EFFECTS OF IONIZING RADIATION
United Nations Scientific Committee on the
Effects of Atomic Radiation
UNSCEAR 2006
Report to the General Assemblywith Scientific Annexes

VOLUME II
Scientific Annexes C, D and E

UNITED NATIONSNew York, 2009

NOTE
The report of the Committee without its annexes appears as Official Records of the General
Assembly, Sixty-first Session, Supplement No. 46 and corrigendum (A/61/46 and Corr. 1). The
report reproduced here includes the corrections of the corrigendum.
The designation employed and the presentation of material in this publication do not imply theexpression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area, or of its authorities, or concerning
the delimitation of its frontiers or boundaries.
The country names used in this document are, in most cases, those that were in use at the time thedata were collected or the text prepared. In other cases, however, the names have been updated,
where this was possible and appropriate, to reflect political changes.

UNITED NATIONS PUBLICATION
Sales No. E.09.IX.5
ISBN 978-92-1-142270-2

ANNEX D
Effects of ionizing radiation on the immune system
Contents
Page
INTRODUCTION. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 85
I.	

GENERAL FEATURES OF THE IMMUNE SYSTEM. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
A.	 Introduction. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
B.	 Organs and tissues of the immune system. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Central lymphoid organs. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Peripheral lymphoid tissues. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Remarks concerning organs and tissues of the immune system . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
C.	 Cells and molecules of the immune system. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Innate immunity. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Acquired immunity. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Human major histocompatibility complex. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 4.	 Antigen-presenting cells . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 5.	 Self tolerance and self-HLA-associated recognition. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 6.	 Cytokines. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 7.	 Remarks concerning cells and molecules of the immune system. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
D.	 Physiological immunosenescence. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Concept of immunosenescence. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Main features of immunosenescence . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Remarks concerning immunosenescence . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
E.	 Summary. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

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II.	 RADIATION-INDUCED ALTERATIONS OF THE IMMUNE SYSTEM. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
A.	 Introduction. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
B.	 Data concerning low-dose irradiation . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Animal data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Human data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Remarks concerning low-dose/low-dose-rate irradiation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
C.	 Data concerning high-dose irradiation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 High-dose-induced immunosuppression. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Immune reconstitution. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Remarks concerning high-dose irradiation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
D.	 Influence of dose rate and radiation quality on immune response. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Low-LET exposures . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 High-LET exposures. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Remarks concerning the influence of dose rate and radiation quality. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
E.	 Radiosensitivity of lymphocyte subsets. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 General considerations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

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		 3.	 Remarks concerning the radiosensitivity of lymphocyte subsets . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 123
F.	 Alterations of the immune response after prenatal irradiation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 124
		 1.	 Animal data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 124
		 2.	 Human data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 125
		 3.	 Remarks concerning the effects of prenatal irradiation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 126
G.	 Immune dysfunction and hypersensitivity to ionizing radiation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 126
		 1.	 Human genetic disorders. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 126
		 2.	 Autoimmune diseases and radiation response. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 130
		 3.	 Ionizing radiation and acquired immune deficiency syndrome . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 130
		 4.	 Remarks concerning human pathologies with immune dysfunction and hypersensitivity
			 to ionizing radiation . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 131
H.	 Summary. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 131

III.	 possible MECHANISMS INVOLVED AND IMPLICATIONS . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
A.	 Lymphocyte apoptosis. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning lymphocyte apoptosis. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
B.	 TCR mutations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning TCR mutations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
C.	 Modification of Th1/Th2 balance. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning modification of Th1/Th2 balance. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
D.	 Bystander effects and genomic instability. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning bystander effects and genomic instability. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
E.	 Shift towards an inflammatory profile. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning the shift towards an inflammatory profile . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
F.	 Acceleration of immunological ageing. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning the acceleration of immunological ageing. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
G.	 Modification of antigen presentation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning modification of antigen presentation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
H.	 Autoimmune reactions . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning autoimmune reactions. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
I.	 Perturbation of immunological homeostasis . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning perturbation of immunological homeostasis . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
J.	 Other possible mechanisms involved. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Remarks concerning other possible mechanisms involved. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
K.	 Immune mechanisms and cancer . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 General considerations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Immune surveillance theory. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Immune response against tumours . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 4.	 Immunologic promotion of tumours. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
82

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135
136
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136
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138
139
139
139
140
140
140
140
143
143
143
143
143
144
144
144
144
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145
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		 5.	 Remarks concerning immune mechanisms and cancer . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 149
L.	 Summary. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 149
IV.	 EPIDEMIOLOGICAL STUDIES. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
A.	 Atomic bombing survivors. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 General considerations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Short-term effects. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Long-term effects . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 4.	 Remarks concerning data on survivors of the atomic bombings. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
B.	 Chernobyl workers and residents. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 General considerations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Emergency and clean-up workers . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Residents of contaminated areas. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 4.	 Radioiodine contamination, immune status and thyroid diseases. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 5.	 Remarks concerning data on Chernobyl workers and residents. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
C.	 Techa River study . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 General considerations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Epidemiological data . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Remarks on the Techa River study. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
D.	 Hanford nuclear site . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 General considerations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Hanford Thyroid Disease Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		 3.	 Remarks concerning the Hanford nuclear site . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
E.	 Patients undergoing radiotherapy . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 1.	 General considerations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 2.	 Review of published data. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 3.	 Remarks concerning data on patients undergoing radiotherapy. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
F.	 Summary. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

151
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155
155
156
157
159
160
160
160
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162
162
162
163
163
163
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163
164
164

V.	 Final summary. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 167
VI.	 CONCLUding remarks . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 171
Abbreviations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 173
References . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 177

83

INTRODUCTION
1. DNA lesions and defective DNA repair are usuallyconsidered to be the key mechanisms that explain the biological effects of ionizing radiation. Recently, radiationinduced non-targeted effects, e.g. genomic instability or the
bystander effect, have been described; they may represent
other critical mechanisms in the initiation and developmentof late radiation-induced effects at the cellular or tissue level.
Acute effects of whole-body irradiation may manifest as
multiple organ failures (involving essentially the haemato­
poietic, digestive and central nervous systems as well as theskin). In this context, alterations of the immune system byionizing radiation represent a field that has not recently beenthoroughly assessed.

U7, U8, U9]. A large number of new papers and ­technologicaldevelopments since then have fostered progress in understanding the basic concepts concerning mechanisms underlying the effects of ionizing radiation on the immune system.
In addition, there exists today a considerable amount of new
data related to impaired immunological functions and therisk of diseases or mortality from causes other than cancer.
3.

The scope of this annex includes reviews of:− R adiation-induced alterations of the immune
response, including immunosuppression (depression) or immunostimulation (activation);− Possible mechanisms by which the immune system
is altered following exposure to ionizing radiation;− Epidemiological assessments of immune system
alterations in various diseases, with emphasis on theeffects of ionizing radiation.

2. The effects of ionizing radiation upon immune system
function were first reviewed in detail by the Committee in1972 [U10]. Aspects of the subject were discussed in further
UNSCEAR reports, as summarized in table 1 [U2, U4, U6,

Table 1 Aspects covered by UNSCEAR documents concerning the effects of ionizing radiation upon immune system function
Content

Reference

Volume II, annex F (“Effects of radiation on the immune system”): the general components of the immune response, effects of radiation on­susceptibility to infection, effects of radiation on antibody formation, effects of radiation on cellular immune reactions, radiation and immunologicaltolerance, immunological aspects of radiation-induced carcinogenesis, effects of variation of condition of irradiation on immunological responses[U10]Radiocarcinogenesis and the immune system. Effects of prenatal irradiation on the haematopoietic and immune systems[U9]

Effects of ionizing radiation on the haematopoietic and immune systems[U8]

Radiation-induced cancer: impairment of immunological surveillance[U7]

Haematological and immunological effects of ionizing radiation[U6]

Annex B, part III: Effects of ionizing radiation on the immune system in the context of adaptive response[U4]

Radiosensitivity and defective recombination in the immune system; immunological effects of exposure to radiation from the Chernobyl accident

[U2]

85

I.
A.

GENERAL FEATURES OF THE IMMUNE SYSTEM

Introduction

located in areas that come into close contact with foreign
substances. In these locations, they are perfectly positioned
to recognize those substances as “non-self” or foreign. Uponsuch recognition, immune cells are activated and function toneutralize or destroy the invading foreign substance.

4. The immune system consists of cells and tissues spreadwidely throughout the body that protect against infections
and cancer. Following the recognition of foreign or novel
antigens, which are present in an immense variety of organisms or neoplastic cells, this system executes a complex
response in order to give protection. Organs or tissues transplanted from other individuals are also recognized by the
immune system as foreign agents. Immune recognition ofthese antigens generally leads to their elimination throughthe destruction and removal of the foreign cells.

6. Immunophenotyping with combinations of anti­bodies
to various cell surface and cytoplasmic proteins allows theidentification of specific cell types, determination of thedegree of cell differentiation and recognition of abnormal
cells. Most of these antibodies are against surface glyco­
proteins, which are often not only associated with particularcell lineages but also vary in expression with maturation, andare thus referred to as differentiation antigens. These antigens have been grouped together in clusters of differentiation(CD), numbered in the order in which they were identified.
Therefore, by incubating cell suspensions with monoclonal
antibodies that bind selectively to these cell membrane components, it is possible to identify the phenotype of different subsets of immune cells and determine their relative andabsolute abundance (see table 2).

5. The immune response is mediated by a number of different cells and molecules. The majority of these cells arewhite blood cells (leucocytes) produced in the bone marrow as precursors. Some develop into mature cells within
the bone marrow, and others are transported by the blood toother tissues where they develop and mature further. Many
molecules of the immune system are soluble or cell surface proteins. The immunocompetent cells are strategically

Table 2 List of CD antigens cited in the text
Adapted from reference [J1]
CD

Cell populationa

Functionb

CD1a, b, c, d, e

Dendritic cells, Langerhans cells, B-cells, thymocytes

Antigen presentation (glycoplipids)

Immunoglobulin

CD2

Thymocytes, NK cells, T-cells

Adhesion molecules; binding to CD58 and Lck activating
T-cells

Immunoglobulin

CD3

T-cells, thymocytes

TCR-associatedImmunoglobulin

CD4

Subpopulation of thymocytes, Th1 cells, Th2 cells,
monocytes, macrophages

Co-receptor of TCR for class II MHC;
receptor of HIV-1/2 gp120; fixation of Lck (src-family tyrosine kinase) to the inner surface of the cell membrane

Immunoglobulin

CD5

Thymocytes, mature T-cells and B-cells

Positive or negative modulation of TCR signalling

Receptor

CD8

Subpopulation of thymocytes, cytotoxic cells

Co-receptor of TCR for class I MHC;
binding to Lck on the inner surface of the cell membrane

Immunoglobulin

CD11b

NK cells and myeloid cells

Binding with CD54, iC3b components and αM subunit ofintegrins

α-integrins

CD14

Monocytes, macrophages, weakly expressed inneutrophils and myeloid dendritic cells

Receptor for the complex of LPS and LPB

Receptor

CD16

Neutrophils, NK cells, macrophages

Low-affinity FcR component (FcRγIII); mediator of phago­cytosis and cytotoxicity

α-integrins

CD19

B-cells

Formation of complexes with CD21 and CD81; B-cell
co-receptor

α-integrins

87

Molecular family

88

UNSCEAR 2006 REPORT: VOLUME II

Cell populationa

CD

Functionb

Molecular family

CD20

B-cells

Ca2+ channel formation; possible role in B-cell activation

Possesses four transmembrane segments

CD23

Mature B-cells, activated macrophages, eosinophils,
megakaryocytes, dendritic cells

Receptor with low affinity for IgE

Lectin-C-like

CD25

Activated T-cells, B-cells, monocytes

Subunit α of the human interleukin-2 receptor

α-chain type I glycoprotein
containing two complement
control protein domains

CD27

Medullar thymocytes, T-cells, NK cells and certain
B-cells

Co-stimulator of T- and B-cells

TNF receptor

CD28

T-cell subpopulations, activated B-cells

Naive T-cell activation; co-stimulatory pathway involving
CD80 and CD86

Immunoglobulin and CD86

CD38

Activated T- and B-cells

Multifunctional enzyme (NAD glycohydrolase, ADP-ribosyl
cyclase, cyclic ADP ribose hydrolase); regulation of T- andB-cell activation; also functions in cell adhesion, signaltransduction and calcium signallingType II glycoprotein

CD40

B-cells, macrophages, dendritic cells, basal cells,
epithelial cells

Co-stimulator of B-cells; cytokine production by macrophages and dendritic cells

TNF receptor

CD43

Leucocytes (except resting B-cells)

Anti-adhesive

MucineCD44

Leucocytes, erythrocytes

Link with hyaluronic acid; adhesion receptor

Adhesion molecule

CD45

All haematopoietic cells

Tyrosine phosphatase

Fibronectin type III

CD45ROT- and B-cell subpopulations, monocytes,
macrophages

Isoforms of CD45 without A, B and C exons

Fibronectin type II

CD45RA

Naive T-cells, monocytes

Isoforms of CD45 with the A exon

Fibronectin type II

CD48

All leucocytes except neutrophils

Involved in lymphocyte activation through the interaction
with its receptor (CD2)

