RadBio Flashcards

1
Q

Phases of cell cycle.

What is the role of each

A

1) G1 = Period of metabolic activity, growth and repair,
2) S= DNA synthesis
3) G2 = Confirm accurate replication before M phase
4) M (broken into subphases of Mitosis and finally exocytosis)

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2
Q

Phases of mitosis

A

Paedo Priests Meet At The Cathedral
1) Prophase:
■ condensation of chromosomes, each containing two sister chromatids
■ moving apart of centrosomes
■ assembly of mitotic spindle in between centrosomes
2) prometaphase
■ breakdown of nuclear envelope
■ chromosomes attach to spindle microtubules and undergo active movement.
3) metaphase
■ chromosomes are aligned at the equator of the spindle
4) anaphase:
■ sister chromatids separate and pulled towards spindle pole
■ the spindle poles also move apart.
5) telophase:
■ chromosomes arrive at the spindle poles
■ new nuclear envelope reassembles- forming 2 nuclei

Cytokenesis
● Mitosis ends with formation of two nuclei and beginning of cytokinesis
○ cytoplasm is divided in two by a contractile ring
○ pinched into two daughters

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3
Q

DNA damage response activate x distinct checkpoints?

Where and what are they called?

A

There are 4 (remember DEAB 4(6), 2, 2,(1) 1)

1) G1: Cyclin D-CDK4, Cyclin E-CDK2
2) S: the interphase check point - Cyclin A - CDK2 (the initiator of replication)
3) G2: Cylina - now paired with CDK1 which activates cyclin B-CDK1 - signal to start making spindles as well as progress to M phase.

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4
Q

Checkpoint activation requires inhibition of:

And

by what 2 broad pathways?

A

Checkpoint activation requires inhibition of cyclin-CDK complex:
○ by activation of CDK inhibitors
○ by affecting phosphorylation and activity of the CDK itself.

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5
Q

What is E2F? How is it activated?

A

E2F is the main G1/S checkpoint regulator
● In G1 E2F is bound to Rb protein.
● Phosphorylation of Rb by Cyclin D-CDK 4 and Cyclin E-CDK 2 releases E2F
● Released E2F stimulates Cyclin E production, initiating DNA replication and therefore S phase

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6
Q

For IR induced damage what is the key pathway for cycle arrested in G1?

A

Double stranded break:

1) Sensor = MRN complex
2) Transducer = ATM
3) Activators gammaH2Ax, BRAC1
4) CHK2 phosphorylated (see below)
5) stabilisation and activation p53: DNA repair, upregulates p21, cell arrest (via p21), apoptosis

Direct action of p21: Inhibit cyclin D-CDK4 complex
Direct action of CHK2: Inhibit CDC25CC which maintains CDK2 (i.e leads to DEphosphorylaed = inactivated CDK2)
CHK1 also does this
inhibtion and release of E2F)

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7
Q

The S “intra phase” checkpoint does what?

A

Delays DNA replication and initiates repair.

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8
Q

The S phase checkpoint is regulated by?

Check point is activated by?

A

● Regulated by ATM and ATR

● Checkpoint activated by phosphorylation and activation of CHK1 and CHK2 proteins.

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9
Q

What does CDC stand for?

What do they do?

A

Cell Division Cycle Phosphatases (CDC)
● Multiple types of CDC.
○ CDC25A, B and C
● Remove phosphate groups from cyclin-CDK complexes and activating them.
● Inactivation of CDC renders cyclin-CDK complexes inactive.

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10
Q

What does CDC25CC do?

A

CDC25CC maintains activity of (dephophorylates) CDK2

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11
Q

Activation of CHK 1 and 2 causes what?

A

● CHK1/2 phosphorylate and inactivate CDC25CC which maintains activity (dephosphorylation) of CDK2
● As a result, there is increased phosphorylated (inactive) CDK2 and cell cycle does not progress.
● BRCA1/2 also plays a role in DNA repair (HR)

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12
Q

How do the concentrations of cyclins and CDK vary throughout the cell cycle?

A

Cyclin concentration varies for each phase while [CDK] is constant

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13
Q

How does cyclin D work?

A

Binds CDK 4 and 6 in G1, these activated kinases then phosphorylate Rb releasing E2F which increases [cyclin E)

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14
Q

How does cyclin E work?

A

Binds CDK 2 in G1, Complex does 3 things:

1) completes phosphorylation of Rb protein leading to release of E2F and increased Cyclin E concentration.
2) Phosphorylates p27 and p21, causing their proteolysis (p27 and p21 are CDK complex inactivators)
3) initiates assembly of the pre-replication complex.

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15
Q

What induces cyclin D?

A

Induced by Ras/Raf/MEK/ERK pathway

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16
Q

How does cyclin A work

What drives its transcription?

A

Binds CDK2 in S phase. and CDK 1 in early G2. Transcription driven by E2F.

○ In S-phase associates with CDK 2
■ complex initiates DNA replication
■ also inhibits the action of Cyclin E/CDK 2

○ In G2 phase associated with CDK 1
■ Involved in activation of Cyclin B

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17
Q

What mediator removes cylin A, what other cyclin does this mediator remove?

A

Destroyed by APC (anaphase promoting complex) in prometaphase. Also removes cyclin B

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18
Q

How does Cyclin B work? What inactivates it? What destroys it

A

Active in late G2, Bound to CDK 1
Complex called the mitosis promoting factor:
■ involved in expression of proteins for creation of the mitotic spindle
■ necessary to progress into M-phase
■ inactivated by p53.
Destroyed by APC (anaphase promoting complex) in prometaphase. Also removes cyclin

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19
Q

What are cyclin dependent kinase inhibitors?

What are the main groups? Examples from each group

A

Group of proteins which inhibit production or function of cyclin-CDK complexes

● Two major families:
1) INK4 proteins inhibit binding of Cyclin D to CDK4 and CDK6 causing G1 arrest. P16
2) CIP/KIP proteins bind and inhibit function of Cyclin E-CDK2 and Cyclin D-CDK4
■ P21, P27, P57

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20
Q

How does p16 work?

A

Triggered by overactivation of Ras/MAPK pathways, DNA damage ect.
Cyclin dependent kinase inhibitor INK4 gene (same locus on chromosome 9p21 as ARF) coding p16 that inhibits binding of Cyclin D to CDK4 and CDK6 causing G1 arrest.
I.e CDK-INK4 complexes rather than CDK-cyclin complexes

The “INK4” = INhibitors of cdK 4
CIP/KIP proteins are capable of inhibiting all CDKs.

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21
Q

How does p53 work?

A

Guardian of the genome
Activates P21 which inhibits CDC2 and cdk2 in addition
● Regulates pathways related to DNA repair, apoptosis, angiogenesis and cell cycle arrest.
● Activators:
○ MAPK family: membrane damage, oxidative stress, osmotic shock etc
○ ATM/CHK2/DNA-PK: DNA damage
○ P14 (via inactivation of MDM2): oncogene activation
● Loss of p53 leads to dysregulation of the cell cycle

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22
Q

Li-Fraumeni syndrome ?

A

Autosomal dominant p53 gene mutation (the gene is called Tp53). Leads to multiple tumours and onset at an early age.

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23
Q

Cell Cycle Kinetic Parameters.
Time for G1, S, G2, M
For tumours?

A

Cell cycle time varies among different tissues
○ Bone marrow and gastrointestinal epithelial cells have short cell cycle times
● Time for G2, S and M phases are similar for different cell types
● G1 is the most variable, ranging from 1-2 hours to months.
● S~ 6 hrs
● G2~1-3 hrs
● M~1-2 hrs

Cell cycle time for tumours are similar to normal cells
○ SCC ~ 30-40 hours.

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24
Q

Compare DNA damge in G1, S, G2 early and late

A

Think the more repair mechanisms and the more accessible the DNA the less sensitive (i.e more able to repair)
Most to least sensitive: M>G2late > G2early > G1 > Searly > Slate
Need to know the graph (x axis Gy, Y cell survival)

G1: DNA damage leads to ATM-dependent stabilization and activation of p53 (Also ATR activation to a much lesser degree)

S: intra phase checkpoint delays replication and initiates repair.Reduction in rate of DNA synthesis is dose dependent. Regulated by ATM and ATR

G2 early: Only small doses required to activate the checkpoint. Rapid drop in mitotic cells after irradiation. ● ATM/ATR- CHK1/2-CDC25A/C

G2/M most sensitive to damage
Early G1 and S least sensitive (more access to repair mechanisms)

G2 Late: Indep of ATM, ATR dependent. Long delay which is dose dependent. Likely reflects damage that persists after irradiation in G1 or S phase

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25
Q

Describe how a eukaryote cell nucleus is enclosed

A

Double membrane enclosed organelle (the nuclear envelope) communication with the cytoplasm is mediated by protein lined nuclear pores

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26
Q

A transcribed segment of a gene is translated into RNA and contains:
Which part is lat a removed and what is then name of the process?
Each end contains?

A

Introns and exons

Exons are removed by splicing

Each end contains a 5’ and 3’ untranslated region

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27
Q

What is a reading frame?

What is an open reading frame?

A

Divides the nucleotide sequence into non overlapping nucleotide triplets which specify specific amino acids.

An open reading frame is a continuous sequence of triplets from start codon to stop codon

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28
Q

The most common start codon is?

A

The most common start codon is AUG. The start codon is often preceded by a 5’ untranslated region (5’ UTR).

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29
Q

Non-transcribed parts of a gene include:

A

Start and stop codons

Regulatory segments: promotors, silencers that help control expression.

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30
Q

Chemically DNA strands are what type of polymer?
The monomers are?
What do these monomers consist of?

A

Polynucleotides
Nucleotides:
- Nucleobase (adenine, guanine, cysteine, thymine)
- Deoxyribose sugar group
- Phosphate group
The deoxyribose phosphate group forms the backbone

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31
Q

What are the nucleobase pairs?

They are paired by what type of bonds?

A

Nucleobase pairs C-G, A-T

With hydrogen bonds

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32
Q

From the level of DNA double helix describe packaging into chromosome:

Differentiate between packing for dividing and non-diving cells

A

1) Nucleosome: DNA double strand wraps around 8 histones twice (really 1.65 times)
2) Chromatosome: Nucleosomes pair with a H1 histone to form a chromatosome (DNA wrapped twice around the 9 histone configuration (about 11nm wide). Strands now 7 times shorter than fully unravelled DNA.
“Beads on a string” - genes under active transcription
3) 30nm fibre: Nucleosomes coiled into compact 30nm fibre - these are less active genes

During mitosis chromatin is further compacted using scaffold proteins into the classic for-arm chromosome

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33
Q

Basic components of a four arm chromosome:

A

sister chromatids joined by a centromere

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34
Q

Brief outline of the process of DNA replication:

Why is it semi-conservative?

A

The process of creating two DNA double stands from a single double strand.
Both strands of Original DNA are used to create complimentary strands.
Semi-conservative because each daughter double strand contains one strand of the original DNA double strand

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35
Q

To begin replication of DNA a special protein (?name) must interact with DNA at a specific site (?name). What next steps does this interaction lead to?

A

Initiator protein binds to a replication origin

Starts to unwind DNA, attracts the proteins that make up the replication machine

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36
Q

What are the subunits of the replicator machine and their function?

A

Helicase (+single stranded binding protein) unwind DNA

Gyrate makes nicks to prevent supercoiling

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37
Q

After DNA has been unwound at the replication origin, what is the next step?

A

Initiator protein bind replicator origin -> helicase + single-stranded binding protein and DNA gyrase recruited.
2 replicator machines built
2 replication forks formed at origin
Machines move away from replication origin, as forks open in opposite directions

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38
Q

As the replication forks open what are the key proteins needed to create a daughter strand from the template?

A

DNA polymerase, this in tern needs RNA polymerase to generate a 3’ end (primer) for polymerase.

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39
Q

In what direction are DNA strand replicated?

This creates issues because

A

5’ to 3’ - i.e DNA polymerase adds nucleotides to the 3’ end.

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40
Q

Because DNA replication is directional, what happens at the lagging strand?

A

as the replication fork moves long the strand extending in the 3’ to 5’ direction needs to be replicated using fragments produced 5’ to 3’ and put together (Okazaki fragments).

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41
Q

The other role of DNA polymerase

A

Proofreading after each nucleotide added to ensure no mismatch. If error then 3-5’ exonuclase removes

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42
Q

3 basic differences between RNA and DNA:

A

Ribose rather tha deoxyribose backbone
Uracil instead of thymine
single stranded and oft folded

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43
Q

RNA polymerase binds to …… of the gene.
○ Once bound, the polymerase …… the double helix.
○ One of the DNA strands act as template for RNA synthesis which continues to ………

A

RNA polymerase binds to promoter region (TATA box) of the gene.

Once bound, the polymerase opens up the double helix.

One of the DNA strands act as template for RNA synthesis which continues to the terminator site (stop site).

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44
Q

RNA is synthesized in the ….. direction.
○ Synthesized RNA is processed to increase stability
Adding what to both ends?

A

RNA is synthesized in the 5’-3’ direction.
○ Synthesized RNA is processed to increase stability:
■ Capping modifies the 5’ end
■ A poly-A tail is added at the 3’ end

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45
Q

After a 5’ cap and 3’ poly A tail is added what is the final step to make mature mRNA

A

Exons are spliced and exons stitched together

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46
Q

○ mRNA can be translated in three possible reading frames but only one is used.
How?

A

Ribosome searches for start codon (usually methionine) to begin translation
mRNA is pulled through the ribosome in the 5’-3’ direction and is read in nucleotide triplets until stop codon reached (e.g UAG)

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47
Q

2 Main factors other than DNA that regulate gene expression

A

Epigenetic factors:
Methylation - Increased methylation of promotor regions leads to decreased expression
Acetylation - of histones makes DNA more accessible

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48
Q

Acetylation results in

A

○ Acetylation of histone proteins alter DNA structure, making them more accessible
○ Acetyl groups also attract proteins that promote transcription
○ Acetylation of different histones has different effects:
■ acetylation of p53 causes activation
■ acetylation of BCL-6 (transcription inhibitor) causes inactivation

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49
Q

Direct action of CHK2 (Also CHK1)?

To which pathway (trigger, sensor, transducer, activator) does each belong?

A
DSB: MRN-ATM-CHK2-p53
SSB: RPA+ssDNA-ATR+ATRIP-TOPBP1-CHK1-p53
Direct action of CHK2: 
Inhibit CDC25CC which maintains CDK2 (i.e leads to DEphosphorylaed = inactivated CDK2)
CHK1 also does this
tion and release of E2F)
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50
Q

Broadly the two key pathways to cell arrest are those that respond to DNA damage (name 2) and those that respond to stress (name 2 and name 2 key triggers which are surrogates for persisting cell problems/DNA issues)

A

1) DNA damage. DSB =MRN-ATM-CHK2, SSB=RPA-ATRIP+ATR-CHK1
2) [Reactive Oxygen Species], mitogen stimulation: The INK4a = p16 - block Cyclin D CDK4/6 complex
ARF = ARF-MDM2-p53-p21 inhibit CyclinD-CDK4/6

INK4a, ARF, INK4b are at the same location on chromosome9

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51
Q

p16 Pathway:

A

G1:

Increased ROS -> p16 - inhibits cyclin D-CDK4/6 complex (Prevents phosphorylation of Rb to relate E2F)

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52
Q

Extrinsic control of cell growth and proliferation is achieved by what hormone and what class of signalling molecule?

A

Growth hormone

Growth factors

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53
Q

Growth factor activity is mediated by binding of ?receptors that influence expression of genes that can:

Besides growth, GFs can drive?

A

Bind Tyrosine kinase receptors:
○ promote entry into cell cycle
○ remove blocks on cell cycle progression
○ prevent apoptosis
○ enhance biosynthesis of cellular components required for cell growth and division.

Can also drive cellular migration, differentiation and synthetic capacity.

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54
Q

Gain of function mutations lead to ……

A

Gain of function mutations lead to uncontrolled proliferative ability.

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55
Q

The EGFR family includes:

A

Epidermal Growth Factor and Transforming Growth Factor α

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56
Q

EGF is:

1) Produced by?
2) Has what effect?
3) Targets which cells?
4) Mutations implicated in which tumours?

