Clinical Response of

Normal Tissues
Hall, Ch 19, with additional
material
Overview
 Cells and tissues
 Early (acute) and late effects
 Functional subunits (FSUs) in normal tissues
 Volume effect in radiotherapy: Tissue
Architecture
 Radiation pathology of tissues
 Casarett’s classification of tissue
radiosensitivity
 Michalowski’s H and F-type populations
Overview, continued
 Growth Factors
 Specific tissues and organs
 Skin
 Hematopoietic system
 Lymphoid tissue and the immune system
 Digestive tract
 …
 LENT and SOMA
 Summary of pertinent conclusions
Cells and Tissues
 Majority of radiation effect on “normal” tissues
attributed to cell killing,
 But some cannot
 Nausea or vomiting hours after irradiation of
abdomen
 Fatigue of patients with large volume irradiation
 Acute edema or erythema from radiation-induced
acute inflammation and vascular leakage
Normal tissues – more than
cells
 Not independent
 Complete integrated structure
 Cell death and birth balanced to maintain
tissue organization
 Response to damage governed by
 Inherent cellular radiosensitivity
 Kinetics of the tissue
 Way cells are organized in the tissue
Weaknesses in Single-Cell
Study
 Individual cells
 Continuous monotonic relationship between dose and
fraction of cells “killed” (e.g., loss of reproductive integrity)
 Tissues
 No effect observed after small doses
 Effects observable & increase after threshold reached
 Conclusion –
 Killing a few cells in a tissue matters very little, requires
more massive killing
 Also, time between irradiation and expression of damage
varies greatly among tissue types.
Cells and tissues, continued
 Cell death after irradiation mainly occurs as
cells attempt to divide
 Tissues with rapid cell turnover consequently
show damage more quickly (e.g., hours for
intestinal epithelium, days for skin & mucosa)
 Tissues where cells rarely divide may have
long latency to express damage
Cells and tissues continued
 Radiation damage to cells and tissues
already on the path to differentiation is of little
consequence
 Radiation damage to stem cells has serious
repercussions
 (programmed to divide many times)
 If reproductive integrity lost, they and their
descendents are lost
Cells and tissues continued
 Interestingly
 Cells that are differentiating may appear more
radioresistant than stem cells
 In fact, the fraction of cells surviving a given dose may be
identical (at the single-cell level)
 It is their radioresponse that differs – not their
sensitivity
 Consistent with the law of “Bergonié and
Tribondeau” who noted that tissues appeared more
“radiosensitive” if their cells are less differentiated,
have a greater proliferative capacity, and divide
more rapidly
Early (Acute) and Late Effects
 Radiation effects commonly divided into early and
late
 Shows different patterns of response to dose fractionation
 Dose-response relationships characterized by α/β ratios
(more on this later)
 Late effects – more sensitive to changes in
fractionation than early effects
 Early (acute) effects result from death of large
number of cells and occur within weeks to days of
irradiation in tissues with rapid rate of turnover
Examples of early effected
tissues
 Examples:
 Epidermal layer of skin
 Gastrointestinal epithelium
 Hematopoietic system
 Response is determined by hierarchical cell
lineage composed of stem cells and
differentiating offspring.
 Time of onset correlates with lifespan of
mature functional cells
Example of late-effected
tissues
 Late effects appear after delay of months or
years
 Occur predominantly in slowly proliferating
tissues
 Lung
 Kidney
 Heart
 Central nervous system
Distinction between early and
late effects
 Progression distinguishes early and late
effects
 Acute (early) damage
 Repaired rapidly because of rapid proliferation of
stem cells
 May be reversible
 Late damage
 May improve
 Never completely repaired
Example of late effect
 May result from a combination of vascular damage and loss of
parenchymal cells
 Vascular damage not the dominant factor in every instance
(otherwise dose-effect response would be the same for all
tissues)
 If intensive fractionation protocols deplete the stem-cell
population below levels needed for tissue restoration, early
reactions (in rapidly proliferating tissues) may persist as a
chronic injury.
 This has been termed a “Consequential Late Effect”
 Which means this late effect is a consequence of persistent
severe early effects
 The damage is most often attributed to an overlying acutely
responding epithelial surface – e.g., fibrosis or necrosis of skin
consequent to desquamation and acute ulceration.