Adhesion molecule

CD56

NK cells

Isoform of NCAM molecules

Immunoglobulin

CD69

Activated B- and T-cells, activated macrophages andNK cells

Antigen of early activation

Lectin C

CD80 (B7.1)

B-cell subpopulation

Co-stimulator; ligand for CD28 and CTLA-4

Immunoglobulin

CD86 (B7.2)

Monocytes, activated B-cells, dendritic cells

Ligand for CD28 and CTLA-4

Immunoglobulin

Broadly expressed in different cell lines

Binding with FasL (TNF-like),
apoptosis induction

TNF receptor

Haematopoietic progenitor cells

Stem cell factor receptor

Immunoglobulin, tyrosine
kinaseCD119

B-cells, monocytes, macrophages, endotheliumInterferon-γ receptor

Fibronectin type III

CD120

Broadly expressed

TNF receptor

TNF receptor

CD121

T-cells, thymocytes, B-cells, macrophages, monocytes

IL-1α and IL-1β receptor

Immunoglobulin

CD124

T-cells, B-cells, haematopoietic precursors

IL-4 receptor

Cytokine receptor,
fibronectin type III

CD125

Activated B-cells, eosinophils, basophils

IL-5 receptor

Cytokine receptor,
fibronectin type III

CD127

Monocytes, pro-B-cells,
T-cells, lymphoid precursors

IL-7 receptor

Fibronectin type III

CD130

Broadly expressed

Common subunit shared with IL-6, IL-11 and leukaemia
inhibitor factor

Immunoglobulin, cytokine
receptor, fibronectin type III

CD132

B-cells, T-cells, NK cells, mastocytes, neutrophils

γ-chain of the IL-2 receptor; common subunit shared with
IL-4, IL-7, IL-9 and IL-15

Cytokine receptor

CD95
CD117 (c‑Kit)

a NK = natural killer.
b	TCR = T-cell receptor; MHC = major histocompatibility complex; HIV = humanimmunodeficiency virus; LPS = lipopolysaccharide; LPB = LPS-binding protein;
TNF = tumour necrosis factor.

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

B.

Organs and tissues of the immune system

7. Like red blood cells (erythrocytes) and platelets (thrombocytes), the cells of the immune system arise in the bonemarrow from pluripotent stem cells by a process called
haema­topoiesis. Myeloid precursors develop into a group ofwhite blood cells known as phagocytes. Phagocytes include
monocytes, macrophages and neutrophils. Other myeloid
descendants become granule-containing inflammatory
cells such as eosinophils, basophils and mast cells. Lymphoid ­precursors develop into the small white blood cells
called lymphocytes. The two major classes of lymphocytes
are B-cells and T-cells. Cells and molecules of the immune­system are discussed in detail in section I.C.
8. The bone marrow and thymus are termed the primary(or central) lymphoid tissues, because mature lymphocytes
are produced within these organs. Mature lymphocytes
then enter the blood and travel to the secondary (or peripheral) lymphoid tissues such as lymph nodes, spleen andmucosa-associated lymphoid tissue. A notable feature oflympho­cytes is that they can cross from the blood into
the lymphatic ­circulation and then return, a phenomenon referred to as lymphocyte traffic or recirculation.
The direct migration of lymphocytes to specific tissues iscalled homing.
1.

Central lymphoid organs

9. All cells of the immune system originate from just one
cell type, called a haematopoietic stem cell, in the bonemarrow of adults (for prenatal life, see section II.F below).
Pluripotent stem cells multiply to produce more pluri­
potent stem cells (self-renewal), thus ensuring the steadyand lasting supply of stem cells. Homeostatic regulation
stabilizes the number of pluripotent stem cells. Some of thepluripotent stem cells differentiate to become ­committed to
one of two blood cell lineages: lymphoid or myeloid. Thenlymphoid and myeloid stem cells become progenitor cells
for each type of mature blood cell. These cells have lostthe capacity for self-renewal and are committed to a given
cell lineage: T- and B-cell progenitors, and progenitor cells
for granulocytes, monocytes, eosinophils, basophils, mast
cells, platelets and erythrocytes. Dendritic cells belong to
the myeloid cell lineage, and it is likely that monocytes
and dendritic cells arose from a common myeloid precursor. Progenitor commitment depends upon the acquisition of responsiveness to different growth factors such as­colony-stimulating factors (CSFs), erythropoietin (EPO)
and interleukins (ILs). The particular microenvironment
within which the progenitor cell resides controls differentiation. The haematopoietic cells grow and mature on ameshwork of stromal cells, which are non-­haematopoietic
cells that support the growth and differentiation of thehaema­topoietic cells (figure I). In the absence of infection, bone marrow stromal cells are the major source of
haemato­poietic cytokines. In the presence of infection,cytokines produced by certain activated immunocompetent89

cells induce additional haematopoietic activity, resulting
in the rapid expansion of the white blood cells that participate in fighting infection. After a period of maturationand expansion within the bone marrow, more differentiatedcells enter the bloodstream and are distributed throughout
the body in different tissues. B-lymphocytes develop andmature in the bone marrow before entering the bloodstream,in contrast to T-lymphocytes, which leave the bone marrow
as T-cell precursors and complete further m­ aturation in thethymus [A25].
10. The thymus is an organ located anterior in the upper
mediastinum. Immature T-lymphocytes migrate from thebone marrow into the thymus, where they become mature
immunocompetent T-cells. A minority of lymphocytes
become mature T-lymphocytes by extrathymic maturation
processes. After thymic involution (see below), this pathway of extrathymic lymphocyte maturation becomes more
relevant [B32]. Thymus cells are called thymocytes and are­predominantly immature T-cells at various stages of development. There are also scattered epithelial cells, macrophages
and dendritic cells [A25]. The thymus is very large in thefirst years of life, reaches maximum size at puberty and thenbecomes smaller in a process called involution. During thisdegenerative process, connective tissue, fibres and fat cells
replace the previously functional tissue. Although only a few
pieces of functional tissue remain, they suffice to continue tosupply the organism with enough mature lymphocytes. Cervical lymphoid organs with thymic structure and function
have recently been found in BALB/c and C57BL/6 mousestrains. Although cervical thymus tissue has been observedin other species, the presence of cervical thymus tissue inhumans is considered rare after birth [T18].
11. The main functions of the thymus include:− Production of immunocompetent T-lymphocytes;− P roduction of mature T-cells for peripheral tissues
and circulation;− R egulation of T-cell maturation, proliferation andfunction;− I mmunological self tolerance via positive and­negative selection.

2.

Peripheral lymphoid tissues

12. After maturing in the thymus, T-cells move throughthe circulation to other organs. Lymph nodes are small,bean-shaped structures that are spread throughout the bodyalong the lymphatic routes. They contain specialized compartments where immune cells congregate and where theycan encounter antigens. Lymph nodes constitute groups inareas where lymphatic vessels come together to form larger­vessels, such as in the groin, neck and axilla. All lymphatic
vessels draining back to the venous circulation from the­tissues pass through lymph nodes, which filter and purify thedrain fluid of the lymphatic vessels (lymph) before it flows

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UNSCEAR 2006 REPORT: VOLUME II

Figure I. Regulation of haematopoiesis in the bone marrow by cytokines that stimulate the proliferation and/or differentiationof various haematopoietic cells (adapted from reference [G14]).
GM-CSF: Granulocyte–macrophage colony-stimulating factor.
Thymocyte
IL-7

IL-7

IL-2, IL-4

TH

T-progenitor
IL-7

IL-4, IL-2

IL-3

IL-5, IL-6

Lymphoidstem cellTC

B-progenitor
B-cellIL-3

IL-3-like
Dendritic cell

Bone marrowstromal cell

Self renewal

GM-CSF,
IL-

6

IL-3
SF
GM-C

Myeloidstem cell

GM

IL-CS

3

Monocyte

GM-CSF
IL-5
Eosinophil
progenitor

Eosinophil

F

IL-9

1
L-1
3, I EPO
F,
-CS

IL-

GM

GM
Basophilprogenitor

-CS
F
IL-4

GM-C

IL-3
O
SF, EP

Basophil
GM-CSF
EPO, IL-6

Platelets

Megakaryocyte
EPO
Erythrocyte
Erythroid progenitor

Macrophage
IL-8

Neutrophil

IL-

3,

GM

-C

SF

IL-3

CSF
GMF
M-CS
GMCSF
G-CS
F
Granulocyte-monocyte
progenitor

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

into the venous system [J1]. Several immune functions takeplace in the lymph nodes:− P hagocytosis of microorganisms by fixedmacrophages;− T-lymphocyte activation;− B -lymphocyte activation and proliferation (plasma
cell formation and antibody production);− I nteraction between antigen-presenting cells andcirculating lymphocytes.
13. The spleen is a soft organ located in the left hypochondrium that removes abnormal blood cells through phagocytosis, collects and disposes of senescent red blood cells,
provides storage of iron from recycled red blood cells andplays a role in foetal and sometimes adult haematopoiesis.
Spleen cells are called splenocytes. It is in the spleen that theinitiation of immune responses by B-cells and T-cells takes
place in response to antigens circulating in the blood. The
spleen has a “red pulp” (its colour due to the presence oflarge numbers of erythrocytes in the blood vessels) that ischaracterized by a parenchyma that consists of macrophages
and blood cells surrounded by numerous venous sinuses.
The “white pulp” of the spleen is characterized by the lack ofthese sinuses and consequently the presence of fewer erythrocytes, and consists of B- and T-lymphocytes located in two
different areas of the spleen. B-cells are located in the lymphoid follicles scattered throughout the organ. T-cells arelocated around the central arteries and form a kind of sheath(periarteriolar lymphoid sheath) [G27].
14. Mucosa-associated lymphoid tissue (MALT) consistsof connective tissue containing lymphocytes and is locatedbeneath mucous membranes of the respiratory, gastrointestinal, urinary and reproductive tracts. MALT has no distinct
capsule like that of the lymph nodes but does often have agerminal centre containing actively dividing lymphocytes.
Waldeyer’s throat ring (comprising the adenoids and thepalatine, lingual and pharyngeal tonsils), Peyer’s patchesof the small intestine, and the appendix are all examples ofmucosa-associated lymphoid tissue [J1].
15. The skin is the largest organ in the human body. It protects against injury, infection, heat and cold, and it storeswater, fat and vitamins [C30]. Although classically described
as an anatomic barrier of the innate immune system (seesection I.C.1 below), the skin may also be considered as anorgan of the immune system. The ability of the cutaneous
barrier to help defend the body against pathogens depends
on both acquired and innate immune responses [B17, B27].
16. The “skin immune system” (SIS) has been proposedas the term for the complex of immune-response-associatedcells present in normal human skin. Approximately half ofhuman skin cells are directly or indirectly involved in the
immune response (e.g. keratinocytes, endothelial cells,
dendritic cells, T-lymphocytes, monocytes/macrophages,
granulocytes and mast cells). Some of these cells are skin91

residents, others can be recruited or are recirculating cells.
This concept of the SIS also includes human skin humoral
constituents such as immunoglobulins, cytokines, chemo­kines, complement, cathelicidins, defensins, dermcidins,
prostaglandins and free radicals [B28, R13].
3.

Remarks concerning organs and tissuesof the immune system

17. On the basis of the preceding discussion, some concepts
may be highlighted. The bone marrow and the thymus are
the central lymphoid tissues. All cells of the immune system originate in the bone marrow from haematopoietic stem
cells. After maturation and expansion, more differentiatedimmune cells enter the bloodstream to be distributed in the
different tissues. Some immature lymphocytes move fromthe bone marrow to the thymus, where they become immuno­
competent T-cells. Spread throughout the body, lymph nodes
are peripheral lymphoid tissues where immune cells congregate and where these cells can encounter antigens. It is in the
spleen, another peripheral lymphoid organ, that the initiationof the B- and T-cell immune responses to circulating antigens
takes place. MALT consists of connective tissue containing
lymphocytes. The skin and mucous membranes are the firstline of defence against pathogens. Classically they have been
described as anatomic barriers of the innate immune system
alone; however, around half of human skin cells are involvedin both innate and acquired immunity.
C. Cells and molecules of the immune system
18. The cells and molecules of the immune system execute two different but related forms of immunity: innate andacquired. While innate immunity is fully functional before
any foreign agent enters the body, acquired immunity is
activated only after a pathogen has entered the organism.
Acquired immunity mediated by B- and T-lymphocytes
recognizes pathogens by rearranged high-affinity receptors. However, as acquired immunity involves activation andgene expression as well as cell proliferation, it is often not
rapid enough to eradicate microorganisms. Innate immunity­provides more rapid defence mechanisms.
1.

Innate immunity

19. The innate immune system comprises several defensive barriers:− Anatomic barrier: skin and mucous membranes;− P hysiological barrier: temperature, pH, lysozymes
and circulating factors such as interferon andcomplement;− I nflammatory barrier: cellular and chemical mediators of the inflammatory response (histamine, acutephase proteins, fibrin, kinin);− Phagocytic barrier (see below).

