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Radiotherapy remains a mainstay of cancer treatment, being used in roughly 50% of patients. The precision with which the radiation dose can be delivered is rapidly improving. This precision allows the more accurate targeting of radiation dose to the tumor and reduces the amount of surrounding normal tissue exposed. Although this often reduces the unwanted side effects of radiotherapy, we still need to further improve patients’ quality of life and to escalate radiation doses to tumors when necessary. High‐precision radiotherapy forces one to choose which organ or functional organ substructures should be spared. To be able to make such choices, we urgently need to better understand the molecular and physiological mechanisms of normal tissue responses to radiotherapy. Currently, oversimplified approaches using constraints on mean doses, and irradiated volumes of normal tissues are used to plan treatments with minimized risk of radiation side effects. In this review, we discuss the responses of three different normal tissues to radiotherapy: the salivary glands, cardiopulmonary system, and brain. We show that although they may share very similar local cellular processes, they respond very differently through organ‐specific, nonlocal mechanisms. We also discuss how a better knowledge of these mechanisms can be used to treat or to prevent the effects of radiotherapy on normal tissue and to optimize radiotherapy delivery. Here, we discuss the complexity of radiotherapy‐induced side effects and approaches for prevention or treatment. Radiation damage develops at a cellular level, progresses to intercellular interactions resulting in intra‐ and interorgan functional responses. These need different approaches for prevention or treatment, for instance intracellular signaling modification, sparing of specific stem cell‐containing areas or contributing organs, and stem cell therapies.

Radiotherapy for head and neck cancer is associated with impairment of salivary gland function and consequent xerostomia, which has a devastating effect on the quality of life of the patients. The mechanism of radiation-induced salivary gland damage is not completely understood. Cellular senescence is a permanent state of cell cycle arrest accompanied by a secretory phenotype which contributes to inflammation and tissue deterioration. Genotoxic stresses, including radiation-induced DNA damage, are known to induce a senescence response. Here, we show that radiation induces cellular senescence preferentially in the salivary gland stem/progenitor cell niche of mouse models and patients. Similarly, salivary gland-derived organoids show increased expression of senescence markers and pro-inflammatory senescence-associated secretory phenotype (SASP) factors after radiation exposure. Clearance of senescent cells by selective removal of p16Ink4a-positive cells by the drug ganciclovir or the senolytic drug ABT263 lead to increased stem cell self-renewal capacity as measured by organoid formation efficiency. Additionally, pharmacological treatment with ABT263 in mice irradiated to the salivary glands mitigates tissue degeneration, thus preserving salivation. Our data suggest that senescence in the salivary gland stem/progenitor cell niche contributes to radiation-induced hyposalivation. Pharmacological targeting of senescent cells may represent a therapeutic strategy to prevent radiotherapy-induced xerostomia.

Dysfunction of the salivary gland and irreversible hyposalivation are the main side effects of radiotherapy treatment for head and neck cancer leading to a drastic decrease of the quality of life of the patients. Approaches aimed at regenerating damaged salivary glands have been proposed as means to provide long-term restoration of tissue function in the affected patients. In studies to elucidate salivary gland regenerative mechanisms, more and more evidence suggests that salivary gland stem/progenitor cell behavior, like many other adult tissues, does not follow that of the hard-wired professional stem cells of the hematopoietic system. In this review, we provide evidence showing that several cell types within the salivary gland epithelium can serve as stem/progenitor-like cells. While these cell populations seem to function mostly as lineage-restricted progenitors during homeostasis, we indicate that upon damage specific plasticity mechanisms might be activated to take part in regeneration of the tissue. In light of these insights, we provide an overview of how recent developments in the adult stem cell research field are changing our thinking of the definition of salivary gland stem cells and their potential plasticity upon damage. These new perspectives may have important implications on the development of new therapeutic approaches to rescue radiation-induced hyposalivation.

Head and neck cancer is a common cancer worldwide. Radiotherapy has an essential role in the treatment of head and neck cancers. After irradiation, early effects of reduced saliva flow and hampered water secretion are seen, along with cell loss and a decline in amylase production. Currently, there is no curative treatment for radiation-induced hyposalivation/xerostomia. This study aimed to develop and optimize a validated manufacturing process for salivary gland organoid cells containing stem/progenitor cells using salivary gland patient biopsies as a starting material. The manufacturing process should comply with GMP requirements to ensure clinical applicability. A laboratory-scale process was further developed into a good manufacturing practice (GMP) process. Clinical-grade batches complying with set acceptance and stability criteria were manufactured. The results showed that the manufactured salivary gland-derived cells were able to self-renew, differentiate, and show functionality. This study describes the optimization of an innovative and promising novel cell-based therapy.

