Compared to conventional photon-based external beam radiation (PhXRT), carbon ion radiotherapy (CIRT) has superior dose distribution, higher linear energy transfer (LET), and a higher relative biological effectiveness (RBE). This enhanced RBE is driven by a unique DNA damage signature characterized by clustered lesions that overwhelm the DNA repair capacity of malignant cells. These physical and radiobiological characteristics imbue heavy ions with potent tumoricidal capacity, while having the potential for simultaneously maximally sparing normal tissues. Thus, CIRT could potentially be used to treat some of the most difficult to treat tumors, including those that are hypoxic, radio-resistant, or deep-seated. Clinical data, mostly from Japan and Germany, are promising, with favorable oncologic outcomes and acceptable toxicity. In this manuscript, we review the physical and biological rationales for CIRT, with an emphasis on DNA damage and repair, as well as providing a comprehensive overview of the translational and clinical data using CIRT.

DNA double-strand breaks (DSBs) are deleterious DNA lesions that if left unrepaired or are misrepaired, potentially result in chromosomal aberrations, known drivers of carcinogenesis. Pathways that direct the repair of DSBs are traditionally believed to be guardians of the genome as they protect cells from genomic instability. The prominent DSB repair pathway in human cells is the non-homologous end joining (NHEJ) pathway, which mediates template-independent re-ligation of the broken DNA molecule and is active in all phases of the cell cycle. Its role as a guardian of the genome is supported by the fact that defects in NHEJ lead to increased sensitivity to agents that induce DSBs and an increased frequency of chromosomal aberrations. Conversely, evidence from tumors and tumor cell lines has emerged that NHEJ also promotes chromosomal aberrations and genomic instability, particularly in cells that have a defect in one of the other DSB repair pathways. Collectively, the data present a conundrum: how can a single pathway both suppress and promote carcinogenesis? In this review, we will examine NHEJ’s role as both a guardian and a disruptor of the genome and explain how underlying genetic context not only dictates whether NHEJ promotes or suppresses carcinogenesis, but also how it alters the response of tumors to conventional therapeutics.

Telomeres are nucleoprotein complexes comprised of tandem arrays of repetitive DNA sequence that serve to protect chromosomal termini from inappropriate degradation, as well as to prevent these natural DNA ends from being recognized as broken DNA (double-strand breaks; DSBs) and triggering of inappropriate DNA damage responses. Preservation of telomere length requires telomerase, the specialized reverse transcriptase capable of maintaining telomere length via template-mediated addition of telomeric repeats onto the ends of newly synthesized chromosomes. Loss of either end-capping function or telomere length maintenance has been associated with genomic instability or senescence in a variety of settings; therefore telomeres and telomerase have well-established connections to cancer and aging. It has long been recognized that oxidative stress promotes shortening of telomeres, and that telomerase activity is a radiation-inducible function. However, the effects of ionizing radiation (IR) exposure on telomeres per se are much less well understood and appreciated. To gain a deeper understanding of the roles telomeres and telomerase play in the response of human cells to ionizing radiations of different qualities, we tracked changes in telomeric end-capping function, telomere length, and telomerase activity in panels of mammary epithelial and hematopoietic cell lines exposed to low linear energy transfer (LET) gamma(γ)-rays or high LET high charge, high energy (HZE) particles, delivered either acutely or at low dose rates (LDR). In addition to demonstrating that dysfunctional telomeres contribute to IR-induced mutation frequencies and genome instability, we reveal non-canonical roles for telomerase, in that telomerase activity was required for IR-induced enrichment of mammary epithelial putative stem/progenitor cell populations, a finding also suggestive of cellular reprogramming. Taken together, the results reported here establish the critical importance of telomeres and telomerase in the radiation response and as such, have compelling implications not only for accelerated tumor repopulation following radiation therapy, but for carcinogenic potential following low dose exposures as well, including those of relevance to spaceflight-associated galactic cosmic radiations.

The enrichment of putative CD44+/CD24-/low breast stem cell populations following exposure to ionizing radiation has been ascribed to their inherent radioresistance and an elevated frequency of symmetric division during repopulation. However, recent studies demonstrating radiation induced phenotypic reprogramming (the transition of non CD44+/CD24-/low cells into the CD44+/CD24-/low phenotype) as a potential mechanism of CD44+/CD24-/low cell enrichment have raised the question of whether a higher survival and increased self-renewal of existing CD44+/CD24-/low cells or induced reprogramming is an additional mode of enrichment. To investigate this question, we combined a cellular automata model with in vitro experimental data using both MCF-10A non-tumorigenic human mammary epithelial cells and MCF-7 breast cancer cells, with the goal of identifying the mechanistic basis of enriching the CD44+/CD24-/low cell pool in the context of radiation-induced cell senescence. Quantitative modeling revealed that incomplete phenotypic reprogramming of pre-senescent non-stem cells (reprogramming whereby the CD44+/CD24-/low phenotype is conveyed, but along with the short-term remaining proliferation capacity of the original cell) could be an additional mode of enriching the CD44+/CD24-/low subpopulation. Further, the stem cell enrichment in MCF-7 cells occurs both at lower doses and earlier time points, and has longer persistence, than that observed in MCF-10A cells, suggesting phenotypic plasticity appears to be less regulated in breast cancer cells. Taken together, these results suggest that reprogramming of pre-senescent non-stem cells may play a significant role in both cancer and non-tumorigenic mammary epithelial populations following exposure to ionizing radiation, a finding with important implications in radiation therapy and radiation carcinogenesis.

The penta-aza macrocyclic manganese compound GC4419 is in phase 3 clinical trials as a modifier of mucositis in H&N cancer treated by radio-chemotherapy based upon its properties as a superoxide dismutase mimetic. In studies to address the potential for tumor radioprotection, a significant anti-tumor effect was identified in tumors generated from the non-small cell lung cancer (NSCLC) cell line H1299, when GC4419 was combined with radiation. This effect was directly related to the size of the radiation dose as demonstrated by greater efficacy in tumor growth delay when biologically equivalent irradiation regimens using a limited number of dose fractions was substantially more effective compared to regimens where the fraction number was higher and dose per fraction decreased. Furthermore, a TCD50 assay using H1299 tumors that tested the combination of GC4419 with radiation revealed a Dose Enhancement Factor of 1.67. Based upon these results the hypothesis that GC4419 was generating cytotoxic levels of hydrogen peroxide during the superoxide dismutation process. Peroxide flux did increase in cells exposed to GC4419 as did the expression of the oxidative stress markers 4-HNE and 3-NT. H1299 cells that overexpressed catalase were then challenged as tumors by the combination of radiation and GC4419 and the tumoricidal effect was nearly eliminated. The enhanced radiation response was not specific to NSCLC as similar findings were observed in human head and neck squamous cell carcinoma and pancreatic ductal adenocarcinoma xenografts. RNA sequencing analysis revealed that GC4419, in addition to generating high levels of hydrogen peroxide in irradiated cells, alters inflammatory and differentiation signaling in the tumor following irradiation. Together, these findings provide abundant evidence that the radioprotector GC4419 has dual functionality and will increase tumor response rates when combined with agents that generate high levels of superoxide like stereotactic ablative body radiotherapy (SAbR). Combining SAbR with GC4419 may be an effective strategy to enhance tumor response in general but may also allow for fully potent radiation doses to tumors that might not necessarily be able to tolerate such doses. The potential for protection of organs at risk may also be exploitable.