Download - Dose rate effect in brachytherapy
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IN THE NAME OF HIM
Z.MANSORI
Z.DOORANDISH
E.GHASEMLOY
E.MAROUFZADE
APRIL2014
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THE DOSE RATE EFFECT
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DNA DAMAGES
LETHAL DAMAGE: LD
SUB-LETHAL DAMAGE: SLD
POTENTIAL LETHAL DAMAGE: PLD
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SURVIVAL CURVE
A CELL SURVIVAL CURVE IS A PLOT OF SURVIVING FRACTION AGAINST DOSE
INITIAL PORTION HAS A SHOULDER AND TERMINAL PORTION BECOME STRAIGHT LINE
S = E-(AD + BD2)
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SURVIVAL CURVE
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SURVIVAL CURVEAT HIGH LETS, SUCH AS Α-
PARTICLES OR LOW-ENERGY NEUTRONS, THE CURVE IS A STRAIGHT LINE
FOR LOW LETS,STARTS OUT STRAIGHT WITH A FINITE INITIAL SLOPE
• INCREASING LET:
• INCREASES THE STEEPNESS OF THE SURVIVAL CURVE
• SHOULDER DISAPPEARS DUE TO INCREASE OF KILLING BY SINGLE-EVENTS
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SURVIVAL CURVELINEAR AND QUADRATIC
CONTRIBUTIONS TO CELL KILLING ARE EQUAL WHEN THE DOSE IS EQUAL TO THE RATIO OF A TO B
AD = B D2 D = A/ B
A COMPONENT IS REPRESENTATIVE OF DAMAGE CAUSED BY A SINGLE EVENT
B COMPONENT IS REPRESENTATIVE OF DAMAGE CAUSED BY MULTIPLE EVENTS
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DOSE RATE D° =D/T
DOSE RATE. LDR
MDR
HDR
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THE DOSE-RATE EFFECT
FOR X- OR R-RAYS, DOSE RATE IS ONE OF THE PRINCIPAL FACTORS THAT DETERMINE THE BIOLOGIC CONSEQUENCES OF A GIVEN ABSORBED DOSE.
THE CLASSIC DOSE-RATE EFFECT RESULTS FROM THE REPAIR OF SLD THAT OCCURS DURING A LONG RADIATION EXPOSURE.
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THE DOSE-RATE EFFECT• CONTINUOUS LOW-DOSE-
RATE(LDR) IRRADIATION MAY BE CONSIDERED TO BE AN INFINITE NUMBER OF INFINITELY SMALL FRACTIONS.• NO SHOULDER, SHALLOWER THAN
FOR SINGLE ACUTE EXPOSURES.
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THE DOSE-RATE EFFECTTHE LINEAR COMPONENT
OF CELL DAMAGE WILL BE UNAFFECTED BY DOSE RATE SINCE THE TWO CHROMOSOME BREAKS THAT INTERACT TO FORM A LETHAL LESION ARE CAUSED BY A SINGLE ELECTRON TRACK
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THE DOSE-RATE EFFECTTHE QUADRATIC COMPONENT,
HOWEVER, IS CAUSED BY TWO SEPARATE ELECTRON TRACKS; IF THERE IS A LONG TIME INTERVAL BETWEEN THE PASSAGE OF THE TWO ELECTRON TRACKS, THEN THE DAMAGE CAUSED BY THE FIRST MAY BE REPAIRED BEFORE THE SECOND ARRIVES
SUB-LETHAL DAMAGE REPAIR
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THE DOSE-RATE EFFECT
• CELLS CHARACTERIZED BY A SURVIVAL CURVE FOR ACUTE EXPOSURES THAT HAS A SMALL INITIAL SHOULDER EXHIBIT A MODEST DOSE-RATE EFFECT
• CELL LINES CHARACTERIZED BY A SURVIVAL CURVE FOR ACUTE EXPOSURES WHICH HAS A BROAD INITIAL SHOULDER EXHIBIT A DRAMATIC DOSE-RATE EFFECT
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THE DOSE-RATE EFFECT IN HELA CELLS
SURVIVAL CURVES FOR HELA CELLS CULTURED IN VITRO OVER A WIDE RANGE OF DOSE RATES – FROM 7.3 GY/MIN TO 0.535 CGY/ MIN
THE DOSE-RATE EFFECT CAUSED BY REPAIR OF SUBLETHAL DAMAGE IS MOST DRAMATIC BETWEEN 0.01 GY/MIN AND 1 GY/MIN
HELA CELLS ARE CHARACTERIZED BY A SURVIVAL CURVE FOR ACUTE EXPOSURES THAT HAS A SMALL INI- TIAL SHOULDER, WHICH GOES HAND IN HAND WITH A MODEST DOSE-RATE EFFECT
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SURVIVAL CURVES FOR HELA CELLS
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THE DOSE-RATE EFFECT IN(CHO)CELLSCHINESE HAMSTER (CHO) CELLS HAVE A BROAD
SHOULDER TO THEIR ACUTE X-RAY SURVIVAL CURVE AND SHOW A CORRESPONDING LARGE DOSE-RATE EFFECT
THIS DIFFERENCE IN SHOULDER SIZE AND CORRESPOND- ING MAGNITUDE OF THE DOSE-RATE EFFECT CORRELATES WITH THE DOMINANT MECHANISM OF CELL DEATH
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SURVIVAL CURVES FOR CHINESE HAMSTER
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THE DOSE-RATE EFFECT
survival curves for 40 different cell lines of human origin, cultured in vitro and irradiated at HDR and LDR
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THE INVERSE DOSE-RATE EFFECT
DECREASING THE DOSE RATE RESULTS IN INCREASED CELL KILLING
AN INVERSE DOSE-RATE EFFECT IS OFTEN SEEN OVER A NARROW RANGE OF DOSE RATES, WHEREBY DECREASING THE DOSE RATE ACTUALLY INCREASES THE EFFICACY OF CELL KILLING
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THE INVERSE DOSE-RATE EFFECT
DECREASING THE DOSE RATE FOR THIS CELL LINE FROM 1.53 GY/H TO 0.37 GY/H. INCREASES THE EFFICIENCY OF CELL KILLING, SO THAT THIS LDR IS ALMOST AS EFFECTIVE AS AN ACUTE EXPOSURE.
