The biological effect of radiation is directly correlated with the pattern of energy transfer to biological material along its path and the amount of energy imparted per unit distance travelled is described as the linear energy transfer (LET). The LET of alpha-particles emitters under clinical development (²²⁵Ac, ²¹¹At, ²¹³Bi, ²¹²Pb, ²²³Ra, ²²⁷Th) is typically around 100 keV/µm. In comparison, the LET of 250 kVp X-rays is 2 keV/µm, 10 MeV photon is 4.7 keV/µm and the LET of beta particles from internal emitters like ⁹⁰Y, ¹³¹I and ¹⁷⁷Lu is 0.2 keV/µm. Low LET photons and electrons deposit their energy almost exponentially decreasing from the source. Heavy charged ions such as alpha particles, however, deposit energy very differently along their tracks for a much shorter range (µm vs. mm). As the alpha particles slow down due to loss of energy, the interaction cross-section increases (i.e., they have higher probability to interact with more materials) and results in higher LET at the end of their tracks known as Bragg peaks (Figure 1A). The range of the alpha particles and hence the position of the Bragg peaks are correlated to the initial energy of the alpha particles.

In heavy ion beam therapy, the steep Bragg peaks can thus be modulated to deposit most of the energy in the tumor mass. Since the LET is relatively lower before the Bragg peaks and drops abruptly to zero afterwards, this physical characteristic of heavy ion particles provide a significantly better therapeutic ratio between tumors and normal tissues than the photon beams that do not exhibit Bragg peaks. In the early years of proton and alpha beam studies at Berkeley, the Bragg peak effect of alpha beams had already been utilized to treat breast cancer and glioma. Dosimetry of tumor and skin showed the sparing effect of the Bragg peaks from alpha beams delivering tumor dose of 50 to 85 Gy with less than 20 Gy to the skin [13]. Current ion beam delivery is realized with a combination of range shifter, modulator, lateral spreading and collimator to achieve uniform dose distribution in the tumors (spread out Bragg peak, SOBP) and minimize doses to the surrounding normal tissues [17] (Figure 1B).

The alpha-particles from natural decays have relatively lower energy compared to helium and carbon ions generated from the ion accelerator. Their short ranges (<100 µm, Figure 1A) enable them to deposit all their energy within the distance of about five cell diameters, sparing normal tissues surrounding them. Unlike ion beam therapy where toxicity to the normal tissues surrounding the tumors is the main concern, normal tissue toxicity in radioimmunotherapy is determined by in vivo distribution of the radiolabeled antibody and dose limiting organs are typically red marrow and, in the case of high dose myeloablative treatment, lungs, liver and kidneys. This difference between alpha-article radioimmunotherapy and ion beam therapy makes the high LET Bragg peak a much less contributing factor in determining normal tissue toxicity for internal alpha-emitters. The range of the alpha particle (Figure 1A) seems to suggest that alpha-particle emitter labeled antibody will be less effective against single cells (mammalian cells are about 20 µm in diameter) compared to multi-cellular small metastasis since the high LET Bragg peak of alpha particles emitted from cell surface will miss single cells. Measuring relative biological effectiveness (RBE) at different LET can shed some light on this possibility.

The first study on RBE of heavy ion particles at different LET was performed by Barendsen et al in the 1960s using monoenergetic alpha particle beams [18,19,20,21,22,23]. Monoenergetic alpha particles with initial energy ranging from 2.5 MeV to 26 MeV were used to irradiate human kidney T1 cells with track segment (entrance plateau region of LET curve, not within Bragg peak) and compared to deuteron beam and X-rays. LET from alpha particles range from 25 keV/µm to 185 keV/µm while LET from deuterons and 250 kVp X-rays are below 20 keV/µm (Figure 2A). The data clearly showed that high LET alpha particles are more effective than low LET deuterons and X-rays. For alpha particles, the RBE increases with increasing LET until it peaks at slightly over 100 keV/µm and declines afterwards. This decline is attributed to the fact that once cells are killed applying even higher LET alpha particle is simply a waste of energy without enhancing the probability of cell kill. For internal alpha-emitters, due to the relatively low initial energy of the alpha particles, the LET is already in the range of the peak RBE (~100 keV) suggesting these antibody delivered alpha particles are optimal to kill single cell and micrometastasis.

