bravo 36
Fractionation
• Tends to spare late reacting normal tissues - the smaller the size of
the fraction the more sparing for tissues with low α/β
1
0 2 4 6 8 10
0.1
0.01 cell kill (low a/b)

fractionated (low a/b)
fractionated (low a/b)
0.001
Dose (Gy)
Isabel Bravo 37
Impact of fraction size on tumor and normal

tissues response
• Radiobiological data show that both tumores and acutely
tissues are less sensitive to change in fraction size then late
responding tissues.
• The sensitivity to changes in fraction size for each tissue can

be quantified with the use of the α/β ratio which marks the
shape of the fractionation response.
• Dose per fraction is the dominant factor in determining late

effects.
Isabel Bravo 38
Impact of fraction size on tumor and normal

tissues response
• A high α/β ratio (7 - 20 Gy), as in acutely responding tissues
and in tumors, indicates a more linear survival response of the
target cells.
• A low α/β ratio (0,5 – 6 Gy), as in late responding tissues,

defines a survival curve of the target cells that is significantly
curved.
• Therefore, the effects of fractionation are relatively larger in

the latter than in the former tissues.
Isabel Bravo 39
Important assumptions:
– There is full repair between two fractions
– There is no proliferation of tumour cells
Isabel Bravo 40
Repopulation
• The repopulation time of tumour cells appears to
vary during radiotherapy - at the commencement it
may be slow (e.g. due to hypoxia), however a
certain time after the first fraction of radiotherapy
(often termed the “kick-off time”, Tk) repopulation
accelerates.
• Repopulation must be taken into account when

protracting radiation e.g. due to scheduled (or
unscheduled) breaks such as holidays.
Isabel Bravo 41
Repopulation in Tumor Tissue
Rat rhabdosarcoma Human SCC head and neck
T2 T3
70
Total local control
Dose
(2 Gy equiv.)
55 no local control
40
Treatment Duration
4 weeks to start of accelerated repopulation.
Thereafter T1/2 of 4 days = loss of 0.6Gy per day
Treatment breaks are often “bad”

Isabel Bravo 42
The 5 Rs of radiotherapy: Influence on time

between fractions, t, and overall treatment
time, T
• Reoxygenation • Need minimum T

• Need minimum t
• Redistribution
• Need minimum t for
• Repair normal tissues
• Repopulation (or • Need to reduce T for
Regeneration) tumour
Isabel Bravo 43
The 5 Rs of radiotherapy: Influence on time

between fractions, t, and overall treatment
time, T
• Reoxygenation • Need minimum T

• Need minimum t
• Redistribution
Cannot achieve •allNeed
at once -
minimum t for
• RepairOptimization of schedule
normal tissues
for individual circumstances
• Repopulation (or • Need to reduce T for
Regeneration) tumour
Isabel Bravo 44
The radiation exposure of normal tissues must be considered
over a wide range of overall treatment durations
1 On a short scale of minutes to hours, incomplete recovery of sublethal

damage may reduce the radiation tolerance of a tissue.
2 Over a range of days to weeks (i.e during a course of fractionated

radiotherapy with varying overall treatment times) radiation-induced
tissue regeneration (‘repopulation’) may modulate radiation tolerance.
This radiation-induced regeneration response is seen in early-responding
tissues.
3 Over a range of months to years, long-term restoration can occur in some

tissues, which renders them more resistant to re-irradiation.
Also, long-term progression of the damage can occur in other tissues,
which causes decrease re-irradiation tolerance.
Isabel Bravo 45
Repopulation
Repopulation:
Regeneration response of early-reacting tissues to fractionated irradiation,
which results in an increase in radiation tolerance with increasing OTT
(overall treatment time).
The biological basis of repopulation is a complex restructuring of the

proliferative organization of the tissue.
The majority of investigations have been performed in oral mucosa as the

dose-limiting early side-effect in head and neck cancer radiotherapy.
Isabel Bravo 46
CHART (continuous hyperfractionated accelerated radiation
therapy)
Clinical studies with accelerated RT protocol (i.e. with a shortened OTT)