A

■ Produced by macrophages and epithelial cells
■ mitogenic for epithelial cells, hepatocytes and fibroblasts.
■ Mutations/amplifications implicated in many tumours: lung, brain, head and neck, breast.

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57
Q

VEGF is:

1) Produced by?
2) Induced by?
3) Stimulates?

A

■ Produced by mesenchymal cells
■ Induced by hypoxia and other factors (eg. PDGF, TGF-α)
■ stimulates lymph and angiogenesis.
■ VEGF antibodies used in treatment of renal and colon cancers.

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58
Q
Growth Hormone
●	synthesized, stored and secreted by?
●	regulated by?
●	Activates the?
●	Also stimulates?
A

Growth Hormone
● synthesized, stored and secreted by the anterior pituitary gland.
● regulated by the hypothalamus
● Activates the MAPK/ERK pathway, stimulating cell division esp of chondrocytes.
● Also stimulates insulin-like growth factor-1 which activate the PI3K-AKT-MTOR pathway, promoting proliferation and inhibiting apoptosis.

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59
Q
Receptor tyrosine kinases
○	transmembrane proteins with extracellular an .........  domain and intracellular  ........... domain.
○	Usually activated transiently by:
○	activated receptor .........
○	Can be .......... activated in tumours
A

Receptor tyrosine kinases
○ transmembrane proteins with extracellular ligand-binding domain and intracellular tyrosine kinase domain.
○ Usually activated transiently by binding of specific growth factor, causing dimerisation
○ activated receptor autophosphorylates tyrosine residues and recruits signalling proteins.
○ Can be constitutively activated in tumours

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60
Q

Give 3 ontologically important TKRs:

A

EGFR: ERBB1 mutation (lung) ERBB2 mutation (breast)

ALK: translocation and point mutation in lung adenoma and lymphomas.

VEGF

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61
Q

Activation of TKR stimulate 3 pathways:

The ultimate end-point of this is?

These are all frequently involved in what type of mutation?

A
RTK is the initial event for all
1) RAS (most important to remember, i.e. Cyclin D-CDK4 trigger, also stimulates MAPK)
2) MAPK aka the RTK-RAS-MET-ERK pathway
3) PI3K/AKT:   RTK-AKT-mTOR
The end-point is cell proliferation

All frequently involved in gain of function mutations

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62
Q

How is RAS activated?

Primary protein for reversing this?

A

Growth factor binds RTK activated RTK tyrosine kinase phosphorylates RAS-GDP to RAS-GTP

Inactivated by the GTPase neurofibromin

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63
Q

Give the PI3K pathway
What inhibits it?

Draw a diagram if possible

A

RTK-PI3K-AKT-mTOR promotion of cyclin D (ie. G1 to S)

Inhibited by PTEN (i.e a tumour suppressor gene)
● AKT also inactivates BAD, a pro-apoptotic protein
○ PTEN mutations seen in endometrial cancer
● PI3K activity inhibited by PTEN (hence tumour suppressor).
○ PI3K mutation seen in breast cancers.

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64
Q

Give the MAPK (MAPKinase) Pathway

Most well-known mutation

A

RTK binding -> RAS-RAF-MEK-ERK-transcription

BRAF mutation in hairy cell leukemias, melanomas, colon cancers

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65
Q

EGF binds what type of receptor?
What is the classic cancer in which over expression is seen?

Overexpression of EGFR, through either mutation or amplification is implicated in several cancers. 2 examples are?

A

Tyrosine kinase

Over expression of EGF is seen in pancreatic cancers, and is associated with more aggressive phenotype and poorer survival.

Overexpression of EGFR, through mutation or amplification is implicated in several cancers eg. lung and breast.

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66
Q

Hallmarks of Cancer - 6+2?

A

6 Hallmarks + 2 enabling characteristics

1) Sustained proliferative signaling (e.g. autocrine, increased TKR or GFs)
2) Evading Growth Suppressors
3) Resisting Cell Death
4) Angiogenesis
5) Activating invasion and/or metastasis
6) Replicative immortality

Enablers:
Genome Instability
Tumour-promoting inflammation

Emerging hallmarks:
Evading immune destruction
Deregulating cellular energetics

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67
Q

Arguably the most fundamental hallmark of cancer:

By what pathways does it achieve this?

A

Sustaining proliferative signalling:

Increase receptors
Mutate receptors to be more active
Increase GFs or stimulate other cells to release
Autocrine activation
Constitutive activation of a component of signalling pathway

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68
Q

Give an example of GF over expression (include events at the receptor, and in what diseases it may be seen):

A

Overexpression of EGF
● Produced by macrophages and epithelial cells
● EGF binds to EGFR which dimerizes and phosphorylates its tyrosine kinase residues, activating pathways that lead to cellular proliferation
● Hence EGF is mitogenic.
● Overexpression of EGF is seen in pancreatic cancers, and is associated with more aggressive phenotype and poorer survival.

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69
Q

The two main types of mutations that may lead to autonomous functioning of signal transduction pathways:

Give examples of each

A

Signal transduction pathways are chain reactions of activated intracellular molecules leading to cellular proliferation
Gain of function:
● Most relevant are Ras/Raf/MEK/ERK and PI3K/AKT/mTOR pathways.

● Loss of function of inhibitory molecules eg. GAP and PTEN also lead to oncogenesis

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70
Q

High risk subtypes HPV

A

High risk subtypes HPV are 16 and 18

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71
Q

Broadly HPV mediates what, which leads to cancer

A

HPV mediates loss of tumour suppressor function

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72
Q

All HPV are non-enveloped ……….-………… …… viruses.

Encode X major proteins, Y located in the “early” region Z in the “late” region

A

All HPV are non-enveloped double stranded DNA viruses.

Encode eight major proteins, 6 located in the “early” (i.e. E1,..E6) region 2 in the “late” region

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73
Q

What are the broad classes of protein coded for by the HPV genome

They are in how many key open reading frames?

A
Late encode capsid
Replication proteins
ONCOGENES - E5,6,7
○	L1,2 encode capsid proteins
○	E1,2,4 regulate viral replication
○	E 5,6,7 are oncogenes.
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74
Q

What are the HPV oncogenenes:

How are they expressed?

A

E5, E6, E7

HPC invades basal layer of epithelium which acts as a continuous reservoir of HPV DNA.

Inserts into DNA (i.e it is DS-DNA virus), host expresses oncoproteins

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75
Q

HPV E5 oncoprotein does what?

A

(5,6,7 EGF, p53, Rb)

Activates EGF signalling pathway (i.e RAS-Raf-Mek-Erk, and PI3K-AKT-mTOR) ->Cell growth and proliferation

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76
Q

HPV E6 oncoprotein does what?

A

(5,6,7 EGF, p53, Rb)

Binds p53 induces its degredation

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77
Q

HPV E7 oncoprotein does what?

A

(5,6,7 EGF, p53, Rb)

Binds Rb releasing E2F: Cyclin E increases, Cylcin A-CDK2 stimulated, cell goes into S Phase.

Inactivates CIP/KIP (p21, p27)

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78
Q

Broadly the HPV open reading frame segments do what?

A

ORFs E5,6 &7

Promote check point inhibition and mitosis

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79
Q

Define: Oncogene

A

Mutated genes that encode proteins which result in continuous replicative potential of the cell

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80
Q

Define: Tumour suppressor gene

A

Genes that check and regulate cell growth and repair, preventing proliferation of mutated or damaged cells.

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81
Q

Name 4 mechanisms for the activation of oncogenes and/or loss of function of tumour suppressor genes:

A

1) Point mutation = change of a single base
2) Deletions and insertions: single or pair of BASE PAIRS deleted = frameshift mutations.
IFF pairs involved are in multiples of 3 then an abnormal protein results - either gaining or loosing an amino acid
3) Translocations = re-arrangement of sequences between non-homologous chromosomes
4) Amplifications: Overexpression due to reduplication and presence of multiple copies within the cell. Can be double minutes (extrachromosomal) or homog eneously staining regions (intrachromosomal).

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82
Q

Deletion mutations often result in?

2 key examples are?

A

Deletions usually result in loss of tumour suppressor genes eg. Rb1 and VHL genes.

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83
Q

What are translocation mutations?

A

Rearrangement of parts between nonhomologous chromosomes.

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84
Q

What are proto-oncogenes?

How are they activated

A

Proto-oncogenes are translocation mutations.

Activated by loss of regulatory element or gain of promotor:
○ removal from their regulatory elements eg. Burkitt’s Lymphoma t(8,14)
○ formation of hybrid oncogenes that encode growth promoting oncoproteins. CML t(9,22)

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85
Q

What are amplification mutations?

Give an example

A

Overexpression due to reduplication and presence of multiple copies within the cell. Can be double minutes (extrachromosomal) or homogeneously staining regions (intrachromosomal).

Eg. ERBB2 (HER2 receptor) in breast, ovarian and stomach cancer, NMYC in neuroblastoma, Cyclin D1 gene in head and neck cancers.

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86
Q

How are oncogenes and tumour suppressor gene mutations quantified?

What is the general principle of both

A

Either:

Comparative Genome Hybridisation (used to detect of chromosomal copy number changes)

In-Situ Hybridisation

Both methods use DNA or RNA probe(s) labelled with fluorescent dye.

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87
Q

What is Comparative Genome Hybridisation?

What is it used for?

A

Detection of chromosomal copy number changes

○ Test DNA and reference (normal) DNA are labelled with different fluorescent dyes.
○ The samples are hybridized to an array with DNA probes spanning all 22 autosomes and sex chromosomes.
○ The binding of the samples are compared
○ If both samples bind equally the spots will fluoresce yellow
○ If deletion or duplication is present, fluorescence will skew towards red or green

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88
Q

What is In-situ Hybridisation?

A

Technique for identifying/quantifying an RNA/DNA sequence of interest using RNA/DNA probes labelled with a fluorescent dye (FISH) that hybridise to a target sequence.

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89
Q

What are the steps in In-Situ Hybridisation?

A

○ DNA denaturation by heating, separates the strands.
○ Probes are introduced, labelled with fluorescent dye (FISH).
○ Probes are hybridized to target sequence
○ Sample is washed, removing excess, unbound probes.
○ Sample is viewed under fluorescent microscope
○ Spectral karyotyping (multicolour FISH) uses different coloured fluorescent labels to visualize the entire genome.

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90
Q

Chromosomal structural aberrations are divided into main types? 2 examples of each?
How do they differ in outcomes?

A

Chromosomal structural aberrations are either:

1) Stable (there are for): Are not lethal to the cell and include translocations and deletions (as well as duplications and inversions)
2) Unstable: Gross changes to chromosomes that are lethal to cells - e.g Dicentrics (anaphase bridge), ring chromosomes

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91
Q

What is Knudson’s 2 hit hypothesis?

A

● Model of tumour suppressor gene inactivation by Knudson in familial retinoblastoma.
● Developed bilateral disease and much earlier.
● Proposed that patients inherited a germline mutation in one RB gene but required a mutation in the other (‘second hit’) to develop RB, whereas sporadic patients required mutations in both genes.

● Thus, tumour suppressor genes are recessive genes that require inactivation of both functional copies before malignancy develops, whereas loss of one functional copy leads to increased susceptibility.

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92
Q

Knudson’s 2 hit hypothesis relates to what type of genes?
What does it imply about those genes?
How does it explain early presentation of a disease?

A

Tumour suppressor genes

Tumour suppressor genes are recessive genes that require inactivation of both functional copies before malignancy develops

Infant patients inherited a germline mutation in one Rb gene but required a mutation in the other (‘second hit’) to develop RB, whereas sporadic patients required mutations in both genes.

As one mutant is inherited (leaving only one functional allele) early (infant) disease has an autosomal dominant pattern.

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93
Q

Factors other than DNA sequences that regulate (onco)gene expression?

A

Epigenetic changes.
1) Methylation - Decrease access to DNA. Hyper and hypomethylation seen in many tumours, leading to under or over production of multiple genes.

2) Acetylation - Increase access to DNA. Acetyl groups attract promotors

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94
Q

● Altered DNA methylation throughout the genome is seen in various tumours, as ………. or ………methylation

● Hypomethylated genomes also lead to?

● Local hypermethylation of the promoter regions of tumour suppressor genes lead?

● Usually hypermethylation occurs in one allele, the other functional copy?

● One example?

A

● Altered DNA methylation throughout the genome is seen in various tumours, as hyper or hypomethylation

● Hypomethylated genomes also lead to chromosomal instability.

● Local hypermethylation of the promoter regions of tumour suppressor genes lead to silencing.

● Usually hypermethylation occurs in one allele, and the other functional copy is lost through another mechanism eg. deletion or point mutation.

● One example is CDKN2A which is a locus that encodes tumour suppressors p14 and p16 that enhance p53 and pRb activity.

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95
Q

CREBBP (a histone acetyltransferase) mutation is seen in 40% of?

A

CREBBP (a histone acetyltransferase) mutation is seen in 40% of DLBCL.

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96
Q

Carcinogenesis involves which 2 complimentary processes?

Briefly describe each:

A

Carcinogenesis involves Initiation and Promotion

● Initiation results from exposure to carcinogens causing permanent DNA damage.

● Promoters are non-tumourigenic but enhance the proliferation of initiated cells. Eg. unopposed oestrogen and chronic inflammation.

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97
Q

What are ‘ultimate carcinogens’

A

Some carcinogens require metabolic activation into

‘ultimate carcinogens’

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98
Q

Vogelstein model?

A

Vogelstein model of colon adenocarcinoma- the adenoma-carcinoma sequence:

Hyperplasia (1→ Dysplasia (2→ Adenoma (3→ Carcinoma

1) APC - Adenomatous Polyposis Coli
2) K-Ras - GTPase mutation leading to increased proliferative signal
3) p53 - decreased apoptosis and cell cycle arrest

Studies of tumour gene expression do not support this model (e.g. data sows very rare to have both K-Ras and p53 mutation)

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99
Q

2 Main cell types (beside control!!) used for in-vitro models of tumours?

A

1) Transformed cells are created by irradiation of embryo or fibroblast cells.
2) Malignant cells

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100
Q

Compare the appearance of transformed and malignant cells when plated:

What are the experimental benefits of Malignant cells?
Major pitfall?

A

● Transformed cells are created by irradiation of embryo or fibroblast cells.
○ When plated, cells replicate in disorganized fashion

● Malignant cells
○ when grown in suspension grow as spheroids = large spheric clump of cells
○ The spheroids mimic characteristics of solid tumours, with hypoxic core and cycling cells on the outside
○ They are reproducible and inexpensive
○ However they lack ECM and vasculature, hence not a fully accurate model of tumour behaviour.

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101
Q

5 key histological difference between benign and malignant cells (a common exam question is to make a table):

A

Benign:

1) Well Differentiated
2) Few mitotic figures, appear normal
3) Normal Karyotype
4) Limited number of cell divisions
5) Exhibits contact inhibition- Stops proliferating when cells come into contact with each other

Malignant:
1) Well to poorly differentiated
2) Many mitotic figures which appear bizarre
3) Abnormal karyotype: Abnormal number of chromosomes or chromosomes with abnormal structure
4) May proliferate indefinitely in culture
Can produce telomerase
5) No contact inhibition- will continue to pile up into mounds of cells

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102
Q

Under normal conditions, Neovascularization is triggered by?

Broadly after being triggered what is activated and where do they go? :

A

Neovascularization :
○ Injury of local basement membrane or hypoxia
○ Pro-angiogenic factors activate endothelial cells which migrate to the site of tissue injury

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103
Q

Steps of normal neovascularisation:

Tumour angiogeneis often leads to subobtimal angiogenesis at which phase?