Functional Subunits (FSUs) in
Normal Tissues
 Fraction of cells surviving determines the success
(or failure) of radiation therapy
 If a single cells survives it may result in regrowth of the
tumor
 Normal tissue tolerance for radiation depends on
 Ability of clonogenic cells to maintain sufficient number of
mature cells suitably structured to maintain organ function
 Survival of clonogenic cells and organ function (or failure)
depends on the structural organization of the tissue
 Many tissues are thought to consist of functional
subunits (FSUs)
Functional Subunits (FSUs)
 Some tissues FSUs
 Are discrete, anatomically delineated structures
whose relationship to the tissue function is clear
 Example – kidney nephron, lobule in liver, acinus
in the lung
 In other tissues, no clear anatomic
demarcation.
 Examples: skin, mucosa, spinal cord
 Radiation response of two tissue types quite
different
 The structure of the liver’s
functional units, or lobules.
 Blood enters the lobules
through branches of the
portal vein and hepatic
artery, then flows through
small channels called
sinusoids that are lined
with primary liver cells (i.e.,
hepatocytes).
 The hepatocytes remove
toxic substances, including
alcohol, from the blood,
which then exits the lobule
through the central vein
(i.e., the hepatic venule).
The Human Kidney & Nephron
Spinal Cord
Structure
 Two major tissues:
 Gray matter - nerve cell
bodies and thousands of
connections between
nerves.
 White matter (composed
of nerve axon fibers)
travels from the spine to
the brain.
 Ventral root carries
motor axon fibers from
cells in gray matter out to
muscles.
 Incoming sensory
signals pass through a
connection  - or synapse
– in the dorsal root
ganglion, and then follow
the dorsal root into the
grey matter
Structure of Skin
Survival of Structurally defined
FSUs to Radiation Exposure
 Depends on survival of one or more
clonogenic cells within the FSU
 Tissue survival tpeends on the number and
radiosensitivity of the clonogens
 Tissues typically composed of large number
of FSUs, each is self-contained entity
independent of its neighbors
Survival of Structurally defined
FSUs to Radiation Exposure
 Surviving clonogens cannot migrate from one FSU
to another
 Each FSU is small and autonomous, low doses can
deplete the clonogens in it.
 Example – kidney composed of large number of small
FSUs (e.g., nephrons); each independent of the neighbor
 Survival of a nephron following irradiation depends on
survival of at least one clonogen within it – therefore on the
initial number of renal tubule cells per nephron and their
radiosensitivity
 Because it is small, it can be easily depleted of clonogens
by low doses,
 Therefore the kidney has a low dose tolerance
Simplified
Other structurally defined
FSUs
 Other organs that resemble the kidney
include:
 Those with branching treelike structure of ducts
and vasculature that terminates in end structures
or lobules of parenchymal cells
 Lung
 Liver
 Exocrine organs
 Many of these have low tolerance to radiation
Lung structure graphic
Radiation response
structurally undefined FSUs
 Clonogenic cells in these systems not
confined to one particular FSU
 Cells can migrate from one FSU to another
 Allows repopulation of a depleted FSU
 Example – re-epithelialization of a denuded
area of skin can occur either from surviving
clonogens within denuded area or by
migration from adjacent areas
Tissue Rescue Unit
 Concept proposed to link survival of
clonogenic cells and functional survival
 Defined as minimum number of FSUs
required to maintain tissue fnction
 Assumes
 Number of TSUs is proportional to number of
clonogenic cells
 FSUs contain constant number of clonogens
 FSUs can be repopulated from single clonogen
Issues with FSUs
 Some tissues defy classification
 Crypts of jejunum (structurally well defined – but
surviving crypts can/do migrate from one crypt to
another to repopulate depleted neighbors
Volume Effect in Radiotherapy:
Tissue Architecture
 Total dose that can be tolerated depends on
volume irradiated
 Tolerance dose is defined as the dose that
produces an acceptable probability of a
treatment complication.
 Includes objective critiera and subjective factors
Dose vs Complications
 Spatial arrangement of FSUs in tissue is
critical
 Serially arranged FSUs
 Example: spinal cord – integrity of each FSU is
critical to organ function
 Elimination of any FSU in this system can result in
measurable probability of complication
 Radiation damage shows binary response –
threshold below which is normal function, above
which there is loss of function
 Dose vs. Complications
100
16 4