have resulted in an aggravation of early radiation side-effects.
CHART head and neck trial 54 Gy in 36 fractions in only 12 days,

compared with 66 Gy in 33 fractions in 6.5 weeks
A significant shift of oral mucosal effects towards more severe, confluent

reactions was observed, resulting in an incidence of 73 per cent with
CHART versus 43 per cent with the conventional fractionation.
Similarly, the EORTC 22851 trial, comparing 72Gy in 5 weeks with 70Gy
given conventionally in 7 weeks, resulted in a clear increase in the rate of
confluent mucositis in the accelerated arm .
Isabel Bravo 47
Repopulation
Oral mucositis heals in a much higher proportion of
patients during the last treatment weeks compared with
earlier times,
This indicates a time delay before repopulation becomes

effective.
Furthermore, data show that the repopulation capacity is
limited by the daily or weekly radiation dose.
Further studies confirmed that the onset of repopulation

occurs within the first weeks after the start of RT.
Isabel Bravo 48
MECHANISMS OF REPOPULATION
Dose is compensated with increasing OTT once repopulation has

become effective
The rate at which this compensation occurs is in the range of 5 x

2Gy/week
The loss of cells is counteracted after the lag phase before

repopulation starts, resulting in more or less constant cell numbers.
In general, the mechanisms of repopulation that can explain the

observations can be described by the following 3 As:
• asymmetry loss,
• acceleration,
• abortive divisions
Isabel Bravo 49
Asymmetry loss
According to the stem cell concept the radiation tolerance of a tissue is defined
by the number of tissue stem cells and their intrinsic radiosensitivity.
Hence, radiation tolerance must decrease during fractionated irradiation

according to the daily stem cell kill.
This is clearly seen during the time lag before the onset of repopulation.
However, after repopulation has started, the effect of at least part of the radiation
dose is counteracted.
This indicates that new stem cells must be produced to replace those sterilized by RT.
In unperturbed tissues, stem cells divide on average into one new stem cell and one differentiating cell.
These divisions are called asymmetrical because two different cells are generated.
The number of stem cells in each cell generation remains constant, independent
of the proliferation rate.
For additional production of new stem cells, as postulated on the basis of dose compensation during repopulation,
stem cell divisions must result in two stem cell daughters, a pattern that is depicted as symmetrical division
Isabel Bravo 50
Acceleration of stem cell proliferation
Oral mucosa (and other tissues) are able to compensate weekly doses of
about five times 0.5–1.0 fractions of 2Gy.
For this to occur, assuming the surviving fraction of the stem cells after each
radiation fraction to be about 0.5, five symmetrical divisions are needed
within 7 days.
This requires an average cell-cycle time of 1.4 days.
Compared with cell-cycle times of at least 3.5 days in unperturbed tissue this
indicates clear acceleration of stem cell proliferation as the second
mechanism of repopulation
Isabel Bravo 51
Abortive divisions
In unperturbed mucosa,with a relative stem cell number of 100 per cent, the cells proliferate with a
cell cycle time of at least 3.5 days.
A dose of 5 x 2Gy during the first treatment week, before repopulation sets in, reduces the stem cell
number to clearly below 10 per cent.
Hence, to result in the same number of cells as in controls, the remaining stem cells would have to proliferate with
a cycle time of only a few hours
This is extremely unlikely on the basis of epithelial biology, which indicates a minimum cell-cycle time of 10–12 hours.
Therefore, cells must be produced from other sources. It has been shown in vitro that ‘sterilized’ cells can undergo a
limited number of divisions even after high doses of radiation.
It can therefore be assumed, and indirectly concluded from experimental studies that similar, so-called abortive
divisions of sterilized or doomed cells can also occur in vivo.
This limited proliferative activity results in cells that undergo near-normal differentiation, and hence counteract the
ongoing cell loss.
Quantitatively, in oral mucosa, the radiation-sterilized cells on average have to undergo two or three abortive divisions
each to account for the cell production measured.
Isabel Bravo 52
Isabel Bravo 53
Key points: Repopulation
The radiation tolerance of early-responding normal tissues increases with increasing