Since the classic studies by Barendsen, the relationship between RBE and LET was widely accepted and a single RBE vs. LET curve was assumed to fit for different types of radiation. In the early 1990s, Belli et al., in a series of studies using low LET alpha particles generated with alpha particles accelerated to very high initial energy since the higher the energy the lower the initial LET [24,25,26,27], found that at the same low LET, protons have higher RBE than the alpha particles (1.2 MeV proton vs. 30.5 MeV alphas) with different endpoint for RBE including cell survival and mutation, but much less so for induction of DNA double strand breaks. Several other studies generated similar results [28,29,30,31]. Although LET of alpha particles from internal emitters are much higher with greater RBE than protons and other low LET radiation, these studies highlighted the importance of track structure of different radiations and the microscopic distribution of energy deposition, which is especially important for antibody delivered alpha radiation since antigen heterogeneity and slow tumor penetration of antibody lead to highly non-uniform distribution of alpha-particle emitters.

The RBEs for internal alpha-emitters have also been examined both experimentally and theoretically [4,32,33,34,35,36]. For internal alpha emitter, since cells can be irradiated with different LETs along the alpha tracks RBE is reported, instead of LET, with individual alpha emitter or by the initial energy of the alpha particle they emit. Aurlien et al. reported that alpha particle emitter ²¹¹At labeled antibody has an RBE of 3.43 for osteosarcoma cell line OHS-s1 and 1.55 for bone marrow cells using 37% cell survival as the biological endpoint and ⁶⁰Co γ-rays as reference [36]. Bäck et al. reported an RBE of 4.8 for ²¹¹At labeled MX35 F(ab’)₂ in an ovarian cancer NIH:OVCAR-3 tumor model [37]. In vivo measurement of RBE using mouse testes as an experimental model and testicular spermhead survival as the biological endpoint, Howell et al. found that the RBE of ²¹²Pb with alpha particle emitting daughters ²¹²Bi and ²¹²Po was 4.7 using 120 kVp X-rays as reference [38]. The same model was also used to find that the RBE of two other alpha particle emitters, ¹⁴⁸Gd and ²²³Ra, is 7.4 ± 2.4 and 5.4 ± 0.9, respectively [39]. In addition, in vivo studies of alpha emitter ²¹³Bi labeled peptide found an RBE of 2-3 for control of colon cancer and surprisingly close to 1.0 for marrow toxicity using beta emitter ⁹⁰Y labeled peptide as reference [40,41]. Nayak et al. found similar RBE of 3.4 for ²¹³Bi labeled DOTATOC when treating pancreatic adenocarcinoma cells using ¹³⁷Cs as reference radiation [42]. The reported RBEs of internal alpha-emitters, probably an average of LET along its tracks with different biological endpoints and reference radiations, are still in the range of those reported in the high LET ion beams studies (Figure 2A). Review of alpha-emitters for medical therapy by an expert panel on a Department of Energy workshop recommended an RBE value of 5 for ²¹³Bi and ²¹¹At in phase I clinical trials and suggested establishment of “clinical” RBE values as trials progress [43].

In radiobiology, understanding the distribution of energy deposition in irradiated tissues is of high significance in evaluating biological effects of different types of radiation. It is widely accepted that the DNA molecules are the primary targets for radiation induced damage and that DNA DSBs are the principal cause of biological damage. Pairs of DNA damage interact with each other in the micrometer range and the probability of interaction is distance-dependent. The diameter of DNA is about 2 nanometer and the distribution of absorbed energy in the nanometer and the micrometer level can cause observed effects and their relative contributions determine the relative biological effectiveness [44].

