The myofibroblast markers α-SM actin and β-actin are differentially expressed in 2 and 3-D culture models of fibrotic and normal skin

To characterize the differences between fibrotic myofibroblasts and normal fibroblasts, we studied two differentiation markers: α-smooth muscle (SM) actin, a specific marker of myofibroblast differentiation, and β-actin, which is overexpressed in the fibrotic tissue. Experiments were performed on fibroblasts isolated from normal pig skin and on subcutaneous myofibroblasts isolated from pig radiation-induced fibrosis. Three culture models were used: cells in monolayers, equivalent dermis, consisting of fibroblasts embedded into a matrix composed of type I collagen, and in vitro reconstituted skin, in which the matrix and containing life fibroblasts were overlaid with keratinocytes. Samples were studied using immunofluorescence and western-blotting. In monolayers cultures, both fibrosis and normal cells expressed α-SM actin. Furthermore, similar amounts of β-actin protein were found. In these conditions, the resulting alterations in the phenotypes of cells made comparison of cultured fibrotic and normal cells irrelevant. Under the two 3-D culture models, normal fibroblasts no longer expressed α-SM actin. They expressed β-actin at the basal level. Moreover, the fibrotic myofibroblasts in both 3-D models retained their differentiation features, expressing α-SM actin and overexpressing β-actin. We found that this normalization was mainly related to the genomic programmation acquired by the cells in the tissue. Cellular motility and microenvironment were also involved, whereas cellular proliferation was not a major factor. Consequently, both three-dimensional models allowed the study of radiation-induced fibrosis in vitro, provided good extrapolations to in vivo conditions and avoided certain of culture artefacts.

Accumulation of Glycosaminoglycans in Radiation-induced Muscular Fibrosis

The content and biosynthesis of glycosaminoglycans (GAGs) were studied in the pig thigh muscle after acute local gamma-irradiation. Seven months following irradiation, the muscular tissue next to the irradiation cone was replaced by severe mutilating fibrosis delimited by an intermediary perifbrotic zone. Fibrosis, perifibrotic tissue and normal muscle, were sampled and incubated with [3H]glucosamine and [35S]sulphate, and GAGs were isolated following pronase digestion. Results showed a parallel increase of collagen and GAG content in perifibrotic and fibrotic tissues. Sulphated GAGs, heparan sulphate and dermatan sulphate were preferentially accumulated in fibrotic tissue, while the hyaluronic acid content increased only slightly. Synthesis of sulphated GAGs was more elevated in fibrotic tissue than in perifibrotic zone as compared with normal muscle. Seven months after irradiation well-developed fibrotic tissue continued to synthesize and to accumulate extracellular matrix macromolecules, indicating the invasive aspect of post-irradiation fibrosis.

An interdisciplinary approach to investigate the impact of cobalt in a human keratinocyte cell line

Since in nuclear power plants, risks of skin contact contamination by radiocobalt are significant, we focused on the impact of cobalt on a human cutaneous cell line, i.e. HaCaT keratinocytes. The present paper reports an interdisciplinary approach aimed at clarifying the biochemical mechanisms of metabolism and toxicity of cobalt in HaCaT cells. Firstly, a brief overview of the used instrumental techniques is reported. The following parts present description and discussion of results concerning: (i) toxicological studies concerning cobalt impact towards HaCaT cells (ii) structural and speciation fundamental studies of cobalt-bioligand systems, through X-ray absorption spectroscopy (XAS), ab initio and thermodynamic modelling (iii) preliminary results regarding intracellular cobalt speciation in HaCaT cells using size exclusion chromatography/inductively coupled plasma-atomic emission spectroscopy (SEC/ICP-AES) and direct in situ analysis by ion beam micropobe analytical techniques.

A comparison of cellular irradiation techniques with alpha particles using the Geant4 Monte Carlo simulation toolkit

A comparison of three cellular irradiation techniques using the Monte Carlo simulation toolkit Geant4 is presented in this paper. They involve electrodeposited source of alpha particle-emitting radionuclides, random classical alpha beam irradiation and single cell targeted irradiation using a focused alpha microbeam line. The simulation allows the calculation of hit distributions among the cellular population as well as the absorbed dose for two typical cellular geometries.

Promoter sequences involved in transforming growth factor beta1 gene induction in HaCaT keratinocytes after gamma irradiation

Transforming growth factor beta 1 (TGFB1) is a cytokine involved in the development of both acute and late cutaneous radiation syndromes. We previously demonstrated that ionizing radiation induces TGFB1 expression in vivo in pig skin within a few hours. The purpose of the present study was to develop an in vitro human model to identify the mechanisms of this early activation. Accordingly, human HaCaT keratinocytes were irradiated with a single dose of 20 Gy. First, radiation-induced TGFB1 overexpression was checked at both the transcriptional and transductional levels in HaCaT cells. Then electrophoretic mobility shift assays (EMSA) and transient transfection with various TGFB1 promoter constructs were used to identify the sequences involved in regulating this promoter. EMSA analysis showed the induction of nuclear protein binding activity by gamma irradiation to the -365 AP1 sequence (TGTCTCA), suggesting the involvement of AP1 sequences in the regulation of TGFB1 transcription. In gene reporter assays, maximal TGFB1 promoter activation was found for the longest construct, which contains two AP1 sequences. However, assays with constructs including deletions showed that these two AP1 sequences were not sufficient to confer TGFB1 inducibility. These results showed for the first time, to our knowledge, that transcriptional regulation is involved in radiation-induced activation of TGFB1 gene expression.

[Reversibility of radiation-induced fibroatrophy]

PURPOSE

The radiation-induced fibro-atrophic process described in numerous tissues and organs is a localized and irreversible late effect of high-dose radiation therapy. Our purpose is to show that this process is today reversible.

CURRENT KNOWLEDGE AND KEY POINTS

This review describes a synthesis of various clinical, paraclinical and histopathological aspects of radiation-induced fibro-atrophic process, and of cellular and molecular process regulation. Schematically, there exists a prefibrotic aspecific inflammatory phase, then a constituted and cellular phase, then a matricial densification and remodeling phase, associated in some cases with a tissular terminal necrosis. The respective parts and their evolution during time of the main protagonists as myofibroblast, extracellular matrix and growth factor TGF beta 1 are clarified. From the pathophysiological mechanisms described, curative therapeutic attitudes are proposed for the different progressive phases. Especially, superoxide dismutase (not available) and the pentoxifylline-tocopherol combination seem to allow reduction and reversibility of the fibro-atrophic radiation-induced established process, in clinics as in animal experiments.