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20. Phagocytes include granulocytes, peripheral monocytes, tissue macrophages and dendritic cells. Phagocytes
are cells capable of surrounding, engulfing and digesting
complete microorganisms by phagocytosis. Some of themplay an important role in producing molecules involvedin the inflammatory response associated with infections.
They migrate towards the site of infection by margination,­diapedesis and chemotaxis.
21. Granulocytes include three types of cell: neutrophils,
eosinophils and basophils. Neutrophils play an essential
role in the body’s innate immune defence and are one of the
primary mediators of the inflammatory response. They arehighly specialized for their primary function, which is thephagocytosis and destruction of microorganisms. To defend
the host, neutrophils employ a wide range of microbicidal
products, such as oxidants, microbicidal peptides and lytic
enzymes. The generation of microbicidal oxidants by neutrophils results in a respiratory burst with generation ofhighly reactive oxygen and nitrogen species (ROS/RNS)[G13, Q1]. Eosinophils attack parasites and phagocytose
antigen–antibody complexes. Basophils secrete anticoagulant and vasodilatory substances, such as histamines andserotonin. Even though they possess phagocytic capability, their main function is the secretion of substances that­mediate hypersensitivity reactions.
22. Monocytes in peripheral blood are young cells that
already possess phagocytic capabilities. After migration
into tissues, monocytes undergo further differentiation to
become multifunctional tissue macrophages. Macrophages
and dendritic cells present antigens to be recognized bylymphocytes, and are thus called antigen-presenting cells(APCs). (Although less efficient, B-lymphocytes are also
APCs, as will be discussed later.) Macrophages play a central
Table 3role in the immune response. Among other functions, theyseek out, ingest and destroy bacteria, viruses, tumour cells
and other foreign material. They present foreign material tothe cells of the immune system and in this way regulate theimmune response. The understanding of the role of macro­phages has changed since the identification of a particularfamily of receptors called pattern recognition receptors(PRRs). These PRRs recognize highly conserved antigenic
structures, termed pathogen-associated molecular patterns(PAMPs), shared by large groups of pathogens. PRRs are
secreted (complement, lectins) or expressed at the surface ofcells (Toll-like receptors (TLRs)) [B23].
23. The TLR family constitutes an important componentof the innate immune system. Although most commonly
considered to be expressed on immune cells, e.g. phagocytes and T-regulatory cells, TLRs are also known to befunctionally expressed on a variety of other cell types, suchas airway and gut epithelial cells [A3, A16, C3, G31, J2,
K40]. Ten members of the TLR family have been identified in humans; each recognizes a small range of conserved
pathogen molecules (table 3). The binding of PAMPs to
TLRs induces the production of pro-inflammatory cytokines
and the up-regulation of surface co-stimulatory molecules.
Recent studies have identified intracellular signalling pathways specific for individual TLRs that lead to the release ofcytokine profiles specific for particular PAMPs. The abilityof individual TLRs to discriminate among different PAMPs
is an important determinant of the unique gene expression
profiles activated in the host by different invading pathogens
or environmental “danger signals” [V6]. Thus TLRs confer acertain degree of specificity to the innate immune response.
Moreover, TRL-mediated recognition represents a crosstalk between the innate and the acquired immune system[A2, N8, R4].

Ligands recognized by Toll-like receptors
TLR
TLR2

PAMP

LigandGram (+) bacteria
Gram (+) bacteria
Bacteria
Spirochaetes
Leptospiras and porphyromonas
Mycobacteria
Yeast
Trypanosoma
Schistosoma
Neisseria
Klebsiella
Host

Peptidoglycan (PGN)
Lipoteichoic acid (LTA)
Lipoproteins
Glycolipids
Lipopolysaccharide (LPS)
Lipoarabinomannan
ZymosanGlycosylphosphatidylinositol (GPI)
Phosphatidylserine (PS)
Porin
Membrane protein A
Heat shock proteins (HSPs)

TLR2/TLR1

Chemicals
Bacteria
Neisseria meningitides

JBT-3002
Lipoproteins
Soluble factor

TLR2/TLR6

Staphylococcus
Streptococcus (Group B)
Mycoplasma

ModulinSoluble factor
Lipoprotein

Chemicals
Virus

Poly (I:C)
Double-stranded RNA

TLR3

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

TLR

PAMP

LigandTLR4Gram (–) bacteria
Chlamydia
Murine retroviruses
RS virus
Plant
Host

LPS, LTA
HSP60
Envelope proteins
F protein
Taxol
HSPs

TLR5

Bacterial flagellum

Flagellin

TLR7

Chemicals

Imidazoquinolines

TLR9

Bacteria, virus, insects
Host

Unmethylated DNA rich in CpG
Chromatin-IgG complexes

TLR10

Unknown

Specific ligands and functions are currently unknown

24. Natural killer (NK) cells are large granular lymphocytes able to kill a number of different target cells andthat, in contrast to T- or B-lymphocytes, do not express clonally distributed receptors for antigens [M10]. They belong
to the innate arm of the immune response because theircytotoxic activity is spontaneous, although activation may
be mediated by cytokines. NK cells do not show secondaryor memory responses. NK cells may recognize, bind andkill virus-infected host cells and tumour cells [H18, T12].

their function, NK cell receptors can be divided into activation and inhibition receptors; NK cells are regulatedby the integration of these opposing signals [L3, M10].
Normally NK cells are prevented from lysing “self” cellsby the interactions of inhibitory receptors on the NK
cell surface with the major histocompatibility complex(MHC). The MHC in humans is called the human leucocyte antigen (HLA), which will be discussed in moredetail in section I.C.3 below. Upon self class I HLA binding, inhibitor NK receptors trigger a signalling pathway
resulting in inhibition of cytotoxicity, thus providing protection for normal cells. Cells that have lost class I HLA
molecules, or express insufficient amounts of them, arefrequently found in viral infections or tumour transformation, are not able to trigger these inhibitory signals
and thus are lysed by NK cells. Although a combinationof several activating receptors may also boost lysis by
NK cells, the higher affinity of the inhibitory receptors
by self class I HLA prevents autoimmunity [B7, C5, L2,
M11]. NK receptors may be classed within several families: killer cell immunoglobulin-like receptors (KIRs),
lectin-like receptors (NKG2 and CD95), leucocyte Iglike transcripts (ILTs), natural cytotoxicity receptors(NCRs) and Fcγ receptor III (CD16). These are describedin table 4.

25. The heterogeneity of NK cells presents a major problem in their identification. They do not express CD3, but
exhibit subsets expressing CD16 and CD56. Most humanNK cells are mainly involved in cytotoxicity, have lowdensity expression of CD56 and have high levels of CD16
(CD3– CD56low CD16high), but around 10% of NK cells
play a role in cytokine-mediated immunoregulation and
are CD3– CD56high CD16–/low [C14, S19]. It was recently
reported that peripheral CD56high NK cells are terminallydifferentiated cells indistinguishable from mature CD56low
NK cells activated by IL-12, and do not constitute a functionally distinct NK cell subset [L23].
26. The different NK cell subsets have receptors on
their surface that are not antigen specific. Depending on

Table 4
FamilyaKIR

93Natural killer cell receptors
Receptor

Functionb

LigandComments

KIR2DL(KIR2DL4)

(–)

HLA-C
(HLA-G)

2D: two extracellular Ig-like domains;
L: long cytoplasmic tailKIR3DL

(–)

HLA-B
HLA-A

3D: three extracellular Ig-like domains;
L: long cytoplasmic tailKIR2DS(+)

HLA-C

2D: two extracellular Ig-like domains;
S: short cytoplasmic tailKIR3DS(+)

HLA-B

3D: three extracellular Ig-like domains;
S: short cytoplasmic tail

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UNSCEAR 2006 REPORT: VOLUME IIFamilya

Functionb

LigandCD94/NKG2A(heterodimer)

(–)

HLA-E
(indirect recognition of HLA-G as peptide
presented by HLA-E)

CD94/NKG2C(heterodimer)

(+)

HLA-E
(indirect recognition of HLA-G as peptide
presented by HLA-E)

CD94/NKG2E(heterodimer)

(+)

HLA-E
(indirect recognition of HLA-G as peptide
presented by HLA-E)

NKG2D/NKG2D(homodimer)

(+)

MICA
MICB
ULBP

MICA/MICB: up-regulated on stressed cells and overexpressed in many tumours;
ULBP: UL16-binding proteins from human cytomegalovirus

ILT

ILT2

(–)

HLA-A
HLA-B
HLA-F
HLA-G

Also termed leucocyte Ig-like receptors or CD85j

NCR

NKp46

(+)

Viral and tumour proteins

Expressed in resting and activated NK cells

NKp30

(+)

Viral and tumour proteins

NKp44

(+)

Viral and tumour proteins

Expressed only in activated NK cells

CD16

(+)

Low-affinity receptor for IgG

Facilitates antibody-dependent cellular cytotoxicity

Lectin C

Fcγ
receptor
III

Receptor

Comments

CD94 functions as a chaperone (transports NKG2 to cellsurface)a	KIR = killer cell Ig-like receptor (Ig superfamily); ILT = Ig-like transcript;
NCR = natural cytotoxicity receptor.

b Functions: (–) = inhibitory; (+) = activating.

27. A particular type of lymphocyte called an NKT cell
exhibits certain characteristics of both T-cells and NK cells.
NKT cells, by definition, are T-lymphocytes, as they expressa T-cell receptor (TCR) on the surface of their membranes.
This distinguishes them from NK cells, although NKT cells
do share some markers characteristic of NK cells. In contrast
to conventional T-lymphocytes, the NKT cell TCR does notinteract with peptide antigen presented by classical class I
or II HLA molecules but instead recognizes glycolipids presented by CD1d, a non-classical antigen-presenting mole­cule. NKT cells also express a far more limited range of
TCR variable (V) region genes. Unlike NK cells, NKT cells
develop in the thymus and are either CD4+ or CD4–. When
activated, NKT cells secrete large amounts of cytokines,
such as interferon-γ (IFN-γ) and interleukin-4 (IL-4). The
activation of NKT cells can lead, paradoxically, either tosuppression or to stimulation of immune responses, depending on the type of signal received. The cells play a criticaland probably unique role in the immune system by linking
innate and acquired immunity. NKT cells have been implicated in the regulation of immune responses associated witha broad range of diseases, including autoimmunity, infection
and cancer [S9].

only maturing once in a tissue site. They are present in mosttissues in the vicinity of blood vessels, and are especiallyprominent near the boundaries between the outside world
and the internal milieu (skin and mucosa). When activated,a mast cell rapidly releases its characteristic granules andvarious molecules into the intercellular environment: histamine, heparin, serine proteases, prostaglandin, leukotrieneand cytokines.

28. Mast cells (or mastocytes) are considered part of theimmune system, where they play a role in innate immunity.
Although best known for their role in allergy and anaphylaxis,
mast cells are also involved in wound healing and in defence
against pathogens. Mast cells circulate in an immature form,

29. The complement system refers to a series of serum
proteins produced by different tissues and cells, including
hepatocytes, macrophages and gut epithelial cells. These
proteins circulate in an inactive form, but in response to therecognition of molecular components of a microorganism,
they become sequentially activated in a cascade where thebinding of one protein promotes the binding of the next one.
Three pathways may activate the complement system: theclassical complement pathway, the lectin pathway and thealternative complement pathway. These pathways differ inthe manner in which they are activated. Antibody–antigen
complexes activate the classical pathway. The lectin pathway is mediated by the mannan-binding protein (MBP),
a protein that binds to the mannose groups found in many
microbial carbohydrates but not usually found in humancarbohydrates. The alternative pathway provides a meansof non-specific resistance against infection without the participation of antibodies and hence provides a first line ofdefence against a number of infectious agents. Activation of
the complement system results in the production of several

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

biologically active molecules (e.g. kinins, chemotactic factors and opsonins), which may lead to lysis, opsonization,
inflammation or clearance of immune complexes.
2.