A

1) Pro-angiogenic factors activate endothelial cells which migrate to the site of tissue injury
2) Endothelial cell proliferation
3) Regulated by angiogenic factors
4) After neovascularization there is a resolution phase where blood vessels mature and stabilize

■ This phase occurs less in tumour angiogenesis hence tumour blood vessels are crap (leaky, disorganised, small, prone to collapse)

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104
Q

After angiogenesis there is a resolution phase where blood vessels mature and stabilize
■ This phase occurs ……… in tumour angiogenesis

■ Tumour blood vessels are:

A

After angiogenesis there is a resolution phase where blood vessels mature and stabilize
■ This phase occurs less in tumour angiogenesis hence tumour blood vessels are:

●	leaky
●	disorganized
●	smaller in diameter
●	prone to collapse
●	high permeability to large molecules
●	variable blood flow
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105
Q

Angiogenesis is controlled by balance between?

Examples of each?

Catch phrase to describe this

A

Angiogenesis is controlled by balance between pro- and antiangiogenic factors. When the balance is in favour of angiogenesis “angiogenic switch”

○ pro: bFGF (FGF-2), VEGF, TGF alpha and beta, TNF alpha
○ anti: angiostatin, endostatin, thrombospondin-1, Interferon

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106
Q

Targets for regulation of tumour angiogenesis include:

A

● Regulators include proteases (produced by the tumour or ECM), p53, RAS/MAPK signalling
● Hypoxia is a major trigger of angiogenesis.
● VEGF inhibitors not as effective as hoped suggesting other escape pathways.

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107
Q

8 Steps of Metastatic Cascade:

A

1) Dissociation of cancer cells from each other
Loss of E-cadherin facilitates detachment and infiltration of surrounding tissues. E.g. SNAIL and TWIST downregulate expression.
2) Degradation of basement membrane
Secretion of proteases. Changes in attachment to ECM proteins.
3) This enables Locomotion
4) Movement through the basement membrane
and Intravasation = Invasion of endothelium to enter the circulation
5) Formation of tumour emboli
Tumour cells aggregate in clumps by adhesion with platelets and T-lymphocytes

6) Adhesion to endothelium basement membrane and extravasation
Adhesion molecules involved: CD44 adhesion molecule expressed on normal T lymphocytes
7) Arrest at distant organ site, Trapping in first capillary bed, tumour organ topism
8) Survival in tumour microenvironment
e.g. Angiogenesis, evasion of immune mediated destruction
9) Colony formation

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108
Q

Intravascularly, tumour cells are vulnerable to destruction in 3 ways:

A

Intravascularly, tumour cells are vulnerable to destruction
● mechanical shear stress
● apoptosis
● innate and adaptive immunity

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109
Q

SNAIL and TWIST downregulate expression of?

Why is this important?

A

1 step of Metastatic cascade.
Dissociation of cancer cells from each other
Loss of E-cadherin facilitates detachment and infiltration of surrounding tissues. E.g. SNAIL and TWIST downregulate expression.

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110
Q

Numerically tumour growth typically exhibits:

A

Sigmoid (Gompertz) growth.

Where the mass is typically only clinically detectable at the plateau phase.

Sigmoid Characterised by:

1) Initial Exponential Growth: Small number of tumour cells with adequate nutrition undergo division. Each progeny is able to survive and divide. The growth fraction close to 100%.
2) Linear Growth: Competition for nutrients/oxygen make tumour micro environment less favourable, not all progeny survive.
3) Plateau: Tumour microenvironment increasingly unfavourable - only a reducing minority of cells are able to proliferate. Eventuallycell loss factor is equal to the growth fraction. The tumour mass is clinically detectable and causing symptoms. May also be areas of necrosis from hypoxia.

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111
Q

In drawing a Gompertz curve for tumour growth how would you label the x and y axis?

A

Y - axis: Number of cells 10^9 [0 .2, 0.4,….. 1]

X Axis: Time (Arbitrary units)

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112
Q

Define Growth Fraction in terms of tumour growth

What is it’s opposite (i.e the opposite force acting especially in the Gompertzian plateau)?

A

The ratio of proliferating cells over total number of cells

Cell loss factor: The ratio of the rate of cell loss over the rate of new cell proliferation

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113
Q

Tumour doubling time is the:

Potential doubling time:
What is Pdt useful for?

A

Tumour doubling time is the time taken for a tumour to double its initial volume.

Potential doubling time is the theoretical doubling time in the absence of cell loss. Used to calculate cell loss Fraction.
Tpot = Tc/GF (Tc = cell cycle time, GF = growth fraction)

i.e (time to make new cell/number of proliferating cells) = number of new cells per unit time (assuming no death) (e.g. cells/sec)

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114
Q

Define Cell loss factor:

A

The ratio of the rate of cell loss over the rate of new cell proliferation

● 1- (Tpot/Td) where Tpot is the potential doubling time and Td is the actual doubling time.

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115
Q

Determinants of tumour growth RATE:

A

1) Cell cycle time
2) Growth Fraction (#prolif/#cells)
3) Cell Loss Factor = 1- (potDt/Dt)
4) Accelerated re-population
5) Tumour micro environment: stroma and hypoxia

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116
Q

Hypoxia activates pathways that allow tumour cells to adapt to hypoxic stress. 3 Key adaptations:

A

Hypoxia activates pathways that allow tumour cells to adapt to hypoxic stress. 3 Key adaptations:
○ anaerobic glycolysis
○ changes in blood flow
○ stimulate angiogenesis.

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117
Q

The concept that tumour doubling time for certain tumours is shorter during or shortly after a course of treatment compared to an untreated tumour = ?

In experiments of SCC head and neck, this seems to take place approximately:

A

Accelerated re-population
In experiments of SCC head and neck, this seems to take place approximately 28 days after starting treatment.
● The dose required to compensate for this repopulation is about 0.6Gy/day

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118
Q

2 key components thought to underlie accelerated re-population:

A

1) Improved/less competitive tumour microenvironment: reduction in number of tumour cells, improvement in oxygen and nutrient supply to the remaining tumour cells resulting in a more favourable tumour microenvironment.
2) regeneration response of clonogenic cells, similar to that seen in normal epithelial tissue, potentially triggered by EGFR

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119
Q

Approaches to counteract Accelerated Repopulation:

A

Methods to counteract this is to reduce overall treatment time by accelerated hyperfractionated treatment, combined chemoradiotherapy, or higher total dose.

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120
Q

Tumours become detectable at about X cells?

A

Tumours become detectable at about 10^9 cells

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121
Q

Earliest event in sensing DNA damage?

A

Phosphorylation of H2AX to gammaH2AX

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122
Q

H2AX → γH2AX
Leads to:
Can be seen as

A

Leads to recruitment of proteins to site of DNA damage

Form ionising radiation induced foci (IRIF) - if stained with antibodies.

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123
Q

3 related kinases can phosphorylate H2AX at sites of DNA damage:

A

3 related kinases can phosphorylate H2AX at sites of DNA damage:

1) ATM-MRN (the main one)
2) DNA-PKcs-KU
3) ATR-ATRIP

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124
Q

The main sensor pathway for DNA damage?

What are the steps?

A

■ MRN (MRE11, RAD50, NBS1) assembles at site of DNA breaks
■ MRN recruits and activates ATM
■ ATM phosphorylates H2AX

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125
Q

Potential doubling time?

A

Potential doubling time:
Tumour doubling time when there is no cell loss
Tpot = Tc/GF (Tc = cell cycle time, GF = growth fraction)

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126
Q

Cell loss factor:

A

Cell loss factor:
Ratio of rate of cell loss to rate of new cell production
1 – Tpot/VDT

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127
Q

What is volume doubling time be dependent on?

A

Number of cells replicating and time for them to replicate is dependant on:

1) Number of tumour cells actively going through cell cycle and replicating (growth fraction)
2) Duration of cell cycle in these cells (cell cycle time)
3) Rate of Cell Loss

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128
Q

Define growth fraction:

A

Number of Cells Replicating/number of cells in tumour

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129
Q

Lab method for determining the ratio of replicating cells to total number of cells (aka?)

A

Ki67 proliferation index in a tumour is an Indication of growth fraction:

Ki67 cell cycle specific protein
Detected by IHC using monoclonal antibody

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130
Q

Most solid tumours have growth fractions below:

A

Most solid tumours have growth fractions below 50%

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131
Q

How long is an average cell cycle?

A

For a typical rapidly proliferating human cell with a total cycle time of 24 hours, the G1 phase might last about 11 hours, S phase about 8 hours, G2 about 4 hours, and M about 1 hour.

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132
Q

Common biochemical technique for studying cell cycle kinetics

A

2 Examples:
1) Identification of S phase cells by incorporation of radioactive thymidine.

2) Cells at different stages of the cell cycle can also be distinguished by their DNA content. Cells in G1 are diploid so their DNA content is referred to as 2n. Cells in S have DNA contents ranging from 2n to 4n. DNA content remains at 4n for cells in G2 and M, decreasing to 2n after cytokinesis.

Incubation of cells with a fluorescent dye that binds to DNA, followed by analysis of the fluorescence intensity of individual cells in a flow cytometer

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133
Q

For 1 Gy of radiation
>? damaged bases
about ? ss DNA breaks
about ? ds DNA breaks

A

For 1 Gy of radiation
>1000 damaged bases
about 500 - 1000 ss DNA breaks
about 20 - 40 ds DNA breaks

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134
Q

Repair mechanism for each type of IR induced DNA damage:
● Damage to bases:
● Single strand breaks:
● Double stranded breaks:
Types of DNA damage not seen in therapeutic range IR

A

● Damage to bases- repaired through base excision repair or nucleotide excision repair
● Single strand breaks- repaired through SSB repair
● Double stranded breaks- repaired through homologous recombination or non-homologous end-joining.

● Other lesions not directly related to radiation damage:
○ mismatch bases can occur when attempting replication- repaired through mismatch repair
○ bulky lesions or DNA adducts formed by UV light or chemotherapy- repaired through nucleotide excision repair.

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135
Q

What is histone H2AX (in relation to there histones)?

A

Variant of histone H2A
10 – 15% total cellular histone H2A
Distributed throughout nucleus
H2AX phosphorylation occurs at site of DNA damage, within 30 mins of DNA damage
Recruits proteins to sites of DNA damage and signals activation of effector pathways

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136
Q

ataxia–telangiectasia patients have a mutation in?

Which causes?

A

ATM mutation: H2AX-MRN-ATM-CHK2

Sufferers of AT or cells that have inhibition of ATM are very radiosensitive – defective DNA damage response

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137
Q

What does H2AX do?

What is the key activator?
Much lesser influence?

A

When phosphorylated to gammaH2AX recruits proteins to sites of DNA damage and signals activation of effector pathways.

MRN-ATM is key activator (missing in AT patients), if missing ATR-ATRIP and DNA-PKcs-Ku will phosphorylate H2AX

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138
Q

2 Main mechanisms for DSB repair.

For the error-free mechanism, what is needed for this to occur.

A

Homologous recombination - slow, but error free
Non-homologous end-joining - Fast, cell can survive DSB, but deletion and insertion errors.

For Homologous recombination to occur there bust be a sister chromatid therefore DSB must occur in late S and G2.

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139
Q

Steps in Homologous recombination

A

Homologous Recombination uses sister DNA with the same sequence as a template for repair:

1) Single stranded filaments made around DSB
2) Filaments coated with RPA
3) RAD51 displaces RPA and SEARCHES and INVADES sister chromatid
4) Helices UNWIND and polymerases SYNTHESISE
5) Finally crossover points are CUT by RESOLVES, and ligated.

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140
Q

Steps in Non-homologous End-joining:

A

Detection→Recruitment/activation→Processing→Ligation:

1) Detection: DSBs detected by Ku70 and Ku80 proteins which bind to site. They protect ends of DNA strands, prevent exonucleases degrading DNA.
2) Recruit: DNA-PKcs recruited - autophosphorylates & phosphorylates other proteins.
Artemis (protein complex) recruited to DNA break, forms complex with DNA-PKcs and is activated by phosphorylation.
3) Processing: Artemis endonuclease activity processes the DNA ends ready for ligation. If DNA damage or repair process causes a non-blunt end of DNA i.e. a 3’ or 5’ overhang, then the absent DNA can be generated by polymerases.
4) DNA ends ligated through ligase IV and XRRC4 and XLF proteins.

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141
Q

In the Processing phase of NHEJ:

……… ……….. activity processes the DNA ends ready for ligation.

If DNA damage or repair process causes a non-……. end of DNA i.e. a 3’ or 5’ ………, then the absent DNA can be generated by ………….

A

Artemis endonuclease activity processes the DNA ends ready for ligation.

If DNA damage or repair process causes a non-blunt end of DNA i.e. a 3’ or 5’ overhang, then the absent DNA can be generated by polymerases.

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142
Q

Mutations in genes associated with which four DNA repair mechanisms are associated with increased radio sensitivity?

What type of DNA damage is associated with each?

A

1) Damage to Base = Base excision and repair
2) SSB = Single Stranded Brake Repair
3) DSB - Non-homologous End joining
4) DSB - Homologous Repair

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143
Q

Basic steps of Base excision repair:

A

Damaged DNA detected and removed by glycosylases:
○ Each glycosylase is specific for a particular type of base damage.
○ They cut out the damaged base without cutting the DNA backbone resulting in an abasic site.

2) AP endonuclease then cuts the DNA backbone making a nick (SSB).

3) Subsequent repairs follow one of two pathways:
■ Short patch
● involves replacing the damaged base only
● DNA synthesis carried out by DNA polymerase β
● Ligated by ligase 3
■ Long patch
● involves cutting out and replacing up to 10 nucleotides.
● DNA polymerases δ and ε
● ligase 1

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144
Q

Basic steps of Single Stranded Break Repair

A

1) Damage detected by PARP-1.
2) Breaks are ‘dirty’ and require end-processing step by polynucleotide kinase PNK

BER (ie. proceeds from the point of nick):
3)Once clean nick produced, short or long patch repair follows BER.
■ Short patch
● involves replacing the damaged base only
● DNA synthesis carried out by DNA polymerase β
● Ligated by ligase 3
■ Long patch
● involves cutting out and replacing up to 10 nucleotides.
● DNA polymerases δ and ε
● ligase 1

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145
Q

Key points for γ-H2AX:

A

Phosphorylated form γ-H2AX:

○ recruits proteins involved in DSB repair
○ opens tertiary structure of DNA allowing access to repair proteins
○ activates checkpoint proteins
○ involved in formation of ionizing radiation induced foci

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146
Q

Why may ATR be activated by the ATM-MRN pathway?

A

ATR may also be activated by ATM-MRN pathway when processing ds DNA breaks which creates ss DNA

ATR-ATRIP-CHK1
MRN-ATM-CHK2

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147
Q

How is IR induced DNA measured:

A

1) Chromosome aberrations. Assessed for at 1st metaphase after exposure.

2) Assays for DNA damage
i. γ-H2AX - Radiation induced foci immunofluresence
ii. Comet Assay - i.e the more fragmented the DNA the longer the tail behind the head (nucleus)
iii. Pulse field Gel electrophoresis - post electrification (current applied in diff directions) fragmentation corresponds to DNA damage
iv. Micronucleus assay
v. Plasmid assay

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148
Q

Steps for comet assay:

A

● Single cell electrophoresis
● Irradiated cells embedded in agarose gel on microscope slide
● Cells lysed using high salt and detergent solution
● DNA electrophoresed
● Fluorescent staining of gel performed with ethidium bromide or propidium iodide which is specific for DNA
● DNA fragments move away from nucleus, forming a ‘comet’ with head formed by the nucleus and tail composed of smaller DNA fragments.
● Comet tail length correlates with DNA damage.

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149
Q

Steps for Pulse field Gel electrophoresis:

A

Pulse field Gel electrophoresis - post electrification (current applied in diff directions) fragmentation:
● Used to assess DNA DSB and large fragments up to 10 Mbp
● Comet assays not effective in base pairs >50kb
● irradiated cells suspended in agarose gel and poured into moulds
● cells lysed and gel electrophoresis performed
● Current applied switching from different directions: straight across and 60 degrees either side
● Larger pieces will react slower to change in direction
● Over the course of time bands will begin to separate
● Gel is read after staining with fluorescent ethidium bromide
● Fragmentation of DNA correlates with amount of DNA damage.

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150
Q

Modes of Cell Death:

A
Mitotic catastrophe
Necrosis
Apoptosis (Type 1 Death)
Autophagy (Type 2 Death)
“Senescence” = Reproductive Death
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151
Q

How does Mitotic catastrophe occur?
Why is it cell death?