In targeted alpha radionuclide therapy, the range of emitted particles is comparable to the size of the cells and the distance between the sites of radionuclide deposition is also small hence, random spatial distribution of disintegration has non-negligible effect on the local energy deposition. In other words, statistical variation in the energy deposition from high-LET radiation such as alpha particles is large in a small volume and that the macrodosimetic quantities such as mean absorbed dose can be a misleading index for the biological effects of high-LET radiation [4]. In such cases, microdosimetric concepts and their associated quantities such as specific energy (energy per unit mass) and lineal energy (energy per unit path length) that accounts for the stochastic nature of energy deposited in a small volume are more suited to understanding biological effects. The criterion as to when microdosimetry should be considered was defined by Kellerer and Chmelevsky [45], which states that the stochastic nature of energy deposition within the target should be taken into account when the relative deviations of the local dose from the mean in the target region exceeds 20%. The applicability of microdosimetric concepts in targeted alpha particle therapy has been extensively reviewed by Sgouros et al. [4] and also recently by Chouin and Bardies [46].

At present the use of microdosimetry in radiobiology is constrained by the lack of biological information at the microscopic level by experimental methods and not due to the lack of microdosimetric models. It is envisioned that advances in molecular techniques would shed some light in the analyses of the spatial distribution of DNA lesions that can be correlated to the spatial fluctuations of energy deposition by different ionizing radiations in the near future [47].

Radiation kills cancer cells primarily by damaging DNA [48]. Quantity and “quality” of DNA damages are two important factors that determine the severity of ionizing radiation caused by low and high LET radiation, which is mainly due to different levels of indirect (free radicals) and direct (physical interaction between radiation and DNA) effects that will be discussed in detail in the next section. So far, evidence suggested that high LET radiation does not induce significantly higher amount of DNA breaks than low LET radiation that can explain its more severe effects on DNA damages. Both supercoiled plasmid DNA and cell based assays using pulse-field gel electrophoresis (PFGE) have shown that the yield of DNA double strand breaks (damage site/Mbp/Gy) with high LET is only slightly higher than with low LET [26,49,50,51] or in some studies decreases with increasing LET in mammalian cells [52,53]. Increasing LET meanwhile was shown to induce more DSBs per track traversing cells [54], suggesting that most DSBs induced by high LET radiation are concentrated on fewer tracks compared to low LET radiation. The induction of DNA DSBs/cell/Gy also does not correlate well with other measurement endpoints for RBE such as cell survival and mutation induction, both of which clearly show the trend of higher RBE with increasing LET. Uncertainty still exists in the measurement of DNA fragments to quantify DSBs where Monte Carlo simulation has shown that the yield of short DNA fragments (0.1–1.0 kbp) continues to increase with higher LET while yield of intermediate DNA fragments (1.0–1000 kbp) peaks at around 100 keV/µm LET raising the possibility that short DNA fragment undetected in the measurement can significantly affect the yield of DSBs and artifactually lower the calculated RBE of high LET radiations [55].

On the other hand, it has been established that high LET radiation induces more complex DNA damage where DNA lesions occurring close to each other form clustered DNA damage [56,57]. These lesions include DNA DSBs and non-DSB oxidative clustered DNA lesions (OCDL) [57,58]. For non-DSB oxidative clustered DNA lesions, both Monte Carlo simulation and experimental measurements using DNA base excision repair enzymes, such as DNA glycosylases and AP endonucleases isolated from E. Coli. [59], have confirmed that induction of non-DSB OCDL decreases with high LET radiation compared to low LET radiation [52,53,60,61,62,63]. This decrease is attributed to the possibility that high LET simply generates fewer amounts of single strand breaks (SSBs) and damaged bases relative to low LET radiation. Most importantly, these observations of DNA damage inductions by high LET radiation showed that their higher RBE in cell survival and mutation induction is not the result of higher yield of DNA DSB and OCDL lesions. Rather, most DNA lesions of higher LET radiation are concentrated in DNA damage clusters. Theoretical analysis revealed that low LET radiation can generate cluster with as many as 10 lesions while high LET radiation is able to induce significantly more, up to 25, lesions in one cluster [64]. Recently, immunofluorescent staining of DNA repair proteins, 53BP1 (DSB damage), XRCC1 (SSB damage), and hOGG1 (base damage) foci, have also shown that most clusters induced by high LET radiation have colocalization of all three DNA repair proteins suggesting the prevalence of complex DNA damage [65]. Volume of foci colocalization is also significantly higher in high LET radiation treated cells and most clustered DNA damage induced by Fe ion irradiation is irreparable [65], supporting the model that “high quality” or complexity of high LET-induced DNA damage, not the yield of DNA damage, induced by high LET radiation is the cause of its high RBE.