Acquired immunity

30. The main features of acquired immunity are thefollowing:− M emory: recovery from one infection frequently
protects against subsequent infection by the sameorganism (the individual is said to have become“immune”);− S pecificity: recovery from infection by one patho­
gen does not usually give protection against
another;− D iversity: the immune system can respond to animmense variety of foreign antigens;− S elf and non-self discrimination: an individual does
not normally make an immune response against the
antigens usually present in the body and distinguishes such antigens from those that do not belong
to that individual (immune tolerance).
31. Lymphocytes are the predominant cells involvedin acquired immunity, which includes humoral and cell­mediated responses. Soluble antibodies present in the serum
mediate humoral responses, while cell-mediated responses
result from the interaction between different types of cell.
This distinction correlates, respectively, with the existenceof two types of lymphocyte: B-cells and T-cells.
32. Cells involved in immune recognition have surface
molecules called receptors that allow them to interact withother cell-attached or soluble molecules in their environment. Each receptor has a conformation complementary
to the specific molecule (ligand) to be recognized. The
ligand becomes bound to the receptor when recognition
occurs. The term “antigen” includes any molecule thatcan be recognized by an antibody or by a lymphocyte
receptor. However, lymphocyte receptors recognize onlya small part of a whole molecule or ligand. The different
parts of an antigen that can be recognized by lymphocyte
receptors are called antigenic determinants or epitopes.
The diversity and specificity of immune response imply
that an enormous number of different specific receptors
should exist. The diversity of the receptor repertoire isacquired during the maturation process of lymphocytes,
which involves a large number of gene rearrangements
and results, among the clones existing in the final mature
population, in more than 108 types of receptor for different specific epitopes [J1].
33. B-lymphocytes are the effector cells of the humoral
response. They originate and mature in the bone ­marrow,then they move through the circulation to various sites
throughout the body. Upon interaction with a foreign95

antigen, B-lymphocytes become mature antibody-secreting
cells called plasma cells. Plasma cells are rarely found in thecirculation but reside mostly in connective tissue, beneathepithelia, in the medullary cords of lymph nodes and in thewhite pulp of the spleen. Most plasma cells in the spleen andlymph nodes migrate into bone marrow.
34. B-cell receptors (BCRs) are able to recognize “free”
soluble antigens in unmodified form, referred to as native
antigens. B-cells can secrete antibodies in a soluble form
when they are activated and develop into plasma cells.
The BCRs found on mature B-cells consist of a membrane immunoglobulin (Ig) acting as an antigen-bindingsub­unit, associated with a signalling subunit, which is a­disulphide-linked Ig-α/Ig-β heterodimer [M31]. Immuno­
globulins are usually Y-shaped and consist of two lightchains (λ or κ) and two heavy chains (α, δ, γ, ε or μ). The
type of heavy chain determines the immunoglobulin isotype (IgA, IgD, IgG, IgE and IgM, respectively). Each lightchain has a molecular weight of ~25 000 daltons and iscomposed of two domains, one variable domain (VL) and
one constant domain (CL). The heavy chain has a molecular weight of ~50 000 daltons and contains one variabledomain (VH) and either three or four constant domains(CH1, CH2, CH3 and CH4), depending on the antibody
class or isotype. Variable regions are contained within theamino (NH2) terminal end of the polypeptide chain andserve as the antigen-binding sites. Constant regions are, incomparison, rather uniform from one antibody to anotherwithin the same isotype. The four polypeptide chainsare held together by covalent disulphide (-S-S-) bonds­(figure II). While IgG is the predominant serum form, IgA
is the main class of immunoglobulin found in secretions
such as saliva, breast milk and tears, and in the digestive
tract [G27].
35. Although in certain conditions B-cells may be susceptible to T-cell-independent activation [F15], the majority of B-cells require interaction with helper CD4+ T-cells
to become activated and proliferate. The B-cell firstexpresses Ig on the cell surface as the B-cell receptor. If
the B-cell receptor binds specific antigen, then the cellinternalizes the antigen and presents it to T-cells, where it
is recognized by the T-cell receptor (TCR). T-cell interaction with the B-cell involves additional regulatory signals
involving stimulation, e.g. interactions CD40/CD40L and
CD28/CD80. Fas ligand binding to Fas between B- andT-cells may negatively modulate B-cell activation, inducing apoptosis that limits B-cell proliferation and activation. Cytokines such as IL-2, IL-4 and IL-10 also play animportant role in B-cell activation. B-cells express class II
HLA molecules. They can find T-cells in secondary lymphoid organs shortly after antigen entrance, BCR-mediatedendocytosis allows them to concentrate small amounts ofspecific antigen, and BCR signalling and class II HLA
expression direct their antigen-processing machinery tofavour presentation of antigens internalized through the
BCR. These characteristics allow B-cells to be considered
as antigen-presenting cells (APCs).

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Figure II. Molecular structure of immunoglobulins (adapted from reference [J1]).

Antigenbinding
NH

2

NH

NH

2

2

NH

VH

VH

2

VL

VL
1

CL

CH

CH

-S-

1

-S-SCH2 -S-S- CH2
H

Isotypedeterminants

-S-

S-

-S

CO
O

Fc fragment

CH3

CH3

COOH

COOH

36. T-lymphocytes move from the bone marrow into thethymus as immature cells, take up residence and become
thymus-dependent or mature T-lymphocytes. Prothymocytes in the superficial cortex of the thymus (CD2+) giverise to cortical thymocytes (CD1a+, CD2+, CD3+) andmature T-cells (CD4+ or CD8+). Medullary thymocytes
are fewer and larger, and express CD4 or CD8 [A25].
Mature T-cells pass through the circulation to find homes
in lymph nodes, mucosa-associated lymphoid tissue or the
spleen. Most of the T-cells belong to one of two subpopulations, distinguished by the presence on their surface of oneof two glycoproteins, designated CD8 and CD4. The typeof these glycoproteins present determines the cell type towhich T-lymphocytes can bind (see section I.C.3 below).
The majority of CD8+ T-lymphocytes are cytotoxic T-cells,
and the majority of CD4+ T-lymphocytes are helper T-cells.
Cytotoxic and helper T-lymphocytes perform very different

Fab fragment

CLH

carbohydrateOCOfunctions in the immune system. Cytotoxic T-lymphocytes
are effector cells that, once activated, can remove foreignorganisms. Helper T-lymphocytes induce other immune cells
to become better effectors. There are at least two subsets ofhelper T-cells (Th1 and Th2); they secrete very different
cytokines upon activation [S36]. While the Th1 subset produces large amounts of cytokines that promote cell-mediatedimmune response, the Th2 subset produces an environment
favouring humoral immunity by providing B-cell help for
antibody production. The Th1 response (now sometimes
called “type 1 immunity”) is characterized by production of
IFN-γ, IL-2, TNF-β and TNF-α. Characteristics of the Th2
response (“type 2 immunity”) include production of IL-4,
IL-10, IL-13 and IL-5, and stimulation of the production of
IgE and IgG1 antibodies [K11]. Immune regulation involves
homeostasis between Th1 and Th2 activity directing different immune response pathways (table 5).

Table 5 Characteristic molecules produced by CD8+ and CD4+ T-cells
Adapted from reference [J1]
T-cell type
CD8+
Production of molecules withcytotoxic activity

Antigenbinding

Molecule
Perforins
Granzymes
Fas ligand
IFN-γ
TNF-β
TNF-α

ActionPore-forming proteins
Proapoptotic intracellular proteases
Transmembrane death activator
Inhibition of viral replication
Cell death
Cell deathANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

T-cell type

Molecule

CD4+/Th1
Production of molecules capableof activating macrophages

IFN-γ
TNF-α
Fas ligand
GM-CSF
CD-40-L
IL-3
TNF-β
IL-2

Control of viral replication, Th2 inhibition
Cell deathTransmembrane death activator
Granulocyte–macrophage colony stimulation
Activation of target cells (via CD40 receptor)
Growth and differentiation of target cells
Cell death
Lymphocyte activation and proliferation

CD4+/Th2
Production of molecules capableof activating B-cells

IL-4
IL-5
IL-6
CD-40-L
IL-3
GM-CSF
IL-10
TGF-β
EotaxinB-cell activation
Eosinophil growth and differentiation
Plasma cell and stem cell differentiation, antibody secretion, acute phase response
Activation of target cells (via CD40 receptor)
Growth and differentiation of target cells
Granulocyte–macrophage colony stimulation
Macrophage inhibition
Chemotaxis and IL-1 synthesis
Attracting eosinophils

97

Action

37. Although most CD4+ T-cells belong to either the Th1or Th2 subsets, 5–10% of CD4+ T-cells do not belong tothese two subsets; these cells express CD25, the receptor for
IL-2, and the αβ TCR. Their repertoire of antigen specificities is as broad as that of naive T-cells. These “T-regulatory”(Treg) cells are activated by binding to the class II HLA
mole­cule, and they also receive co-stimulatory signals thatserve to initiate, maintain and regulate the activation cascade.
Most CD25+ CD4+ Treg cells are produced by the normal
thymus as a functionally distinct and mature subpopulationof T-cells [S5]. The major function of Treg cells is to inhibit
other T-cells from mounting an immune response against
self components, thus protecting against autoimmunity.
Upon TCR stimulation, Treg cells secrete large amounts ofpowerful immunosuppressor cytokines, which inhibit both
Th1 help for cell-mediated immunity and Th2 help for antibody production.
38. Treg cells also express several members of the TLR
family. Stimulation of Treg cells through TLRs can expand
their numbers and strengthen their suppressive activity[S4]. This effect is apparently in opposition to the TLRdependent stimulation of APCs, which enhances productionof pro-inflammatory cytokines, thereby augmenting T-cell­mediated acquired immunity. However, the PAMP concentrations required for stimulation of Treg cells through TLRs
are several orders of magnitude higher than those required
for activation of APCs. If a large amount of PAMP, e.g.
bacterial lipopolysaccharide (LPS), is produced, Treg cell
activation may prevent severe systemic reactions, such as
septic shock due to the production of large amounts of proinflammatory cytokines [S4]. Therefore CD4+ CD25+ Treg
cells are an evolutionarily unique T-cell subpopulation bearing two kinds of receptor: TCRs and TLRs. This dual signalling source, together with other signals, may enable CD4+
CD25+ Treg cells to finely tune their activity to modulateacquired response against self and non-self antigens.
39. Normally lymphocytes are in a resting state, andbefore any contact with an antigen they are referred to as“naive”. They become activated to carry out their specificfunctions when an immune response is triggered. Activatedlymphocytes begin to proliferate in a process termed “clonal
expansion”, giving rise to a clone of descendant cells. This
activation also induces the cells to differentiate into primary effector T-cells, which can secrete cytokines and kill
infected cells, and leads to rapid clearance of the pathogen.
Once the response has ceased, lymphocytes revert to theirprevious inactive state, the primary effector cell population begins to contract and the majority of the cells die by
apoptosis over the following weeks. A minority of cells,
however, escape this period of cell death; the cells that survive constitute an expanded population of “memory” cells
able to trigger a vigorous and effective secondary response
should the same antigen be encountered in the future. The
maturation status of CD4+ and CD8+ lymphocytes (naive/
memory) can be determined on the basis of expression of
CD45RA molecules. The phenotypes are CD45RA+ for
naive T-cells and CD45RA– for memory T-cells. Although
T-cells express CD45RO, the expression of CD45RO by
T-cells is not a marker per se for memory cells, because
other types of immune cell also express it. Phenotypicallynaive T-cells also express high levels of CD27 and CD28
molecules (CD45RA+ CD27+ CD28+). T-cells belonging to
the memory pool have lost CD45RA expression (CD45RA–
CD27+ CD28+). After repeated stimulation by antigen,memory T-cells down-regulate CD28 and subsequently
CD27, and give rise to memory/effector cells (CD45RA–
CD27– CD28–) and terminally differentiated effector T-cells(CD45RA+ CD27– CD28–) [V2]. The number of memory
cells remains remarkably constant over time; this is due totheir ability for self-renewal by undergoing slow, periodic
turnover, referred to as “homeostatic turnover”, and thesecells can protect against secondary infections [A10, C1, J3].
40. T-cells can be divided into two subsets on the basis of thestructure of their TCRs. Most T-cells express a TCR hetero­dimer consisting of α- and β-chains (αβ T-cells), whereas aminor subpopulation expresses an alternative TCR isoform
made of γ- and δ-chains (γδ T-cells). Each chain consists

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of a variable domain, a constant domain, a transmembrane
domain and a cytoplasmic domain. The TCR is encoded bymultiple constant (C), joining (J), diversity (D) and variable(V) gene segments that are selectively recombined to generate TCR diversity. This diversity is necessary for the recognition of the many antigenic peptides possible. First, V(D)J
recombination assembles unique BCR and TCR genes fromthree separate gene segments—the V, D and J genes—during
lymphocyte differentiation. In addition to this recombination,
which occurs in the central lymphoid tissues, somatic hypermutation may take place during a late phase of the immune
response in peripheral lymphoid tissues [G37]. As immature T-cells undergo maturation in the thymus, the TCR andother molecules are responsible for the selective processes
involved in creating immunocompetent T-cells [J1]. While
αβ T-cells only recognize ligands presented within class I orclass II MHC (see section I.C.3), most γδ T-cells recognize
intact proteins, as well as a variety of other types of organic
molecule that are fundamentally different from the short peptides seen by αβ T-cells in the context of MHC. Most of theseγδ T-cells have neither CD8 nor CD4 on their surface (they do
not recognize class I and class II HLA) [H28].
41. The multichain TCR/CD3 complex is one of the mostelaborate cell surface signalling receptors and plays a keyrole in antigen recognition, T-cell activation and triggering
antigen-specific immune response. This process is induced
by direct interaction of the TCR with an antigen presented
by the MHC on APCs. Upon the structural and functional
cooperation of the TCR with the CD3 complex, the activating signal is transmitted through the cell membrane to the
nucleus [F10, S2]. The structure of the TCR/CD3 complex
is represented schematically in figure III.
42. Engagement of the TCR by the antigen leads to a series
of intracellular biochemical events culminating in the transcription of new genes and T-cell activation. One or more tyrosine
kinases phosphorylate first the CD3 chains themselves andsubsequently other substrates. Subsequent to tyrosine kinase
activation, a series of secondary events follow TCR engagement, including activation of serine/threonine kinases, activation of the guanosine triphosphate (GTP)-binding protein
p21ras and activation of transcription factors for receptors andgrowth factors such as the major T-cell growth factor IL-2. The
CD4 and CD8 co-receptors bind a tyrosine kinase (p56Lck) by
their intracytoplasmic tail, which plays a critical role in T-cellsignalling. However, TCR binding is not sufficient to activate T-cells, and a ­second (co-stimulatory) signal is required.
Indeed, as originally envisaged in the “two-signal hypothesis”,
T-cell activation required stimulation both by the TCR (signal 1) and through additional co-stimulatory molecules (signal 2). The principal co-stimulatory molecules expressed on
APCs belong to the B7 family: B7-1 (CD80) and B7-2 (CD86).
T-cells ­display receptors for these B7 molecules—CD28 andcytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)—with
similar structures but opposite functions. While CD28 helps toinitiate T-cell activation, CTLA-4 down-regulates the response[I14, L30]. Activated T-lymphocytes may be identified by theexpression of certain surface markers, e.g. CD25, CD38 and