Morphological changes:

A

Occurs after mitosis because cells have entered mitosis with DNA damage still present. Cells can no longer replicate due to the chromosomal damage = Reproductive death. This form of cell death can trigger other cell death pathways such as apoptosis.

Morphological changes: multinucleated giant cells, chromosome aberrations, dicentric nuclei

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152
Q

How does Necrosis occur?

Morphological changes:

A

Occurs due to unfavourable growth conditions, e.g change in pH in cellular environment, but also due to insults which damage DNA such as radiation.

Morphological changes: cellular swelling and rupture,
In nucleus – uncondensed chromosomes, micronuclei, clumping of DNA
In Cytoplasm - organelle degeneration, mitochondrial swelling, release of lysosomal enzymes, vacuolation of cytoplasm

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153
Q

What is Apoptosis/normal role?
What leads to it?
How is it relevant to cancer?

A

Regulated form of cell death.
Essential component of development and in maintaining tissue homeostasis

Triggered from within cell or by external cell signals

Changes in apoptosis control can contribute to cancer development

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154
Q

Morphological appearance of Apoptosis:

A

1) Chromatin condensation and nuclear fragmentation
2) DNA laddering
3) Cell membrane blebbing
4) Formation of apoptotic bodies (vesicle containing parts of a dying cell) - Prevents leakage of potentially damaging cellular proteins

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155
Q

Compare the morphology of necrosis to Apoptosis:

A

NECROSIS
Cell body: Cellular Swelling
Chromatin: Does not condense
Cell integrity: Blebbing -> cell becomes leaky
Resolution: Cellular and nuclear lysis causes inflammation

APOPTOSIS
Cell body: Shrinks
Chromatin: Condenses
Cell integrity: Budding
Resolution: Buds become apoptotic bodies which are phagocytised without inflammation
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156
Q

The apoptosis pathaway can be broken into which two classes of molecule?

Apotosis proceeds through …….. activation of ………..

Main counter balance molecules to this process?

A

Sensor molecules = sensor caspases
Involved in initiating apoptosis
Activation of sensor caspase (8 or 9)

Effector molecules = Effector caspases
Subsequent activation of downstream effector caspases (including caspase 3)

Sequential activation of caspases
Usually in inactive form (procaspase)

Inhibitors of apoptosis proteins (IAP)

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157
Q

The 2 signal pathways to apoptosis and their key trigger molecules are:

A

Extrinsic pathway:
■ sensor caspase 8, activated by binding of extracellular ligand which activates death receptor. Not usually activated by radiation damage.
■ Extracellular ligands include – TNF, TRAIL, FAS.

Intrinsic pathway:
■ sensor caspase 9, activated in cell by presence of cell damage (e.g p53 signal).
■ Balance of Pro and anti-apoptotic factors in cell (around or in mitochondria) will determine if sensor caspase 9 activated.

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158
Q

Detail the Extrinsic pathway for apoptosis:

A

Extrinsic pathway:
1) sensor caspase 8, activated by binding of extracellular ligand which activates death receptor. Eff
■ Extracellular ligands include – TNF, TRAIL, FAS.
2) Effector caspases activated (Caspase 3, also 6 and 7)
3) Apotosis

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159
Q

Detail the Intrinsic pathway for apoptosis:

A

Intrinsic pathway:
1) Presence of cell damage. Signalled by p53, PI3K-AKT
■ Pro and anti-apoptotic factors in cell (around or in mitochondria) will determine if sensor caspase 9 activated.
■ Normally anti-apoptotic factors predominate and caspase 9 is inactive, but if cell damage occurs pro-apoptotic factors activated (e.g. by p53) and balance changes in favour of caspase 9 activation.

 ■	Pro-apoptotic proteins include BAX, BAK, PUMA. BAD from PI3K - AKT activates BAX and BAK
 ■	Anti-apoptotic: BCL-2 

IAP family inhibit Caspase 9 and 3.

2) If balance altered: cytochrome C released from mitochondria into cytoplasm - apoptosome formed
Caspase 9 activated

3) Effector caspases especially 3 (others 6 and 7) mediate apotosis.

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160
Q

What is Autophagy?
How can it be activated?
Key regulatory molecule?
Normal role?

A

Part of cytoplasm of cell digested to release molecules and energy
Can be activated in response to loss of nutrients or growth factors
Regulated by mTOR kinase (i.e. PI3K-AKT-mTOR)

Can prolong cell survival in adverse conditions
Can also lead to a form of programmed cell death (Type II) that is not caspase dependent
Autophagy acting as a tumour suppressor function – if genes associated with initiation of autophagy lost then increased cancer development in mice studies

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161
Q

Evidence of a role for Autophagy in Cancer?

A

Autophagy acting as a tumour suppressor function – if genes associated with initiation of autophagy lost then increased cancer development in mice studies

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162
Q

Morphological apperance of type II cell death

A

Autophagy can lead to a form of programmed cell death (Type II) that is not caspase dependent:
Looks like Apotosis
BUT no: DNA laddering, vesicles no apototic bodies (but still vesicles present)

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163
Q

What is senescence?
Usually associated with?
Can occur prematurely when?

A

Metabolically active but Reproductive Death - Cell-cycle stopped - “G0”

Usually associated with telomere shortening in aging
DNA damage

Premature senescence can be induced by cellular stress and IR DNA damage (not related to telomere length, activated by other pathways).

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164
Q

Different cell types have different propensity to undergo senescence – common in ………. cells after radiation

A

Different cell types have different propensity to undergo senescence – common in fibroblast cells after radiation

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165
Q

Morphological appearance of Senescence:

A

Heterochromatic nuclei
Increased granularity of cytoplasm
Flattening of cytoplasm

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166
Q

Cell Death soon after radiation (i.e. within 7 hours) is due to activation of ……. pathway

Which leads to upregulation of:

A

DNA Damage Response (DDR)

DDR activation of apoptosis: upregulation of pro-apoptotic proteins and activation of p53

Genes regulating apoptosis can influence radiosensitivity of cell in this situation

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167
Q

A late IR induced Cell Death is after:

As opposed to Cell death soon after radiation, the trigger for apoptosis is?

A

After cells have attempted to divide or after 2 or 3 replications

DDR activates cell cycle checkpoints and DNA repair
DDR does not lead to apoptosis even if p53 activated.

Signal for cell death is the inability to undergo mitosis properly

168
Q

What is the Bystander Effect?

A

Death of cells owing to irradiation of neighbouring cells, not as a direct action of irradiation

● Not fully understood but thought to be:
○ secretion of factors by irradiated cells that are damaging to unirradiated cells
○ Sharing of reactive oxygen species between cells
○ This phenomenon is seen more clearly when cells are connected by gap junctions.

169
Q

What is the Abscopal Effect?

A

Phenomenon where local irradiation results in cell kill outside the radiation field, even in a distant site.
○ Mechanisms
■ Release of cytokines which mediate a systemic inflammatory reaction to radiation
■ Enhances innate immune recognition of tumour cells

170
Q

Titration of Dose According to Tumour Burden is based on:

A

Large tumours require higher doses to control compared to small tumours
● This is true even if intrinsic radiosensitivity, hypoxia and repopulation rates are equal

171
Q

Sensors consists of a group of proteins that actively survey the genome for presence of damage.

These proteins then signal this damage to three main effector pathways:

A

Sensors consists of a group of proteins that actively survey the genome for presence of damage.

These proteins then signal this damage to three main effector pathways:
○ programmed cell death
○ DNA repair
○ Cell cycle arrest

172
Q

Main source of phosphorylation of H2AX at ds DNA breaks:

Components of the Sensor part:

A

Main source of phosphorylation of H2AX at ds DNA breaks:
MRN-ATM pathway.

MRN complex:
MRE11
RAD50
NBS1 (directly binds to ATM)

173
Q

After assembly of MRN complex at site of dsDNA break, what happens?

A

Recruits ATM (inactive in cell until recruited to ds DNA break by MRN)
Activated ATM phosphorylates H2AX
-Spreads over large area chromatin in both directions
Other proteins also phosphorylated in this pathway including p53 and MDM2

174
Q

The two lesser DSB response pathways:

A

1) DNA-PKcs-Ku. Alternative mechanism to ATM-MRN but delayed kinetics
2) ATR-ATRIP. Does not play a substantial role in the initial recognition of DSBs (is SSB dominant pathway). Can be activated by the SSBs produced during processing of DSBs.

175
Q

DNA-PKcs is structurally similar to?

A

Structurally similar to ATM

176
Q

How does DNA-PKcs phosphorylate H2AX?

A

Ku70-Ku80 complex binds to ends of DSBs and recruits DNA-PKcs which phosphorylate H2AX

177
Q

In G1 cell cycle arrest is mediated by … which upregulates …, a … inhibitor

A

In G1 cell cycle arrest is mediated by p53 which upregulates p21, a CDK inhibitor

178
Q

In S and G2, CDK activity is regulated by ……… The inactivation of this by ……..1/2 results in S and G2 phase arrest.

A

In S and G2, CDK activity is regulated by CDC25. The inactivation of CDC25 by CHK1/2 results in S and G2 phase arrest.

MRN-ATM-CHK2
ATR-ATRIP-CHK1

179
Q

Colongenic cells are cell able to form colonies of >x

A

Colongenic cells are cell able to form colonies of >50

180
Q

What molecules acetylate histones?

A

Histone acetyltransferases acetylate histones

● This modification alters chromatin structure, allowing greater accessibility to the underlying DNA
● Acetyl groups also attract transcription factors.

181
Q

γH2AX recruits other repair proteins to form the ionizing radiation induced foci (IRIF).

Proteins include:

A

γH2AX recruits other repair proteins to form the ionizing radiation induced foci (IRIF).

Proteins include: RAD51, BRCA1 and 2, MDC1, 53BP1

182
Q

ATM is involved in phosphorylation of

1) Repair Proteins:
2) Cell cycle proteins:

A

ATM is involved in phosphorylation of

1) Repair Proteins: H2AX, BRCA1, SMC1, p53
2) Cell cycle proteins: p53, CHK 2

183
Q

Genetic diseases affecting DNA repair are generally of what form?

A

Autosomal recessive

184
Q

A key genetic disease associated with an MRN complex protein is?
Hence it is similar to another syndrome?

A

Nijmegan Breakage Syndrome (NBS1 is the part of MRN that attracts ATM)
Similar therefore to Ataxia telangetasia Syndrome

185
Q

Symptoms/phenotype of NBS?

A

Patients have similar radiosensitivity to AT.

Patients have phenotype of:
short stature
microcephaly,
distinctive facial features
immunodeficiency 
increased risk of cancer
186
Q

Symptoms/phenotype of AT?

A
  • progressive cerebellar ataxia
  • oculocutaneous telangiectasia
  • immunodeficiency
  • increased risk of cancer.

Hypersensitive to ionising radiation and agents that result in DNA breaks.

Not hypersensitive to UV light.

187
Q

What is Fanconi Anaemia?

A

Fanconi Anemia
● Autosomal recessive disorder
● Spontaneous chromosomal instability, sensitivity to DNA crosslinking, and IR.
● FANCD2 group of genes (including BRCA2) that play an important role in DNA repair and homologous recombination.

188
Q

The genetic disease due to a mutation of the Artemis protein is called?

A

Artemis-deficient Severe Combined Immunodeficiency Syndrome (SCID)
● Artemis complexes with DNA-PK, plays an important role in NHEJ and VDJ recombination (for B- and T- cell genes).
● Artemis-deficient cells are radiosensitive and exhibit increased chromosomal instability.

189
Q

Technique to generate cell survival curve from in vitro cells

A
  1. Cells from actively growing culture prepared into suspension using trypsin to help them detach from vessel
  2. Number of cells/volume counted (electronically)
  3. Cells seeded onto plate and incubated 1-2 weeks. Number of cells seeded recorded
  4. Colonies counted.
  5. Calculate plating efficiency (PE = #colonies/#seeded)
  6. Multiple plates seeded (one for each dose level being studied), if surviving fraction likely to be very low use more cells for that plate. # of cells seeded recorded.
  7. Exposure. Incubation 1-2 weeks. Staining and counting of colonies.
  8. Surviving fraction (SF) for each dose: SF = #colonies/(PE*number cells seeded)
  9. Plot serving fraction (y-axis) versus Dose (Gy)
190
Q

List in vivo techniques for quantifying cell survival:

Give a late responding tissue model

A

Basically count number of something (jejunal crypts, renal tubules ect)/volume and plot for dose.

1) Jejunal crypt cells - animals exposed to range of doses, sacrificed day 3, number of jejunal crypts/volume vs dose
2) Testes stem cells - similar to above but 6 weeks
3) Kidney tubules - For late responding tissue. Count regenerating tubules after 60 weeks.
4) Spleen colony assay - For lymphomas
5) Lung colony assay - transplant mouse tumours that are known to met to lung

191
Q

The biological effect of a given dose can be reduced by lowering (and consequently the …….. time) the dose rate (which increases ?).

Broadly this is due to what?

A

Biological effect of a given dose is reduced with lowering dose-rate and increasing exposure time.

● This results from the repair of sublethal damage that occurs during long radiation exposure.

192
Q

How would you graph acute exposure/high dose rate, versus low dose rate:

A

● For acute exposures at high dose rates, the SF has a significant initial shoulder (more “beta-like”).
● As dose rate decreases and treatment time increases, more SLD can be repaired during radiation exposure.
● Hence, SF curve becomes more shallow and the shoulder tends to disappear (could draw up arrows w/”SLD repair” labelled on)

193
Q

The inverse dose rate effect:

A

For some cell lines, if the dose rate becomes slow enough (1.5cGy/min) damage isn’t significant enough to trigger cell-cycle arrests in less sensitive /resistant phases of the cell cycle (e.g G1, S) and so cycle continues until sensitive phase G2 reached where the cell becomes arrested. This accumulated minor damage leading to increased cell kill at a low rate.

This can be exploited to give low dose rate treatments (implants) to susceptible tumours

194
Q

Give both forms of the linear quadratic equation:

What is the unit(s) for the alpha/beta ratio? Why?

A

S = e^-1(alphaD + betaD^2)

hence,

  • ln(S) = alphaD + betaD^2

Where Dose is in Gy,
alphaD/betaD^2 = alpha/(beta Gy)
Therefore in units Gy^-1

195
Q

The traditional X component biological explanation for the LQ model

When are these components equal?

A

(Its just the simplest 2nd -order equation describing a monotonically decreasing function - this over interpretation is dumb)

The LQ model assumes two components to radiation cell kill:
○ one that is proportional to dose and is the result of a single electron track (α)
○ one that is proportional to the square of the dose, resulting from chromosome breaks from two separate electron tracks (β)

● The components of cell killing are equal at a dose that is equal to the ratio of α and β
○ D=α/β
(ie. where single and double tracks equally as likely)

196
Q

The demarcation value between low and high LET is at about:

A

The demarcation value between low and high LET is at about 10 keV/μm.

197
Q

The α and β components of mammalian cell killing are equal at approximately what for early and late responding tissues?

A

The α and β components of mammalian cell killing are equal at approximately α/β = 10 Gy and α/β = 3 Gy for early and late responding tissue, respectively.

198
Q

Studies on experimental tumours suggest well oxygenated carcinomas of head and neck, and lung have α/β values similar to:

A

Oxygenated carcinomas of head and neck, and lung have α/β values similar to acutely responding tissues

199
Q

Limitations of the LQ model:

A

● Based on in vitro data – For example does not reflect fundamental in vivo processes like radiation induced T-cell response and revascularisation ect
● At very low doses per fraction <1 Gy, the LQ model could underestimate the biological effect of a given dose, due to the low-dose hyper-radiosensitivity phenomenon.
● At very high doses per fraction >6 Gy, the LQ model underestimates the biological effect due to factors such as vascular and stromal damage not being taken into account.
● Difficult to relate to underlying radiobiological mechanisms
● The LQ formula does not include a time factor and assumes sufficient time between fractions for repair of sublethal damage
● It does not take into account tissue/tumour repopulation over time
● It has not been validated with concurrent chemotherapy.