A key difference between high LET ion beam therapy and antibody delivered alpha-particle emitters is the dose rate. In the current operational heavy ion beam therapy facilities including GSI in Darmstadt Germany and the HIMAC in Japan, the typical dose rate of carbon ion beam is 1 Gy/min with maximum dose rate of 5 Gy/min [66]. In comparison, internal alpha-particle emitters are delivered at much lower dose rate. For long-lived alpha particle emitters such as ²²⁵Ac (T_1/2 = 10.0 day), ²²³Ra (T_1/2 = 11.4 day) and ²²⁷Th (T_1/2 = 18.7 day), delivering 20 Gy to the tumors amounts to an initial dose rate of 0.001Gy/min, 0.0008 Gy/min and 0.0005 Gy/min, respectively. Even for short-lived alpha-emitters ²¹³Bi (T_1/2 = 45.6 min), ²¹²Bi (T_1/2 = 60.6 min) and ²¹¹At (T_1/2 = 7.2 h), the initial dose rates will be approximately 0.3, 0.2, 0.03 Gy/min.

Protracting radiation dose over longer period of time lowers the RBE for low LET radiation primarily because cells are allowed more time to repair radiation induced DNA damage before it accumulates and leads to cell death. For high LET radiation, when cell survival was evaluated as the biological endpoint, alpha particle irradiation with dose rate ranging from 0.5 to 100 cGy/min did not affect RBE [67]. Interestingly, when neoplastic transformation and somatic mutation was examined, unlike low LET radiation where low dose rate causes fewer number of event, low dose rate of high LET radiation including neutrons and heavy ion beam actually lead to enhanced neoplastic transformation and somatic mutation. This effect of high LET radiation is termed inverse dose rate effects and has been shown in several cell models [68,69,70,71]. Tauchi et al. showed that the inverse dose rate effect observed with carbon ion beams could be attributed to the observations that cells in G2/M phase are hypersensitive for mutation induction by high LET radiation while low LET radiation only induces mutation in the G1 phase [71,72]. A series of other studies also found that this inverse dose rate effect is limited to the LET range of 30 to 130 keV/µm [73,74,75]. The absence of inverse dose rate effect over 130 keV/µm can be explained by fewer number of cells being hit at the same dose while lower than 30 keV/µm radiation is not sufficient to saturate DNA repair processes [70].

Similar to low dose rate studies, fractionated high LET ion beam studies have shown a sparing effect on normal tissues while maintaining cell kill on tumor cells all of which are dependent on tissue types, LET and dose rates. Barendsen et al. first investigated the effect of fractionation on cell survival. Fractionating alpha particle radiation (12 h apart) with various energies (24.6, 60.8, 85.8 keV/µm) using a human kidney cell model, they observed no significant repair which was attributed to a “single event” caused by alpha particle that is hard to repair [67]. Goldstein et al. showed and confirmed by other groups that fractionation of heavy ion beams enhanced the peak-to-plateau RBE compared to single dose radiation in mouse intestine [76,77,78] because cells irradiated with spread out Bragg peak region had less recovery after fractionation compared to cells irradiated with plateau region (Figure 3). Chang et al. reported that when an iron ion beam (146 keV/μm at the sample position) was fractionated into five daily doses, significantly lower levels of micronucleated reticulocytes in peripheral blood at 48 h were observed and lead to a sparing effect on cytotoxicity to the hematopoietic system [79]. High LET carbon ions were also used to investigate the change in surviving fraction of four human tumor cell lines after fractionated dose irradiation. Again, fractionation was found to enhance the peak-to-plateau RBE ration compared to single dose [80].