FUTURE PROSPECTS AND PROJECTS

Some phase II trials try to assess the therapeutic interest of combined pentoxifylline-tocopherol in various radiation-induced sequelae, as in osteo-radionecrosis. A clinical randomized trial phase III has just been achieved and could support the results of these experimental and retrospective clinical trials.

[Mature bone radionecrosis: from recent physiopathological knowledge to an innovative therapeutic action]

Osteoradionecrosis is a severe radiotherapy (RT) injury by healing failure, late effect and spontaneously irreversible by tissue death. Histologically, it consists in a pagetoid mosaic that combines a defective osteogenesis with an osteoclastic osteolysis and more marginally an osteolytic osteolysis, turned to account to fibroblastic and collagenic fibrosis. Several pathogenic hypotheses favor sometimes a vascular hypoxic hypotheses, sometimes a fibro-atrophic hypothesis. Various events start up or favour ORN as traumatisms (dental extraction, surgery,...) or bacterian infection on fistula. In clinic, adult mature bone concerned is the mandible after head and neck RT by septic ORN, and the hip after pelvic RT by aseptic ORN. For each, epidemiology, clinic and therapeutic aspects are developed. Usual therapeutic attitudes consisted in restriction of defavorable associated events (dental extraction, infection, RT dose, chemotherapy,...) and devitalized tissue removal. Physiopathological therapeutic innovatives aspects are proposed to struggle against radiation-induced fibrosis associated and to limit bone destruction.

Cu/Zn superoxide dismutase modulates phenotypic changes in cultured fibroblasts from human skin with chronic radiotherapy damage

PURPOSE

As we previously observed that bovine liposomal Cu/Zn SOD (LipSOD) reduces cutaneous radiation-induced fibrosis (RIF) in human therapeutic assays the mechanisms involved were investigated here by an in vitro study of the LipSOD effects on cellular antioxidant metabolism and regulation of matrix degradation.

METHODS

Primary cultures of human fibroblasts harvested from normal or RIF skin were treated with various doses of LipSOD. Catalase, Cu/Zn and Mn SOD endogenous cell enzyme activities and protein amounts were assayed by polyacrylamide gel electrophoresis and western blotting. Gene expressions of tissue inhibitor of metalloproteinases (TIMP) and TGF-beta1 was investigated by northern blot analysis.

RESULTS

A deficiency of endogenous Mn SOD, considered to favour cell proliferation, was observed in cultured RIF cell. The present study showed that bovine Cu/Zn SOD entered the cells. Exposure to LipSOD (a) enhanced endogenous Mn SOD activity and protein level, without changes of endogenous Cu/Zn SOD and catalase, and (b) significantly reduced TIMP and TGF-beta1 gene expression, in RIF cells. No changes in these parameters were noted in treated control skin fibroblasts.

CONCLUSION

Modulation of RIF skin fibroblasts by LipSOD seems effective via indirect endogenous Mn SOD activation, which might explain the cell phenotype reversion observed. TIMP reduction accounts for the elimination of collagenase activity inhibition and the subsequent digestion of excess extracellular matrix deposition, as well as RIF reversibility in vivo. The reduction of TGF-beta1 expression might explain the breaking of maintaining fibrotic cell activation connected with this growth factor.

Antifibrotic action of Cu/Zn SOD is mediated by TGF-beta1 repression and phenotypic reversion of myofibroblasts

Skin fibrosis is characterized by the proliferation and accumulation of activated fibroblasts called myofibroblasts. They exhibit specific cytoskeletal differentiation, overexpress the fibrogenic cytokine TGF-beta1, synthesize excess extracellular matrix compounds and exhibit a depleted antioxidant metabolism. Recently, SOD was successfully used as an antifibrotic agent in vivo, thus challenging the postulate of established fibrosis irreversibility. We postulated that myofibroblasts could be a direct target for this therapeutic effect. To test this hypothesis, we used three-dimensional co-culture models of skin, in which specific phenotypes of normal fibroblasts versus myofibroblasts are retained. These 3-D models were treated with liposomal and carrier-free Cu/Zn SOD, and examined for their effects on cell number, cell death, and phenotypic differentiation. The results show that SOD did not induce myofibroblast cell death, whereas it significantly reduced TGF-beta1 expression, thus demonstrating that SOD might be proposed as a potent antagonist of this major fibrogenic growth factor. We also found that SOD significantly lowered the levels of the myofibroblast marker alpha-sm actin, of beta-actin, and of the extracellular matrix components alpha1(I) collagen and tenascin-C. In conclusion, our results suggest that SOD antifibrotic action occurred in vitro through the reversion of myofibroblasts into normal fibroblasts.

[Evaluation of late radiation-induced changes in superficial microcirculation after acute beta-irradiation. II. Prognostic importance of cutaneous Doppler laser]

OBJECTIVE

The changes that occur in the tissular microcirculation after accidental acute irradiation account for some of the early effects of such irradiation, especially at the cutaneous level. The prognostic importance of the cutaneous laser doppler was tested in an experimental model of acute beta-irradiation.

METHODS

Ten pigs were given beta-irradiation with a high single localized dose of 90Sr/90Y (32 or 64 Gy, 7 mg/cm2) delivered to the flank, and were evaluated 2, 7, 14, 21 and 28 days thereafter. Each individual was its own control. The local microcirculation was measured in the resting state and during thermal stimulation at 42 degrees C, using a Periflux cutaneous Doppler laser with p413 probes. Three periods of six minutes each were continuously recorded: period 1 (P1) represented basal resting cutaneous perfusion, with the slope p corresponding to the increase in perfusion when two minutes of thermal stimulation at 42 degrees C began; P2 to plateau perfusion during this stimulation; and P3 to perfusion on the return to equilibrium.