200
Q

In terms of cell survival, how would you graph:

1) Difference between densely ionising and sparsely ionising radiation
2) Early versus late responding tissue

A

Y axis: Surviving fraction [10^-4, 10^-3 …… 10^0]
X axis: Dose (Gy): 0, 2, 4, 6, 8, 10, 12 (allows α/β <3, and α/β > 10 Gy)

1) High LET (e.g. α particle): Pretty much a straight line terminating at 4Gy intersection w/10^-3. Low LET (e.g. XR) draw a normal curve: a bit of the shoulder, then hits 10^-3 around 10Gy
2) Draw horizontal line x=10^0. Draw 2 limit slopes 1st. The straighter high α/β should go under the high α/β at until 6Gy then terminate at 10^-3 at >12Gy. Draw limit slope in way that α/β = >10Gy. Terminate Low α/β line around 10Gy, α/β <3Gy

201
Q

On a cell survival graph, what are:

D0 (Dzero)
D1
n
Dq

A

D0 (Dzero) = On exponential part of curve the change in dose that results in a scaling of survival by e^-1 (ie. SF x 0.37). This has historical roots in Target Theory

D1 = Is like D0, but is the dose required for the initial 37% reduction in SF

n = where a straight line from D0 would intersect y-axis (once thought related to number of target in cells)

Dq = where above line to n intersects the horizontal line y=1.

202
Q

What type of graph would you use to relate the LQ model to fractionation?

How would you show late versus early responding tissues?

A

The Effective Survival curve =
Where sufficient time is allowed for SLD repair, then effective curve is a composite of initial shoulder curve repeated for the number fractional doses.

If the initial shoulder is repeated then early responding tissues (straight line/high α/β) should be more suited to fractionation. I.e late responding tissues need big enough fractions to overcome the shoulder and reach the exponential portion of the curve.

203
Q

5 Rs of fractionation:

A

1) Repair
2) Repopulation
3) Redistribution
4) Re-oxygenation
5) Radiosensitivity (intrinsic)

204
Q

● Late responding tissues have:
a ….. α/β ratio and are ……. sensitive to changes in dose per fraction
● Early responding tissues have:
a ….. α/β ratio and are ……. sensitive to changes in dose per fraction

A

● Late responding tissues have low α/β ratio and are more sensitive to changes in dose per fraction
● Early responding tissues have high α/β ratio and are less sensitive to changes in dose per fraction

205
Q

The LQ model assumes sufficient time between fractions to allow for repair

If insufficient time for repair is given between treatments, there will be accumulated residual unrepaired damage and damage from the next fraction.

This results in:

It is determined by what metric?

A

1) Decrease in isoeffective dose
2) Decreased tissue tolerance

Determined by the repair halftime of the tissues
○ time required between fractions in low dose rate treatments, for half the maximum repair to take place.
○ 4-5 hours for some organs, possibly longer for spinal cord and brain.

206
Q

What measure typically suggests fractions given only 4 hours apart is a bad idea?

A

The repair halftime of the tissues
○ time required between fractions in low dose rate treatments, for half the maximum repair to take place.
○ 4-5 hours for some organs, possibly longer for spinal cord and brain.

207
Q

Define BED

Can it be used to predict responses in different tissues?

A

Relates a tissue response/Captures the relationship between the dose required to produce a particular effect (BED)The total dose, delivered in infinitely small fractions, that would be required to produce a particular effect as indicated by the LQ-equation.

● BED=total dose (nd) x relative dose effectiveness (rde)

rde = 1+(dose/(α/β )

BED for different α/β ratios are not directly comparable. i.e. different tissues, also differnt endpoints

208
Q

Define EQD2

What is a critical dependency of this calculation?

A

Equivalent dose in 2Gy #s:

EQD2 = D(d+α/β )/(2+ (α/β ))
where D = total dose given with fraction doses d.

It is critically dependent on the end-point being considered.

209
Q

In terms of fractionation, how can tumour proliferation be taken into account when deciding a dose to achieve a particular end-point?

A

The reduction in biological effectiveness (BED) can be determined by considering the potential doubling time of tumour

BED- gamma(t/Tpot)

where gamma is ln(2)/Tpot - which relates to the doubling time of the tumour within the between fractions time window t.

210
Q

What is “Double Trouble”

What does it imply?

A

A hot spot within a treatment field receives BOTH:

1) a higher dose, and
2) higher dose per fraction

Markedly increases the biological effect (i.e the Biologically effective dose increases).

● It is important to note where hotspots are in the treatment plan and if they could lead to more normal tissue toxicity than expected.

211
Q

The LQ model assumes sufficient time between fractions to allow for repair. How then can brachytherapy be related to it?

A

LDR equivalent to multiple infinitely small fractions without interfraction intervals
○ damage induction and repair takes place simultaneously.

212
Q

The relative biological effectiveness (RBE) is:

It is an empirical value that varies depending:

A

The RBE is:
The ratio of biological effectiveness of one type of ionizing radiation (E.g LET) relative to another (Dome standard), given the same amount of absorbed energy.

The RBE is an empirical value that varies depending on:

1) type of ionizing radiation,
2) energies involved,
3) biological effects being considered such as cell death,
4) oxygen tension of the tissues (oxygen effect).

213
Q

Relative biological effectiveness (RBE) is typically used to describe the differnece between:

How would you graph that?

A

Difference bettwen high LET (e.g. α particle) and conventional photons.

Make a Cell Survival curve. Graph a straightish line terminating at 4-5Gy for high LET. A “mid” responding tissue line for XR. Pick an outcome (e.g 10^-2 SF) draw a horizontal line between the points on each graph at this outcome - thats the RBE.

214
Q

How would you correct BED to account for tumour profliferation?

What about to account for time between fraction

A

BED gives the total dose required (give n in small fractional doses) to produce a particular effect. Which is dependedent on total dose, dose per fraction and α/β

d=dose
BED = (d x num #s)(1 + d/αβratio)

T is time between doses
ln(2) = 0.693
Proflif during Tx = BED - (0.693xT)/(αTpot)
i.e the equivalent dose is less due to interval time and proliferation scaled by sensitivity

215
Q

The 2 methods of calculating iso-effective doses for different fractionation.

How are they different/related

A

Biologically effective dose
EQD2 = Equivalent dose

BED=total dose (D) x relative effectiveness (RE)
RE = 1+(d/αβratio)

EQD2 = D(d+α/β )/(2+ (α/β ))
Hence,
EQD2 = BED/1+(2/αβratio)

So while one if more concerned with finding a biologically effective dose, and the other an equivalent dose, they use the same terms, and hence can be related to each other.

216
Q

Why is EQD2 preferred over BED?

A

Easier to under stand
More clinically practical
More familiar to clinicians
More easily related to clinical experience

217
Q

A BED for Brachytherapy can be derived, and relies on what variables?

A

Dose rate
Time interval of dose rate
Repair rate constant
α/β

218
Q

What is the “double benefit” of brachytherapy?

A

1) The volume effect (less volume of normal tissue treated) and
2) Low dose rate effect on normal tissues.
Hence, ‘double benefit’

219
Q

In terms of the 5 R’s of fractionation, explain how Repair may lead to preferential tumour cell kill:

A

Normal cells have intact repair pathways to repair sub-lethal DNA damage before the next fraction is given but cell cycle checkpoints and repair mechanisms are usually lacking in tumour cells (from lack of tumour suppressor function eg p53), leading to preferential cell kill.

220
Q

What is the role of Repopulation in fractionation?

What type of cell is it mainly concerned with?

A

The regeneration response of early-responding tissues in between fractions, leading to increased tolerance for normal tissues and increased radioresistance for tumours, with increasing overall treatment time.

I.e the longer the treatment the more regeneration with radioresistant tumour cells.
BUT
The more regeneration of tolerant normal tissue.

221
Q

Repopulation is important in what tumours, and what tissues?

Has little consequence in?

A

Repopulation is important in:

  • tumours whose stem cells are capable of rapid proliferation
  • acutely responding normal tissues, e.g. skin, GI tract, oral mucosa

has little consequence in late-responding, slowly proliferating tissues, e.g. kidney

222
Q

Repopulation, occurring at 2-4 weeks after start of RT, is due to increase
in proliferation of ? and results in:

How was this found?

A

Repopulation, occurring at 2-4 weeks after start of RT, is due to increase
in proliferation of clonogenic cells and results in:
 Decreased local control of cancer cells
 Decreased acute toxicity

Whithers 1988 - review of H&N SCC - little diff in dose for 50% tumour control for shedules <4weeks, but control dose incre 0.4 - 0.8 Gy/# after 4 weeks

223
Q

In terms of the 5 R’s of fractionation, how does Redistribution occur?

A

Radiosensitivity of cells varies through cell cycle (M > G2 > G1 > S early > S late)

The population that survive irradiation become more synchronous (e.g. more cells in S phase have maintained their reproductive integrity)

At the next fraction a greater proportion of surving cells may therefore be in a more sensitive phase. Also some damage accumulated in less sensitive phases may cause arrest in G2 where cells may still be when next fraction delivered (and therefore be more sensitive).

224
Q

In terms of the 5 R’s of fractionation, Redistribution implies what about fractionation?

What about high dose (possibly single fraction treatments)?

A

Redistribution makes the cell population more sensitive to fractionated treatment as compared with a single dose.

For high dose/low or single fraction treatments cells in less sensitive phase of cycle may evade death.

225
Q

How may (re)oxygenation relate to increased cell kill using fractionation?

A

1) When oxic cells are killed by radiation, the hypoxic fraction moves closer to the blood supply and become relatively oxic and hence more radiosensitive with the next fraction.
2) In acute hypoxia tumour cells that are transiently hypoxic could be oxic when the next fraction is given.

226
Q

How is instrinsic radiosensitivity often measured/subsequently described?

A

Often described in terms of surving fraction after 2Gy (SF2) - Alternative is area under survival curve.

227
Q

Examples of:

1) Radiosensitive tumours
2) Intermediate
3) Resistant

A

1) Radiosensitive tumours:
Neuroblastoma, lymphoma, myeloma 0.19
SF2 of about 0.19

2) Intermediate:
Breast, bladder, cervix ca. Lung SCC SF2 of about 0.46,

3) Resistant:
Melanoma, osteosarcoma,
glioblastoma, renal ca.
SF2 of about 0.52

228
Q

α/β Ratio for tumours of:

1) Prostate
2) Breast
3) Melanoma
4) Skin
5) General H&N

A

α/β Ratio for tumours of:

1) Prostate = 1.1
2) Breast = 4.6
3) Melanoma = 0.6
4) Skin = 8.5
5) General H&N = 10.5

229
Q

Relevance of the “5 Rs” to Hypofractionation/Stereotactic XRT

A

Hypo fractionation causes more hypoxia = less oxic enhanced cell killing (it has been argued enhanced immune response offsets this).

Hypo fractionation may benefit slow growing tumours (low α/β e.g. melanoma/prostate) where IR sensitivity is low (i.e. larger dose per/# needed)

Shorter courses limit accelerated repopulation

Hypo fractionation may not benefit greatly from redistribution BUT more damage per fraction may also be more difficult to repair.

230
Q

Hypo fractionation may improve cell kill for …… responding tumours,

But the effects of hypofractionation on normal tissue will depend very much on whether the normal tissue is a ……. or ……. arranged organ.

A

Hypo fractionation may improve cell kill for late responding tumours,

But the effects of hypofractionation on normal tissue will depend very much on whether the normal tissue is a serial or parallel arranged organ. (i.e serial much more sensitive)

231
Q

For external beam RT of tumours.:

Must fractionate treatment because:
1)
2)

Must prolong treatment to:

Would like to shorten treatment because:

A

For external beam RT of tumors…

Must fractionate treatment:

1) To overcome hypoxia
2) So fractionation spares late-responding tissues compared to most tumours

Must prolong treatment:
To limit early sequelae

Would like to shorten treatment:
To prevent accelerated repopulation

232
Q

Normal tissue repair is typically around ? But in some cases (e.g. spinal cord) may be as long as?

What variable captures this interval?

A

Normal tissue repair is typically around 6hrs. But in some cases (e.g. spinal cord) may be as long as 24hrs.

The influence of incomplete repair is described by the repair half time (T-half)

233
Q

The implication of incomplete time for repair between fractions is?

Therefore:

A

The implication of incomplete time for repair between fractions is accumulation of unprepared damage, and an interaction with damage from previous fraction(s) and the next.

Therefore much less dose needed to produce the same effect.

234
Q

Incomplete time for repair between fractions causes accumulation of unprepared damage, and an interaction with damage from previous fraction(s) and the next.

Therefore much less dose needed to produce the same effect.

How can this dose schedule be related to standard fractionation

A

Modify EQD2 by incorporating incomplete repair with variable Hm which depends on the number m of fractions, the time interval between them, and the Thalf of tissue.

EQD2 = D( d(1+Hm)+α/β / 2+ α/β )

235
Q

Define hyper fractionation:

A

Hyper fractionation =

Treatment schedule where dose per fraction is reduced below the conventional 1.8-2Gy fractions.

236
Q

Aim of HYPERfractionation:

Underlying mechanism for this

Main pitfall, and method to overcome it

A

Aims to increase total dose to the tumour while sparing late normal tissue side effects.

Due to more time for normal tissue repair.

But conversely increased possibility of tumour repopulation.
Therefore usually given twice daily

237
Q

Define HYPOfractionation:

A

Treatment schedule where dose per fraction more than 1.8-2 Gy is used

238
Q

Why hypo fractionate?

A

1) Decrease treatment time
2) Increased late responding tumour cell kill
3) Stereotactic radiotherapy- ablative doses while sparing surrounding normal tissues
4) Palliative radiotherapy- less concern for late side effects, more convenient for the patient.

239
Q

Main pitfall of HYPOfractionation:

Potential work around:

A

Due to increased effects on normal tissue (especially serial arranged tissue), total dose is usually decreased.

240
Q

Define Accelerated fractionation:

A

Accelerated fractionation =

Increased weekly dose >10Gy/ week

241
Q

Benefit and pitfalls of Accelerated Fractionation:

A

○ Shortens overall treatment time to counter tissue repopulation
○ normal early effects expected to increase

○ often hyperfractionated to reduce late side effects.
○ Care must be taken to ensure sufficient repair time between fractions

242
Q

In terms of effects of fractionation:

Early effects are dependent on:
Late effects are dependent on:

A

Early: Total dose, Treatment time (increasing T causes more acute effects), dose per fraction less important.

Late: Total dose, dose per fraction, overall treatment time has little effect.

243
Q

Increasing total treatment time (e.g. from 2 to 4 weeks) will likely?

Increasing dose per fraction (without changing total dose or total treatment time i.e compensating for larger time intervals) will likely?

A

Increase acute effects, but not change severity of late effects.

Increase late side effects, not change degree of acute side effects very much.

244
Q

The reason behind using ‘typical’ fractionation schedules for curative intent versus those used palliatively:

A

Can be broken into 3 considerations:

1) Aim: Symptom control vs reproductive death of all tumour cells.
2) Dose required for desired effect: e.g symptom relief balanced by toxicity vs eradicate all clonogens, tolerate more toxicity
3) Acute and late toxicities have different emphasis in these 2 groups.

245
Q

How do the ‘5 Rs’ relate to Brachytherapy?

A

Brachy = infinite number infinite small #s.

Repair - modifies radio sensitivity at higher dose rates (favours late responding tissue relative to tumours)
Repopulation - modifies sensitivity at very low dose rates (favours tumours)
Redistribution/reoxygenation are intermediate.

Radiosensitivity determine how effective treatment is with increasing distance from source.

246
Q

How does the effectiveness of Brachytherapy vary with dose rate?

A

● As dose rate decreases below 1 Gy/min, radiosensitivity decreases, curves become straighter.
● As dose decreases below <1 cGy/min repopulation further improves cell survival.
● Inverse dose rate effect
○ low-dose hyper-radiosensitivity
○ slight increase in cell kill with further lowering of the dose rate
○ Thought to be due to accumulation of cells in G2, increasing radiosensitivity and radiation damage.