% Probability
1
of
Complications

C B A

0
52 54 Dose, (Gy) 76
Clinical tolerance
 For both kidney and lung, clinical tolerance depends on the volume
irradiated
 Both organs are sensitive to irradiation of their entire volume, but small
volumes can be treated to much higher doses
 Considerable functional reserve capacity (only ~ 30% of organ
required to maintain function under normal physiologic conditions)
 Parallel organization of functional nephrons and alveolar subunits.
 Inactivation of small number of FSUs does not lead to loss of organ
function
 Implication: there is a threshold volume of irradiation below which
functional damage does not develop, even after high dose
irradiation
 Above threshold, damage is exhibited as a graded response
(increasing severity of functional impairment) rather than binary-all
or nothing response
Clinical tolerance- structurally
undefined FSUs
 Example - Skin and mucosa have no well defined FSUs
 Respond similarly to defined FSUs with parallel
architecture
 Do not show volume effect at lower doses where healing
can occur from surviving clonogens scattered throughout
treatment volume
 However, large irradiated volumes that become
ulcerated result in prolonged healing time and increase
likelihood of infection
 The severity of skin reaction is relatively independent of the area
irradiated because healing occurs through regeneration from
clonogens scattered throughout the tissue, but tolerability is not.
 Therefore there is a volume effect (in practice)
Radiation Pathology of
Tissues
 Response of tissue to radiation depends on 3
factors:
 Inherent sensitivity of the individual cells
 Kinetics of the tissue as a whole
 Way the cells are organized in the tissue

 These factors combine to account for the

substantial variation in radiation response
characteristics of different tissues
Casarett’s Classification
 Suggested classification of mammalian cell
radiosensitivity based on histilogic observation of
cell death
 Divide parenchymal (functioning) cells into 4 major
cateogries, I-IV
 Supporting structures (e.g., connective tissue and
endothelial cells of small blood vessels) were regarded as
intermediate in sensitivity between groups II and III of
parenchymal cells
 Exceptions exist – small lymphocyte (never divides, but
disappears early from blood after very low doses)
Casarett’s Classification,
cont’d
 Most sensitive cells die mitotic death after
irradiation
 Most cells that don’t divide require very large
doses to kill them
 Lymphocyte
 Does not usually divide
 Dies an interphase death
 One of the most radiation sensitive cells
 Casarett’s Classification of Mammalian Cell Tissue
Radiosensitivity

Cell Type Properties Examples Sensitivitya

I Vegetative Divide regularly, no Erythroblasts, High

intermitotic cells differentiation intestinal crypt cells
II Differentiating Divide regularly; some Germincal cells of
intermitotic cells differentiation between epidermis Myelocytes
divisions
Connective tissue
cellsb
III Reverting Do not divide regularly; Liver
postmitotic cells variably differentiated