RESULTS

After acute beta-irradiation in the pig, all the cutaneous microcirculation parameters measured (P1, p, P2 and P3) had risen at day 2 in the irradiated area by a factor of 2 to 4, depending on the dose (p < 0.001), compared to the adjacent control area. On the other hand, as from day 7, the resting and the stimulated microcirculation varied little, except for a reduction of the slope p by a factor of 2 (p < 0.05) after the strongest radiation dose.

CONCLUSION

After acute irradiation, the increase in the resting cutaneous microcirculation may correspond to immediate but transitory capillary vasodilatation that accompanies the initial erythema in accidental irradiation. The absence of vascular response to thermal stimulation seems to be a good means of reaching an early diagnosis of delayed cutaneous radiation necrosis.

[Evaluation of late radiation-induced changes in superficial microcirculation. I. Clinical benefit of the cutaneous Doppler laser]

OBJECTIVE

The changes that occur in the tissular microcirculation after therapeutic irradiation (RT) account for some of the late effects of irradiation, especially on the cutaneous level. As a rule, the methods of exploring the superficial microcirculation only measure blood flow indirectly. Only the Doppler laser can provide direct measurements of blood parameters in vivo in man.

METHODS

Thirty women who had been irradiated with 45 + 20 Gy of locoregional fractionated adjuvant RT for breast cancer developed local radiation-induced fibrosis six years later (+/- 5). The local microcirculation was measured in the resting state and during thermal stimulation at 42 degrees C, using a Periflux cutaneous Doppler laser with p413 probes. Three periods of six minutes each were continuously recorded: period 1 (P1) represented basal resting cutaneous perfusion, with the slope p corresponding to the increase in perfusion when two minutes of thermal stimulation at 42 degrees C began; P2 to plateau perfusion during this stimulation; and P3 to perfusion on the return to equilibrium. Each individual was its own control.

RESULTS

In the women treated by RT, the resting microcirculation in the skin underlying an area of late fibrosis rose by a factor of 2 during P1 (p < 0.001), and the P2/P1 ratio decreased by a factor of 2 (p < 0.001), compared to the control area. After thermal stimulation, there was no change in p, P2 or P3.

CONCLUSION

Although a hypovascularization is frequently found in late sequelae of RT, we observed an increase of the cutaneous microcirculation associated with a maladjustment of the endothelial response to a thermal stimulation. These observations seem to reflect the presence of dilated new capillaries of the telangiectatic type, which are macroscopically undetectable.

[Radiation-induced superficial fibrosis and TGF-alpha 1]

Radiation-induced fibrosis is a late sequela of both therapeutic and accidental irradiations, which has been described in various tissues, including the lung, liver, kidney and skin. This review presents different aspects of superficial radiation-induced fibrosis, such as clinical observations, histological changes, cellular and molecular regulations, and medical management. Recent evidence on the critical role played by TGF-beta 1 in the initiation, development and persistence of fibrosis are discussed, as well as the possibility that this cytokine may constitute a specific target for antifibrotic agents.

In vivo K-edge imaging with synchrotron radiation

We present in this paper two imaging techniques using contrast agents assessed with in vivo experiments. Both methods are based on the same physical principle, and were implemented at the European Synchrotron Radiation Facility medical beamline. The first one is intravenous coronary angiography using synchrotron radiation X-rays. This imaging technique has been planned for human studies in the near future. We describe the first experiments that were carried out with pigs at the ESRF. The second imaging mode is computed tomography using synchrotron radiation on rats bearing brain tumors. Owing to synchrotron radiation physical properties, these new imaging methods provide additional information compared to conventional techniques. After infusion of the contrast agent, it is possible to derive from the images the concentration of the contrast agent in the tumor area for the computed tomography and in any visible vessel for the angiography method.

Imaging radiation induced muscular necrosis with antimyosin-scintigraphy and computed tomography

Radiations accidents involving high exposures require accurate assessment of radiation dose for correct surgical or medical management. Techniques involving computed tomography and antimyosin-antibody scintigraphy were evaluated in an experimental model of acute localized irradiation overexposure to 192Ir. Ten rabbits were exposed to a single dose of 192Ir gamma irradiation (120 Gy) on the back (right iliospinal muscle). Computed tomography and antimyosin-antibody scintigraphy results were compared with those in four control animals. Planar scintiscans (posterior views) were performed 48 h post-injection of antimyosin-antibody each week for 2 mo after exposure. An antimyosin uptake was observed in irradiated muscle five weeks after exposure and correlated with computed tomography and histopathology results, showing muscle necrosis. Biodistribution assessed at 7 and 9 wk post exposure confirmed antimyosin-antibody accumulation in damaged muscle. A semi-quantitative analysis of a region of interest over the uptake area in the irradiated muscle (on the right side) and a contralateral non-irradiated region of interest used as control showed that uptake was significantly higher in irradiated animals than in control animals (p < 0.02). Antimyosin-antibody scintiscans used in nuclear cardiology to explore ischemic heart disease, myocarditis or heart transplant rejection could be realized to assess the extent of muscle necrosis after trauma or radiation induced injury.

Striking regression of chronic radiotherapy damage in a clinical trial of combined pentoxifylline and tocopherol

PURPOSE

Radiation-induced fibrosis (RIF) remains the most morbid complication of radiotherapy because of the absence of spontaneous regression and the difficulty of patient management. RIF treatment with combined pentoxifylline (PTX) and tocopherol (Vit E) was prompted by recent advances in cellular and molecular biology that have improved researchers' understanding of radiation-induced late-injury mechanisms and by the excellent results from our previous human and animal studies.

PATIENTS AND METHODS

Forty-three patients (mean [+/- SD] age, 59 +/- 10 years) presenting with 50 symptomatic RIF areas involving the skin and underlying tissues were treated from April 1995 to September 1997. Patients had had radiotherapy for head and neck or breast cancer a mean period of 8.5 +/- 6.5 years previously. RIF developed in the first year after irradiation and gradually worsened, without spontaneous regression. The mean measurable surface area of RIF ([S]) at the time of this study ([S(0)]) was 42 +/- 34 cm(2). The initial Subjective Objective Medical management and Analytic (SOMA) injury evaluation score was 13.2 +/- 5.9 and included evidence of edema, plexitis, restricted movement, and local inflammatory signs. A combination of PTX (800 mg/d) and Vit E (1,000 IU/d) was administered orally for at least 6 months.