Organoids are innovative three-dimensional and self-organizing cell cultures of various lineages that can be used to study diverse tissues and organs. Human organoids have dramatically increased our understanding of developmental and disease biology. They provide a patient-specific model to study known diseases, with advantages over animal models, and can also provide insights into emerging and future health threats related to climate change, zoonotic infections, environmental pollutants or even microgravity during space exploration. Furthermore, organoids show potential for regenerative cell therapies and organ transplantation. Still, several challenges for broad clinical application remain, including inefficiencies in initiation and expansion, increasing model complexity and difficulties with upscaling clinical-grade cultures and developing more organ-specific human tissue microenvironments. To achieve the full potential of organoid technology, interdisciplinary efforts are needed, integrating advances from biology, bioengineering, computational science, ethics and clinical research. In this Review, we showcase pivotal achievements in epithelial organoid research and technologies and provide an outlook for the future of organoids in advancing human health and medicine. Organoid research is moving beyond developmental and disease biology, driving insights into current and emerging health threats and enabling personalized and regenerative medicine applications.

The salivary gland (SG) is vital for oral function and overall health through secretion of saliva. However salivary dysfunction due to aging, medications, autoimmune disorders, and cancer treatments poses significant challenges. We established the first diverse and clinically annotated salivary regenerative biobank at Mayo Clinic to study salivary gland stem/progenitor cells (SGSPCs). Optimization of cell isolation and progenitor assays revealed SGSPCs enriched within the CD24/EpCAM/CD49f+ and PSMA- phenotypes of both submandibular and parotid glands, with clonal differentiation assays highlighting heterogeneity. Induction of PSMA/FOLH1 expression was associated with SGSPC differentiation. Using mass spectrometry-based single cell proteomics, we identified 2461 proteins in SGSPC-enriched cells, including co-expressed cytokeratins, expressed in rare salivary ductal basal cells. Additionally, PRDX, a unique class of peroxiredoxin peroxidases enriched in SGSPCs, demonstrated H 2 O 2 -dependent growth, suggesting a role in salivary homeostasis. These findings provide a foundation for SGSPC research and potential regenerative therapies for salivary gland dysfunction.

Purpose Multifocal disease in PTC is associated with an increased recurrence rate. Multifocal disease (MD) is underdiagnosed with the current gold standard of pre-operative ultrasound staging. Here, we evaluate the use of EMI-137 targeted molecular fluorescence-guided imaging (MFGI) and spectroscopy as a tool for the intra-operative detection of uni- and multifocal papillary thyroid cancer (PTC) aiming to improve disease staging and treatment selection. Methods A phase-1 study (NCT03470259) with EMI-137 was conducted to evaluate the possibility of detecting PTC using MFGI and quantitative fiber-optic spectroscopy. Results Fourteen patients underwent hemi- or total thyroidectomy (TTX) after administration of 0.09 mg/kg ( n  = 1), 0.13 mg/kg ( n  = 8), or 0.18 mg/kg ( n  = 5) EMI-137. Both MFGI and spectroscopy could differentiate PTC from healthy thyroid tissue after administration of EMI-137, which binds selectively to MET in PTC. 0.13 mg/kg was the lowest dosage EMI-137 that allowed for differentiation between PTC and healthy thyroid tissue. The smallest PTC focus detected by MFGI was 1.4 mm. MFGI restaged 80% of patients from unifocal to multifocal PTC compared to ultrasound. Conclusion EMI-137-guided MFGI and spectroscopy can be used to detect multifocal PTC. This may improve disease staging and treatment selection between hemi- and total thyroidectomy by better differentiation between unifocal and multifocal disease. Trial registration NCT03470259

The salivary gland (SG) is an essential organ that secretes saliva, which supports versatile oral function throughout life, and is maintained by elusive epithelial stem and progenitor cells (SGSPC). Unfortunately, aging, drugs, autoimmune disorders, and cancer treatments can lead to salivary dysfunction and associated health consequences. Despite many ongoing therapeutic efforts to mediate those conditions, investigating human SGSPC is challenging due to lack of standardized tissue collection, limited tissue access, and inadequate purification methods. Herein, we established a diverse and clinically annotated salivary regenerative biobanking at the Mayo Clinic, optimizing viable salivary cell isolation and clonal assays in both 2D and 3D-matrigel growth environments. Our analysis identified ductal epithelial cells in vitro enriched with SGSPC expressing the CD24/EpCAM/CD49f+ and PSMA- phenotype. We identified PSMA expression as a reliable SGSPC differentiation marker. Moreover, we identified progenitor cell types with shared phenotypes exhibiting three distinct clonal patterns of salivary differentiation in a 2D environment. Leveraging innovative label-free unbiased LC-MS/MS-based single-cell proteomics, we identified 819 proteins across 71 single cell proteome datasets from purified progenitor-enriched parotid gland (PG) and sub-mandibular gland (SMG) cultures. We identified distinctive co-expression of proteins, such as KRT1/5/13/14/15/17/23/76 and 79, exclusively observed in rare, scattered salivary ductal basal cells, indicating the potential de novo source of SGSPC. We also identified an entire class of peroxiredoxin peroxidases, enriched in PG than SMG, and attendant H2O2-dependent cell proliferation in vitro suggesting a potential role for PRDX-dependent floodgate oxidative signaling in salivary homeostasis. The distinctive clinical resources and research insights presented here offer a foundation for exploring personalized regenerative medicine.Competing Interest StatementThe authors have declared no competing interest.