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THE INVERSE DOSE-RATE EFFECTTHE EXPLANATION OF THIS
PHENOMENON IS ILLUSTRATED AT THIS PICTURE.
AT ABOUT 0.3 GY/H, CELLS TEND TO PROGRESS THROUGH THE CYCLE AND BECOME ARRESTED IN G2, A RADIOSENSITIVE PHASE OF THE CYCLE
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THE DOSE-RATE EFFECT SUMMARIZED
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1.HDR
FOR ACUTE EXPOSURES AT HDR, THE SURVIVAL CURVE HAS A SIGNIFICANT INITIAL SHOULDER.
surv
ivin
g
fract
ion
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2.LDR THE SURVIVAL CURVE
BECOMES PROGRESSIVELY SHALLOWER, AND THE SHOULDER TENDS TO DISAPPEAR.
REPAIRsu
rviv
ing
fract
ion
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REPAIR
• REPAIR OF SUBLETHALLY DAMAGED DNA CAN OCCUR IF THE CELL CONTAINS THE FULL COMPLEMENT OF DNA DAMAGE DETECTION PROTEINS AND REPAIR ENZYME SYSTEMS, BUT THERE MUST ALSO BE SUFFICIENT TIME FOR THESE MECHANISMS TO OPERATE.
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3. FOR LOWER DOSE RATEWHAT IS EXPECTED: RESULT:
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REDISTRIBUTION / REASSORTMENT
• WITH MULTIPLE DOSES, CELLS PROGRESS THROUGH TO A NEW PHASE OF THE CELL CYCLE (SENSITIVE)
• “SENSITIZATION DUE TO RE-ASSORTMENT” CAUSES THERAPEUTIC GAIN.
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3. BELOW CRITICAL DOSE RATE:
surv
ivin
g
fract
ion
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EARLY RESPONDING TISSUES
EARLY-RESPONDING TISSUES ARE USUALLY SELF-RENEWING TISSUES AND ARE CHARACTERIZED BY A RAPIDLY PROLIFERATING STEM CELL COMPARTMENT THAT PROVIDES CELLS TO DIFFERENTIATE AND BECOME THE MATURE FUNCTIONING CELLS.
EXAMPLES: SKIN, INTESTINAL EPITHELIUM, BONE-MARROW
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LATE RESPONDING TISSUES
LATE-RESPONDING TISSUES ARE MUCH LESS ABLE TO TOLERATE RETREATMENT BECAUSE THEY DO NOT HAVE THE ABILITY TO RECOVER FROM THE INITIAL DAMAGE INASMUCH AS THEY DO NOT HAVE A RAPIDLY PROLIFERATING STEM CELL COMPARTMENT.
EXAMPLES : SPINAL CORD, LUNG, KIDNEY
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EARLY AND LATE RESPONDING TISSUES
THE DOSE–RESPONSE RELATIONSHIP FOR LATE-RESPONDING TISSUES IS MORE CURVED THAN THAT FOR EARLY RESPONDING TISSUES.
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THE DOSE-RATE EFFECT AND CLINICAL DATA
PATERSON IN THE 1960S POINTED THAT THE DOSE-LIMITING FACTOR IN THE CASE OF INTERSTITIAL IMPLANTS IS THE TOLERANCE OF NORMAL TISSUES.
60 GY IN7 DAYS AS THE STANDARD, THE EXPERIENCE WAS BASED ON TREATMENT WITH RADIUM NEEDLES IMPLANTED ACCORDING TO THE MANCHESTER SYSTEM.