Figure III. Structure of the TCR/CD3 complex (adaptedfrom reference [J1]).
T-cell

CD3

ε δ

γ ε

CD3

TCR
Peptide fragment
presented

MHC

Antigen-presenting cell

HLA-DR. Only a low percentage of circulating lymphocytes
are in an activated state in healthy individuals; these activatedlymphocytes can be rapidly mobilized against aggressors andthey help in the further recruitment of defending cells [J1].
43. The stages of T-cell development within the thymus are
identified by the expression of specific cell surface markers,
such as TCR, CD3 (which serves as the signal transduction
component of TCR) and CD4/CD8. Direct cell-to-cell interaction between these cells and thymic cells induces their proliferation and also differentiation. Pre-T-cells do not express anyof the above-mentioned T-cell markers; at this stage they arereferred to as “double-negative” cells (CD4– CD8–). At thispoint the β-chain of TCRs undergoes rearrangement. The successful rearrangement of this chain serves as a signal for thesecells to undergo further proliferation. During this time, both
CD4 and CD8 start to be expressed; thus these cells are referred
to as “double-positive” cells (CD4+ CD8+). It is only at thispoint that the α-chain of the TCR undergoes rearrangement. At
the double-positive stage, a second molecular sensor assembles
and controls the transition to the single-positive CD4+ CD8– orCD4– CD8+ stage on the basis of the specificity of the TCR
αβ heterodimers (table 6). Likewise, thymocytes committed tothe γδ lineage also find a checkpoint at the penultimate doublenegative stage (CD44– CD25+), which counterbalances thestochastic nature of the concurrent TCR γ and δ rearrangements
and allows only cells expressing a γδ TCR to mature rapidly
into CD25+ CD4– CD8– γδ cells and leave the thymus [N15].

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

99

Table 6 T-cell αβ+ development and its correlation with CD expression on the cell surface
Adapted from reference [J1]Double-negative(CD4- and CD8-negative)
Surfacemolecule

CD44+
CD25–

CD44+
CD25+

Double-positive(CD4- and CD8-positive)
Pre-TCR

Proliferation

CD4/CD8

TCR

Single-positivea

CD2
C-Kit
CD44
CD25
CD3
CD4

a

CD8

a

CD24
a Single-positive: CD4+ or CD8+.

44. The expression of CD4, CD8, CD3 and TCR chainschanges during the different stages of thymocyte development, and this is shown in figure IV. First, immature thymocytes do not express the above-mentioned markers. These
double-negative CD4– CD8– cells are precursors of two
populations of cells: a minor proportion are CD3+ γδ+ thymocytes and a larger proportion are CD3+ αβ+ thymocytes.
CD3+ γδ+ thymocytes express neither CD4 nor CD8, evenwhen they reach maturation and are exported to the periphery. In contrast, CD3+ αβ+ thymocytes go through further
stages of development, including changes in CD4 and CD8
expression. Large double-positive thymocytes (CD3+ αβ+CD4+ CD8+) differentiate into small double-positive cells,
and the majority (97%) die by apoptosis within the thymus.
The remaining cells (3%) lose the expression of either CD4
or CD8 and become single-positive thymocytes (CD3+
CD4+ CD8– or CD3+ CD4– CD8+), which are exported tothe periphery after maturation.
45. The immune system is a site of intense DNA modifications, which result from programmed and specificmechanisms during its maturation, or as a consequence of­non-specific injuries inflicted during cellular proliferation
and/or cellular activation. The V(D)J recombination is initiated by lymphoid-specific proteins through the introductionof a DNA double-strand break. The terminal maturation of
B-lymphocytes, which occurs during an immune responsein the germinal centre of secondary lymphoid organs suchas the spleen, is characterized by two important modifications of the rearranged immunoglobulin genes. The isotype
class switch recombination and the generation of somatic
hypermutations ensure the production of efficient antibodies of various isotypes. These two B-cell-specific processes
are triggered by the activation-induced cytidine deaminase

protein through DNA modification within immunoglobulin genes. Beside these three DNA-altering mechanisms,
B- and T-lymphocytes are also exposed to general DNA
injuries known to occur, for example, during DNA replication, as several waves of intense cellular proliferationaccompany not only their maturation but also their expansion during immune responses. Lastly, one important aspectof an immune response relies on the inflammatory reaction,
during which several soluble factors and/or natural reactive
metabolites are produced that can be considered as possible
causes of DNA damage. Altogether this demonstrates thatthe lymphoid tissue is at particular risk for mutagenic events
inflicted through defective DNA repair machineries [R20].
3.

Human major histocompatibility complex

46. TCRs recognize specific epitopes on the surface ofAPCs, once these are degraded into small peptides, a form
referred to as “processed antigen”. The major histocompatibility complex (MHC), which in humans is called thehuman leucocyte antigen (HLA), plays a fundamental role inenabling T-cells to recognize antigens by forming complexes
with the peptides. Antigen processing and presentation are
intracellular processes that result in fragmentation (proteolysis) of proteins, association of the fragments with MHC
mole­cules and expression of the peptide–MHC complexes atthe cell surface, where they can be recognized by the TCR on
a T-cell (figure V). The peptide-binding cleft of MHC mole­cules is the location where an antigen is attached for display
to a T-cell. However, not the entire antigen is bound to thecleft. Only a few “anchoring” residues of the antigen needactually to attach to the MHC molecule for the antigen to
be displayed. This makes it possible for only a few common

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residues on antigens to allow binding to one form of MHC.
This is important because it allows many different antigens
with only a few residues in common to be displayed by one
form of an MHC molecule, giving these molecules broad

specificity. Furthermore, the size of the peptide-binding cleft(larger in class II MHC) is proportional to the size of thepeptide that it can accommodate (class II MHC molecules
bind larger residues).

Figure IV. Stages of thymocyte development. The expression of CD4, CD8, CD3 and TCR chains changes during the different
stages of thymocyte development (adapted from reference [J1]).
Double-negative
thymocytes CD3-4-8-

Large double-positive
thymocytes CD3+
preTα: β+4+8+
CD3+γ:δ+CD4-8Peripheral exportation>95%

Small double-positive
thymocytes CD3+ α: β+4+8+<5%

Apoptosis

Small single-positive
thymocytes CD4+ 8-

Small single-positive
thymocytes CD4- 8+

Peripheral exportation

Peripheral exportation

47. The MHC is a complex of closely linked genes thatcode for two families of glycoproteins (class I and class II
MHC). While class I molecules are constitutively expressedby virtually all somatic nucleated cells, class II molecules
are expressed only by APCs. The class I MHC family inhumans is divided into classical and non-classical subfamilies composed of HLA-A, -B and -C, and HLA-E, -F
and -G, respectively. The Class II MHC family in humans
includes HLA-DR, -DP and -DQ. Classic class I and class II
HLA molecules are characterized by polymorphisms; withineach class, and even at a single locus, an enormous numberof variants (alleles) are found among different individuals
in a population. A haplotype is a group of alleles that are
inherited together on a single chromosome. Even though
the human population is outbred, because the HLA genes
are tightly linked, they are frequently inherited together,and patterns of inheritance have been identified among certain groups of HLA antigens. Each individual has only avery small set of different HLA genes and expresses one(homozygous) or a maximum of two (heterozygous) alleles
for each locus.
48. HLA-G is a non-classical class I MHC molecule
involved in immunotolerance, with restricted tissue distribution. It was first found in extravillous cytotrophoblast cells[C4] and was subsequently demonstrated in a variety ofnormal tissues, including T-cells. The class I MHC chainrelated molecule MICA belongs to a novel family of heatshock-induced proteins, by which the immune system canrecognize and destroy stress-induced cells. This represents
an immune surveillance mechanism for the detection of damaged, infected or transformed cells [D4, S12]. MICA mole­cules are recognized by TCR γδ. It has been demonstrated
that HLA-G mediates a dominant negative signal leading totumour escape from immune surveillance by counteracting
the MICA-activating signal [R9].

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

101

Figure V. Upper panel: origin of the peptides presented by MHC; lower panel: mechanism of antigen presentation to CD8+
and CD4+ T-cells by class I and class II MHC (adapted from reference [J1]).

ORIGIN OF THE PEPTIDES PRESENTED BY CLASS I AND II MHCCYTOSOLIC PATHOGENSINTRAVESICULAR PATHOGENS EXTRACELLULAR PATHOGENSAND TOXINSEndoplasmic

Endogenous antigens

Endoplasmic Exogenous antigens
reticulum

Golgi
apparatus

reticulum

Extracellular pathogens
and toxins

Endoplasmic
reticulum

Golgi
apparatus

Golgi
apparatus
Nucleus

Nucleus

Nucleus

Macrophage

All the cells

B-cells

MECHANISM OF ANTIGEN PRESENTATION TO CD8+ AND CD4+ T-CELLS BY CLASS I
AND II MHC
CD 8+ T-CELL
T-cell receptor

CD 4+ T-CELL
T-cell receptor

CYTOSOLGOLGIAPPARATUS

T-cell receptor

Degradation byproteases

Degradation byproteases

FusionCYTOSOL

CD 4+ T-CELL

FusionGOLGIAPPARATUSCYTOSOLGOLGIAPPARATUS

Endoplasmic
reticulum
TAP transporter

MHC-I

Peptidefragments

MHC-II

Endoplasmic
reticulum

MHC-II

Endoplasmic
reticulum

ImmunoproteasomeCYTOSOL

Presentation by theclass I MHC molecule

CYTOSOL

Presentation by theclass II MHC molecule

CYTOSOL

Presentation by theclass II MHC molecule

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49. The central MHC region or human class III encodes,
within a ~700 kb sequence located between the centromericclass II MHC and the telomeric class I MHC regions, ahetero­geneous collection of more than 60 genes where a few
families do emerge. These genes include those involved in
the activation cascades of the complement system, steroid
hormonal synthesis, inflammation and cell stress (tumour
necrosis factor, lymphotoxins, heat shock proteins) andextracellular matrix organization (tenascin), as well as
immunoglobulin superfamily (Ig-SF) members. The remainder (the majority) of the loci are involved mainly in more“core” biological functions with no immediate implication
for the immune system [H21].
50. T-cells are grouped functionally according to the classof HLA molecules that associate with the peptides theyrecognize. CD8+ cytotoxic and CD4+ helper T-cells tend
to ­recognize peptides bound to class I and class II HLA
mole­cules, respectively. Endogenous antigens may be viral­proteins synthesized within the infected cell or the specificproteins synthesized by tumour cells. These cytosolic patho­
gens are degraded into peptide fragments that form complexes with class I HLA and are then transported through theendoplasmic reticulum towards the cell surface. Proteasomes
are the major non-lysosomal protein degradation machinery in eukaryotic cells. They deal primarily with endogenous proteins. Specialized proteasomes called immuno­proteasomes are responsible for the processing of antigens

Table 7for presentation by the class I HLA pathway. In mammals,
activation of the immune system leads to the release ofcytokines, causing the activation of immunoproteasomes
and degradation of the antigenic protein into peptides about
10 amino acids in length. These peptides are then transported
from the cytosol into the endoplasmic reticulum, where eachenters the groove at the surface of a class I HLA molecule.
This peptide–HLA complex then moves through the Golgi
apparatus and is inserted into the plasma membrane, where
it can be recognized by CD8+ T-cells to induce cell death(cytotoxicity) [R6, T3] (figure V). Exogenous antigens aredegraded by APCs by endocytosis. The pH of the endosomes
containing the engulfed pathogens progressively decreases,
activating proteases that reside within these acidified endocytic vesicles to degrade the engulfed material. The resulting
peptides are located within class II HLA molecules, which
are then exported towards the cell surface. Toxins are extracellular pathogens, for example the majority of bacteria,
which mainly reside and replicate extracellularly. They are
degraded inside intracellular acidified vesicles and associatewith class II HLA molecules to be presented to CD4+ T-cells
that can help B-cells to secrete Ig against these bacteria.
Other exogenous antigens, for example some bacteria andparasites, grow intracellularly (intravesicular pathogens).
Once degraded in acidified vesicles, their peptides are also
bound to class II HLA and presented to CD4+ T-cells. Upon
recognition of these peptides by the TCR, the presenting cellis activated to kill the pathogens (table 7).