RESULTS

Treatment was well tolerated. All assessable injuries exhibited continuous clinical regression and functional improvement. Mean RIF surface area and SOMA scores improved significantly (P <.0001) at 3 months ([S(3)], -39%; [SOMA(3)], -22%), 6 months ([S(6)], -53%; [SOMA(6)], -35%), and 12 months ([S(12)], -66%; [SOMA(12)], -48%), and mean linear dimensions ([D]) diminished from the start of the study ([D(0)], 6.5 +/- 2.5 cm) to the end of treatment 12 months later ([D(12)], 4 +/- 2 cm). At the time of the treatment, we did not attempt to achieve the maximum effect, and the study was continued.

CONCLUSION

The PTX-Vit E combination reversed human chronic radiotherapy damage and, because no other treatment is presently available for RIF, should be considered as a therapeutic measure.

Histopathological and cellular studies of a case of cutaneous radiation syndrome after accidental chronic exposure to a cesium source

This study was designed for the histopathological, cellular and biochemical characterization of a skin lesion removed surgically from a young male several months after accidental exposure to cesium-137, with an emphasis on expression of transforming growth factor beta1 (TGFB1) and tumor necrosis factor alpha (TNFA) and the occurrence of apoptosis. Under a hypertrophic epidermis, a highly inhomogeneous inflammatory dermis was observed, together with fibroblastic proliferation in necrotic areas. Immunostaining revealed overexpression of TGFB1 and TNFA inside the keratinocytes of the hypertrophic epidermis as well as in the cytoplasm of the fibroblasts and connective tissue of the mixed fibrotic and necrotic dermis. Inside this dermis, the TUNEL assay revealed areas containing numerous apoptotic fibroblasts next to areas of normal viable cells. Overexpression of TGFB1 was found in the conditioned medium and cellular fractions of both hypertrophic keratinocytes and fibrotic fibroblasts. This overexpression lasted for at least three passages in tissue culture. The present observations were consistent with the central role of TGFB1 in the determination of chronic radiation-induced damage to the skin and a significant involvement of TNFA. In addition, programmed cell death appeared to take place during the remodeling of the mixed fibrotic and necrotic tissue.

Striking regression of subcutaneous fibrosis induced by high doses of gamma rays using a combination of pentoxifylline and alpha-tocopherol: an experimental study

PURPOSE

To establish a successful treatment of subcutaneous fibrosis developing after high doses of gamma rays, suitable for use in clinical practice.

METHODS AND MATERIALS

We used an animal model of acute localized gamma irradiation simulating accidental overexposure in humans. Three groups of 5 Large White pigs were irradiated using a collimated 192Ir source to deliver a single dose of 160 Gy onto the skin surface (100%) of the outer side of the thigh. A well-defined block of necrosis developed within a few weeks which had healed after 26 weeks to leave a block of subcutaneous fibrosis involving skin and skeletal muscle. One experimental group of 5 pigs was dosed orally for 26 weeks starting 26 weeks after irradiation with 1600 mg/120 kg body weight of pentoxifylline (PTX) included in the reconstituted food during its fabrication, and another group of 5 was dosed orally for the same period with a daily dose of 1600 mg/120 kg body weight of PTX combined with 2000 IU/120 kg body weight of alpha-tocopherol. Five irradiated control pigs were given normal food only. Animals were assessed for changes in the density of the palpated fibrotic block and in the dimensions of the projected cutaneous surface. Depth of scar tissue was determined by ultrasound. Physical and sonographic findings were confirmed by autopsy 26 weeks after treatment started. The density, length, width, and depth of the block of fibrotic scar tissue, and the areas and volume of its projected cutaneous surface, were compared before treatment, 6 and 13 weeks thereafter, and at 26 weeks.

RESULTS

The experimental animals exhibited no change in behavior and no abnormal clinical or anatomic signs. No modifications were observed in the block of fibrotic scar tissue of pigs dosed with PTX alone. However, significant softening and shrinking of this block were noted in the pigs dosed with PTX + alpha-tocopherol 13 weeks after treatment started and at autopsy, when mean regression was approximately 30% for length, approximately 50% for width and depth, and approximately 70% for area and volume. Histologic examination showed completely normal muscle and subcutaneous tissue surrounding the residual scar tissue. The 50% decrease in the linear dimensions of the scar tissue, were comparable to the results obtained in our previous clinical studies, and were highly significant compared to the clinical and autopsy results for the controls. Histologic examination of the residual scar tissue revealed tissue which was more homogenous and less cellular and inflammatory than in control and PTX-dosed pigs. The tissular and cellular immunolocalization of tumor necrosis factor alpha (TNFalpha) was similar in the residual fibrotic tissues of all three groups of pigs, whereas the immunostaining of transforming growth factor beta-1(TGFbeta-1) diminished much more in the residual fibrotic scar tissue of the PTX + alpha-tocopherol-dosed pigs than in the two other groups.

CONCLUSIONS

The present results showed a striking regression of the subcutaneous fibrotic scar tissue that develops as a consequence of high doses of gamma rays.

Diagnosis of acute localized irradiation lesions: review of the French experimental experience

In the last 50 years several radiation accidents occurred in which industrial radiographers and others suffered severe radiation injuries from inadvertent contact with radiation sources. Such accidents involving acute localized injuries are characterized by a severe initial reaction progressing through erythema to skin necrosis with a spontaneous resolution of the lesion over a 2-mo period for the lower doses. However, the early symptoms observed on the skin give no indication as to the in-depth pathology, and cutaneous and muscular radionecrosis started generally from early epithelial, microvascular, and vascular lesions and from delayed muscular and connective tissue lesions. In a case of acute localized irradiation, different biophysical techniques are able to give real responses in biological dosimetry. More numerous are the methods, especially imaging methods, that make it possible for the clinician to evaluate the extent of the early injuries and to manage the medical intervention. We have developed animal experimental models of acute localized irradiation: overexposure to the gamma rays of a 192Ir industrial radiographic collimated source (in the pig and the rabbit) and overexposure to the beta rays of a 90Sr-90Y collimated source (in the pig). In these experimental models, most of the imaging techniques used in clinical practice, as infra-red thermography, microwave thermography, cutaneous and tissular vascular scintigraphy (beta or gamma emitters), cutaneous blood flow measurements by cutaneous laser Doppler, x ray computed tomography, nuclear magnetic resonance imaging, and skin topography, were correlated with clinical evaluation and histopathological observations, after high doses of gamma or beta irradiations ranging from 4 to 340 Gy at the skin surface. All these techniques are not for isolated use and the present review indicates that their combination is necessary to give an improved diagnostic and prognostic picture of early and late delayed radiation damage to the skin and subcutaneous tissues.

