Medical Physicist, RSO

Courtesy

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 2

On November 8, 1895 while

was working in his laboratory

in Wurzburg when he
accidentally discovers the

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 3

discovered emitted by
uranium compounds in 1896.

isolated the
radioactive elements
in 1898

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 4

 In 1901, Becquerel, Pierre,
and Marie Curie got a
on their skin

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 5

is the study of the action of
ionizing radiations on living things
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 6
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 7
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 8
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 9
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 10
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 11
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 12
 • Renewal of tissues in the body is performed
by the stem cells

• Stem cells can replicate themselves or

proliferate into different cell types

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 13

• For the non-proliferating cells (nerve, muscle,
or secretory cells), death can be defined as
the

• For proliferating cells (stem cells), cell death

means the loss of the capacity for sustained
proliferation or

• A dose of 100 Gy is necessary to destroy cell

function in non-proliferating systems

• The mean lethal dose for loss of proliferative

capacity is usually less than 2 Gy

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 14

Stem cells which have abnormal proliferating capacity is known as .
Carcinomas are derived from such cells

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 15

A tumour volume contains both neoplastic stem cells and normal host cells. Since, tumour growth is driven by
neoplastic stem cells, they must be eradicated

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 16

• Tumour response to therapy is depends on
how many neoplastic stem cells are left.

• Stem cells can be detect by developing cell

assays. They have the ability to form a
colony within some growth environment.
Such cells are as
.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 17

 Cells which are damaged by radiation exposure do
not immediately die. They may produce modest
family of descendants.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 18

The basic idea of clonogenic assay is to remove cells from the tumour, place them in a defined growth
environment, and test for their ability to produce a defined colony of descendants.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 19

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 20
 • It is a plot of surviving fraction of
cells against dose (of radiation,
cytotoxic drug, or cell-killing agent).

• ED50 is the dose required to kill 50%

of the cells; 50% cells will survive.

• ED90 is the dose required to kill 90%

of the cells; 10% of the cells will
survive.

• Logarithmic scale of surviving

fraction is useful since the cure of a
tumour requires many orders of
magnitudes of cell kill.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 21

Low LET (sparsely ionizing) radiation
• At low doses, the survival curve starts with a finite initial slope
(i.e. the surviving fraction is an exponential function of dose)
• At higher doses, the curve bends. This bending or curving
region extends over a dose range of a few grays
• At very high doses, the survival curve often tends to
straighten again (the surviving fraction returns to be an
exponential function of dose)

High LET (densely ionizing) radiation

• The cell survival curve is a straight line from the origin (i.e.
survival approximates to an exponential function of dose)

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 22

If a small dose of radiation, dD, inactivates a small
number, dN, of biological entities in a sample contains N
biological entities,
1
𝑑𝑁 = − 𝑁 𝑑𝐷
𝐷0
Integrate the above equation yields:

If D = D0 :
𝑁 = 𝑁0 𝑒 −1 = 0.37 𝑁0
The mean lethal dose, D0, is the dose required to reduce
the population of entities from any value N to 0.37 N on
parts of the survival curve that are exponential.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 23

If the initial rate of inactivation continued until a dose
dD = D0 had been given, the number of inactivation
would be dN = N0. Thus, the mean lethal dose, D0, is
the dose that would be required to place one
inactivating event (“hit”) in each of the biological
entities if none were wasted.
However, due to the random nature of the
energy deposits, some energy will go to cells that have
already been destroyed and will be wasted, while some
cells will escape altogether so that instead of
destroying all the cells, the mean lethal dose, D0, only
destroys 63% of them.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 24

Suppose the cell has “n” targets, each of which must be inactivated to cause cell death.
The probability of a single target not being hit is
𝑒 −𝐷Τ𝐷0
Therefore, the probability that any individual target will be hit is
1 − 𝑒 −𝐷Τ𝐷0
Hence the probability of the n targets within one cell being hit is
(1 − 𝑒 −𝐷Τ𝐷0 )𝑛
Thus, the probability of survival of a cell that contains n targets is
𝑛
1 − 1 − 𝑒 −𝐷Τ𝐷0
This leads us to the multitarget single hit equation:

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 25

 For doses large compared with D0, i.e. D >> D0,
the multitarget single hit equation reduces to:

If we place D = 0 in above equation, then

N = n N0, determines the number of targets n
(extrapolation number), a measure of the width of
the shoulder.