ELLIS PROPOSED AN ESSENTIALLY IDENTICAL SCHEME FOR USE IN CLINICAL PRACTICE
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IR-192 INESTED OF RA-226
PATIENT COMFORT , BUT ALSO RESULTED IN A MUCH LARGER VARIATION OF DOSE RATE BETWEEN INDIVIDUAL IMPLANTS. FOR TOW REASONS:
1. SHORT HALF-LIFE OF IRIDIUM-192 (74 DAYS) THE LINEAR ACTIVITY WILL VARY.
2. IRIDIUM-192 IMPLANTS, WHERE ALL SOURCES HAVE THE SAME LINEAR ACTIVITY WITH VARYING SEPARATION BETWEEN WIRES FOR DIFFERENT LENGTHS.
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IR-192 INESTED OF RA-226
BECAUSE ALL WIRES IN AN IRIDIUM-192 IMPLANT HAVE THE SAME LINEAR ACTIVITY, THERE IS A CORRELATION BETWEEN IMPLANTED VOLUME AND DOSE RATE
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IR-192 INESTED OF RA-226
PIERQUIN AND HIS COLLEAGUES (1973) SAID THAT IN IRIDIUM-192 IMPLANTS, THE DOSE RATE WAS UNIMPORTANT.
THE PARIS SCHOOL RECOMMENDED THE SAME PRESCRIBED DOSE IRRESPECTIVE OF OVERALL TIME WITHIN THE RANGE 3–8 DAYS.
MANY HUNDREDS OF PATIENTS WERE TREATED WITH IR-192 IMPLANTS USING STANDARD DOSES UNCORRECTED FOR DOSE RATE,IT DOES NOT AGREE WITH THE EXPERIMENTAL RADIOBIOLOGICAL DATA(PATTERSON & ELLIS)
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DOSE-RATE EFFECTS FROM ANANALYSIS OF THE IRIDIUM IMPLANT
DATAIN THE FIRST, MAZERON AND COLLEAGUES(1991B)
STUDIED TUMOR CONTROL & NECROSIS OF T1 AND T2 SCC OF THE MOBILE TONGUE AND FLOOR OF MOUTH TREATED WITH INTERSTITIAL IR-192.
THE DATA ARE COMPARE TUMOR CONTROL AND NECROSIS IN PATIENTS TREATED AT DOSE RATES ABOVE OR BELOW 0.5 GY/H.
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RESULTS
TWO PRINCIPAL CONCLUSIONS CAN BE DRAWN FROM THIS ANALYSIS:
1. THERE IS LITTLE OR NO DIFFERENCE IN LOCAL CONTROL BETWEEN THE TWO DOSE-RATE RANGES PROVIDED A SUFFICIENTLY HIGH TOTAL DOSE IS USED (65–70 GY), BUT THERE IS A CLEAR SEPARATION AT LOWER DOSES (AROUND 60 GY) WITH THE LOWER DOSE RATE BEING SIGNIFI CANTLY LESS EFFECTIVE.
2. OVER THE ENTIRE RANGE OF DOSES USED, THERE WAS A HIGHER INCIDENCE OF NECROSIS ASSOCIATED WITH THE HIGHER DOSE RATE RANGE
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MAZERON ET AL. NEXT STUDY
THEY STUDIED CARCINOMA OF THE BREAST WHO RECEIVED AN
IR-192 IMPLANT AS A BOOST TO EBRT.
A FIXED STANDARD TOTAL DOSE WAS USED,REGARDLESS OF THE DOSE RATE, A FIXED STANDARD TOTAL DOSE WAS USED(IR:37GY)
A CLEAR DIFFERENCE IN TUMOR CONTROL COULD BE SEEN BETWEEN 0.3 GY/H AND 0.9 GY/H
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THE BIAS OF TUMOR SIZE AND DOSE RATE
FOR INTERSTITIAL IMPLANTS, THE DOSE RATE TENDS TO INCREASE AS THE SIZE OF THE IMPLANT INCREASES.
THIS CORRELATION IS PARTICULARLY TRUE IN THE PARIS SYSTEM, BUT LESS TO PARKER-PATTERSON.
PIERQUIN AND HIS COLLEAGUES (1973) POINTED THAT LARGER TUMORS BEING ASSOCIATED WITH HIGHER DOSE
RATES, WHILE SMALLER TUMORS ARE ASSOCIATED WITH LOWER DOSE RATES
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THE BIAS OF TUMOR SIZE AND DOSE RATE
LARGER TUMORS OF COURSE REQUIRE A LARGER DOSE FOR A GIVEN LEVEL OF LOCAL CONTROL, WHILE THE THE MAXIMUM DOSE THAT CAN BE TOLERATED BY NORMAL TISSUES DECREASES AS THE VOLUME IMPLANTED INCREASES. THIS WILL TEND TO FLATTEN THE ISOEFFECT CURVE FOR TUMOR CONTROL AND STEEPEN THE ISOEFFECT CURVE FOR NORMAL TISSUE TOLERANCE.
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• THE PATERSON/ELLIS RECOMMENDATIONS WERE BASED ON EQUALIZING ONLY LATE EFFECTS & RA NEEDLES ,& PARIS RECOMMENDATIONS WERE BASED ON EQUALIZE LATE AND EARLY EFFECTS & IR WIRES .
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•THANKS FOR YOUR ATTENTION