IV Fixed postmitotic Do not divide; highly Nerve cells, muscle Low

cells differentiated cells
a
Sensitivity decreases for each successive group
b
Intermediate in sensitivity between groups II and III
Vegetative Intermitotic Cells.
(VIM)
 Undifferentiated rapidly dividing cells which
generally have a quite short life cycle.
Examples are erythroblasts, intestinal crypt
cells and basal cells of the skin.
 Essentially continuously repopulated
throughout life.
Differentiating Intermitotic
Cells (DIM)
 Actively mitotic cells with some level of
differentiation. Spermatogonia are a prime
example as well as midlevel cells in
differentiating cell lines.
 Have substantial reproductive capability but
will eventually stop dividing or mature into a
differentiate cell line
Multipotential Connective
Tissue Cells
 Cells which divide at irregular intervals often
in response to a need. Relatively long cell
life cycle.
 Major examples are fibroblasts although
recently more examples of such cells have
been identified in a number of tissues
Reverting Postmitotic Cells
(RPM)
 does not normally undergo division but can
do so if called upon by the body to replace a
lost cell population. These are generally long
lived cells.
 Mature liver cells, pulmonary cells and kidney
cells make are examples of this type of cell.
Fixed Postmitotic Cells. (FPM)
 These cells do not and cannot divide.
 They are highly differentiated and are highly
specialized in there morphology and function.
 May be very long lived or relatively short lived
but replaced by differentiating cells below
them in the cell maturation lines.
 Examples are: Neurons, muscle cells and
RBCs
Perceived Radiation Sensitivity
 VIM cells are the most sensitive cells to
radiation and FPM cells are most resistant.
The others are of intermediate sensitive in
the order presented.
 However, this perception is a product of the
longer cell cycle time in more highly
differentiated cell lines
Michalowski’s H- and F- Type
Populations
 A more modern type of classification which
essentially says the same thing in another
way.
Michalowski Classification
 Tissues follow either a hierarchical (H) or flexible (F)
model
 Within tissues 3 distinct categories of cells:
 Stem cells –continuously divide and reproduce to give rise
to both new stem cells and cells that eventually give rise to
mature functional cells.
 Maturing cells arising from stem cells and through
progressive division eventually differentiate into an end-
stage mature functional cell.
 Mature adult functional cells that do not divide
(H-type)
 There are many cell types that progress from
the stem cell through the mature cell with
nonreversible steps along the way. These
cell lines are said to be hierarchical (H-type)
populations.
 They include bone marrow, intestinal
epithelium, epidermis and many others.
F-type populations
 There are other cell lines in which the adult
cells can under certain circumstance be
induced to undergo division and reproduce
another adult cell. These cell are said to be
flexible tissue (F-type populations).
 Examples include; liver parenchymal cells,
thyroid cells and pneumocytes as well as
others.
Michalowski Classification
 These two types represent extremes and there
are many tissues which exhibit characteristics
of both types where mature cells are able to
divide a limited number of times.
 The rapidity of response to and hence the
sensitivity to radiation at the tissue level is
dependent on the length of the life cycle and
the reproductive potential of the critical cell line
within that tissue.
Growth Factors
 Radiation causes injury of normal tissue
through cell killing,
 But in addition to mitotic and apoptotic cell
death, radiation can induce changes in
cellular function secondary to tissue injury:
 altered cell-to-cell communication,
 inflammatory responses,
 compensatory tissue hypertrophy of remaining
normal tissue, and
 tissue repair processes
Growth Factors
 Recognition of these "non-cytocidal" radiation
effects has enhanced understanding of normal
tissue radiation toxicity, and
 Allowed an integrated systems biology-based
approach to modulating radiation responses and
providing a mechanistic rationale for interventions to
mitigate or treat radiation injuries
 Changes in cytokines can be detected over time
and, radiation fibrosis may be partly reversible
Growth Factors
 Several agents are now under investigation that
prevent or reduce progression of radiation damage,
or reduce symptoms of radiation injury, when given
to the patient after exposure
 Examples include pentoxifylline, angiotensin-
converting enzyme inhibitors, and angiotensin II
(AII) receptor antagonists.
 The mechanism by which these drugs act remain to
be determined, although pentoxifylline targets
fibrosis and AII antagonists ameliorate kidney and
possibly lung injury.
Growth Factors
 Complementing the drugs that interfere with the
progression of damage are agents that facilitate
recovery from radiation-induced injuries:
 hematopoietic cytokines such as granulocyte and
granulocytemacrophage colony-stimulating factors,
 mucosa-stimulating growth factors such as keratinocyte
growth factor, and
 stimulators of the immune response or bone marrow such
as 5-androstenediol.
 These cytokines have been used to treat the
hematopoietic system syndrome in accident victims
General Organ System
Responses
Individual Organ/Tissue
“sensitivity to radiation injury”
Hemopoietic
(blood and lymph)
 Refers to the parenchymal cells of the bone
marrow and the circulating blood.
 Does not refer to the vessels themselves
 Critical cells are the marrow blast cells and
circulating small lymphocytes.
 Non-circulating lymphocytes and other
circulating white cells fairly radioresistant
Hemopoietic
(blood and lymph)
 Red Blood Cells are the most resistant cell in
the mammalian body to radiation injury.
 Irradiation of a small region of the body
generally has no effect on circulating levels
 An exception is lymphocyte counts following
therapy level doses to the chest.
Hemopoietic
(blood and lymph)
 Irradiation of a majority of the bone marrow
will cause marked decreases in circulating
cell levels post irradiation.
 Platelets at 2-4 days
 White cells at 5-10 days
 Red cells at 3-4 weeks
 Due to irradiation of stem cells of these cell
lines.
Hemopoietic
(blood and lymph)
 Effect is dose related
 High dose = increase rate and severity of drop
and longer recovery period
 Lower dose = decreased rate and severity of drop
and more rapid recovery.