Origin of the peptides presented by class I and II HLA
Property

Cytosolic pathogen

Intravesicular pathogen

Extracellular pathogen or toxin

Degraded in

Cytoplasm

Acidified vesicles

Acidified vesicles

Peptides bind toClass I HLAClass II HLAClass II HLA

Presented to

CD8+ T-cells

CD4+ T-cells

CD4+ T-cells

Effect on presenting cell

Cell death

Activation to kill intravesicular bacteria
and parasites

Activation of B-cells to secrete Ig toeliminate extracellular bacteria or toxin

4. Antigen-presenting cells
51. The immune system contains three types of antigenpresenting cell (APC): macrophages, dendritic cells andB-lymphocytes. These three types of APC present different
sets of antigens and may also serve to activate helper T-cells
at different points during the immune response. As previously discussed, T-cell activation requires stimulation bothby the TCR and through additional co-stimulatory molecules. The most relevant property of APCs is that, in addition
to antigen presentation, they provide co-stimulatory signals.
APCs (except dendritic cells) do not constitutively express
these co-stimulatory molecules. Since these cells potentially
phagocytose both self and infectious materials, there has
to be some mechanism for the recognition of self and nonself. Upon this recognition, the APCs will up-regulate theirco-stimulatory molecules (namely B7 molecules), and only
then activate T-cells, by interacting with B7 receptors.
52. Macrophages are part of the innate response. Unlike
T- and B-cells, they do not contain specific receptors but
do express TLRs that allow them to recognize differential PAMPs on foreign cells. Stimulated macrophages up-­regulate class II HLA and express co-stimulatory molecules(B7 molecules). It is at this point that antigen presentation byclass II HLA will activate CD4+ helper T-lymphocytes.
53. Dendritic cells are mostly found in the skin andmucosa epithelium (Langerhans cells). Dendritic cells also
possess TLRs that can recognize PAMPs, and they continuously express high levels of co-stimulatory molecules (B7molecules). Upon recognition of infectious particles, theseANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

cells migrate through the lymphatic system to the nearest lymph node, where they come into close contact withnaive T-cells. Unlike macrophages, however, dendritic cells
can also recognize viral particles as non-self. In addition,
they can present antigen via both class I and class II HLA.
Thus they can directly activate both CD8 and CD4 T-cells.
Once the T-cells are activated, they leave the lymph nodes
and travel to the sites of inflammation. Since dendritic cells
present viral particles, these should also activate CD8 cells,
the main effector cells for fighting viral infections. Dendritic
cells are also very numerous in the thymus, where they act
in T-cell selection during development. While a role of dendritic cells in the negative selection in the thymus has been
well established [W13], their role in the positive selection isstill questionable [W11].
54. The skin is equipped with specialized cells called
Langerhans cells (LCs) which play a central role in theskin’s immune system as an integral part of the body’s total
defence system. LCs are epidermal antigen-presenting dendritic cells originating in the bone marrow. They migrate to
the epidermis, where they form a regularly ordered network
representing 1.86% of all epidermal cells. A constant numerical ratio (1:53) exists between LCs and the other epidermal
cells. The surprisingly constant relationship of LCs to otherepidermal cells supports the hypothesis of an epidermal LC
unit where one LC seems to be responsible for the immune
surveillance of 53 epidermal cells [B21].
55. After contact with the corresponding antigens (viruses,
contact allergens, skin transplants), LCs migrate from theepidermis to the regional lymph nodes for presentation of
antigenic peptides to T-cells. On their journey, LCs undergoa maturation process leading to the presentation of the antigen on the cell surface. The migrating LCs are replaced by acorresponding number of new LCs from the bone marrow. In
the lymph nodes the mature LCs activate the helper T-cells
that have the matching antigen-specific receptors on theirsurfaces. In this way they direct the reaction of the immune
system [K42].
56. Epidermal LCs have a spectrum of different functions
with implications that extend far beyond the skin. They havethe potential to internalize particulate agents and macro­molecules, and display migratory properties that endow
them with the unique capacity to journey between the skinand draining lymph nodes where they encounter antigenspecific T-lymphocytes. In addition, LCs are considered
to play a ­pivotal role in infectious disease, allergy, chronic
inflammatory reactions, tumour rejection or transplantation[V10]. Factors influencing the activity of the LCs in the epidermis include cytokines such as IL-10, immunosuppressive drugs such as corticoids, and ultraviolet and ionizing
radiation [K39].
57. B-cells are the least efficient APCs. Unlike the other
two APCs, they possess specific antigen receptors (surface
immunoglobulins). B-cells effectively ingest soluble antigens that bind to cell surface immunoglobulin receptors by103

receptor-mediated endocytosis. Thus B-cells can present
specific antigens to activated T-cells. However, resting
B-cells do not express co-stimulatory molecules; in order todo so, most of the B-cells need to be activated by helper
T-lymphocytes. The role of B-cells as APCs in vivo is notvery well understood [R21].
5.

Self tolerance and self-HLA-associated recognition

58. As seen, a diverse and polymorphic T-cell repertoireis generated in the thymus by random recombination of discrete TCR gene segments. This repertoire is then shaped byintrathymic selection events to generate a peripheral T-cellpool of self-HLA-restricted, non-autoaggressive T-cells.
To ensure that self tolerance is achieved, self antigens arepresented to the matured T-cells by APCs in the thymus.
At this stage, these cells undergo the processes of positive
and negative selection. During positive selection, doublepositive T-cells that can recognize self HLAs are selected
for proliferation, and those T-cells that do not recognize
self HLAs die by apoptosis. Positive selection has been
associated mainly with cortical thymic epithelial cells andtheir associated HLA molecules, both of which are necessary and sufficient for positive selection of double-positive
thymocytes and the development of single-positive cells[G15]. By negative selection, those T-cells that are strongly
activated by self HLA and self peptides are eliminated in
the thymus. This process of clonal deletion prevents lymphocytes from subsequently reacting against self antigens
and causing autoimmune diseases. Mature T-cells leave
the thymus, go into the circulation and eventually findtheir way to lymph nodes, mucosa-associated lymphoidtissue or the spleen [J1] Although the majority of selfreactive T-cells are clonally deleted in the thymus, somemature lymphocytes may remain capable of responding toself antigens. Intrinsic biochemical and gene expression
changes, as well as a lack of co-stimulation, can reduce
this ability by triggering a process generally termed clonalanergy. Finally, even if the lymphocytes have evaded thesecontrols, mechanisms of extrinsic control, such as active
suppression by Treg cells, can prevent the danger of selfreactive receptors [G37].
59. The achievement of immunological self tolerance
raises the question of how T-lymphocytes that are reactive to proteins expressed only by non-thymic tissues canbe identified and addressed. The clinical relevance of thisquestion is related to the fact that many of these tissuerestricted proteins (e.g. insulin, thyroglobulin, myelin, retinal S-antigen) are associated with organ-specific autoimmune diseases (e.g. type 1 diabetes, thyroiditis, multiple
sclerosis, uveitis). A classical explanation for this phenomenon was that, while tolerance to ubiquitously expressedor blood-borne antigens is centrally achieved in the­thymus, tolerance to tissue-restricted antigens is secured
by peripheral extrathymic mechanisms. However, ectopic
synthesis of these peripheral tissue-restricted proteins has
recently been demonstrated in thymic medullar epithelia

104

UNSCEAR 2006 REPORT: VOLUME II

cells [A22]. A startling discovery for the understanding of
this ectopic synthesis is the autoimmune regulator AIRE
gene that enables a battery of tissue-restricted antigens to
be expressed in thymic medullar epithelia cells, thus playing an important role in controlling tolerance induction. In
the absence of AIRE, autoimmunity, and ultimately overt
autoimmune disease, develop [A23, M16]. Although AIRE
transcripts are by far most abundant in the thymus, they
were also detected in peripheral lymphoid organs at significantly lower levels [A22].
60. Although 1–24% of T-cells are alloreactive, i.e. they
respond to MHC molecules encoded by a foreign haplotype, it is generally believed that T-cells cannot recognize
foreign peptides binding foreign HLA molecules [D21]. The
term “MHC restriction” refers to the phenomenon whereby
T-cells from one individual recognizing an antigen fail torecognize cells presenting the same antigen unless the presenting cells express one or more HLA alleles identical tothose on this individual’s cortical thymic epithelial cells,
in which those T-cells matured. This phenomenon derives
in part from the requirement to recognize self HLA (selfHLA-associated recognition) and in part from the different­peptide-binding specificity of different HLA alleles. Throughpositive and negative selection in the thymus, self peptides
bound to autologous HLA molecules determine the repertoire of peripheral T-cells, which then respond to infection
by recognizing foreign peptides bound to those same HLA
molecules [P13].

6.

Cytokines

61. As described above, the immune system has many different types of cell acting together to deal with unwanted
infections and altered cells. Cytokines are small proteinsproduced by the immune cells for signalling and for orchestrating the attack. They generally act over short distancesand short time spans and at very low concentrations by binding to specific membrane receptors, which then signal via
second messengers, often tyrosine kinases. Responses tocytokines may include increased or decreased expressionof membrane proteins, secretion of effector molecules andcell proliferation. By these actions cytokines mediate and­regulate immunity, inflammation and haematopoiesis.
62. Many cell populations make cytokines, but the predominant producers are CD4+ helper T-cells and monocytes/
macrophages. Cytokines made by lymphocytes are called
lymphokines, and cytokines made by monocytes are called
monokines. Other groups of cytokines include interferons(IFNs) and chemokines. While IFN-α and IFN-β inhibit
virus replication in infected cells, IFN-γ has the additional
property of stimulating HLA expression. Chemokines arecytokines with chemotactic properties that attract leucocytes
to infection sites. The general term interleukins (ILs) is used
to define cytokines made by one leucocyte and ­acting on otherleucocytes. Interleukins have been numbered in the order inwhich they were identified. Thus the first IL identified wasnamed IL-1; about 30 different ILs have been ­identified sofar (table 8).

Table 8 Main cytokines and their functions
Adapted from reference [J1]
Cytokinea
IL-1 α and βMain sourceb
APCs

Target cells

FunctionTh cells

Co-stimulation

B-cells

Maturation and proliferation

NK cells

Activation

VariousHaematopoiesis, inflammation, fever, acute phase response

IL-2

Th1 cells

T-, B- and NK cells

Activation, growth, proliferation

IL-3

Th1 cells, NK cells

Stem cells

Growth and differentiation

Mast cells

Growth and histamine releaseB-cells

Proliferation, differentiation, IgG and IgE synthesis

T-cells

Proliferation

Macrophages

Expression of class II HLA

Eosinophils

Proliferation

B-cells

Proliferation, differentiation, IgA synthesis

B-cells

Differentiation (into plasma cells)

Plasma cells

Antibody secretion

Stem cells

Differentiation

VariousAcute phase response

IL-4

IL-5

IL-6

Th2 cells, mast cells

Th2 cells

APCs, Th2 cells, stromal cells

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

Cytokinea

Main sourceb

IL-7

Marrow stroma, thymus stroma

Stem cells

T- and B-lymphopoiesis

IL-8

Macrophages, endothelial cells

Neutrophils
T-cells

Chemoattractant

IL-9

T-cells

Stem cells, thymus cells

Haematopoiesis and thymopoiesis

IL-10

Th2 cells, macrophages,
Tc cells, B-cells

Macrophages,
B-cells,
mast cells

Inhibition of cytokine production
Proliferation, differentiation, Ig synthesis
Inhibition of growth
Suppression of cell-mediated immunity

IL-11

Stromal cells

Marrow cells

Haematopoiesis and thrombopoiesis

IL-12

Macrophages,
B-cells

Tc cells
NK cells

Differentiation, promotion of cell-mediated immunity
Activation, proliferation, IFN-γ production

Macrophages, neutrophils,
fibroblasts

Various

Inhibition of viral replication
Induction of class I HLA expression

Th1 cells, NK cells

Various

Inhibition of viral replication

VariousInduction of HLA expression

B-cells

Ig switch to IgG2a

Th2 cells

Inhibition of proliferation

Macrophages

Chemotaxis and IL-1 synthesis

B-cells

IgA synthesis

Various

Inhibition of proliferation

Macrophages

Cytokine expression

Tumour cells

Cell death

APCs

Phagocytosis, NO production

Tumour cells

Cell death

IFN-α and -β
IFN-γ

TGF-β

TNF-α

TNF-β

T-cells, monocytes

Monocytes, NK cells, mast cells

Th1 cells, Tc cells

Target cellsa	IL = interleukin; IFN = interferon; TGF = transforming growth factor;
TNF = tumour necrosis factor.