247
Q

High energy charged particle collision with H20 produces?

Which may then go on to?

A

Hydroxyl free radicals

May then go on to damage DNA.

248
Q

What is the explanation for why oxygen enhance IR damage?

A

The Oxygen Fixation Hypothesis:

1) Sparsely ionising (i.e. low LET) radiation causes damage via free radical production
2) Under hypoxic conditions free radicals are repaired by sulfhydral groups
3) In normoxic conditions damage is not repaired rather it is ‘fixed’ (in the “stuck with”/permanent sense of the word) permanently and irreversibly

249
Q

How much oxygen is needed to demonstrate sensitiser effect?

A

● Concentration of oxygen needed to produce an effect is low.
○ 3 mmHg or 0.5% oxygen concentration results in radiosensitivity halfway between hypoxia and fully oxygenated conditions
○ Radiosensitivity at 30 mmHg or 5% O2 is almost at fully oxygenated levels

250
Q

How may fractionation be effective in:

1) Chronic hypoxia
2) Acute Hypoxia

A

1) Chronic hypoxia
Death of oxygenated cells leads to diffusion of oxygen to hypoxic cells, rendering them more sensitive to radiation at the next fraction.

2) Acute hypoxia
Caused by temporary blockage or closure of a blood vessel. causing intermittent hypoxia
■ hypoxic cells could become oxygenated during the next fraction

251
Q

How does chronic hypoxia occur in tumours?

Hypoxia allows tumour to be divided into what layers?

A

Due to outgrowing of blood supply.
Distance of oxygen diffusion from capillaries is about 70 μm with variations from arterial to venous ends.

Creates three layers of cells:

  1. proliferating well
  2. region where cells can survive and remain clonogenic but radioresistant
  3. dead or dying cells.
252
Q

What is the OER?

A

The ratio of dose under hypoxic conditions to the dose under aerated conditions to produce the same biological effect.

253
Q

Typical values of OER:

A

Low LET radiation: Usually 2.5-3
High LET: Closer to 1 for high LET (ie. no oxygen effect)
Neutrons ~ 1.6

254
Q

Evidence supporting significance of tumour hypoxia in radiotherapy effectiveness comes from what sources?

A

1) Animal studies: Mouse sarcomas air breathing vs Nitrogen asphyxiated
2) Clonogenic assays (normal vs clamped conditions)
3) DNA damage assays
4) Clinical:
i) Observation H&N cancers Eppendorph probes
ii) Pharma Interventional: E.g. DAHANCA 2 and 5, ACRON

255
Q

List methods to overcome hypoxia:

A

1) Fractionation
2) High LET XRT
3) Hypoxic cell sensitisers (the nitronazoles: misonidazole, nimonidazole)
4) Blood transfusion - Nil sigbif benefit
5) Nicotinamide and carbogen gas (95%02, 5%C02) - ACRON trial - improved local control in H&N Ca
6) Hyperthermia - ?evidence
7) Hyperbaric O2 - Small benefit, but difficult to deliver
8) Hypoxic cell cytotoxins: Inactive in aerobic cells. Highly toxic but big effect.

256
Q

What is the main class of Hypoxic cell sensitisers (give to examples)?

How do they work?

What limits the dose that can be given?

A

Nitroimidazoles. E.g Misonidazole (old more toxic), Nimonidazole (new, less toxic - DAHANCA 5)

MOA:
○ Mimics sensitizing effect of oxygen
○ Diffuses out of tumour vasculature to reach hypoxic cells.

Dose limited by neurotoxicity

257
Q

Key hypoxic cell sensitiser studies:

A
H&amp;N Ca studies:
DAHANCA 2 (Misonidazole - effective dose limited by toxicity). Less effect than hoped. More effective for worse prognosis Ca.
DAHANCA 5 (Nimonidazole - higher dose could be given as less toxic): both local control and PFS increased.
258
Q

What is the aim of nicotinamide (aka?) and carbogen gas?

What is the trial? What did it find?

A

Overcome BOTH acute and chronic hypoxia.

Vit B3 - prevents transient fluctuations in tumour blood flow - prevents Acute Hypoxia.

Carbogen (5%CO2, 95% O2): Overcome chronic hypoxia.

ACRON trial - improved local control in H&N Ca

259
Q

Hypoxic tumours are more sensitive to effects of hyperthermia because:

A

Hypoxic tumours are more sensitive to effects of hyperthermia
■ reduced blood flow
■ reduced pH

260
Q

Hypoxia and reoxygenation causes aberrant?

leading to?

Hypoxia also reduces expression and function of

Cells have increased …… frequency and genetic …. when grown in hypoxic conditions in vitro.

A

Hypoxia and reoxygenation causes aberrant DNA synthesis, leading to over-replication and gene amplification

Hypoxia also reduces expression and function of DNA repair genes.

Cells have increased mutation frequency and genetic instability when grown in hypoxic conditions in vitro.

261
Q

What are the potential consequences of hypoxia for genetic instability?

A

1) Causes aberrant DNA synthesis, leading to over-replication and gene amplification
2) Reduces expression and function of DNA repair genes.

262
Q

2 types of ionising radiation:

Define each, list main examples

A

1) Directly Ionising:
○ Interacts directly with ionizing electron and ionizes atom.
○ Charged particles
■ alpha particle
■ beta particle
■ heavy charged particles eg protons and ions

2) Indirectly Ionising:
○ requires two step process- liberation of a charged particle that goes on to ionize other atoms
○ Uncharged particles
■ photons: capable of ionizing atoms, majority of energy is deposited via a two-step process hence considered indirectly ionizing
■ neutron: interacts with nucleus, liberates protons

263
Q

Define LET

Units?

A

The energy deposited by a particle per unit length while traversing through matter.

Units: keV/um

264
Q

Two methods to calculate LET?

A

Divide track of radiation:
1) Into intervals of equal length and take average energy in each = TRACK AVERAGE

or,

2) Divide track into intervals each with equal energy, take average interval length = ENRGY AVERAGE

265
Q

Typical LET for Cobalt-60 gamma rays:

Why is this number useful to know?

The alternative?

A

LET = 0.2 keV/um

Often the reference radiation for RBE calculations (which is the ratio of doses required to produce a given biological effect)

The alternative reference for Low LET is
250 keV XRs = 2 keV/um

266
Q

With increasing energy what happens to the LET of charged particles?

A

For a given charged particle, the higher the energy the lower the LET, as secondary electrons travel away from the area of interest.

E.g: 150MeV protons have LET of 0.5keV/um
whereas 10MeV protons have LET 4.7 keV/um

267
Q

Average LET for:
250 keV XRs
Cobalt-60 gamma rays
Alpha particles

A

250 keV XRs = 2 keV/um
Cobalt-60 gamma rays = 0.2 keV/um
Alpha particles = 166 keV/um

268
Q

In comparison to low LET, high LET radiation:

1) Largely causes what type of damage?
2) Its reliance on what is subsequently?
3) Position of cycle is of what importance?
4) Cell survival curves will appear?

A

● High LET
○ Tends to cause direct DNA damage
○ Less reliant on free radical production
■ hence less effect of free radical scavengers

○ Less reliant on oxygen effect (due to less indirect action)

○ Less reliant on position of cell cycle

○ Steeper cell survival curve with less shoulder

269
Q

In comparison to high LET, low LET radiation:

1) Largely causes what type of damage?
2) Its reliance on what is subsequently?
3) Position of cycle is of what importance?
4) Cell survival curves will appear?

A

● Low LET
○ tends to cause indirect damage
■ production of hydroxyl radicals by ionization of water, which cause DNA damage
● hence affected by free radical scavengers
■ Also affected by presence or absence of Oxygen.
■ Affected by position of cell cycle

270
Q

Define Relative Biological Effectiveness

A

RBE := The ratio
dose required to cause biological effect using reference radiation (Dref) - typically low LET cobalt-60 or 250keV

Divided by

dose required to cause same biological effect using test radiation (Dtest)

RBE = Dref/Dtest

271
Q

Relationship between LET and RBE

A

As LET increases the RBE increase, reaching a peak (optimum) around 100keV/um, after this more damage is done than is needed to kill cells - so high LET cannot get anymore effective

272
Q

How would you graph the effectiveness of increasing LET and its relationship with OER?

A

y-axis (left) RBE [0 to 10]
y axis (right) OER [1, 2, 3]
x-axis LET (units keV/um): log10[0.1, 1, 10, 100, 1000]

RBE exponential curve peaking at a little over 100 (point of inflexion around 80), with steep drop off

OER slowly decreasing with til about ~50, then steep drop off

273
Q

At 100 keV/μm the separation of ionizing events is roughly equal to the diameter of?

● Hence 100 keV/μm is the LET that deposits energy causing just enough … … to cause cell death.

A

At 100 keV/μm the separation of ionizing events is roughly equal to the diameter of DNA double helix (2nm)

● Hence 100 keV/μm is the LET that deposits energy causing just enough DNA DSB to cause cell death.

274
Q

The therapeutic window can be demonstrated by plotting which 2 curves?

This shape can be modelled by what type of statistics?

A

The 2 dose response curves:

1) Tumour Control Probability
2) Normal Tissue Control Probability

Can be modelled by Poissonian statistics:
E.g if dose sufficient to on average cause one lethal hit per cell then, number of cells receiving lethal hits is 67%

275
Q

The steepness of of a dose response curve at a given dose is described by the variable?

A

Gamma, which is low at start and end, highest at point of inflexion.

Gamma at 50% response is Gamma50 and is often included in tables.

276
Q

Factors affecting the steepness of a Tumour Control Probability Curve:

A

1) Intrinsic radiosensitivity
2) Tumour heterogeneity
3) Chemical factors: oxygen, radiosensiters and protectors
4) Organisation of tissue
5) Host factors: age, syndromes/co-morbities
6) Radiation quality

277
Q

Factors affecting the steepness of a Normal Tissue Control Probability Curve:

A
risk factors eg. 
■	smoking 
■	previous treatment to the area
■	age
■	concurrent chemotherapy
■	co-morbidities eg. COPD for risk of radiation fibrosis
■	use of radioprotectors
■	hyperbaric oxygen
278
Q

Define Therapeutic Ratio

What is the ideal?

A

Dose to achieve a desired level of tumour control compared with the normal tissue response at that dose.

When TR is high good tumour control is achieved low normal tissue damage.

279
Q

How can the therapeutic Ratio (TR) be improved?

A

1) Sensitisers: I.e increase tumour cell kill relative to normal tissue.
2) Fractionation: I.e Hyperfractionation spares late responding tissue
3) Radioprotectors - protect normal tissue from radiation.

280
Q

What type of fractionation may improve the therapeutic ratio?

Why?

A

Hyperfractionation: spares late-responding tissues relative to tumours

281
Q

“Radiocurability” refers to?

A

The possibility of eradicating the tumour at its primary site with radiotherapy

282
Q

“Radioresponsiveness” refers to?

A

The overall level of clinical response to radiotherapy

283
Q

The major factors influencing tumour control can be divided into what 4 groups?

A

1) Physical: Dose/rate, fractionation, beam quality, temp
2) Chemical: Sensitisers, protectors, Oxygen
3) Biological: Intrinsic radiosensitivity, tissue organisation, tumour size/clonogen number, host factors
4) Technical factors = inaccuracies - hotspots, geographic miss.

284
Q

Give example(s) of each chemical major chemical factor that may influence tumour control.

A

1) Oxygen: nimodazole
2) Sensitisers: Chemotherapy: 5-FU, cisplatin, taxanes
3) Radioprotectors: Amifostine

285
Q

What is Amifostine?

A

Amifostine detoxifies reactive metabolites of platinum and alkylating agents, as well as scavenges free radicals.

Used to prevent or lessen the damage to the kidneys caused by cisplatin (a chemotherapy) or damage to the salivary glands, caused by radiation therapy,

286
Q

Physical factors that influence tumour control:

A
Physical factors
●	Total dose
●	Dose rate
●	Dose/fraction
●	Radiation quality
●	Hyperthermia
○	T>45 C results in direct cellular killing
○	T 40-43 C increases radiosensitivity by stimulating vascular activity, increasing oxygenation.
287
Q

Biological factors that influence tumour control:

A
Biological factors
●	radiosensitivity
○	position in cell cycle
○	cell type
●	organization of tissue
○	serial vs parallel
●	clonogen number/size of tumour
●	host factors
○	age
○	radiosensitivity syndromes
○	comorbidities eg diabetes, scleroderma
○	Volume of normal tissue irradiated !!!!!!!
288
Q

Host biological factors that influence tumour control:

A
host factors
○	age
○	radiosensitivity syndromes
○	comorbidities eg diabetes, scleroderma
○	Volume of normal tissue irradiated !!!!!!!
289
Q

Technical Factors that influence tumour control:

A

Inaccuracies in delivery
○ hot spots- double trouble

○ geographic miss- leads to insufficient treatment of tumour and higher volume of normal tissue being irradiated

290
Q

Law of Bergonie and Tribondeau

A

Cells that are less differentiated, have greater proliferative capacity and divide more rapidly are more radiosensitive

291
Q

In normal tissue most effects of radiation are due to

A

In normal tissue most effects of radiation are due to the depletion of a cell population by cell-killing

292
Q

The response of of normal tissue in terms of cell kill is governed by 3 main factors:

A

○ Inherent cellular radiosensitivity
○ Kinetics of the tissue = Law of Bergonie and Tribondeau
○ Organization of the tissue

293
Q

The official timeframe for calling an effect early/acute is:

These are typically seen in?

Therefore typically reflects:

The upside of this cell population?

A

Within 90 days

Usually tissues with rapid turnover rate.

Therefore results in progressive cell depletion

However rapid growth me imply repaired rapidly and injury may be completely reversible

294
Q

Persistent severe acute normal tissue radiation effects could result in:

A

Persistent severe acute normal tissue radiation effects could result in chronic late effect, the consequential late effects

295
Q

The time-course of the early radiation effects is determined by:

A

The time-course of the early radiation effects is determined by:
1) The overall cell turnover time

2) Dose: I.e fewer stem cells survive - slower repair.

296
Q

Phases of early reactions

A

1) Proinflammatory phase: Proteins COX-2, IL-1, TNF-A
2) Cellular depletion: Due to stem cell loss - leads to inability to sufficiently re-populate functional compartment.
3) Recovery - determined by dose (surviving stem cells) and cell growth

297
Q

Onset of late radiation effects in normal tissue is defined as:

Most often occur in?

Much more sensitive to changes in

A

Onset after 90 days

Most often occur in late responding tissue

Much more sensitive to changes in fractionation

298
Q

Rather than acute cell death, typically late normal tissue toxicity, may reflect:

A

1) Vascular injury - loss capillaries, loss of arteriolar smooth muscle (telangiectasia) = impaired diffusion
2) Fibroblast proliferation - Increased collagen synthesis.
3) Loss of parenchymal cells

299
Q

In regards to normal tissue effects what is “Latency”

A

The time period between radiation and clinical signs of cell injury.

Latency also described as time period during which cells are undergoing mitotic death but there is no evidence of injury clinically.

300
Q

How does the latency of normal tissue effects vary with dose?

A

1) In rapidly dividing cells latency is short, and independent of dose (above some critical amount)
2) In slowly dividing tissues latency is long, and is dose dependent

301
Q

Broadly (without recourse to the arrangement of functional cells within an organ), normal tissue tolerance depends on:

A

Normal tissue tolerance depends on number of surviving cells able to maintain organ function

302
Q

Define the volume effect:

R

A

Generally the total dose that can be tolerated by a normal tissue is dependent on the volume that is irradiated (with larger volumes tolerating less dose). Of critical importance to a tissue’s sensitivity to volume irradiated is the arrangement of functional subunits (FSUs) within the tissue.

303
Q

Relate the volume effect to functional subunits

A

Organs with a serial arrangement of FSUs exhibit a binary (all or nothing) response to radiation - loosing function when a critical dose/volume threshold is crossed.

Organ

304
Q

FSUs are described in terms of 2 things:

A

1) Arrangement: Serial vs parallel

2) Structure: Defined vs undefined

305
Q

What are structurally defined FSUs? Give examples.

Implication for repair?
Dose response pattern?

