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Annotated Bibliography: Radioprotectors

in Radiotherapy
Jackson Baumgartner
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Studies on Silver Nanoparticle–Glycyrrhizic Acid Complex as a Radioprotector and an Adjuvant

in Radiotherapy Under In Vivo Conditions

Chandrasekharan DK, Nair CKK. Studies on Silver Nanoparticle–Glycyrrhizic Acid Complex as

a Radioprotector and an Adjuvant in Radiotherapy UnderIn VivoConditions. Cancer
Biotherapy & Radiopharmaceuticals. 2012;27(10):642-651. doi:10.1089/cbr.2012.1286.

SN, GLY, SN-GLY as a Radioprotector: An In Vivo Study

This is a peer reviewed article assessing the ability of glycyrrhizic acid-silver

nanoparticle complex (referred to as SN-GLY for the remainder of this paper) to protect against

radiation induced toxicity of the hemopoietic and gastrointestinal system in Swiss albino mice. In

order to study the effects of this complex, researchers followed the “gold standard” for

evaluation, which was a 30-day survival using rodents as test subjects. During this trial, the

capacity of the agent to modulate the recovery and regeneration of the GI epithelium and

hemopoietic cells in the bone marrow were evaluated.

To prepare for this trial, male Swiss albino mice were obtained as subjects, all ranging

from the ages of 8-10 weeks old and weighing 22-25g. These mice were kept under standard

conditions of temperature and humidity, and were also fed mouse chow and water per standard

guidelines. SN was obtained in powder form and combined with GLY to create the final SN-

GLY complex to be administered orally. SN and GLY were also independently used as

interventions in addition to the SN-GLY complex. Radiation was administered to the mice using

a Cobalt-60 unit with a dose rate of 188 cGy/minute. Finally, mice were divided up into 8

different groups, each with a different intervention (either SN, GLY, or SN-GLY) and a different

prescribed radiation dose to the whole body (4, 6, or 8 Gy). After the completion of the mice’s

course of radiation, all mice were given a standard diet and water, while their body weight and
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survival were monitored. Mice were checked on a daily basis to record any changes in either of

these parameters.

At the conclusion of the trial, researchers found that an exposure of 6 Gy to the whole

body significantly impacted hemopoietic cell levels. WBC counts (10^9 cells/L) dropped from

8.13 +/- 1.80 to 1.81 +/- 0.67 and bone marrow cellularity (10^6 cells/femur) from 20.22 +/- 3.01

to 8.56 +/- 1.30. These measurements were obtained 24 hours after radiation was administered.

Groups receiving and intervention (SN, GLY, or SN-GLY) administrated 1 hour before

irradiation minimized the radiation induced depletion of these counts. Total WBC counts were

measured at 4.12 +/- 1.08 (GLY), 3.38 +/- 1.07 (SN), and 5.83 +/- 0.35 (SN-GLY) after

irradiation and bone marrow counts were recorded at 17.24 +/- 1.36 (GLY), 12.68 +/- 1.05 (SN),

and 18.28 +/- 0.50 (SN-GLY) postradiation.

Researchers then turned their attention to the gastrointestinal cells and noted severe

damage to the intestinal villi and crypts in the control group compared to normal animals after 6

Gy was delivered to the whole body. Maximum damage occurred roughly 72 hours after

irradiation. For animals exposed to GLY, SN, or SN-GLY, damage was much less than that

observed in the control mice. The mice receiving an intervention of GLY, SN, or SN-GLY

retained near normal villus and crypt structure.

For animals receiving 8 Gy, those in the control group began dying roughly 4 days after

receiving radiation. After 9 days the death rate of the control group was 100%. However, in the

group receiving GLY, only 20% died followed by 50% death rate in the SN treated group, and

0% death rate in the SN-GLY group. Animals in the SN-GLY group only started dying after 12

days, and by the end of the 30 day period, 60% had died.
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In conclusion, researchers felt they showed that SN and its complex with GLY offer

protection against ionizing radiation damage and ultimately enhances survival of the animals as

well as effectively protecting normal cells following an exposure of a lethal dose of radiation.

I thought that this was a good study that followed guidelines for conducting a trial. Since

the mice all had the same cancerous cells injected in them, it did not matter whether or not they

were randomized. Unfortunately, researchers did not disclose how many mice were a part of this

study, and as always, the results of an In Vivo study only has external validity to a limited extent.

Until phase II and III studies are conducted, it will be difficult to determine the exact effect of

SN-GLY as a radioprotector, and whether it will improve survival and cure rates while

effectively sparing hemopoietic and gastrointestinal cells.