Unlike high LET ion beam therapy where effects of dose rate and fractionated dose irradiation are well established to enhance the tumor to normal tissue (peak-to-plateau) RBE ratio, controlled delivery of peak-to-plateau RBE ration is not possible for antibody delivered internal alpha-particle emitters and the dose rate depends upon the radionuclide half-life and is orders of magnitude lower than that available from heavy ion beams. Thus, the achievable therapeutic ratio between normal tissue and tumors are mostly determined by antibody targeting and, potentially, fractionation. Few studies have investigated fractionation of internal alpha particle radiation on tumor and normal tissue RBE in vivo or in vitro. Barendsen et al. observed no survival difference of the kidney cells in vitro between single and fractionated irradiation with alpha particles (3.4 MeV) from ²¹⁰Po [67]. Elgqvist et al. found no advantage in therapeutic efficacy with fractionated alpha particle emitter ²¹¹At labeled MX35 F(ab’)₂ compared to single administration [81]. Another important aspect of antibody delivered alpha-emitter that needs to be taken into consideration is the possible saturation and turnover rate of tumor antigens during fractionated doses of radiolabeled antibodies that could reduce fractionated doses.

It has long been established that radiosensitivity of mammalian cells to low LET radiation is cell cycle dependent. Cells in mitosis and the G2 phase are the most sensitive and become most resistant in the S phase [48]. For high LET radiation, significant cell cycle delay was found in G2 phase in asynchronized and synchronized Chinese hamster V79 cells and increase of dose prolongs G2 arrest [82,83]. More importantly, irradiation of synchronized V79 cells with different LET radiation has found that variation of cell cycle dependent survival curves are gradually reduced with the increase of LET [84], suggesting that RBE of high LET is cell cycle independent. Claesson et al. investigated the effects of cell cycle on RBE of alpha particles from ²¹¹At labeled on Trastuzumab, non-specific to the Chinese hamster lung fibroblast cells V79-379A used in the study. It was found that RBE of high LET alpha particles from ²¹¹At is significantly higher than X-rays in both DSB induction and cell survival. Variation of cell survival between different cell cycle phases was significantly reduced for alpha radiation compared to X-rays but such reduction was not as evident for DSB induction, suggesting a weak correlation between DSB induction and cell survival [34].

Like the case for cell cycle, it has also been established for low LET radiation that oxygen has the most effect among many chemical agents to modify the biological effect of ionizing radiation. For X-rays and γ-rays, the typical oxygen enhancement ratio (OER), the ratio of doses needed under hypoxic condition to achieve the same biologic effect as aerobic condition, ranges from 2.5 to 3.5 [48]. This oxygen effect can be explained by the oxygen fixation hypothesis where DNA molecules react with free radicals, typically reversible under hypoxic conditions, become fixed with organic peroxide in the presence of oxygen and result in DNA damage. It is estimated that indirect effects of free radicals account for approximately two-thirds of the DNA damage caused by X-rays [48]. For high LET radiation, classic studies performed by Barendsen et al. and others have shown an inverse relationship between OER and LET where effect of oxygen on cell radiosensitivity becomes diminished (OER = 1.0) for LET greater than 140 keV/µm [21,85] (Figure 2B). The main hypothesis for the decrease of OER with increasing LET is that high LET radiation predominately causes direct DNA damage (estimated at about 75% for alpha particle of 150 keV/µm [86]) independent of the free radical inflicted indirect DNA damage, thereby less affected by oxygen. Clinically, poor tumor oxygenation status (hypoxia defined as O₂ partial pressure less than 10 mmHg) has been repeatedly found to be a prognostic factor for disease free survival after conventional radiation therapy [87,88,89]. High LET radiation could overcome such radioresistance because of its diminished susceptibility to the OER effect. In a clinical trial of high LET carbon ion beam, Nakano et al. compared its efficacy against hypoxic and normoxic cervical tumors and showed similar disease-free survival between hypoxic (<20 mmHg) and oxygenated (>20 mmHg) tumors suggesting that high LET radiation can overcome the radioresistance caused by tumor hypoxia [90]. Modeling analysis, however, suggest that the reduction of OER with high LET radiation under the clinical tumor hypoxic environment (0.5–20 mmHg) is relatively moderate with approximately 15% benefit over photon [85]. Furthermore, the findings that patients with hypoxic tumors are associated with poor prognosis with treatments independent of oxygen status (such as surgery) suggest that hypoxic tumor could have a malignant phenotype as a result of colony selection under hypoxic condition which in turn is maintained by its fast consumption of O₂. Up-regulation of key signaling pathways including angiogenesis, cell survival, glucose metabolism by hypoxia inducible factor-1 alpha (HIF-1α) further promotes the resistance and progression of this malignant phenotype [91]. More studies are needed to establish the advantage of high LET radiation in treating poorly oxygenated tumors, where difference between local control of hypoxic tumors by alpha radiation and progression free survival can indicate whether progression is due to ineffectiveness of alpha radiation against hypoxic tumors itself or against a highly malignant phenotype.