63. Cytokines have several important characteristics:− T he same cytokine may be made by a number ofdifferent cells;− P leiotropy: the same cytokine may have different effects and/or may act on several different cell
types;− R edundancy: similar functions can be induced bydifferent cytokines;− S ynergy: cytokines often act together and increase
one another’s effects;− A ntagonism: some cytokines may cause opposing
effects;− C ascade effect: cytokines are often produced in acascade, as one cytokine stimulates its target cells
to make additional cytokines;− P aracrine actions: cytokines act on cells near tothem or that they actually touch;

105

Functionb Th = CD4+ helper T-cells (Th1- or Th2-type); Tc = CD8+ cytotoxic T-cells.

− A utocrine functions: cytokines may act on the same
cells that secrete them;− E ndocrine functions: some cytokines may act insome instances on distant cells.
7.

Remarks concerning cells and moleculesof the immune system

64. The preceding paragraphs concerned cells and mole­cules of the immune system. Anatomic, physiological,
inflammatory and phagocytic barriers constitute the innate
immune system. Phagocytes (granulocytes, monocytes/macrophages and dendritic cells) engulf and digest pathogens.
They express a special family of receptors (TLRs) capableof recognizing PAMPs. NK cells also belong to the innate
arm of the immune response. NK cells can recognize, bindand kill virus-infected and tumour cells. Spontaneous NK
cytotoxic activity is regulated through activating and inhibiting membrane receptors. NKT cells are a particular type106

UNSCEAR 2006 REPORT: VOLUME IIof lymphocyte expressing some NK surface markers andTCRs, and that bridge innate and acquired immunity. As partof the innate immunity, mast cells are involved in allergy,
anaphylaxis, wound healing and defence against pathogens.
The complement system circulates in an inactive form. In
response to the recognition of certain molecular patterns ofpathogens, complement activation results in the productionof biologically active molecules, which may lead to lysis,
opsonization and inflammation.
65. Lymphocytes are the predominant cells involved inacquired immunity. B-lymphocytes and T-lymphocytes are
the effector cells of the humoral and the cellular response,
respectively. B-cells recognize native antigens throughthe immunoglobulins expressed on their surface as BCRs.
T-cells recognize antigens previously processed into small
peptides through the TCR/CD3 complex expressed on
their surface. B-cell/T-cell interactions involve additionalco-­stimulatory signalization. Most of T-cells belong to theCD8+ or CD4+ subpopulations. CD8+ cytotoxic T-cells are
effectors that, once activated, can remove foreign organisms.
CD4+ helper T-cells induce other immune cells to become
better effectors.
66. By secreting different cytokines, Th1 and Th2 CD4+
helper T-cells promote cellular or humoral immunity,
respectively. A minority of CD4+ T-cells belong to neither
Th1 nor Th2 subsets and are called regulatory T-cells that
express CD25, the receptor for IL-2. These CD4+ CD25+
Treg cells protect against autoimmunity and prevent severe
systemic reactions such as septic shock. Naive (CD45RA+)
lymphocytes have never encountered an antigen. When an
immune response is triggered, they become activated andproliferate (clonal expansion). Once the response ceases,
most of the activated lymphocytes die by apoptosis, but aminority of them remain as memory (CD45RA–) T-cells.
67. TCRs recognize antigenic peptides bound to the MHC(in humans called HLA) on the surface of APCs (dendritic
cells, macrophages and B-cells). While CD8+ T-cells recog­
nize endogenous antigens bound to class I HLA, CD4+
T-cells recognize exogenous antigens bound to class II HLA.
Through positive and negative selection in the thymus, self
antigens bound to autologous HLA molecules determine therepertoire of T-cells to ensure immunological self tolerance.
Cytokines are proteins, mainly produced by CD4+ T-cells
and monocytes/macrophages, that bind to specific ­membrane
receptors that act as second messengers.

D.

Physiological immunosenescence
1. Concept of immunosenescence

68. Immunosenescence can be defined as the progressive
decline in immune function observed in the elderly; it results
in a higher susceptibility to infections and increased morbidity and mortality [B6, G2, H16]. These age-related changes

in immune function have been well documented [H13, R7].
A reduction with age has been reported in the overall capacity for renewal of haematopoietic stem cells, indicating thatsome of the deficits of immunosenescence may be initiatedat the stem cell level [H1, L1].
2.

Main features of immunosenescence

69. The immune property most sensitive to ageing is the
production and export of T-cells from the thymus, which
is manifested by a decrease of naive cells with age [H16].
Naive cells have the greatest diversity of TCR repertoire.
With ageing, the thymus involutes, the supply of naive
T-cells falls and there is a gradual accumulation of memory T-cells. Thus in elderly persons the T-cell population
shifts to a lower naive/memory T-cell ratio, and the TCR
repertoire available to respond to new antigens is reduced[H1, V2, V4].
70. There is a progressive increase with age in the proportion of CD8+ T-cells that lack expression of CD28, a critical co-stimulatory molecule [E2, H16]. This results in lower
proliferative capacity, decreased IL-2 production, telomere
erosion and less response to TCR stimulation. Taking into
account the fact that specific effector cells should be able toproliferate sufficiently to fight an infection, the age-related
limitation of cell division could have devastating consequences for immune function [E1]. Immunosenescence also
involves hyporesponsiveness to mitogens, lowered lytic
capacity, decline in transmembrane signalling and higher
oxidative stress [B6, B15, V2].
71. As a result of thymic involution, the kinetics of thetransition from CD4– CD8– (double-negative) to CD4+
CD8+ (double-positive) thymocytes is altered in old age. It
has been demonstrated that thymic levels of p56Lck, a factor involved in the maturation of T-cells from CD4– CD8–
double-negative into CD4+ CD8+ double-positive T-cells,
are negatively correlated with age, which could lead to theaccumulation of CD4– CD8– double-negative T-cells in theelderly [H15].
72. There exists a chronic inflammatory state in theelderly due to an increased release of pro-inflammatory
cytokines such as TNF-α and IL-6 [B6, E1]. Dysregulation of TNF-α and IL-6 may be involved in age-relateddiseases such as osteoporosis, atherosclerosis, Alzheimer’s
disease, diabetes, cardiovascular disease and cancer [H16].
The balance between Type 1 and Type 2 cytokines, important for the outcome of several infectious diseases, alsochanges with age. Evidence suggests that, while a Th1-type
response predominates in adults, a Th2 response predominates in the elderly. This shift from a Th1 to a Th2 cytokine
profile is a possible mechanism for age-associated immune­dysfunction [R1, S7].
73. As a result of ageing, the immune system may lose
the ability to distinguish self versus non-self antigens.

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

Age-related changes in humoral immunity involve reduced
vaccine responses and increased production of autoanti­
bodies. Although the ability of B-cells to generate antibody
responses declines with age, many of the humoral changes
observed in the elderly are related to declining T-cell function with dysregulation of T-cell/B-cell interactions [B15,F3, H1, L5]. The B-cell repertoire changes with age, and thealtered spectrum of expressed immunoglobulins may affect
the quality of the antibody response in the elderly and behighly relevant for health [V4].
74. The innate response is not free from the effects ofageing. The production of reactive oxygen and nitrogenspecies (ROS/RNS) by neutrophils and macrophages inthe elderly is significantly impaired, which diminishes
the capacity to destroy bacteria. In contrast to the casewith T- and B-cells, the absolute number of NK cells isincreased in elderly persons, but their cytotoxic capacity
on a per-cell basis is impaired [B15, H1]. NK cells fromelderly people show a decreased proliferative response
to IL-2 [H16]; NK cells are thus less able to destroy
virus-infected and tumour cells in the elderly [P8]. The
immune system in older people is also characterized byan increased proportion and number of NKT cells in the
peripheral blood [M9].
75. Several aspects of immune response exhibit diurnal and seasonal circadian rhythmicity related to thelevel of melatonin, which exerts immunoenhancing andantioxidant actions. Such rhythms play an importantrole in immune homeostasis [S22]. The gradual declineof ­pineal melatonin synthesis and secretion over thelifespan could cause immunocompetence to deterioratein the elderly [K6].

107− Increase in the absolute number of NK cells, with adecrease in their cytotoxic capacity;− Gradual decline in melatonin synthesis.
E.

Summary

77. The general features of the immune system can besummarized as follows:− The main function of the immune system is to­protect against infections and cancer;− The bone marrow and the thymus are the primary
lymphoid tissues where maturation of lymphocytes
takes place;− Mature lymphocytes travel by the bloodstream
towards the lymph nodes, spleen and mucosa­associated lymphoid tissue, which are considered
the secondary lymphoid tissues;− The ability of the cutaneous barrier to help defend
the body against pathogens relies on both acquired
and innate immune responses;− Monocytes, macrophages, polymorphonuclear leucocytes, dendritic cells, natural killer cells and mast
cells are the immune cells involved in the innate
immune response;− Lymphocytes are the predominant cells involved in
the acquired immune response. While B-lymphocytes
are the effector cells of the humoral response,­T-lymphocytes (with their two subsets CD4+ helper
T-cells and CD8+ cytotoxic T-cells) are responsible
for cell-mediated responses;− The main features of the acquired immune response
are memory, specificity, diversity and self/non-self
discrimination;

3. Remarks concerning immunosenescence− There is a crosstalk between the innate and theacquired immune response;

76. The main features of immunosenescence are:

− Cells involved in immune recognition have surface
receptors that bind to specific antigens;− Thymic involution;− Progressive decrease of the naive cell pool with age(shift to a lower naive/memory ratio);− Reduced TCR repertoire;− Increase in the proportion of CD8+ CD28– T-cells;− Accumulation of CD4– CD8– T-cells;− Chronic inflammatory status;− Progressive loss of the ability to distinguish self
versus non-self antigens;− Dysregulation of T-cell/B-cell interaction, resulting
in humoral changes;− Impaired phagocytic activity;− The lymphoid tissue is naturally prone to DNA
modifications that occur during the maturation of Band T-lymphocytes and during immune responses;− The MHC complex (HLA in humans) plays afundamental role in enabling T-cells to recognize
antigens;− APCs present antigens and activate helper T-cellsby co-stimulatory signals;− Cytokines are small proteins that mediate and regulate immunity, inflammation and haematopoiesis;− Immunosenescence is a complex process involving
dysregulation, rather than a simple unidirectional
decline of the whole immune system function.

II.

RADIATION-INDUCED ALTERATIONS OF THE IMMUNE SYSTEMA.

Introduction

Radiological Protection [I2] deems that the dose and doserate effectiveness factor (DDREF) should be applied.

78. Radiation-induced effects on the immune system haveattracted interest from the research community for several
decades, and lymphocyte radiosensitivity was one of the earliest subjects of experimental radiobiology [A13, A27, A28,
A29, D11, D29, H24, K54, M30, P12, P15, T19]. Immuno­
suppression is a consequence of whole-body irradiation(WBI) at medium to high doses. Localized radiotherapy canalso result in immunosuppression. In contrast, it has beenreported that very low doses of ionizing radiation may giverise to immunostimulatory effects, particularly at short times
after irradiation. Because of these divergent effects, ionizing radiation is probably better considered as an immuno­
modulatory rather than as an immunosuppressive agent [M2,
U4]. This section summarizes the main alterations inducedby ionizing radiation in the immune system and considers
the influence of dose, dose rate and radiation quality. Data
concerning the radiosensitivity of the different lymphocyte
subpopulations are analysed. Particular attention is given toalterations of the developing immune system following prenatal irradiation. Several human immune pathologies associated with hypersensitivity to ionizing radiation are also
reviewed.

B.

80. The effects of low doses of ionizing radiation on the
immune system were reviewed by the Committee in 1994,
in the context of adaptive response [U4]. At that time, someevidence in animals seemed to indicate that low doses ofionizing radiation may enhance immune response, but theevidence for a similar effect on the human immune system
was sparse. It was concluded that further investigations wereneeded on these effects and their clinical significance.
1.

Animal data

81. The effects of external low-dose irradiation upon the
blood and the immune system of experimental animals havebeen studied at several centres. The dose–response relationship of immunological parameters following exposure toionizing radiation is affected by a number of factors, themost important of which are the target cells under observation, dose range, dose rate and dose spacing, as well as
the temporal relationship of the changes and the strain ofanimal used [L20]. Table 9 summarizes the most commonly
observed alterations of immunological parameters in lowdose/low-dose-rate (LD/LDR) irradiated animals.