This study was also performed by giving mice lethal doses of radiation which would

never be performed on a human subject, muddying its usefulness to a human being. However,

based on the evidence of the research, it would wise to continue In Vivo studies on more animals

until researchers deem the study worthy of testing In Vitro and so on up the ladder. Ultimately,

the question is whether or not the intervention will effectively spare normal tissues, reducing side

effects in the process, and still leave tumor volume exposed and controlled. Until phase II and III

studies are conducted, it will be difficult to determine the validity of this research and whether

this complex will serve a larger purpose in the clinical setting.

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Famotidine as a radioprotector for rectal mucosa in prostate cancer patients treated with
radiotherapy: Phase I/II randomized placebo-controlled trial

Razzaghdoust A, Mozdarani H, Mofid B. Famotidine as a radioprotector for rectal mucosa in

prostate cancer patients treated with radiotherapy. Strahlentherapie und Onkologie.
2014;190(8):739-744. doi:10.1007/s00066-014-0602-8.
Reduction in Radiation-Induced Lymphocytopenia by Famotidine in Patients Undergoing
Radiotherapy for Prostate Cancer
Razzaghdoust A, Mozdarani H, Mofid B, Aghamiri SMR, Heidari AH. Reduction in radiation-
induced lymphocytopenia by famotidine in patients undergoing radiotherapy for prostate
cancer. The Prostate. 2013;74(1):41-47. doi:10.1002/pros.22725.

Peer Reviewed Famotidine Study

Radiotherapy is a staple treatment technique along with chemotherapy regimens for the

treatment of prostatic adenocarcinomas. Researchers performed a randomized trial to investigate

the radio-protective effect of Famotidine against radiation-induced acute bowel and bladder

toxicities in patients treated with radiotherapy for prostate cancer. Famotidine is a specific, long-

acting histamine H2 receptor antagonist and does not have significant drug interactions and side

effects. H2 receptors are expressed in a large number of cells and also different sites of the

human gastrointestinal tract. Conversely H2 receptors are not expressed in human prostatic

adenocarcinoma cells. This makes Famotidine an ideal candidate as a radioprotector since it

demonstrates protection of the normal tissue structures that dose should be limited to (i.e. bladder

and lower GI tract), while exposing the tumor volume to radiation toxicities. Radiation may also

produce free radicals and indirect damage. However, the presence of H2 receptors also makes

Famotidine a free radical scavenger, reducing the adverse effects of said free radicals.

To conduct this study, 36 intermediate and high risk patients with prostate cancer were

randomized via a computer generated list into two groups (A and B). Group A received

radiotherapy plus a placebo pill, and group B received radiotherapy plus 40mg of orally
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administered Famotidine. In order to reduce bias from the study, an off-site person was

employed to allocate either Famotidine or placebo to group A and B, and all participants

(including researchers) were blinded to group assignment.

In order for patients to be eligible for this research trial, they must have normal renal and

liver function, HG levels > 9 g/dL, WBC count > 2500/microliter and a platelet count

>100,000/microliter. Patients were excluded if they presented with metastatic prostate cancer

previously treated with radiation or chemotherapy, demonstrate clinically evident pulmonary

insufficiency, and exhibit serum creatinine or liver enzyme serum levels > 1.5 and 2.5 times the

normal values. Patients receiving any H2 receptor antagonist and patients with allergic reactions

to Famotidine administration were also excluded.

Standard dose and fractionation (70 Gy, 5 fractions/week) were prescribed, while only 5

of the patients received 66Gy instead. Patients were treated with a 4 field technique and planned

using 3D computer planning software. 20 of the prescriptions (10 patients in each group),

included a cone down field after completion of whole pelvic radiotherapy to treat the prostate

and seminal vesicles. Famotidine was administered orally 2x/day (5 days/week), 4 hours prior to

each radiotherapy fraction and the second tablet 3 hours before each fraction. Acute bowel and

urinary toxicities were measured at baseline weekly during therapy treatments, and once 4 weeks

after treatment completion using RTOG toxicity grading criteria.

The results of the study were as follows: Of the 36 patients assigned to groups, 2 patients

dropped out of group B (Famotidine group). Only patients that were able to successfully

complete their entire course of treatment were included in data analysis of the final results, which

the remaining 34 patients were able to do. The ages of the patients ranged from 52-82 years

(mean age = 66.7 years). No grade III or higher acute toxicities were noted in either groups but a
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significant reduction in rectal toxicity was noted in the Famotidine group. Grade II toxicities

were observed in 10/18 patients receiving placebo pills while only 2/16 patients receiving

Famotidine experienced these same toxicities. 5/18 patients using placebo pills experienced

rectal bleeding while none of the Famotidine patients experienced bleeding. Finally, between the

two groups, total rectal toxicity time was reduced in the Famotidine group than in the placebo

group.