 At high doses recovery may only be partial or

not occur at all. M
Hemopoietic
(blood and lymph)
 High dose irradiation of the marrow to
sterilize it prior to bone marrow transplant is
sometime done for cancer therapy
 Many metallic radioisotopes are bone marrow
seekers and can result in marrow toxicity if
ingested
 An example are the phophonates and calcium
containing chemicals.
Hemopoietic
(blood and lymph)
 Radiation doses to the entire marrow of
greater than 8 gray are quite likely to result in
marrow death and patient death unless a
successful marrow transplant can be
performed.
 Doses of the this magnitude are very unlikely
to occur in clinical medicine
 Exception is pre transplant marrow sterilization
Skin and Oral Mucosa
 The surface of the skin is covered by cells
that are essentially FPM cells
 The deep basement layers of the skin are
composed of Stem cells which give rise to the
superficial cell layers.
 Basal cells of the skin
 Source of skin sensitivity to radiation
 Skin recovery dependent on this cells
Skin and Oral Mucosa
 Little or no reaction below 6-8 gray
 Erythema w/ early and late effects at 10 gray
and above.
 Early effects
 Erythema
 Dry desquamation
 Moist desquamation
 Necrosis
Skin and Oral Mucosa
 Late effects occur and increase with dose
 Recovers well from fairly high doses but late
effects seen:
 Thinning of skin
 Pigmentation or depigmentation
 Loss or thinning of hair.
 Loss or thinning of subcuntaneous fat
 Cancer induction years later.
Skin and Oral Mucosa
 Sources of radiation injury
 Solar UV
 Probably major threat for most people
 Diagnostic x-ray
 Fluoroscopy – Especially cardiac
 CT – High speed spiral in juveniles
 Radiation therapy
 Modern techniques keep dose low – below 5 gray
 Exception is when skin is primary target.
Digestive System
 Extends from mouth through rectum
 Sensitivity of individual parts rests with the
number and reproductive activity of the stem
cells in the basal mucosal layer
 Mouth and esophagus relatively resistant
 Stomach more sensitive and has more secretory
cells
 Small bowel very sesitive > highly active
 Colon and Rectum similar to esophagus
Digestive System
 Early effects are mucosal depopulation
 Clinical soreness and possible ulceration
 With very high doses bleeding and necrosis
 Loss of secretory cells
 Stomach and Intestine – decreased mucus
 Decreased digestive enzyme production
 Decreased hormone production
 Clinical infections
Digestive System
 Late effects
 Repopulation – functional recovery ~ partial?
 Epithelial metaplasia – loss of function
 Scarring – severe loss of function
 Chronic clinical signs
 Stricture - obstruction of GI tract
 Surgical mediation required.
Digestive System
 Severity of response is dose and volume
dependent;
 High dose and low volume
 Lower dose and larger volume
 Diagnostic x-ray and nuclear medicine
procedures not generally a threat.
 Radiation therapy can result in severe
changes.
Male Reproductive System
 Adult sperm are FPM cells – resistant
 But, chromosomal damage may be passed on to
a fetus. Mutations can result.
 Germinal cells very sensitive though
 2.5 gray to testis causes temporary sterility
 5-6 gray to testis causes permanent steritity
 Other secretory and hormonal cells more
resistant because RPM and FPM cells
 Hormonal activity may be retained w/ sterility
Male Reproductive System
 Diagnostic x-ray and nuclear medicine
studies not a threat to function
 Mutation threshold may be lower
 Radiation therapy near testis probably cause
temporary sterility
 Radiation therapy including testis causes
sterility and possibly loss of function.
 Functional sperm present 1-2 weeks after 1st dose
Female Reproductive System
