title: Implications of intercellular signaling for radiation therapy: a theoretical dose-planning study.
abstract: OBJECTIVE
  Recent in vitro results have shown significant contributions to cell killing from signaling effects at doses that are typically used in radiation therapy. This study investigates whether these in vitro observations can be reconciled with in vivo knowledge and how signaling may have an impact on future developments in radiation therapy.
  
  
  METHODS
  Prostate cancer treatment plans were generated for a series of 10 patients using 3-dimensional conformal therapy, intensity modulated radiation therapy (IMRT), and volumetric modulated arc therapy techniques. These plans were evaluated using mathematical models of survival following modulated radiation exposures that were developed from in vitro observations and incorporate the effects of intercellular signaling. The impact on dose-volume histograms and mean doses were evaluated by converting these survival levels into "signaling-adjusted doses" for comparison.
  
  
  RESULTS
  Inclusion of intercellular communication leads to significant differences between the signalling-adjusted and physical doses across a large volume. Organs in low-dose regions near target volumes see the largest increases, with mean signaling-adjusted bladder doses increasing from 23 to 33 Gy in IMRT plans. By contrast, in high-dose regions, there is a small decrease in signaling-adjusted dose due to reduced contributions from neighboring cells, with planning target volume mean doses falling from 74 to 71 Gy in IMRT. Overall, however, the dose distributions remain broadly similar, and comparisons between the treatment modalities are largely unchanged whether physical or signaling-adjusted dose is compared.
  
  
  CONCLUSIONS
  Although incorporating cellular signaling significantly affects cell killing in low-dose regions and suggests a different interpretation for many phenomena, their effect in high-dose regions for typical planning techniques is comparatively small. This indicates that the significant signaling effects observed in vitro are not contradicted by comparison with clinical observations. Future investigations are needed to validate these effects in vivo and to quantify their ranges and potential impact on more advanced radiation therapy techniques.
authors.affiliation: Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom. Electronic address: stephen.mcmahon@qub.ac.uk.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: McMahon
authors.forename: Conor K
authors.initials: CK
authors.lastname: McGarry
authors.forename: Karl T
authors.initials: KT
authors.lastname: Butterworth
authors.forename: Joe M
authors.initials: JM
authors.lastname: O'Sullivan
authors.forename: Alan R
authors.initials: AR
authors.lastname: Hounsell
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Prise
mesh_terms: D024201:Bystander Effect / Q000502:physiology / Q000528:radiation effects; D002450:Cell Communication / Q000502:physiology*; D002470:Cell Survival / Q000502:physiology / Q000528:radiation effects*; D006801:Humans; D008297:Male; D008954:Models, Biological; D058958:Organs at Risk / Q000528:radiation effects; D011471:Prostatic Neoplasms / Q000532:radiotherapy; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D020266:Radiotherapy, Conformal / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods; D001743:Urinary Bladder / Q000528:radiation effects