A

Anatomically delineated structures with clear corresponding tissue function eg. nephrons, liver lobules.
Each FSU is small and autonomous.

Implication for repair:
■ Surviving clonogens cannot migrate from one FSU to another.

Dose response pattern:
■ Depleted by small doses.

306
Q

An alternative to describing tissue in terms of FSU (structurally defined or undefined) is what classification?
What two types of populations does it define?

A

Michaelowski Classification of Tissues:
described tissues as either hierarchical or flexible, based on their cell populations comprised of a combination of 3 types of cell: Stem cell, Mature functional cell, in between = maturing.

● Hierarchical type:
Populations of all three types, with stem cells constantly giving rise to maturing cells which eventually fully differentiate and become functional cells. Hierarchical tissues include most epithelial layers and the bone marrow.

● Flexible cells:
Cells rarely divide but may be induced to by damage. Their cells are functional but retain the ability to re-enter the cell cycle if required. F-type tissues include the liver, thyroid and the dermis of the skin.
○ no compartments and strict hierarchy.

307
Q

In general,

H-type tissues:

A

In general, H-type tissues

1) Respond rapidly to radiation damage as the stem cell population is killed.
2) This prevents the production of more maturing cells and leads to symptoms related to this – eg: thinning of epithelium or decrease in blood cell production.

308
Q

F-type tissues:
Respond to radiation damage at what speed?
Why?
The symptoms reflect:

A

F-type tissues may not display damage for some time, particularly if the dose is small, because not all cells enter the cell cycle immediately.
○ can be triggered to divide by damage to the tissue
○ no compartments and strict hierarchy.

309
Q

The Abscopal effect is thought to be mediated by:

A symptom due to the abscopal effect is?

A

Release of cytokines, hormones and immune (e.g Tcell mediated) sensitising.

A symptom due to the abscopal effect is fatigue.

310
Q

The Bystander effect is thought due to:

Most prominent in cells that are:

A

○ thought to be due to release of cell-damaging enzymes during death
○ seen in cells connected with gap junctions.

311
Q

In relation to normal tissue injury, in broad terms stem cell depletion is a response to?

Whereas tissue hypoplasia reflects both ….. and …..

A

In relation to normal tissue injury, in broad terms stem cell depletion is a response to dose. Therefore stem cell asymmetry loss is a dose response as may be accelerated repopulation.

Whereas tissue hypoplasia reflects both dose and volume. Therefore accelerated proliferation and abortive proliferation are more responses to volume.

312
Q

Post radiation regeneration of normal tissues is considered over a timeframe:

1) Within minutes to hours what occurs?
2) In days to weeks:
3) Months to years for some tissues:

A

○ Within minutes to hours there is repair of sublethal damage
○ In days to weeks there is radiation induced tissue regeneration
○ In months to years some tissues exhibit long term restoration

313
Q

List the 3 broad mechanisms of repopulation:

A

1) Acceleration of stem cell proliferation
2) Stem cell asymmetry
3) Abortive proliferation

314
Q

In terms of post radiation generation of normal tissue, what is Asymmetry loss?

A

■ New stem cells are produced to replace those that are killed by irradiation
■ Normally, stem cells divide into one stem cell and one differentiating cell asymmetric division)
■ Under duress, stem cells can divide into two stem cells to repopulate the pool (asymmetry loss)

315
Q

Define acceleration of stem cell proliferation

what is it dependent on?

A

■ Shortening of cell cycle time to compensate for cell loss

■ Dose dependent: higher dose = faster acceleration

316
Q

Abortive proliferation plays a role in?

What is it?

A

Abortive proliferation plays a role in post radiation generation of normal tissue.

■ Irradiated cells can undergo limited number of divisions before death, to maintain cell numbers.

317
Q

Asymmetry loss is controlled by ….. … ……… to compensate for …., whereas tissue ……. induces acceleration of proliferation and abortive proliferation to compensate for …. and ….. ……

A

Asymmetry loss is controlled by stem cell depletion to compensate for dose, whereas tissue hypoplasia induces acceleration of proliferation and abortive proliferation to compensate for dose and cell loss.

318
Q

Define normal tissue tolerance dose

A

The maximum dose that can be given without causing an unacceptably high probability of treatment complications.

319
Q

Tissue tolerance is dependent on:

A

Radiation quality, volume, concurrent treatments, patient/organ status

320
Q

In FSUs arranged in parallel there is a marked volume effect which determines ………. ….

A

In FSUs arranged in parallel there is a marked volume effect which determines tolerance dose

321
Q

Give an example of how a large volume, even with low dose, can determine clinical tolerance in parallel organ.

A

It is important to remember clinical tolerance, as opposed to just objective measures of some kind of injury.
E.g. Large skin ulcer leads to pain and slow healing whereas small ulcers heal quickly

322
Q

In discussing the mechanisms and effects of radiation on normal tissues. You could could divide the discussion into what 4 tissues/systems:

A

1) Parenchymal cells: Decreases in sensitivity according to Casarett from type I to IV
2) Connective tissue
3) Vascular system - commonly implicated in late effects. Includes vessels and heart.
4) Immune system

323
Q

According to Casarett Parenchymal tissue can be divided into what types?

Example of each.

A

○ 4 classes according to Casarett
○ Decreases in sensitivity from I to IV
Type:
I) Rapidly dividing undifferentiated = most sensitive. E.g germinal epidermis.
II) Dividing cell becoming differentiated. E.g myleocytes
III) Functional cells that can re-enter mitosis: E.g hepatocytes, renal cells
IV) Fully differentiated post mitotic cells - Cardiac myocytes, neurons, lymphocytes (lymphocytes are super radiosensitive however - go into apoptosis easily)

324
Q

The effect/consequence of radiation to connective tissue:

A

1) Fibroblasts: Radiation drives differentiation into fibrocytes (via TGF-B), similar to hypoxia. This results in collegen production and deposition and can clinically appear as radiation fibrosis.

325
Q

The mechanism for radiation fibrosis:

A

Radiation drives differentiation of fibroblasts into fibrocytes (via TGF-B), similar to hypoxia. This results in collegen production and deposition and can clinically appear as radiation fibrosis.

326
Q

Besides fibroblasts, what are some other radiation effects on connective tissue?

Give very basic mechanisms.

A

1) Cartilage: Very sensitive to radiation. Results in death of condroblasts. Dose >20Gy results in irreversible deficit. Adult cartilage is more resistant.
2) Bone: OsteoRADIOnecrosis - due to vascular effects.

327
Q

In the short term radiation to small capillaries may lead to:

Longer term? Resulting in?

In larger vessels, what major potential consequence?

A

Thrombosis and capillary necrosis

Smooth muscle cells diminish over several years resulting in telangestsia (larger capillaries and veins), and stenosis where college has replaced muscle.

In larger vessels, sub intimal deposition of lipids may result in atherosclerosis.

328
Q

Which are more sensitive to XRT veins or arteries?

Threshold for arterial damage:

Threshold for capillary damage:

A

Arteries - more myocytes/active tissue

> 50Gy is threshold for arteries
40Gy is threshold for capillaries

329
Q

What is the threshold dose for acute pericarditis?

When does it typically occur?

A

■ Acute pericarditis occurs after 12 months
■ Threshold dose is 20 Gy
■ 11% incidence at 45-50 Gy

330
Q

Radiation induced cardiomyopathy evolves over a period of:

Results from:

Threshold dose:

A

■ Radiation induced cardiomyopathy evolves over a period of years.
■ Results from dense and diffuse fibrosis
■ Threshold dose ~30 Gy if most of the heart treated. I.e volume effect in parallel tissue.

331
Q

Which immune cells are most sensitive to IR? Which the least?

A

Lymphocytes most sensitive

Macrophages the least

332
Q

Lymphocytes are very sensitive to IR, with sufficient dose they quickly go into:

Doses that result in prolonged T-cell lymphopoenia:

A

Lymphocytes are very sensitive to IR, with sufficient dose they quickly go into apoptosis

■ Total lymphoid irradiation of 30-40 Gy leads to prolonged T-cell lymphopoenia

333
Q

A person is exposed to radiation. They are not wearing any form of monitor. If you were asked to quantify the exposure what do you do?

A

1) Estimate the physical circumstances: The field, position in the field and duration spent there.
2) Biological dosimetry:
- Clinical symptoms. In particular onset of vommiting. Relate to acute radiation syndrome (e.g. provided by CDC)
- Lab investigations
i) Blood count - especially lymphocyte count over time (typically 6hrly/48hrs)
ii) Chromosome aberrations in peripheral lymphocytes
iii) Assays - especially Comet assay
iv) gammaH2AX

334
Q

Data for Acute Radiation Syndrome is derived from:

Can be seen in patients with how much exposure:

A

● Data from survivors of atom bombs and nuclear accidents

● Occurs with short exposure of dose >0.7 Gy to the whole body.

335
Q

If onset of vomiting after radiation exposure is greater than 2 hours this suggests absorbed dose:

If onset less than 30 mins suggests dose

A

○ If onset of vomiting greater than 2 hours after exposure suggests absorbed dose <2 Gy

○ If onset less than 30 mins suggests dose >6-8 Gy

336
Q

After radiation exposure lymphocyte count is typically monitored:

What other information is collected from lymphocytes?

A

After radiation exposure lymphocyte count is typically monitored every 6 hours for 48hrs

Chromosome aberrations in peripheral lymphocytes

337
Q

Chromosome aberrations in peripheral lymphocytes are a measure of radiation exposure.

What is a major limit to this method

Initial steps are necessary prior to assay.

A

Rapidly reducing numbers of lymphocytes following exposure may make studying them difficult.

As peripheral lymphocytes are typically in G0, PHA is needed to make them re-enter cell cycle.
Colchicine is then used to arrest cells in metaphase.
Chromosomes are then assessed by some form of assay (e.g. dicentric assay, translocation assay ect)

338
Q

Acute Radiation Syndrome is divided into what phases

A

1) Prodromal syndrome
2) Latent period
3) Manifest illness
4) Recovery or death

339
Q

In terms of the 1st phase (?name) of Acute Radiation Syndrome (ARS):
What is dose dependent?

A

Prodromal syndrome of ARS:

Time of onset, severity, and duration depends on dose.

340
Q
Acute Radiation Gastrointestinal Syndrome:
Is usually seen in doses >?
But can occur for doses as low as?
Onset and duration of prodromal phase?
The LD100 is about?
A

Dose>10Gy (But as low as 6Gy)

Onset within a few hours, lasts about 2 days.

The LD100 is about 10Gy

341
Q
Acute Radiation Gastrointestinal Syndrome:
Underlying mechanisms is:
Latent stage:
Death within?
Why do they die?
A

● Depopulation of the gastrointestinal epithelium
● Latent stage of a few days
● Death within 2 weeks from infection, dehydration and electrolyte imbalance

342
Q

What are the syndrome of Acute Radiation Syndrome?

At what doses do they occur?

A

1) Hematopoietic Syndrome: Dose>0.7Gy.
2) Gastrointestinal Syndrome: Dose >=10Gy (can be as low as 6)
3) Cerebrovascular Syndrome: Dose <50Gy

343
Q

Haematopoietic Syndrome
● Occurs when dose >?
● Due to?
● Latent phase? and due to?

A
Haematopoietic Syndrome
●	>0.7 Gy
●	Bone marrow failure.
●	Latent phase 1-6 weeks
●	Death in a few months from infection and haemorrhage.
344
Q
Cerebrovascular Syndrome
●	When dose is?
●	Onset within?
●	Causes?
●	death within?
A
Cerebrovascular Syndrome
●	>50 Gy
●	Onset within minutes
●	Uncontrolled intracranial hypertension and circulatory collapse, likely due to damage of microvasculature
●	death within 3 days
345
Q

The LD50/60 is the dose necessary to:

The LD100 is the dose necessary to:

A

The LD50/60 is the dose necessary to kill 50% of the exposed population in 60 days.
‡ The LD100 is the dose necessary to kill 100% of the exposed population

346
Q

At what dose would whole body radiation begin to cause epilation? At this dose, when might these Sx 1st appear?

A

> 2Gy, usually begins around day 15

347
Q

Diarrhoea is associated with total body doses greater than?

A

Diarrhoea is associated with total body doses greater than 6Gy

348
Q

Treatment of ARS?

One particular intervention is suitable when?

A

Treatment of ARS
● Predominantly supportive.
● Protective isolation and antibiotics can double LD50 to ~7 Gy

● Narrow window of bone marrow transplant
○ <7 Gy probably no benefit
○ >10 Gy patient will die from gastrointestinal syndrome.

349
Q
Cutaneous Radiation Injury
●	Radiation burns
Differ from thermal and chemical burns: 
●	Threshold for:
 epilation? ,
 erythema?
desquamation and ulceration?

Major complications:

A

Cutaneous Radiation Injury
● Radiation burns
Differ from thermal and chemical burns
1) latent period between exposure and effect
2) undergo recurrent breakdown even after scar formation
● Threshold for
epilation is 3 Sv,
erythema 6 Sv,
desquamation and ulceration >10 Sv.
● Can persist to develop chronic ulceration and infection.

350
Q

Major phases of foetal development. For each, what is the threshold dose of radiation after which developmental problems may occur?

A

1) Preimplantation 0-9 days
2) Organogenesis 10 days to 6 weeks
3) Foetal period 6 weeks to 9 months

The threshold dose for all is 0.1Gy

351
Q

For foetal development how long is the Preimplantation phase? What is the nature of the response to radiation?

A

Preimplantation 0-9 days.

All or nothing embryonic death response with threshold around 0.1Gy

352
Q

For foetal development how long is the Organogenesis phase? What is the nature of the response to radiation?

A

Organogenesis 10 days to 6 weeks
○ Radiation causes major structural congenital anomalies
○ Severe intrauterine growth reduction from cellular depletion
○ Microcephaly

Threshold dose 0.1 Gy

353
Q

For foetal development how long is the Foetal Period? What is the nature of the response to radiation?

A

Foetal period 6 weeks to 9 months

1) Mental retardation - 25 IQ points per Gy, threshold 0.1Gy, due to failure of neurons to migrate peripherally.
2) Microcephaly
3) Eye, skeletal, genital abnormalities
4) Intrauterine growth restriction

354
Q

A discernable increase the risk of childhood cancer begins at what dose?

A

10mSv (i.e. Wr for XRs = 1, so 0.01Gy)

The excess absolute risk coefficient at this level of exposure is approximately 6% per gray

355
Q

In terms of population radiation exposure, what is “Doubling Dose”?

What is it thought to be? On what data is this based?

A

The dose required to double the spontaneous anomalies within a population.

Atomic bomb data suggests this is about 2 Sv.

356
Q

Heritable effects of radiation are due to?

A

Epigenetic changes - leading to transgenerational genomic instability.

357
Q

Current recommendations following exposure of radiation to the gonads?

A

Current recommendations to wait 6 months before attempting pregnancy following exposure of radiation to the gonads.

358
Q

Effects of radiation on male fertility?

A

○ 0.15 Gy- oligospermia
○ 0.5 Gy- temporary sterility
○ Cumulative dose >2 Gy- permanent sterility

359
Q

Effects of gonadal radiation on hormone production? Why?

A

○ Does not produce changes in hormone balance, libido or physical capability
■ controlled by testosterone which is secreted by Leydig cells
■ >20 Gy

360
Q

Why is there a latent period until male sterility or oligospermia following gonadal radiation?

A

○ Division of spermatogonia to mature sperm takes about 64 days
○ Mature and maturing cells more resistant to radiation
○ Hence latent period after exposure to radiation until clinical oligo/azoospermia is seen

361
Q

Lydia cells begin to die after what does

A

> 20Gy

362
Q

Effects of radiation on female fertility?

Subsequent other effects?

A
○	Oocytes present at birth
○	No cell division until puberty
○	Radiation above a threshold dose produces permanent sterility
■	12 Gy prepuberty
■	2 Gy premenopausal

○ Radiation sterility produces hormonal changes

363
Q

What principles should a standardized classification system for radiation toxicity follow (ughhhhhh sigh yawn)?