 Radiation therapy is major sterility threat
 6.25 Gray to both ovaries – expect sterility
 Oocytes do not divide – thus no repopulation
 Radiation therapy is hormonal function threat.
 Hormonal function decreased/lost above 25 gray
 May require hormonal supplementation
Female Reproductive System
 Oocytes do not divide like spermatagonia
 Themselves relatively resistant
 Chromosomal damage carried on and may
become evident after fertilization.
 Ovarian sensitivity more tied to follicular cells
which support oocytes during
 During follicle development there is great cellular
growth activity in these cells.
 Inactive follicular cells are less sensitive
Eyes
 Eyes are a major dose limiting structure
 The lens is vary sensitive to radiation
 Cataract formation is major effect
 Seen with doses as low as 2 gray
 Very likely at 4 gray
 Occupational dose from diagnostic x-ray is a
threat for cataract formation.
 Wear eye shields, esp. during fluoroscopy
 Major side effect of RT to head and neck
Cardiovascular System
 Vessels
 Endothelium is target cell type
 Endothelial injury causes thrombosis and possibly
hemorrhage.
 Endothelium can repopulate to limited degree
 Exuberant replacement may occlude vessels
 Endothelium can be default critical cell line
 Other cells in vessel wall are FPM and RPM
hence resistant
Heart
 Considered resistant
 Late effects maybe seen years later.
 Acute or Fibrosing pericarditis most common
 At higher doses myocardial fibrosis seen
 Late effects seen are slowly progressive
 Revealed or exacerbated by chemotherapy
 Diagnostic radiation not usually a threat
 Radiation therapy dose/volume related threat
Bone and Cartilage
 Mature bone is composed of FPM cells from
hierarchical cell lines ~ resistant
 At high RT doses osteonecrosis and fx. Seen
 D/t loss of mature osteocytes
 Growing cartilage cells at growth plate are a
target at risk. Especially at < 2 yrs old.
 Causes stunted growth and possibly deformity
 High dose to joint can cause “dry” joint
Bone and Cartilage
 Diagnostic exposure in children from Multi-
slice spiral CT can be enough to at least
cause some growth arrest.
 Radiation Therapy exposure will cause
permanent growth arrest in open growth plate
of a young person
 Osteonecrosis and fracture possible in adult.
Liver and Kidneys
 Large organs which are fairly radiation
sensitive
 RPM cells with limited repopulation at lower
doses.
 Vascular injury may play an important role.
 Functional subunits arranged in parallel
 In kidneys fractionation has minimal effect
 Whole organ doses of 30 gray are lethal
 Greater tolerance if partially irradiated
Liver and Kidneys
 Major radiation threat is from radiation
therapy fields which include these organs
 The kidneys in particular may be at risk for
damage from some Nuclear Medicine
studies.
 Kidneys and bladder are major excretion route for
many isotopes
 Liver is excretion route for a few isotopes.
Lungs
 One of the most radiosensitive organs
 RPM populations of epithelium & endothelium
 10 gray single dose or 30 gray fractionated to the whole
lung cause progressive fibrosis
 Type II pneumocyte is critical cell > edema
 Edema is acute toxicity (radiation pneumonitis)
 Fibrosis is the late effect.
 The lung has large functional reserve >
 Dose to less than ½ lung has minimal clinical effect
Central Nervous System
 CNS is considered quite radioresistant in adults.
 Development continues to 12 years of age therefore whole
brain dose can reduce development
 Glial cells and vascular endothelium are the critical cells of
interest.
 RT usually avoided in childern.
 Increasing volume or dose ^ the effects
 Large volumes irradiated above 40 Gray lead to decreased
function.