In vivo results with a new device for ultrasonic monitoring of pig skin cryosurgery: the echographic cryoprobe

One of the main difficulties encountered in cryosurgery is the uncertainty in the extent and depth of the tissue effectively treated during the freezing process. The objective of this study was to evaluate in vivo ultrasonic control of skin cryosurgery using a new echographic cryoprobe. An echographic cryoprobe, developed specifically for dermatology applications, combines a high-frequency (20 MHz) miniature ultrasonic transducer and a N2O-driven closed cryoprobe. Knowledge of the ultrasound velocity of frozen skin is a prerequisite for monitoring the iceball formation kinetics. Therefore, in a first study, we estimated the ultrasound velocity of frozen skin specimens. In a second step, the operation of the echographic cryoprobe was assessed, under in vivo conditions similar to those used in human therapeutics, on normal skin of three female "Large-White" pigs under anesthesia. The mean value of ultrasound velocity of frozen skin obtained by pooling the data from all the skin specimens included in this study was 2865 +/- 170 m per s. The average rates of growth (10(-2) mm per s) of the iceballs were found to be 12.2 +/- 1.0 (pig 1), 9.0 +/- 1.0 (pig 2), and 8.4 +/- 0.9 (pig 3). The echographic cryoprobe had a built-in high-frequency ultrasonic transducer that served two functions. It enabled in vivo real-time monitoring of depth penetration of the iceball and it gave important feedback to the operator or to the console relating to the rate of growth of the iceball. Automatic (i.e., operator-independent) detection of the echo signal from the freezing front and calculation of the depth penetration of the iceball was possible.

[Late effects of mammary radiotherapy on skin and subcutaneous tissues]

Late damages to the skin and subcutaneous tissues are almost inescapable because of the high skin doses required in the irradiation of breast tumours. While the clinical and histological descriptions date back to the first decades of the therapeutic use of ionising radiation, the recent advances in cellular and molecular biology have significantly contributed to the increased understanding of late skin injury mechanisms. In particular, sub-cutaneous fibrosis appears to be the partly reversible results of a continuous and self-maintained local process, possibly sensitive to therapeutic intervention. A second very active research avenue is the development of biologic assays potentially able to predict the probability of increased normal tissue injury after irradiation in individual patients. Such a test would allow the adaptation of the treatment modalities to the radiobiological behaviour of normal tissues. To date, these expectations have not been met. The quality of the irradiation and its modalities (total dose, fractionation, inter fraction interval) remain the main ways to achieve an optimal functional and cosmetic outcome.

Abnormal phenotype of cultured fibroblasts in human skin with chronic radiotherapy damage

PURPOSE

The pathophysiological aspects of radiation-induced fibrosis (RIF) have not been well characterized. We therefore cultured human fibroblasts from samples of skin with RIF to investigate the long-term effects of therapeutic irradiation.

MATERIALS AND METHODS

Biopsies of normal and RIF skin were obtained from patients previously irradiated for cancer, without recurrence. Cells were extracted from dermis samples by the outgrowth technique, seeded as monolayers and cultured at confluence. Enzyme activities and proteins were assayed, RNA was isolated and Northern blot analysis was performed on surviving cells between passages 2 and 5.

RESULTS

RIF cell cultures displayed heterogeneous fibroblasts populations. The initial outgrowth consisted of one-third small cells that floated rapidly, one-third spindle-shaped cells migrating far from the explant to form islets and one-third large pleiomorphic cells. In subsequent subcultures, surviving cells exhibited either myofibroblastic characteristics with a normal proliferative capacity or senescent morphology with a reduced proliferative capacity. These RIF cells had a brief finite lifespan, with dramatically reduced growth rate during their initial outgrowth and the following passages. Study of the antioxidant metabolism showed that Mn superoxide dismutase and catalase activities were significantly weaker in surviving RIF cells than healthy fibroblasts. These exhausted RIF cells exhibited no overexpression of transforming growth factor beta or tissue inhibitor of metalloproteinase.

CONCLUSION

Irradiation may lead to apparently contradictory effects such as fibrosis and necrosis in clinical practice. In cell culture, we observed two main cellular phenotypes which may be related to both processes, i.e. myofibroblast-like cells and fibrocyte-like cells. These two phenotypes may represent two steps in the differentiation induced as a long-term effect of therapeutic irradiation of the skin. Cell culture probably accelerates the induction of the terminal differentiation in RIF fibroblasts.

[Physiopathology of human superficial radiation-induced fibrosis]

The radiation-induced fibrosis is a late sequela of both therapeutic and accidental irradiations, and has been described in several tissues such as skin and underlying sub-cutaneous tissues, and lung. Based on the newest findings arising from cellular and molecular radiobiology, this review synthesis different aspects of the human superficial radiation-induced fibrosis: clinical and paraclinical observations, radiobiological aspects, gross histological changes, cellular and molecular regulations, and medical management. However, the underlying mechanisms of the superficial radiation-induced fibrosis still remain to be resolved.