Coppes, R.P., Roffel, A.F., Zeilstra, L.J.W., Vissink, A. and Konings, A.W.T. Early Radiation Effects on Muscarinic Receptor-Induced Secretory Responsiveness of the Parotid Gland in the Freely Moving Rat. Although the salivary glands have a low rate of cell turnover, they are relatively radiosensitive. To study the possible mechanism behind this inherent radiosensitivity, a rat model was developed in which saliva can be collected after local irradiation of the parotid gland without the use of anesthetics or stressful handling. Saliva secretion was induced by the partial muscarinic receptor agonist pilocarpine (0.03–3 mg/kg) with or without pretreatment with the β-adrenoceptor antagonist propranolol (2.5 mg/kg), or the full muscarinic receptor agonist methacholine (0.16–16 mg/min), and measured during 5 min per drug dose before and 1, 3, 6 and 10 days after irradiation. The maximal secretory response induced by pilocarpine plus propranolol was increased compared to that with pilocarpine alone but did not reach the level of methacholine-induced secretion, which was about five times higher. One day after irradiation a decrease in maximal pilocarpine-induced secretion was observed (−22%) using the same dose of pilocarpine that induces 50% of the maximal response (ED50), in both the absence and presence of propranolol, indicating that the receptor–drug interaction was not affected by the radiation at this time. The secretory response to methacholine 1 day after irradiation, however, was normal. At day 3 after irradiation, the maximal methacholine-induced secretion was also affected, whereas pilocarpine (±propranolol)-induced maximal secretion decreased further. At day 6 after irradiation, maximal secretory responses had declined to approximately 50% regardless of the agonist used, whereas ED50 values were still unaffected. No net acinar cell loss was observed within the first 10 days after irradiation, and this therefore could not account for the loss in function. The results indicate that radiation does not affect cell number or receptor–drug interaction, but rather signal transduction, which eventually leads to the impaired response. We hypothesize that the early radiation effect, within 3 days, may be membrane damage affecting the receptor–G-protein signal transfer. Later critical damage, however, is probably of a different nature and may be located in the second-messenger signal transduction pathway downstream from the G protein, not necessarily involving cellular membranes.

To investigate whether secretory granules play a role in the radiosensitivity of the salivary glands of rats, parotid acinar cells, submandibular acinar cells and/or submandibular granular convoluted tubule (GCT) cells were degranulated prior to irradiation. Degranulation of GCT cells was obtained by pretreatment with phenylephrine (5 mg/kg, t = -60 min) and methacholine (3.75 mg/kg, t = -120 min). Degranulation of acinar cells was attained by pretreatment with isoproterenol (5 mg/kg, t = -90 min). Combinations of pretreatments were also tested. Irradiation was performed with a single dose of 15 Gy of X rays. Samples of parotid and submandibular/sublingual saliva were collected 4 days prior to and 1, 3, 6, 10 and 30 days after irradiation. Pretreatment with phenylephrine, isoproterenol and methacholine plus phenylephrine resulted in less radiation damage to parotid gland function as indicated by the lag phase and flow rate. Since the pretreatment with phenylephrine and phenylephrine plus methacholine did not degranulate parotid gland acinar cells, the observed protective effect on this gland cannot be explained by the \"degranulation concept.\" Furthermore, salivary gland function was significantly greater 3 days after irradiation as a result of pretreatment with phenylephrine and phenylephrine plus methacholine compared to rats given only radiation. This may indicate recovery from damage rather than a reduced amount of initial damage. The sparing was most obvious for the later effects (6-30 days). Submandibular/sublingual gland function was improved significantly after pretreatment with methacholine plus phenylephrine, although no increase in degranulation of GCT cells was observed compared to pretreatment with phenylephrine alone, again not favoring the degranulation concept. The results indicate that the secretory granules do not play the often-assumed important role in the radiosensitivity of the salivary gland. The mechanism underlying the observed improvement of salivary gland function may involve second messenger-induced increases in proliferation of salivary gland cells resulting in recovery of tissue after the irradiation.