A

1) simple way of describing severity of toxicity
2) specific for each organ,
3) specific endpoints seen following radiotherapy for that particular organ
4) standardized internationally, enables comparisons between investigators, institutions, studies and treatment modalities

364
Q

What are the grades for the general grading of radiation toxicity?

A

○ Grade 0: no effect
○ Grade 1: mild, reversible and spontaneously heal
○ Grade 2: moderate, patient still able to self care. Requires outpatient treatment without cessation of therapy
○ Grade 3: severe, medically significant, interfere with activities of daily living. Requiring inpatient treatment and supportive care. Radiotherapy may require altering or temporary cessation
○ Grade 4: Life-threatening, requiring intensive treatment and supportive care, and immediate cessation of radiotherapy
○ Grade 5: Death due to radiotherapy toxicity

365
Q

4 key toxicity scoring systems:

A

○ RTOG/EORTC
○ CTCAE v3
○ WHO
○ LENT-SOMA (for late effects)

366
Q

Which toxicity scoring system deals with late effects of radiation?

A

LENT-SOMA

367
Q

What does LENT-SOMA stand for? What is it?

A

Late Effects Normal Tissues (LENT)-Subjective, Objective, Management, Analytic (SOMA) scales by the joint efforts of the EORTC and RTOG in 1995 was an attempt to produce a universal system for measuring and recording the late effects of radiotherapy.

(NB the Analytic part refers to imagining/laboratory tests that may be done)

368
Q

What is Quantec? When was it published?

What is it based on?

A

● Published in 2010

● Summarizes dose/volume/outcome data for many organs, extracted from publications.

369
Q

Limitations of Quantec?

A

○ Based on DVHs
■ not ideal representation of 3D dose distribution
■ do not consider fraction size variations
■ do not account for anatomic variations during therapy
○ Most data relate to conventionally fractionated regimens
○ Does not factor concurrent chemotherapy
○ Does not include host factors
○ Not available for all endpoints

370
Q

The raw data from Qantec is based on what? What are the limitations of this?

A

○ Based on DVHs
■ not ideal representation of 3D dose distribution
■ do not consider fraction size variations
■ do not account for anatomic variations during therapy

371
Q

True/false Qantec data is available for all important endpoints?

A

Not available for all endpoints

372
Q
TD(5) (bonus if you know TD50 as well):
Brain:
Spinal cord:
Heart:
Lung:
A

Brain: 54Gy (TD50 70Gy)
Spinal cord: 50Gy (TD50 60Gy)
Heart: 55Gy (TD50 65Gy)
Lung: 20Gy (TD50 30Gy)

373
Q

TD(5) (bonus if you know TD50 as well):
Testes (sterility):
Ovaries (sterility):
Lymphocytes:

A

Testes (sterility): 1Gy (TD50 2Gy)
Ovaries (sterility): 6Gy (TD50 12Gy)
Lymphocytes: 2Gy (TD50 10Gy)

374
Q

What cancer has the shortest latency post radiation? When does it peak?

A

Leukemia has the shortest latency post radiation. Appears invert few years and peaks at 6-7years.

375
Q

How might the dose response curve look for leukaemia? Why?

A

For irradiated mice the incidence of radiation induced leukaemia is a bell curve with fat right tail (Peak of 40% at 2.5-3Gy). Where x-axis is Dose (Gy) and y axis on left is incidence. On right linear surviving fraction - peak incidence occurring at 0.4Gy.

In contrast For solid tumours ERR/Gy is relatively linear
■ Breast cancer in Hodgkins patients, and A-bomb data

376
Q

Why does the dose response curve look for leukaemia look the way it does?

A

The incidence of radiation induced leukaemia is a bell curve with fat right tail (Peak of 40% at 2.5-3Gy). Where x-axis is Dose (Gy) and y axis on left is incidence. On right linear surviving fraction - peak incidence occurring at 0.4Gy.

Gray suggested this was due to increased induction of transformed cells with dose causing the increase in incidence making left tail of the curve, the right-sided decline in incidence is due to increased cell-kill with dose.

377
Q

The Radiation Protection Committee adopts what model?

Which assumes:

A

Currently radiation protection committee adopts the Linear No-Threshold model.

● LNT states that there is no threshold dose below which exposure to radiation is safe.
● Assumes that radiation carcinogenesis is a stochastic effect

378
Q

The Linear No-Threshold model states that:

A

● LNT states that there is no threshold dose below which exposure to radiation is safe.
● Assumes that radiation carcinogenesis is a stochastic effect
○ No threshold
○ Risk increases with increasing dose
○ Severity of cancer is not dose related

379
Q

Basic principles of radiation protection:

A

1) Justification
2) Optimisation
3) Dose limitation

380
Q

Very briefly explain the 3 basic principles of Radiation Protection:

A

Planned exposure to radiation should be justified (eg. diagnostic imaging)
and
optimized (shielding),
and
dose to public, patient and staff should not exceed individual dose limits, social and economic factors taken into account.

381
Q

What does the the Linear No-Threshold model predict about the severity of a cancer that may develop after exposure?

A

Severity of cancer is not dose related

382
Q

Occupational dose limits do not include radiation doses received by the occupationally exposed individual while:

A

Occupational dose limits do not include radiation doses received by the occupationally exposed individual while 1) undergoing a medical examination,
2) any radiation dose from natural radiation sources, E.g cosmic rays and naturally occurring radioactivity

383
Q

Define effective dose:

A

To obtain an effective dose, the calculated absorbed organ dose DT is first corrected for the radiation type using factor WR to give a weighted average of the equivalent dose quantity HT received in irradiated body tissues, and the result is further corrected for the tissues or organs being irradiated using factor WT, to produce the effective dose quantity E.

384
Q

When is effective dose considered?

A

Used only if there has been non-uniform irradiation of a body. If the body has been subject to uniform irradiation, the effective dose = whole body equivalent dose, and only the radiation weighting factor WR is used.

385
Q

One sievert carries with it what chance of eventually developing cancer?

This is based on what model?

A

One sievert carries with it a 5.5% chance of eventually developing cancer.

Based on the linear no-threshold model.

386
Q

Dose limits for Radiation Workers:

A

Effective Dose:
20 mSv/yr over 5 years
50 mSv/yr

Equivalent Dose:
150 mSv/yr to the lens
500 mSv/yr to Skin

387
Q

The effective dose (sometimes referred to as the whole body dose) limit is concerned with?

Whereas equivalent dose limits are designed to ensure that individual doses are kept below the dose thresholds for?

A

The effective dose (sometimes referred to as the whole body dose) limit is concerned with carcinogenic risk.

The equivalent dose limits are designed to ensure that individual doses are kept below the dose thresholds for deterministic effects.

388
Q

Dose limits for the Public:

A

Effective Dose:
1 mSv/yr (20 times less than worker)

Equivalent Dose (10 times less than worker):
15 mSv/yr to the lens
50 mSv/yr to Skin

389
Q

Define Integral Dose:

Why may it be more relevant for understanding carcinogenesis (second malignancy) after XRT?

A

Integral Dose = Volume x density x average Dose to that volume.

Whole body exposure events (e.g. A-Bomb survivors) often provide the data for predicting risk associated with radiation exposure, however relating ID to second malignancy data may be more relevant for radiotherapy exposures.

390
Q

Biggest malignancy risk after breast Ca treatment?

A

Breast Ca:

○ lung ca risk of <0.6% after 10 years

391
Q

Risk of any 2nd malignancy after prostate cancer treatment?

A

0.3% risk of any malignancy

392
Q

Hodgkins lymphoma patients treated with XRT are at what risk of second malignancy?

A

Hodgkins Lymphoma
○ breast cancer in patients <30- 11.7% at 25 years
■ combination of chemotherapy
■ older techniques

393
Q

What are consequential late effects of radiation?

A

Consequential late effects develop through interactions between early and late effects in the same organ.

Predominantly found in organ systems where the acute response (of the epithelial lining) degrades barrier against mechanical or chemical stress, which may cause additional trauma to the underlying tissues. Therefore, CLE are mainly found in the urinary and intestinal system, in mucosa and, to some extent, in skin.

Amelioration of the acute response to irradiation may be a useful approach to minimize late side effects of effective radiation therapy

394
Q

When combining XRT with surgery, what factors should be considered in deciding whether to give, neo-,intra-, or post-op- XRT?

A

1) Tumour localisation: May be easier to delineate tumour site pre-resection
2) Treatment volume. Larger post op.
3) Clonogen number. Reduced by surg, increased probability therefore of complete killing all colonogens
4) Blood supply - More hypoxia post, (intra op tumours may be normoxic)
5) Time of delivery (repopulation)
6) Normal tissue effects - neoadj may complicate wound healing, post causes higher rates of late effects
7) Diagnostic tissue - obvious

395
Q

Mechanisms that may be exploited by combining XRT with Systemic Therapies:

A

With Chemo
1) Spatial co-operation:
i - micrometastatic disease outside field
ii - Treat ‘Sanctuary sites’ (e.g brain) that cannot be reached by CTx
2) Cytotoxic enhancement:
i - independent action - given sequentially
ii - Additive effect - concurrent, w/reduced dose
iii - Synergistic interaction- concurrent, w/reduced dose

Radio sensitisers:
3) Biological co-operation:
i - Hypoxic sensitizers- Nitroimidazoles,
ii - Hypoxic cytotoxins - Tirapazamine
4) Temporal modulators. Preclinical evidence tumours increase EGFR expression post XRT. Cetuxumab binds EGFR.

396
Q

Combining XRT with CTx can enhance tumour cytotoxic effects.
These effects can be broken into 3 classes:
How would you change the timing of XRT (concurrent or sequential) to exploit each class?
How may you limit toxicity?

A

Cytotoxic enhancement:
i - independent action - given sequentially
ii - Additive effect - concurrent, w/possible reduced dose
iii - Synergistic interaction- concurrent, w/possible reduced dose

397
Q

How would you quantify the benefit of adding a radiosensitizer to you treatment?

A

Dose Modifying Factor is the ratio of isoeffective doses in the absence and presence of radiosensitizer.

398
Q

Mechanisms of improved cell kill with combined chemoradiation

A

1) Spatial co-operation:
i - micrometastatic disease outside field
ii - Treat ‘Sanctuary sites’ (e.g brain) that cannot be reached by CTx
2) Cytotoxic enhancement:
i - independent action - given sequentially
ii - Additive effect - concurrent, w/reduced dose
iii - Synergistic interaction- concurrent, w/reduced dose

399
Q

2 broad classes of radiosensitizers:

A

1) Biological co-operation
- Hypoxic sensitisers
- Hypoxic cytotoxins

2) Temporal Modulators
- Hormonal therapy
- EGFR inhibitor - Cituxumab

400
Q

Examples of hypoxic cell radiosensitizers.

Give MOA

A

Hypoxic cell radiosensitizers
■ nitroimidazoles: eg misonidazole, nimorazole
■ able to diffuse into hypoxic cells and has the same effect as oxygen on DNA damage
■ Requires concurrent delivery with radiotherapy

401
Q

Give an example of an EGFR inhibitor. What is the argument for their use?

A

Preclinical evidence that EGFR is activated following RT in EGFR mutated cells:
○ Tumour cells that overexpress EGFR repopulate more rapidly following RT than non-EGFR mutated cells
○ EGFR inhibitors if given concurrently might therefore reduce their proliferation

Cetuximab has been delivered concurrently with RT for SCC head and neck, but clinical results not as promising as predicted.

402
Q

Main radio-protector compounds?

  • Give example
  • Give MOA
A

Sulfhydryl compounds:
○ eg. amifostine
○ act as free radical scavengers
○ and removes active metabolites from platinum and alkylating agents
○ prodrug, requires activation by alkaline phosphatase which is found in higher concentrations in normal cells

403
Q

Downside of sulfhdryl compounds:

A

Selective activity in normal cells but not 100%, possible protection of tumour cells as well
○ Requires administration <30 mins before RT
○ associated with side effects: hypotension, anaphylaxis, Steven-Johnson syndrome, nausea and vomiting

404
Q

How can the effect of radio protectors be quantified?

A

Effect of these drugs called the Dose Reduction Factor

○ Ratio of dose with drug to dose without drug

405
Q

Discuss how combined chemo XRT may impact early side effects.

Approach to minimising this:

A

● Early toxicity is based on damage to stem cells which are unable to repopulate the cell pool
● Chemotherapy is also active in proliferating cells
● Concurrent treatments therefore increase the likelihood of early side effects

When treatments are given sequentially, normal tissue has time to repair and toxicity is not as high as concurrent treatments

406
Q

Discuss how combined chemo XRT may impact late side effects. Which chemotherapies are particularly likely to increase these?

Approach to minimising this:

A

● Late effects are seen after a latent period of months to years
● Tend to be irreversible
● Can also be due to consequential late effects
● Chemotherapies that interfere with DNA repair can increase the risk of late side effects.
● Risk is also increased in combined modality treatments when drugs have a specific tissue toxicity
○ eg bleomycin for lung, doxorubicin for heart

407
Q

Retreatments may be necessary for local recurrences or development of new malignancies in previously irradiated areas.

This could result in doses over the:

Therefore, among other thing to be considered, what should be calculated?

A

This could result in doses over the tolerance doses for that organ or surrounding normal tissue

Use EQD2 to add both previous and proposed treatments (if doses were/are not given to standard fractionations).
■ α/β ratio used should be that of normal tissues at risk.
■ Retreatment should only be considered if total doses given previously have not exceeded tolerance doses (but consider ‘forgotten dose over time’)

408
Q

In considering whether to retreat an area what needs to be considered:

A

○ Initial dose and proposed re-irradiation dose
○ Dose per fraction -Large doses per fraction will more likely lead to early and late effects
○ Irradiated volume
○ Irradiated tissues. I.e unique repair kinetics
○ Time interval - Most tissues especially early-reacting tissues exhibit ‘forgotten dose’ if enough time for recovery is given
○ Radiation technique
○ Modifiers of radiation dose
○ Other treatment options
○ Patient fitness and life expectancy

409
Q

If enough recovery time is given, what tissues are especially likely to exhibit ‘forgotten dose’?

What is the converse situation?

A

Most tissues especially early-reacting tissues exhibit ‘forgotten dose’ if enough time for recovery is given
= a dose higher than the difference between tolerance dose and initial dose may be given safely
○ eg total of 160% of tolerance dose could be given with a time interval of 3 years.

BUT: Tolerance of some organs worsen over time
● eg kidney, due to progressive fibrosis of glomeruli

410
Q

Pre-clinical data on pretreatment of normal tissues:

A

1) Skin rodent studies
Early skin reactions recover and tolerate almost full repeated doses.
Late skin reaction (use limb deformation) - very poor retreatment tolerance.
2) Primate spinal cord: 167% of EQD2 tolerated after 3 years.

411
Q

Clinical data on pretreatment of normal tissues:

A

!!!!!Caution interpreting data: small n, changing techniques and fractionations, no control groups.

412
Q

Clinical data on pretreatment of Brain:

A

○ Studies of reirradiation of recurrent glioma
○ High risk of radionecrosis if combined total dose >100 Gy
○ No correlation with time interval!!!!!!!
○ Higher retreatment doses possible with more conformal techniques

413
Q

Clinical data on pretreatment of Spinal Cord:

A

Substantial recovery provided initial treatment did not exceed 90% of tolerance dose and there was a time interval of at least year between treatments
○ Data suggest cumulative dose of 130-135% of the acceptable tolerance dose
■ hence 30-35% recovery in a year
○ Consider conformal therapies and dose per fraction <2Gy

414
Q

Clinical data on pretreatment of Head & Neck:

A

○ Retreatment doses of 50-60 Gy required to be effective!!!!!
○ Associated with very high rates of complications including treatment related death
○ Increased risk of complications with shorter time interval and higher combined total dose

415
Q

Clinical data on pretreatment of Boob:

A

○ Retreatment using electron beams or interstitial brachytherapy can be used with low incidence of side effects
○ High doses can be applied to the chest wall with sparing of heart and lungs

416
Q

How does Amifostine work?

A

Pro-drug actived by Alk-phos which is higher in normal tissue.
Activated drug acts as free radical scavenger, decreasing the effect of indirectly ionising radiation.