If n is large (e.g. 10 or 12), the survival curve has

a broad shoulder. If n is small (e.g. 1.5 – 2), the
shoulder of the curve is narrow.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 26

Another measure of the shoulder width is

It is defined as the dose at which the straight portion of the

survival curve, extrapolated backward, cuts the dose axis
drawn through a survival fraction of unity.
A threshold dose is the dose below which there is no effect.
There is no dose below which radiation produces no effect,
so there can be no true threshold dose. Thus, the quasi-
threshold dose is the closest thing.
To determine the quasi-threshold dose, Dq, substitute N = N0
in reduced multitarget single hit equation, i.e.
1 = 𝑛𝑒 −𝐷𝑞 Τ𝐷0 or, 𝑛 = 𝑒 𝐷𝑞Τ𝐷0

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 27

This equation defines a survival curve that is concave
downwards and never becomes strictly exponential.
This concept assumes that two separate sub lesions or
single strand DNA breaks must interact to cause lethality.
That can be caused by a single ionizing track giving a
direct dependence on the first power of the dose, or by two
separate tracks producing SSBs independently, giving a
dependence on (dose)2.
α and β describe the probability of these two mechanisms.
If αD = βD2, D = α/β

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 28

• The effectiveness of treatment (as judged by the time-
scale of tumour recurrence) depends on the
and not on the regression component.
The figure shows the regrowth component due to
repopulation by surviving clonogenic cells.

• Once it begins, speed of repopulation may resemble

the higher growth rate of a very small untreated
tumour. This is known as .

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 29

 • Each radiation dose is assumed to result in a
surviving fraction of roughly 0.5, thus approximately
halving the number of clonogenic cells.

• It is assumed that constant effect per fraction.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 30

 • Focusing the radiation dose to the tumour
and reducing the dose to the normal
structures which are within or nearby the
high-dose volume

• If this is not achieved, radiotherapy will

almost always fail!

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 31

• Radiation interaction with most of the
components in the cells: proteins, enzymes,
membrane components etc. However, they will
be quickly regenerated.

• But, there is one cellular component which is

almost unique: . They possess genes that
contain instructions for proteins and thus for all
aspects of cellular function.

• Radiation damage to DNA may lead to the loss

(or modification) of some genes and thus to a
loss of specific functions (some of which may
be essential for survival).

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 32

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 33
An atom with even number of electrons
(spins are paired) is in high degree of
chemical stability. An atom with an odd
number of electrons (unpaired electron)
is in high degree of chemical reactivity.
It is called a

ℎν ℎν
+ −
𝐻2 𝑂 𝐻2 𝑂 + 𝑒

ℎν
𝐻2 𝑂+ 𝐻+ +

ℎν ℎν
𝐻2 𝑂 𝐻2 𝑂∗ +

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 34

Most cells do not immediately die when they are damaged by
radiation. They usually proceed to mitosis, often fail to complete
mitosis or they may go through one or more further cell cycles
before getting stuck at a subsequent cell division

Lymphocytes as well as some other cell types die before

reaching mitosis. This is called intermitotic cell death.

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Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 36
Split-dose: If dose is delivered as two fractions (means delayed by some hours in between), the effect of
damage is less. Cells can easily recover the damages – Sublethal damage (SLD)

Delayed-plating: If cells are irradiated in a non-growing state and left for a long time before assaying for
survival, an increase in survival is observed – Potentially lethal damage (PLD)

Dose-rate effect: In low dose-rate, there will be a delay in each particle interaction with the cells. Cellular
recovery is possible. It will lead to less overall damage.

Fractionation: Daily dose fractionation can provide cellular recovery before each fractions. Hence, in
clinical radiotherapy, total radiation dose required for tumour control must be increased as the number of
fractions increases.

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 37

 Cells which are in the

Cells which are in the

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 38

Repair: Cells will recover the radiation damage after few hours of irradiation

Reassortment (Redistribution): Cell-cycle progression effect

Repopulation: During the entire course of radiotherapy, the survived tumour cells may
proliferate and thus the number increases

Reoxygenation: Hypoxic cells will selectively survive after a dose fraction

Radiosensitivity: Different tumours have different radiosensitivity

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 39

 𝐷𝑜𝑠𝑒 𝑖𝑛 ℎ𝑦𝑝𝑜𝑥𝑖𝑐
𝑂𝑥𝑦𝑔𝑒𝑛 𝐸𝑛ℎ𝑎𝑛𝑐𝑒𝑚𝑒𝑛𝑡 𝑅𝑎𝑡𝑖𝑜 𝑂𝐸𝑅 =
𝐷𝑜𝑠𝑒 𝑖𝑛 𝑜𝑥𝑖𝑐

(for same biological effect)

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 40

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 41
• Hypoxic fraction refers to the fraction of clonogenic tumour
cells that have a similar radiosensitivity of hypoxic cells

• Hypoxic fraction of a tumour may greater in patients

whose blood has a reduced haemoglobin content

• Smoking reduces blood oxygen tension

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 42

 • Some tumours reoxygenate quickly
(approximately within one day). Other tumours
reoxygenate slowly (a week or more)

• Tumour cells that are hypoxic at the time of one

dose fraction may be oxic by the time a
subsequent dose fraction comes along. So, in
conventional fractionated radiotherapy,
presence of hypoxia may be less serious!