For internal alpha-particle emitters, the plateau LET is between 50 to 100 keV/µm (Figure 1A) which correspond to an OER between 1.2 to 2.0 (Figure 2B), while the LET around Bragg peaks is well above 140 keV/µm (OER = 1). As a consequence, the stochastic distribution of alpha particle radiation within or surrounding the hypoxic region of tumors will determine its overall OER. Few studies have investigated the correlation between pretreatment oxygenation status of tumors and tumor response to antibody labeled alpha-emitters while tumor response to beta emitter labeled antibody was shown to correlate with tumor pO₂ [92]. It is important to note, however, since it is very difficult for antibody as a carrier to penetrate tumor hypoxic regions, the delivery of alpha-emitters is probably the dominating dose limiting factor that determines tumor control. Delivery of alpha radiation with smaller molecules such as peptide, scFv and diabody could potentially lead to a better penetration into the tumor hypoxic core [42,93].

In contrast to the findings that induction of DNA DSBs by high LET heavy ion radiation does not correlate well with cell survival, studies from Tobias’ lab at Berkeley using heavy ion beams have found that the rate of DNA break rejoining becomes significantly slower as LET increases and there is a strong correlation between the efficiency of cell kill and the non-rejoined DNA strand breaks [94,95]. This impaired rejoining rate reaches maximal for LET in the range of 100 to 200 keV/µm and plateaus for higher LET (Figure 4), unlike RBE vs. LET where RBE begins to decrease for higher LET due to overkill. For LET at the maximal impaired rejoining, about 20% of the DNA breaks remain non-rejoined compared to less than 2% for low LET radiation (Figure 4). These percentages are dose independent. More recently, immunostaining of phosphorylated histone protein H2AX (γ-H2AX) had been used as a marker to quantify induction and rejoining of DNA DSB. Carboxy-terminal phosphorylation of histone H2AX is the earliest cellular response to DNA DSB that accumulates at the sites of DSB quickly (within minutes of the damage) [96]. Consistent with prior findings, similar numbers of γ-H2AX foci are formed after low LET and high LET radiation but there are more remaining γ-H2AX foci at 24 h after high LET radiation (20% of initial foci remaining after alpha particle, 120 keV/µm, compared to less than 10% after gamma ray) [54,97,98]. In addition, the repair of DNA DSB appears to consist of two kinetic components, a fast phase and a slow phase, where most of the DNA DSBs caused by high LET radiation is repaired [97]. Studies in our lab with anti-HER2 Trastuzumab labeled alpha-particle emitter ²¹³Bi also see the same trend where higher fraction of γ-H2AX foci remained at 24 h compared to gamma irradiation (unpublished data). The “high quality” DNA DSB (clustered damage) inflicted by high LET radiation is most likely the cause of the 20% non-rejoined DSBs. The 80% rejoined DNA DSBs apparently correspond to DNA lesions that are still reparable by the mammalian cell repair machinery. Better understanding of the DNA DSB repair processes after high LET radiation might yield strategies to further enhance the RBE of high LET radiation in a tumor-specific fashion.