Unlike tenascin-X, tenascin-C is highly up-regulated in pig cutaneous and underlying muscle tissue developing fibrosis after necrosis induced by very high-dose gamma radiation

Fibrosis is characterized by proliferation of fibroblasts and deposition of extracellular matrix (ECM). As alterations in the composition of ECM may account for its chronic extension, we studied the expression of the tenascin-C (TN-C) and tenascin-X (TN-X) ECM glycoproteins in our pig model of the effects of accidental exposures to radiation, in which cutaneous and muscle fibrosis developed after the induction of necrosis after a high single dose (160 Gy at the skin surface) of gamma rays. We found that, in the healed fibrotic dermis and underlying muscle fibrosis, the amount of TN-C mRNA was increased up to 18- and 39-fold, respectively, compared to normal dermis, whereas the level of TN-X mRNA remained almost unchanged. In analyses by Western blotting, the two main TN-C isoforms of 235-240 and 190-200 kDa increased up to 45- and 105-fold in fibrotic tissues, respectively. The large isoform was expressed more strongly than the smaller, although in healed fibrotic scar tissues their ratio was lower in protein than in RNA. Compared to unirradiated skin, an immunohistological study revealed stronger TN-C staining at the dermo-epidermal junction and in areas of remodeling in healed skin. An intense extracellular staining was observed around myofibroblasts in muscle fibrosis. Therefore, the gene encoding TN-C is highly up-regulated in fibrotic tissues, and mechanisms regulating the levels of TN-C variants occur at both the RNA and protein levels. Each isoform might play a distinct role in the chronic activation of fibrosis by differentially regulating mechanisms like cell adhesion, migration or proliferation.

Coactivation of AP-1 activity and TGF-beta1 gene expression in the stress response of normal skin cells to ionizing radiation

Activation of the AP-1 transcription factor and TGF-beta1 growth factor by ionizing radiation was studied both in vivo in pig skin, and in vitro in human fibroblasts and keratinocytes. Three and 6 h after irradiation, the Fos and Jun proteins and their binding activity to an AP-1 consensus sequence were strongly induced by high doses of gamma-rays. c-Fos, c-Jun and JunB proteins were found to be present in gel-shift complexes by probing with specific antibodies. Both keratinocytes and fibroblasts exhibited heightened AP-1 activity following irradiation. As we previously found that TGF-beta1 is involved in the development of skin lesions induced by radiation, TGF-beta1 gene expression was also examined. Two and 6 h after irradiation, the levels of TGF-beta1 transcripts were increased in skin. By immunostaining, TGF-beta1 protein levels were found to be increased in fibroblasts, keratinocytes and endothelial cells. As the TGF-beta1 promoter contains AP-1 binding sites, the relation between AP-1 activity and TGF-beta1 induction was addressed. The -365 TGF-beta1 promoter fragment, which contains a high affinity AP-1 site, exhibited increased binding to Jun and Fos proteins following irradiation. These results suggest that stress-inducible TGF-beta1 expression is mediated by the activation of AP-1 transcription factor.

Dosimetry of 60Co and 192Ir gamma-irradiated agarose gels by proton relaxation time measurement and NMR imaging, in a 0-100 Gy dose range

Localized irradiation of the skin and subcutaneous tissues with large single doses of gamma rays can induce immediate effects characterized by erythema, desquamation, and necrosis. Correlations between the evolution of the lesions and dosimetry studies have to be established by biophysical methods. NMR studies of the effects of an irradiated Fricke solution might be a means of controlling the delivered irradiation doses. After exposition to ionizing radiations, ferrous ions are transformed into ferric ions. Both are paramagnetic ions, and proton spin-lattice relaxation is accelerated depending on the oxidation reaction. In this study, solution of ammonium ferrous sulfate in an acid environment was incorporated into a gelling substance made with agarose, so that T1 weighted image contrast could be used to detect ferric ion formation. Experiments with 192Ir and 60Co gamma rays with doses in the 0 to 100 Gy range were conducted with Fe2+ concentrations of 0.5, 1, 1.5, and 2 mM in a gelling substance containing 4% agarose. A relationship was established between the amount of Fe3+ created and the spin-lattice proton relaxation rate, which led to a straightforward dose-effect relation. The use of such high doses allowed us to reproduce realistic conditions of accidental overexposure. A linear relationship was obtained between the doses absorbed and the NMR parameters measured (T1 and relative image intensity).

In vivo study of rabbit irradiated skeletal muscle by MRI--a long-term follow-up

The delay in the appearance and the extent of a lesion induced by gamma-irradiation, in rabbit iliospinalis muscles, have been evaluated in vivo by MRI. The left side rabbit muscle was irradiated with an 192Ir sealed source at two skin surface doses: 40 Gy and 80 Gy. The progress of the lesion was followed on a long-term basis (12 months) by using T2 weighted spin echo imaging. The irradiation induced lesions were detected by MRI 22 weeks after irradiation for the 40 Gy group and 17 weeks for the 80 Gy group. The atrophy of the muscle and the extent of the lesion increased as a function of the dose at the skin surface. The threshold depth dose, corresponding to the deepest border of the lesion, was calculated by using the monoexponential attenuation law. The results gave the value of 20 +/- 7 Gy for the 40 Gy group and 16 +/- 3 Gy for the 80 Gy group.

[Changes of the cutaneous micro-relief in superficial radiation-induced fibrosis: a qualitative study]

Cutaneous radiation-induced fibrosis (RIF) is characterized by a skin retraction or atrophy, toughness to the palpation and often entails functional limitation. Its clinical evaluation remains poorly quantified. The aim of this study was to propose an analytical method to quantify RIF skin surface with the replica technique. In this preliminary study, we report the qualitative and quantitative evaluation of the cutaneous microrelief in 44 healthy controls and in four patients presenting a superficial RIF, 3 to 20 years after radiotherapy for cancer. The microrelief of these RIF presented an abnormal anisotropy with a parallel reorganization of cutaneous valleys in three cases out of four, suggesting a premature radiation-induced ageing of the skin. Each subject being his own control, the relative vertical amplitude of the skin microrelief was +/-15% in control skin. Vertical amplitude was respectively increased by 84% in one inflammatory fibrosis (3 years after RT), decreased by 18% in one evolutive fibrosis (6 years after RT), decreased by 26% in one voluminous stabilized fibrosis (8 years after RT) and decreased by 53% in one atrophic fibrosis (20 years after RT). The present study suggests that the variations of the microrelief parameters could reflect the RIF evolution. This technique requires a validation in a larger series of patients, including patients with telangiectasia.