Currently, Amifostine, which is another radioprotector, is the only agent approved to be

used in the clinical setting. Although Amifostine has shown itself to be effective in protecting

pelvic patients from radiation toxicities, patients still experienced Amifostine-induced toxicities.

On top of these side effects, Amifostine can only be used under certain limitations (intravenous

administration, blood pressure considerations, and must be delivered at a high dose – 500mg),

while Famotidine did not share any such limitations.

In addition to rectal protection, Famotidine was found to also be effective in protecting

blood lymphocytes, which is postulated to be the result of the radioprotector protecting the bone

marrow stem cells. It is thought that Famotidine neutralizes free radicals diminishing the indirect

effect of ionizing radiation and also by H2-receptor impacts. Within the same study, outlined in a

separate peer reviewed article, researchers obtained pretreatment CT scans and PSA levels. CBC,

serum urea, creatinine, and liver enzymes were assessed at baseline, twice per week during the

patient’s radiotherapy treatments and once 4 weeks after the end of the course. Throughout the

patient’s treatment, researchers obtained blood samples and measured the change from baseline

values (for each patient) in total leucocytes, neutrophils, lymphocytes, monocytes, eosinophils,

platelets, erythrocytes, and hemoglobin levels and the findings of each group were compared

with one another.

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A total of 112 blood counts were evaluated and the Famotidine group showed that the

mean percentage of lymphocyte decrease from baseline was 29% as opposed to 47% in the

placebo group. The neutrophils, monocytes, eosinophils, and hemoglobin levels were not

affected by irradiation in either group. In addition, the platelets and erythrocyte counts were not

affected in the Famotidine or placebo group. Researchers determined that Famotidine likely

proved effective due to its free radical scavenging ability mentioned above.

Researchers concluded that, in comparison to other known radioprotectors, Famotidine is

superior due to being more available, can be taken with less dose and side effects, inexpensive,

stable, and easily administered. Researchers also felt they demonstrated that Famotidine is a

proper radioprotector for the rectal mucosa in patients undergoing radiotherapy for prostate

cancer as well as reducing lymphocytopenia.

I thought that this was a very good study in that it did a good job limiting bias and

randomizing the patients as much as it possible. Some points of praise would be that the groups

were selected at random through a nonhuman agent and that the patients who were selected to

participate met very similar requirements to one another, thus increasing the internal validity of

the research findings. In addition to this, researchers also employed people to administer the

research interventions who were not a part of the research team themselves and had no stake in

the trial. Performing a double blind intervention (neither the patients nor the workers

administering medication knew who was receiving a placebo or Famotidine) served to reduce

bias even further. In order for this study to become stronger, it must perform more randomized

trials on a much larger sample. Doing so would increase the external validity of the research.

These findings could have very strong implications on how physicians treat patients with

prostate cancer. The research seems to suggest that there is a way to reduce the side effects of
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radiation induced toxicity while not sparing the target volume. This would allow physicians to be

more aggressive in their treatment of prostate cancer, since they would not be restricted by the

side effects, and hopefully increase the cure rate. Additionally, patients would be able to tolerate

their treatments more.

The findings of this study also introduce some interesting discussion: since Famotidine

has shown in this small sample that there could be beneficial effects on the rectal mucosa and

lymphocyte levels, could it also be used regularly with other cancers of the pelvis or even

abdomen, not just prostate cancer? The benefit of Famotidine in this case was that it exhibited

H2 receptors which are not expressed in prostatic cancer cells. This enabled the drug to

differentiate between the GI tract and gross tumor volume. If one could demonstrate the absence

of these receptors in other cancerous cells of the pelvis or abdomen, perhaps this drug could find

a wider use than just prostate cancer.

Finally, there are still two considerations for the use of Famotidine in radiotherapy for

prostate cancer. Firstly, although researchers claimed that Famotidine reduced the adverse effects

of free radicals, free radical formation is still an important part of radiotherapy treatments seeing

as they serve to attack and kill cancerous cells. If Famotidine is an effective free radical

scavenger, it would seem that this drug could potentially impede free radicals’ ability to attack

and control tumor volumes. If so, the research should turn towards asking whether free radicals’

effect on normal tissues can be blocked while leaving them open to attack tumor cells. Secondly,

there are no discussions in this paper reflecting on the survival rates of the patients. While it is

intriguing that Famotidine can dramatically reduce toxicities, and can differentiate between

normal and tumor cells for prostate cancer (thanks to H2 receptors discussed above), does it
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ultimately end with higher survival rates? These questions are important and should be addressed

in any future research on the use of Famotidine in radiotherapy as a radioprotector.