Repair of DNA DSBs is mediated mainly through homologous recombination (HR) and non-homologous end joining (NHEJ) pathways. For diploid mammalian cells, DNA DSB is repaired by the HR pathway primarily in late S and G2 phase where an intact DNA template is available, resulting in more precise repair of DNA damage. In contrast, the NHEJ pathway operates throughout the cell cycle but is the only repair mechanism available in G1 and early S phase where no sister chromatid is present. Thus, the homologous-sequence-independent NHEJ pathway is often error prone and leads to apoptosis [99]. The involvement of NHEJ and HR pathways in the repair of high LET induced DNA DSBs has been investigated using cell lines deficient with repair proteins key to each repair pathway. Irradiation of glioblastoma cells MO59J deficient in a key enzyme of the NHEJ pathway, DNA-PKcs, found that no reduction of γ-H2AX foci was detected after 21 h [54,100]. In Ku80 deficient CHO cells (also NHEJ deficient) treated with alpha particles from boron neutron capture reaction, significantly more γ-H2AX foci were present (58.4% to 69.5%) 2 h after radiation compared to normal CHO cells (36.5%–42.8%) [101]. Examination of human fibroblast 180BR with mutated DNA ligase IV, part of a complex with XRCC4 that catalyzes the final step in the NHEJ pathway, found that cell survival was further compromised and more excess chromosome fragments/cell remained after high LET radiation compared to normal fibroblast cell HFL III [102]. Zafar et al. tested the contribution of homologous recombination pathway to repair DNA DSB induced by high LET radiation using RAD51D-deficient CHO cells and found that rad51d^−/− cells are more sensitive than wild type CHO cells [103]. Moreover, studies of ataxia telangiectasia-mutated (ATM) protein, functioning upstream of both NHEJ and HR repair pathways, with ATM deficient cells and ATM inhibitors have also shown that lack of ATM significantly reduced cell survival after treatment with high LET carbon ion radiation [54,104]. All cell lines with deficiencies in DNA DSB repair exhibit increased radiosensitivity to both high and low LET radiation; often the effect is more pronounced for low LET radiation, in one case, Ku80 and DNA ligase IV deficient cells exhibit similar cell survival following X-ray and carbon ion irradiation (70 keV/µm), RBE ≅ 1.0 [102]. This observation supports the idea that high-LET induced clustered damage is not easily repaired and that similar DNA repair pathways are involved in the repair of DNA DSBs induced by high and low LET radiation.

A few studies have investigated the DNA DSB repair response and involvement of repair proteins by antibody delivered alpha-particle radiation. Friesen et al. studied the efficacy of alpha emitter ²¹³Bi labeled anti-CD45 antibody in radio- and chemo- resistant leukemia cells [105]. Using DNA ligase IV deficient cells, it was shown that alpha radiation induced slightly more apoptotic cells in lig.IV^−/− cells compared to lig.IV^+/+ cells while β- and γ- irradiation significantly enhances the amount of apoptotic cells in lig.IV^−/− cells. Yong et al. reported that repair of DNA damage, as evaluated using a comet assay, was delayed in colon cancer cells LS-174T after treatment by ²¹²Pb labeled Trastuzumab [10]. The activation of DNA DSB repair pathways after antibody delivered alpha radiation is not completely the same as that after high LET ion beam radiation. In part, this could be attributed to the biological effect exerted by the carrier antibody.

One example is the anti-EGFR monoclonal antibody Cetuximab. In a clinical phase III study, Cetuximab was found to significantly enhance the loco-regional control, progression survival and overall survival (49.0 months vs. 29.3 months, P = 0.03) of advanced head and neck cancer when combined with radiotherapy compared to radiotherapy alone [106]. Dis-regulation of DNA DSB repair was proposed as one of the mechanisms underlying radiosensitization of Cetuximab. Kriegs et al. showed that inhibition of EGFR by Cetuximab down-regulates NHEJ mediated DNA DSB repair via the MAPK signaling pathway [107]. Myllynen et al. and others also found that DNA DSB repair is activated by ligand EGF and Cetuximab binding can eliminate such activation primarily via the NHEJ pathway and, to a lesser degree, also via the HR pathway independent of p53 status [108,109]. For high LET radiation, a clinical trial evaluating the efficacy of combining Cetuximab, IMRT and carbon ion beam for adenoid cystic carcinoma is underway in Germany [110]. Similarly, blocking insulin-like growth factor-I receptor (IGF-IR) by fully human anti-IGF-IR antibody A12 was found to significantly enhance the antitumor efficacy in a lung cancer xenograft model when combined with radiation compared to either modality alone [111]. γH2AX staining suggested that DNA DSB repair is partially inhibited by A12 binding and such down-regulation of DNA repair by IGF-IR inhibition is associated with impaired activation of ATM kinase [112]. Carrier antibodies whose antigen binding disrupts DNA DSB repair pathways could potentially enhance the efficacy of radioimmunotherapy.