overall treatment time (OTT).
This phenomenon is depicted as repopulation.
Repopulation starts after a tissue-specific lag time.
The biological basis is a complex restructuring of the proliferative tissue organization.
This includes asymmetry loss and acceleration of stem cell proliferation.
Abortive divisions of doomed cells significantly contribute to cell production.
Tissue hypoplasia controls stem cell acceleration and abortive divisions, while the
asymmetry loss is regulated by stem cell depletion
Isabel Bravo 54
CONSEQUENTIAL LATE EFFECTS
Consequential late effects are chronic normal tissue complications,

which are influenced by the extent (i.e. severity and/or duration),
of the early response in the same tissue or organ
As the early response depends on the overall treatment time on the

basis of repopulation processes, the same is therefore true for the
corresponding consequential late effects.
This has been demonstrated in experimental studies for intestinal

fibrosis, and in clinical studies for skin telangiectasia, and for late
(mucosa related) side-effects after head and neck irradiation
Isabel Bravo 55
Isabel Bravo 56
Isabel Bravo 57
Isabel Bravo 58

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Radiobiologia Basica

FASES DA ACÇÃO DA RADIAÇÃO

Fase física: a radiação produz moléculas ionizadas 10 -18 seg

Fase fisico-química: produção de radicais livres 10-13 seg

Fase biológica: resposta sequencial do organismo aos

Produtos químicos da irradiação. Desde 10-6

Pathophysiology of radiation damage

Pathophysiology of radiation damage

• long (1 – several hours)

• intermediate (30-60 min)

• shortest (< 30 min)

• interfraction interval: > 8 hours to avoid late

Normal tissue tolerance

• How can we use this knowledge to predict

Separation of ion clusters in relation to LOW LET

LET is average energy (dE) imparted by excitation

Repairable Sublethal Damage

Radiobiology: normal tissues

Different tissue types

Different tissue types

Effect of radiation on the organ is different

• Tissues with a serial organization (e.g., spinal

• The risk of complication is strongly influenced

Normal tissue tolerance

The tolerance doses is critically dependent on:

What are these tolerance doses?

These are radiobiological mechanisms that impact the response

• Repair of sublethal damage

The purpose of conventional dose fractionation is to increase dose to the tumor

The number of non-homogeneous treatment plans (IMRT) and extreme hypofractionated

Radiobiology allows the optimization of a

• Overall time of the radiotherapy course

• Tumour control probability (TCP) and normal

• One of the simplest and most used is the so called

• α Lethal cell kill

Unrepairable Multiply Damaged Site

Single lethal hit

Also known as  - type killing

Linear Quadratic model

• α/β = dose, at which single

The linear quadratic model

cell kill (low a/b)

The linear quadratic model

• Acute responding tissues have

•  measures the sensitivity of

0.01 cell kill (low a/b)

Impact of fraction size on tumor and normal

• The sensitivity to changes in fraction size for each tissue can

• Dose per fraction is the dominant factor in determining late

Impact of fraction size on tumor and normal

• A low α/β ratio (0,5 – 6 Gy), as in late responding tissues,

• Therefore, the effects of fractionation are relatively larger in

– There is full repair between two fractions

– There is no proliferation of tumour cells

• Repopulation must be taken into account when

Rat rhabdosarcoma Human SCC head and neck

Treatment breaks are often “bad”

The 5 Rs of radiotherapy: Influence on time

• Reoxygenation • Need minimum T

The 5 Rs of radiotherapy: Influence on time

• Reoxygenation • Need minimum T

1 On a short scale of minutes to hours, incomplete recovery of sublethal

2 Over a range of days to weeks (i.e during a course of fractionated

3 Over a range of months to years, long-term restoration can occur in some