• When overall the treatment time is shortened

(in brachytherapy or accelerated external beam
therapy), hypoxia may still be significant!

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 43

 Surviving fraction of cells are different for various
tumours due to their radiosensitivity

A : lyphoma, myeloma, neuroblastoma

B : medulloblastoma, small-cell lung cancer
C : breast, bladder, cervix carcinoma
D : pancreas, colo-rectal, squamous lung cancer
E : melanoma, osteosarcoma, glioblastoma, renal carcinoma

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 44

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 45
 • Steeper curve of High LET radiation shows the
increased radiosensitivity

• High LET radiation (densely ionizing) will produce

more irreparable damage (high energy transfer)
while low LET radiation (sparsely ionizing)
produce more repairable damage (less energy
transfer)

Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 46

 𝐷𝑜𝑠𝑒 𝑜𝑓 250 𝑘𝑉𝑝 𝑥 − 𝑟𝑎𝑦𝑠
𝑅𝐵𝐸 =
𝐷𝑜𝑠𝑒 𝑜𝑓 𝑟𝑎𝑑𝑖𝑎𝑡𝑖𝑜𝑛 𝑢𝑛𝑑𝑒𝑟 𝑖𝑛𝑣𝑒𝑠𝑡𝑖𝑔𝑎𝑡𝑖𝑜𝑛

(for same biological effect)

1. SF = 0.8
2. SF = 0.1
3. SF = 0.01

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Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 48
Radiobiology – Part – 1: Radiobiology of Tumours – Dilshad Kottuparamban 49
Medical Physicist, RSO
Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 51
• Prescribed radiation dose
• Treatment volume
• Dose per fraction
• Short interval between fractions (< 24 h)
• Concomitant therapy (especially with cytotoxic drugs)

• Age and clinical status of the patient

• Concurrent disease
• Genetic make-up
• Lifestyle of patient (smoking or alcohol consumption)

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 52

• They show the effects of radiation damage within few weeks of being irradiated
• Skin, oral mucosa, intestines, bone marrow and testis
• The early reactions are due to of these tissues which usually have
a short functional life span
• Damage to these tissues tends to heal

• They show their response to radiation damage over months to years after exposure
• Lung, kidney and spinal cord
• Damage to them may be the result of (blood vessels)
• Some early-responding tissues may show late response, due to direct damage to connective tissue –
Consequential late effects
• Damage to these tissues tends to be more permanent

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 53

• For a given absorbed dose of radiation, the
consequent biologic response of tumour and
normal tissues must be evaluated; the dose-
response relationship

• Such dose-response curves are usually

sigmoid in shape

• The aim of radiotherapy is higher tumour

control probability (TCP) with less normal
tissue complication probability (NTCP)

• The ratio of the tumour response for a fixed

level of normal tissue damage is called

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 54

• To increase the therapeutic ratio,
hyperfractionation or addition of chemo drug
or radiosensitizers can be applied

• Hyperfractionation produces a greater

sparing of late-responding normal tissues
than tumour control

• Addition of chemo drug or radiosensitizers

with the radiation treatment can produce
same level of NTCP and increased level of
TCP

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 55

Each major tissue of the body shows a characteristic series of reactions to
radiation exposure. They may be classified as

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 56

• The probability of damage increases with radiation dose
• It has no threshold dose; occurs even at low doses
• It can’t be completely avoided
• It occurs only among a small percentage of those exposed
• Prime example is radiation carcinogenesis; i.e. induction of second tumours by radiation

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 57

• Clinically more important; the severity of damage
increases with radiation dose
• It has a threshold dose; deterministic in nature
• It occurs only at high doses
• It can be completely avoided
• There is a casual relationship between radiation
exposure and the effect
• Sure to occur at an adequate dose
• E.g. Effects in skin, mucosae, lung, brain and
spinal cord

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 58

• The severity of radiation damage in normal tissues depends on the volume of tissue irradiated

• Volume effects differ among the various organs depending on their structural organization and on the
migration characteristics of the surviving stem cells

• Partial volumes of some tissues such as kidney or lung can be treated to far higher radiation doses, instead
of irradiating the whole organ. This is because only one quarter to one third of the functional organ volume is
required to sustain life under normal physiological conditions. Such organs are known as