Successful treatment of radiation-induced fibrosis using Cu/Zn-SOD and Mn-SOD: an experimental study

PURPOSE

To establish how far liposomal copper/zinc superoxide dismutase (Cu/Zn-SOD) and manganese superoxide dismutase (Mn-SOD), respectively, reduce radiation-induced fibrosis (RIF), using a well-characterized pig model of RIF permitting the design of a controlled laboratory experiment.

METHODS AND MATERIALS

In this model of acute localized gamma irradiation simulating accidental overexposure in humans, three groups of five large white pigs were irradiated using a collimated 192Ir source to deliver a single dose of 160 Gy onto the skin surface (100%) of the outer side of the thigh. A well-defined block of subcutaneous fibrosis involving skin and skeletal muscle developed 6 months after irradiation. One experimental group of five pigs was then injected i.m. with 10 mg/10 kg b.wt. of Cu/Zn-SOD, twice a week for 3 weeks, and another experimental group of five was injected with 10 mg/10 kg b.wt. of Mn-SOD, three times a week for 3 weeks. Five irradiated control pigs were injected with physiological serum. Animals were assessed for changes in the density of the palpated fibrotic block and in the dimensions of the projected cutaneous surface. Block depth was determined by ultrasound. Physical and sonographic findings were confirmed by autopsy 12-14 weeks after completing SOD injections. The density, length, width, and depth of the fibrotic block, and the areas and volume of its projected cutaneous surface were compared before treatment, 1, 3, and 6 weeks thereafter, and at autopsy, 12-14 weeks after treatment ended.

RESULTS

The experimental animals exhibited no change in behavior and no abnormal clinical or anatomic signs. Whether they were given Cu/Zn- or Mn-SOD, significant and roughly equivalent softening and shrinking of the fibrotic block were noted in all treated animals between the first week after treatment ended and autopsy, when mean regression was 45% for length and width, 30% for depth, and 70% for area and volume. Histologic examination showed completely normal muscle and subcutaneous tissue surrounding the residual scar. This replacement of scar tissue by normal tissue in experimental animals and the 50% decrease in the linear dimensions of the scar were comparable to the results obtained in previous clinical studies and highly significant compared to the clinical and autopsy results for the control animals.

CONCLUSIONS

Our results are striking and comparable to the results obtained in our previous clinical study after liposomal Cu/Zn-SOD treatment. To our knowledge, this is the first time that two agents have been shown to reverse the radiation-induced fibrotic process in experimental animals and to permit the regeneration of normal tissue in a zone of well-established postirradiation fibrosis.

Successful treatment of radiation-induced fibrosis using liposomal Cu/Zn superoxide dismutase: clinical trial

Based on experimental and clinical evidence indicating that the anti-oxidant agent liposomal Cu/Zn superoxide dismutase (Lipsod) is an effective anti-inflammatory drug and possibly might be effective in reducing late radiation-induced tissue injury, a clinical trial using Lipsod to treat long-standing radiation-induced fibrosis (RIF) was begun at the Necker Hospital, Paris in May 1984. Thirty-four patients presenting 42 distinct palpable zones of RIF involving the skin and underlying tissues were treated from May 1984 to January 1986 and followed for an average of 5 years (range, 14-89 months). Lipsod was administered over 3 weeks in twice weekly i.m. injections of 5 mg for a total of 30 mg. Patients underwent two physical examinations by independent physicians at each check-up. Parameters noted included determination of the density of the palpated fibrotic block and the dimensions of the projected cutaneous surface. The extent of change in the fibrotic zone was expressed as the ratio of the sum of the dimensions (L + W) and the ratio of the uncorrected areas (L x W) of the projected cutaneous surface before and after treatment. Changes in density were noted and scored. All patients showed some clinical regression of fibrosis. In most patients, clinically assessable regression begun during the third week of treatment and was maximum by 2 months. The mean decreases in the linear dimensions (L + W) and in the area (L x W) of the projected cutaneous surface were 41 +/- 30% and 57 +/- 26%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Concomitant p53 gene mutation and increased radiosensitivity in rat lung embryo epithelial cells during neoplastic development

A rat lung cell population had been treated with benzo(a)pyrene, and a set of different epithelial cell lines was derived from it. These cell lines carried either a wild-type or mutant p53 gene and represented grading states of neoplastic development. We demonstrate here that the cells lacking both wild-type p53 alleles display a significant decrease in survival after gamma-irradiation with doses of 2 to 12 Gy, compared with their counterparts carrying wild-type p53 alleles. This is the first reported model in which cells bearing a mutation of the p53 gene display enhanced sensitivity to ionizing radiation.

[Radiation-induced cutaneo-muscular fibrosis (III): major therapeutic efficacy of liposomal Cu/Zn superoxide dismutase]

Sub-cutaneous and muscular fibrosis are common and irreversible late effect of radiation on normal tissues. An experiment was designed to test the effectiveness of superoxide dismutase in reducing late radiation injury. This study was performed in an experimental porcine model of acute localized gamma irradiation simulating human accidental overexposure: 12 Large White pigs were irradiated on the thigh with a collimated gamma 192Ir source, so that the dose was 160 Gy/skin (100%) and 40 Gy/2 cm depth (25%). In this model, fibrosis appears in 4 to 5 months. The heterogeneous sclerotic tissue is composed of stable fibrotic areas poorly cellularized and active areas with a high density of myofibroblasts and inflammatory perifibrotic part. Lipsod administration modalities were six intramuscular injections during 3 weeks (twice weekly) either 10 mg/inj (five pigs) or of 100 mg/inj (five pigs). A methodic evaluation by two examiners consisted of measurements being taken before and after treatment: sum of the two largest perpendicular measurable dimensions, cutaneous projected surface of palpated fibrotic block, ultrasound fibrosis deepness and extrapolated volume. We conclude that Lipsod is the first drug ever described that reduces radiation-induced fibrosis. Its efficacy in this model was highly significant, with a regression higher than 40% in size and 70% in surface and volume, 12 weeks after the end of treatment. This response was rapid, reproducible without dose-effect or toxicity in the limits studied. This work confirms previously published results in humans.