The successful (i.e., non-empiric) implementation of conventional radiotherapy largely depended on understanding the “four R’s” of radiation biology: repair of DNA damage, reoxgenation, redistribution of cell cycle and repopulation of cells, all of which are intended to maximize the differential response of tumors and normal tissues to radiation [48]. For high LET ion beam, the differential response is mainly achieved by controlling the deposition of the high LET Bragg peaks in the tumors and the relatively low LET track segment in the surrounding normal tissues. Fractionation of high LET ion beams can also enhance the peak-to-plateau (tumor-to-normal) RBE ratio compared to single dose [76]. For antibody delivered high LET alpha-particle radiation where the tumor-to-normal tissue RBE ratio is primarily achieved by high specificity of the carrier antibody, targeting tumors defective in DNA DSB repair pathways could potentially enhance this RBE ratio.

As a genetic disease, many tumor cells are defective in genes that are involved in DNA repair. For example, hereditary breast (5–10%) [113,114], ovarian (10–15%) [115,116] and pancreatic cancer (5–10%) [117] are caused by mutations in genes, BRCA1 and BRCA2, that are involved in the homologous recombination pathway of DNA DSBs repair responses. Familial form of colorectal cancer (about 3 to 4%), hereditary non-polyposis colorectal cancer (HNPCC), is associated with defective mutations in DNA mismatch repair (MMR) genes, such as MSH2 and MLH1 [118]. In contrast, the normal tissues of these patients often have heterozygous expression of the DNA repair genes that can, though the patients are predestined to higher rates of cancer incidence, still perform the DNA repair function. Nieuwenhuis et al. and others measured the rejoining of DNA breaks in fibroblast and lymphocytes cells with heterozygous BRCA1 and BRCA2 mutations after X-ray radiation with pulse PFGE and comet assay and no defect in their ability to repair DNA breaks was found [119,120,121]. Recently, using more sensitive γ-H2AX immunostaining, Beucher et al. reported that the BRCA-2 (but not BRCA-1) heterozygous carrier exhibit slightly decreased (6 to 9 more foci/cell than wild-type cells at about 10 foci/per) DNA DSB repair capacity in G2 phase (but not G1) [122]. A clinical study screening BRCA1 and BRCA2 mutations in cancer patients with severe normal tissue reactions to radiotherapy found no correlation between normal tissue radiosensitivity and BRCA1/2 mutations [123]. Likewise, heterozygous ATM genes were not linked to normal tissue hypersensitivity to radiation in cancer patients undergoing radiotherapy [124,125]. Zhou et al. found that heterozygosity in one gene, such as ATM, BRCA1 or Rad9, does not increase the transformation frequency of mouse embryo fibroblasts, after irradiation with high LET ⁵⁶Fe ions, even though enhanced transformation frequency was found in cells with heterozygosity in two genes, Atm_hz/Brca1_hz and Atm_hz/Rad9_hz [126]. However, Worgul et al. reported that mice with heterozygous ATM gene are more susceptible to development of cataracts after exposure to high LET ⁵⁶Fe ions compared to wild-type mice [127]. These data point to the possibility that high LET alpha-particle radiation could cause different RBE between tumors with homozygous loss of function in DNA repair proteins and normal tissues with heterozygous DNA repair genes. More studies are needed to confirm the response of tumor and normal tissues with defective DNA DSB repair genes to high LET radiation, particularly when they are delivered by monoclonal antibodies.