• In contrast, other more tube-like structures such as spinal cord have a different volume effect; inactivation of
a short segment causes loss of function of the whole organ (i.e. paralysis). Such organs are known as

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 59

a) Serial organ (e.g. Spinal cord
b) Parallel organ (e.g. Lungs)
c) Serial-Parallel organ (e.g. Heart)
d) Combination of parallel and serial structures (e.g. Nephorn)

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Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 61
Mechanism:
1. Free radical scavenging that protects against oxygen-based free radical generation
by ionizing radiations
2. Hydrogen atom donation to facilitate direct chemical repair at sites of DNA damage

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Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 63
Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 64
Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 65
Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 66
• The concept of LD50 is borrowed from the field of
pharmacology

• LD50 is defined as the dose of any agent or material

that causes a mortality rate of 50% in an experimental
group within a specified period

• Humans develop signs of hematologic damage and

recover from it much more slowly than most other
mammals. The peak incidence of human death from
hematologic damage occurs at about 30 days after
exposure, but deaths continue for up to 60 days. The
LD50 estimates for hematopoietic death for humans are
therefore expressed as the LD 50/60, in contrast to the
LD50/30 for mice, in which peak incidence of death
occurs 10 to 15 days after exposure and is complete by
30 days.

Radiobiology – Part – 2: Radiobiology of Normal Tissues – Dilshad Kottuparamban 67

Medical Physicist, RSO
 1

Cancer cell do not repair damage at low

doses. This is why we typically

Survival fraction
 = 0.3,  = 0.03
fractionate radiotherapy at low doses 0.1
Early reacting tissue

At low doses, survival of normal tissue

cells exceeds that of cancer cells 0.01
 = 0.1,  = 0.06
Late reacting tissue
At high doses, survival of cancer cells
exceeds that of normal tissue cells
0 2 4 6 8 10

Dose (Gy)

Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 69

• Strandqvist worked in controlling skin tumours
using radiation therapy and found that the total
dose required for tumour control increased with
the number of fractions

• He plotted his findings as the total radiation

dose against the overall treatment time

• The lines sloped upwards are referred to as

. They can be considered as
since they indicate different A: Skin necrosis
treatment schedules that produce the same B: Cure of skin carcinoma
biological effect C: Moist desquamation of skin
D: Dry desquamation of skin
E: Skin erythema

Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 70

• Strandqvist found that if the dose lay above the
curve of cure, overdose effects or necrosis of the
normal skin occurred, while if the dose lay below
this curve, underdose effects or tumour
recurrences appeared

• His results imply that 20 Gy in one day is

equivalent to:
30 Gy in 4 days
40 Gy in 11 days
50 Gy in 25 days
60 Gy in 45 days

• He believed the uncertainty of that curves is

0.22

Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 71

• Cohen analysed the Strandqvist curves and
found an exponent for

For normal tissue tolerance,

For the cure of skin carcinoma,

• If a radiation oncologist wished to change the

overall treatment time, he could read off from the
Strandqvist curve a new total dose that should
give the same treatment outcome

Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 72

• Ellis summarised the data of Strandqvist and Cohen and introduced the
system. He used his intuition to separate the exponents for number of fractions
(N) and overall treatment time (T):

• NSD determines the intensity of treatment and is assumed constant for any particular clinical
situation

• However, the scientific basis of NSD was very weak. It worked only for certain well-defined
conditions and within a limited range of fraction numbers. The formula failed to explain the
therapeutic results of fractions greater than 30 and less than 10

• Detailed animal studies showed that a power-law relationship was usually not satisfactory in
representing the data

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Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 74
Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 75
 1

Survival fraction
 = 0.3,  = 0.03
0.1
Early reacting tissue

0.01
 = 0.1,  = 0.06
Late reacting tissue

0 2 4 6 8 10

Dose (Gy)

Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 76

 𝛼𝑑+𝛽𝑑2
𝑆1 = 𝑒 −

𝛼𝑑+𝛽𝑑2
𝑆𝑛 = 𝑒 −𝑛
= 𝑒− 𝑛𝛼𝑑+𝑛𝛽𝑑2

− 𝑙𝑜𝑔𝑒 𝑆𝑛 = 𝑛𝛼 𝑑 + 𝑛𝛽 𝑑 2

−𝑙𝑜𝑔𝑒 𝑆𝑛 𝛽
= 𝑛𝑑 + 𝑛 𝑑 2
𝛼 𝛼
𝛽
= 𝑛𝑑 1 + 𝑑
𝛼

Radiobiology – Part – 3: Dose Fractionation in Radiotherapy – Dilshad Kottuparamban 77

Medical Physicist, RSO

Mob: 8089028355 | 9495365255

E-mail: dilshadkp.dk@gmail.com