Preferential induction of c-fos versus c-jun protooncogene during the immediate early response of pig skin to gamma-rays

The involvement of the nuclear protooncogenes c-fos and c-jun in the immediate early response of pig dermis cells was studied after in vivo gamma-irradiation. Following high radiation doses (8 to 48 Gy), the two protooncogenes were concomitantly induced, although c-fos induction was preferential. Both inductions were time and dose dependent. Therefore, the early response of the skin to high doses of radiation might involve heterodimeric activator protein 1 composed of c-Fos and c-Jun proteins. Following low radiation doses (0.5 to 2 Gy), c-jun was not induced. By contrast, dramatic c-fos induction was observed after 0.5 Gy, suggesting a specific role for c-fos at low doses.

Muscular fibrosis induced after pig skin irradiation with single doses of 192Ir gamma-rays

Localized irradiation of the skin and subcutaneous tissues with large single doses of gamma-rays can induce delayed effects characterized by fibrosis which invades the irradiated tissues. In this study the depth of penetration of muscle fibrosis was measured in the pig 30 weeks after irradiation of the skin surface with single doses of 192Ir gamma-rays of 16-256 Gy. Irradiation was directed either to the outer side of the thigh or to the back, close to the mid-dorsal line. Fibrosis only developed in irradiated muscle after doses that induced moist desquamation of the skin in the acute phase of the reaction, i.e. after skin surface doses of 48-64 Gy. In skeletal muscles, the limit of fibrotic expansion was reached at a depth dose of 14 +/- 4 Gy (+/- SD) for skin surface doses exceeding 48 Gy.

Temporal modulation of TGF-beta 1 and beta-actin gene expression in pig skin and muscular fibrosis after ionizing radiation

Although radiation-induced fibrosis has long been characterized by excess fibroblast proliferation and extracellular matrix deposition, the origin of cell activation in these complications of radiotherapy or radiation accidents is still controversial. The present work was designed to test the hypothesis that the abnormal production of TGF-beta 1 in irradiated tissues results in continuous signals for tissue repair and long-term cell activation. We examined gene expression of this growth factor in a well-characterized pig model of radiation-induced fibrosis, using Northern-blot and slot-blot hybridizations and indirect immunofluorescence. We found that the TGF-beta 1 mRNA level was increased 19-fold in the irradiated skin during the early erythematous phase, which started 3 weeks after irradiation. During the later phases of fibrosis, from 6 to 12 months after irradiation, the TGF-beta 1 gene was highly expressed in the repaired skin and the underlying muscular fibrotic tissue, with 10- and 8-fold maximal increases, respectively. In addition, we found that the beta-actin mRNA level was increased in the fibrotic tissue. Immunostaining for TGF-beta 1 revealed the presence of the protein in endothelial cells of capillaries, in myofibroblasts, and in the collagenous matrix of the fibrotic tissue. These results suggest that TGF-beta 1 may be one of the key cytokines involved in the cascade of events that leads to radiation-induced fibrosis, at both early and late stages.

[Iatrogenic fibrosis in cancerology (2): main etiologies and therapeutic possibilities]

Fibrosis in oncology concerns iatrogenic pathology, after radiotherapy or bleomycin, and also after surgery or neoadjuvant chemotherapy. Specificity of certain etiologic conditions are described in detail. Some therapeutic attitudes are discussed. Corticoids are useful in the management of inflammatory fibrosis attacks. Other drugs under study are used in an attempt to reduce the late fibrotic process, namely liposomal superoxide dismutase.

[Gamma irradiation and delayed effects: muscular fibrosis]

This study was performed on an experimental porcine model of acute local gamma irradiation to simulate accidents which occurred among humans. It enabled us to determine the development and the physiopathological characteristics of the fibrous tissue which developed in skeletal muscle. In the first month after irradiation, the strong inflammatory reaction which initiated the radiation induced fibrosis was characterized by edema as visualized on MRI imaging and X rays computed tomography and by acute phase reactant proteins changes, associated with elevations of local and general temperatures in irradiated animals. At the margin of the irradiated tissue myofibroblasts isolated among collagen bundles or grouped in nodullary reinforcements, are seen associated with intense capillary neogenesis. Several months after irradiation normal skeletal muscle was replaced by atrophic fibrosis delimited by an inflammatory perifibrotic tissue. The muscular fibrosis was characterized by a high density of myofibroblasts and by an inflammatory distribution pattern of collagen types I, III, IV, laminin, fibronectin and fibrinogen as visualized by immunohistochemical methods. Biochemical results showed an increase in collagen content and synthesis in fibrotic tissue whereas the cells in the perifibrotic zone synthesized more non collagenous proteins as compared with the normal muscle. The contributions of granulation tissue, cellular mediators and inhibition of muscular regeneration in the persistence of the invasive character of the muscular radiation induced fibrosis are discussed.

Modification of collagen and noncollagenous proteins in radiation-induced muscular fibrosis

Six months after acute local gamma irradiation of the pig skin and adjacent muscle, the muscular tissue is replaced by a large mutilating and proliferative fibrosis deliminated by a perifibrotic inflammatory zone. The content and biosynthesis of collagen and noncollagenous proteins were studied in both fibrotic and perifibrotic zones after incubation of the biopsies with [14C]proline or [35S]methionine for 24 hr. Cells of perifibrotic and fibrotic regions synthesize about 10 times more proteins than those in the nonirradiated muscle. When compared to normal muscle tissue, our results indicate an important increase in collagen content and biosynthesis in fibrotic tissue. The increase in collagen biosynthesis in the irradiated tissue is more pronounced for type III collagen than for type I collagen. Biosynthesis of type III and type I collagens increases 20- and 10-fold, respectively, compared to the normal muscle. Type I to III collagen ratio in irradiated tissue decreases from 2.3 in normal tissue to 1.1 in fibrotic tissue. Histological examination of the biopsies as well as the protein pattern by polyacrylamide gel electrophoresis show striking differences in the perifibrotic and fibrotic areas as compared to the normal muscular tissue with a progressive disappearance of the myotubes replaced by a dense sclerotic tissue. The results indicate that the perifibrotic inflammatory area is engaged in a remodeling process and that the fibrotic tissue remains active in the neosynthesis of the extracellular matrix macromolecules with a high proportion of type III collagen. This high biosynthetic activity of the irradiated tissue may explain the pseudosarcomatous character of the radiation-induced lesions.