79. For the purposes of this annex, low doses are definedas <0.2 Gy to the whole body. Low-dose-rate exposures are
considered to be those delivered at <0.1 Gy/h. These are
the levels below which the International Commission on
Table 9

Data concerning low-dose irradiation

Effects of ionizing radiation on the immune system of animals irradiated at low doses and low dose rates

Parameter

Animal species

Dose rate(mGy/d)Time of detection of effect,or total dose

Trend of change

Reference

3–128

0–200 dDecrease

200–1700 d

Accommodative phase

30 dDecrease[Y1]

Leucocyte score(blood)Dogs[S40, N23]

Lymphocytes (spleen,
thymus)

CBA mice

10–60

C57BL mice50

100–200–800 mGy

No change[J6]

C57BL mice

100

2a

No change

[C16]

Dogs

75

0–200 dDecrease[S39]

200–800 d

Recovery phase

150 d

Decrease

700–1200 d

Partial recovery

Haematopoietic
progenitors
CFU-GM

CFU-GM

Dogs

18.8

109

[N23]

110

UNSCEAR 2006 REPORT: VOLUME II

Parameter
Lymphocyte mitogenic
response

Cytokines

Animal species

Dose rate(mGy/d)Time of detection of effect,or total dose

Trend of change

Reference

Dogs

>20

>300 dIncrease (T-cells)[Y1]

C57BL mice50

100–200–800 mGy

Increase (T-cells)[J6]

C57BL mice

40

20 d

Increase (T-cells)
No change (B-cells)[N20]

C57BL mice40

200 mGy

Increase (T-cells)[P11, S16, S17]

BALB/c mice

75 mGyIncrease (T-cells)

[L18]

Mice

75 mGyIL-10 decrease[L19]

IL-12 increaseMice

75 mGyIL-1, IL-2 increase[J8]

C57BL mice

40 mGyIL-1β, IFN-γ increase

[I6]

Rats

200 mGy

IFN-γ, TNF-α increase[H20]

TGF-β decrease

Macrophage
phagocytosis andNK activity

C57BL mice40

200 mGy

IFN-γ decrease[P11]

CBA mice

0.02 +
nuclides180 dDecrease[G18]

BALB/c mice

100–200 mGy; 48 h

Increase[C21]

BALB/c mice

200 mGy; 24–72 h

Increase[C21, N24]

200 mGy

Increase[P11]

C57BL mice40

82. Yagunov et al. [Y1] reviewed extensively the haema­
topoietic and immune system effects of LD/LDR irradia­
tion in animal studies. These long-term effects of LD/
LDR irradiation seem largely dependent on the capacityof radiosensitive tissues to repair DNA damage induced
by a given daily dose. Post-irradiation changes in the
peripheral blood counts of experimental animals returned
to control levels within several months of the start of irradiation. The precise mechanisms by which these adaptiveor accommodative processes occur are largely unknown,
although repair, cell cycle and cell selection are considered
to play a role [S40]. The effect of low-daily-dose gamma
irradiation (3–128 mGy/d) on the blood-forming system ofcanines was studied by Seed et al. [S40]. Low but significant suppression of blood leucocytes, including granulocytes, monocytes and lymphocytes, occurred at 3 mGy/d.
As the dose rate increased from 3 mGy/d to 128 mGy/d,the rate of suppression increased approximately eightfold.
The time required to achieve accommodation decreased as
the daily dose rate increased. Within the time required toreach a cumulative dose of 700 mGy, none of the dose rates
affected blood cells sufficiently to compromise short-term
immune function.
83. Clear associations were found between the tissue
responses and marrow progenitor responses of chronically irradiated dogs. The granulocyte–macrophage (GM)­committed progenitor marrow numbers showed a suppressive

phase and a later recovery phase preceding the changes
in blood leucocyte concentration [N23, S39]. Results also
showed that 75 mGy/d represented a threshold below which
the haematopoietic system retained either partial or full trilineal cell-producing capacity (erythropoiesis, myelopoiesis
and megakaryopoiesis) for periods of exposure longer than
one year [S41]. One might interpret these observations asevidence of an adaptive effect and acquisition of resistanceto radiation exposure. However, at long times after exposure, animal populations experienced a high incidence of
myeloid leukaemia and related myeloproliferative disorders[S49]. These animal data also indicated that a high degree of­individual variability existed.
84. Post-irradiation recovery of marrow precursors andmature cells was incomplete, as evidenced by a deficient
response to challenge stimuli (acute haemorrhage or gamma
irradiation). Several factors may account for deficienthaematological recovery after chronic irradiation [Y1]:− Persisting post-irradiation deficiency of haema­
topoietic stem cells observed after exposures of>10 mGy/d for several months;− Accelerated cell cycling of marrow precursors inirradiated animals, leading to increased ratios of
S-phase populations among stem cells (colonyforming units (CFUs)) and committed marrowprecursors;

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

− Shortened lifespan of immature erythroid and­myeloid cells due to decreased cell viability in­irradiated animals.
85. Internal irradiation of animals (using tritiated water
incorporation) caused much more severe and prolonged
immune depression than did external irradiation at the same
total doses, thus indicating the higher relative biologicaleffectiveness (RBE) of incorporated radionuclides, even forthis low-LET (linear energy transfer) beta emitter [Y1].
86. The experimental findings of studies, mainly conductedin rodents and canines, reviewed by Yagunov et al. [Y1] aresummarized as follows:− Haematopoietic stem cells and blood cell progenitors seem to be the main target of chronic LD/LDR
irradiation;− Direct radiation damage to the blood/immune
precursor pool results in a decrease of stem cell
fraction;− Radiation-induced depletion of the stem cell andprogenitor pools results in accelerated cycling ofbone marrow precursors;− Decreased viability of mature blood cells resultsfrom ineffective haematopoiesis, thus causing
restriction of myeloid (and probably lymphoid) cellreserves;− Disturbances of cellular and humoral immunity arelikely to be caused by extreme radiosensitivity oflymphoid tissues and by a restricted progenitor cellpool;
− Post-irradiation recovery is characterized by gradualreconstitution of peripheral blood and bone marrow
patterns. However, residual deficiency of haema­
topoietic and lymphopoietic precursors may be alimiting factor in blood/immune system recovery;− An increased percentage of S-phase marrow cells
well after prolonged radiation treatment presentsa typical response of the haematopoietic system
to LDR irradiation, since this is not observed after
acute or subacute irradiation or following chronic
exposure to certain heavy metal ions;− DNA misrepair following chronic irradiation may
result in stable chromosome aberrations, increased
incidence of micronuclei, and detectable point
mutations in blood/immune populations.
87. Courtade et al. [C16] irradiated C57BL/6 female miceat 100 mGy/a for two years. No changes were found in­cellular immunity parameters regarding CD4+ and CD8+
cells in the thymus and the spleen. In this work, cell subsets
were evaluated by flow cytometry before and after stimulation with lectins. While the number of B-cells in the spleenalso remained unchanged, a significant decrease in IgG1,
IgG2a and IgG2b was observed, at 12, 24 and 18 months
post-irradiation, respectively. Using mice irradiated with a111

single LDR exposure (100 mGy, 10 mGy/min), Sharetskii
et al. [S18] observed increased thymus-dependent humoral
immune response and polyclonal activation of B-cells. The
study of the dynamics of primary immune response showedthat the period of radiation-induced elevation was followed
by a phase of profound reduction of antibody formation.
88. On the other hand, a large number of studies havedescribed stimulative effects of low-dose irradiation, including stimulation of growth rate, enhancement of survival after
lethal high-dose irradiation, prolongation of lifespan, downregulation of tumour incidence and activation of immune
function.
89. Regarding the activation of the immune function,
LDR WBI of mice increased the proliferative response of
splenic and thymic lymphocytes to mitogens such as concanavalin A (Con A), phytohaemagglutinin (PHA) or antiCD3, with an acute exposure of 20 or 75 mGy [I5, L16,
L18] or fractionated doses of 200–800 mGy, 40 mGy/d [J6,J7, N20, S16, S17]. James and Makinodan [J6] investigatedthe proliferative capacity of differentiated effector cells inthe spleen and its correlation with alterations in thymic
precursors and peripheral T-cell subsets. In C57BL/6J
mice exposed to 40 mGy/d over 20 d, the increase inspleen cell proliferative response was associated withan increase in the proportion of thymic progenitor cells(L3T4– Lyt2– equivalent to CD4– CD8–) and an increasein the proportion of mature L3T4+ (CD4+) thymocytes. In
the spleen, the L3T4+ and Lyt2+ (CD8+) cell proportion
was increased and the double-negative cell proportion was
decreased. Interestingly, caloric restriction independently
altered functional activity and T-cell subpopulations in thesame direction as low dose rates. The changes observed areconsistent with an increase in proliferative capacity andcould reflect adaptive mechanisms operating with LDR
irradiation and/or caloric restriction. Interpretation could
be complicated by the metabolic status of the irradiatedanimals. Using the same irradiation protocol, comparable
results were obtained by Nogami et al. [N20]. A findingof interest in this last study is the demonstration that LDR
exposure can significantly enhance the proliferative activity of splenocytes in response to T-cell mitogens, but the
response to LPS, a B-cell mitogen, was not influenced by
the LDR treatment. Recently, Pandey et al. demonstrated apreferential activation of CD8+ T-cells as compared with
CD4+ T-cells in mice following stimulation with Con A
after fractionated 200 mGy exposure [P11].
90. Assays of mitogenic-induced proliferation werealso performed using co-cultures of non-irradiatedsplenolympho­cytes and peritoneal macrophages preirradiated with 20 and 40 mGy. The response was increased to120% and 145% of the control, respectively, suggestingthat the enhancement in Con-A-induced proliferation
resulting from LDR exposure was caused not by direct
activation of splenocytes but by activation of macrophages
in the spleen, and that the lymphocytes were activatedindirectly [I5]. LDR exposure acts on both the APCs and112

UNSCEAR 2006 REPORT: VOLUME II

the T-lymphocytes, facilitating the intercellular reactions
within the immunologic synapse formed between these twocategories of immune cells [L20].
91. Data also indicate that enhancement of immune
response parameters takes place at a certain very narrow
range of dose rate and dose. When WBI with an acute dose
was changed from 20 to 200 mGy, the proliferation was
inhibited [I5]. Likewise, a change in the dose rate from 40 to
100 mGy/d decreased the proliferative response to PHA or
produced no effect [J7, N20].
92. The enhancement of T-cell-dependent immune response
as measured by plaque-forming cell counts after immunization with sheep red blood cells (SRBCs) was reported to
be stimulated by both single-dose WBI of mice (75 mGy,
12.5 mGy/min) [L15] and continuous 1.2 mGy/h irradiation
for up to 140 days [I9, I13]. The in vivo T-cell response wasalso evaluated by delayed-type hypersensitivity (DTH) after
immunization with Myccobacterium vaccae or dinitrofluorobenzene (DNF). While DTH to M. vaccae and DNF was suppressed in C57BL/6 mice, DTH to M. vaccae was increasedin BALB/c mice, and DTH to DNF was not significantly
changed [S17]. In the same study, the authors reported aninverted proliferative response to Con-A, with enhancement
in C57BL/6 mice and suppression in BALB/c mice. Thus
the outcome may depend on the strain of animal, the type ofantigen and the type of response [S17]. Ina and Sakai [I13]examined the effects of continuous LDR irradiation of thewhole body of several wild-type mouse strains and observed
a significant activation of the immune system both before andafter the immunization with antigens. The different strains
displayed different levels of response but with the same tendency: significant increases of CD4+ T-cells, CD8 molecule
expression and CD40+ B-cells, and significant enhancementin SRBC-antibody-producing cells by immunization. Theage at exposure may also determine the intensity of immuno­
enhancement, since the presence of a non-involuted thymus
contributes to this response [P11].
93. Furthermore, the efficiency of the immune response
was measured by the NK activity of splenocytes [C21, N24],
functional response of macrophages and cytokine secretion[G11, H20, L18, L19, P11, S33]. Enhanced cytotoxic activityof NK cells was found between 24 and 72 h post-irradiationin whole-body-irradiated BALB/c mice with single doses of
100 and 200 mGy [C21, N24]. LDR irradiation also enhanced
the phagocytic activity of macrophages from C57BL/6 mice
exposed to a total dose of 200 mGy (40 mGy/d) [P11].
94. Regarding the modulation of cytokine expression by
LDR irradiation, increased secretion of interleukins that activate T- and NK cells, such as IL-2 by mouse splenocytes,
and IL-1 and IL-12 by APCs, has been described, as wellas down-regulation of IL-10 synthesis in splenocytes following WBI with 75 mGy [J8, L14, L18, L19]. There havebeen observations of the increased secretion of TNF-α andIL-1β by macrophages in response to WBI of mice with both
low and high doses [I6, S33]. These two pro-inflammatory

cytokines exert a regulatory effect on lymphocytes, promoting their activation. Hashimoto et al. [H20] showed increased
expression of the genes coding for TNF-α and IFN-γ in
splenocytes of tumour-bearing rats given 200 mGy of WBI,
while mRNA of transforming growth factor β (TGF-β) had
decreased. These findings suggest immune activation, since
IFN-γ plays a key role in both innate and acquired immune
defences and also has antitumour properties, while TGF-β is
an immunosuppressive cytokine that allows tumour escapefrom immune destruction. All of these changes might contribute to a shift of the immune response in favour of Th1
differentiation.
95. In contrast to these observations, Gridley et al. foundthat LDR irradiation (50 mGy at 0.030 mGy/h) enhanced theintracellular expression of IFN-γ in CD3+ CD4+ T-cells from
C57BL/6 mice. Surprisingly, it did not result in increased
levels of secreted IFN-γ after protracted irradiation alone orwhen mice were exposed to a protracted low-dose followedby an acute high-dose irradiation [G11]. In the carefully conducted study of Pandey et al. on immunomodulation inducedby LDR irradiation, the secretion of IFN-γ by C57BL/6 mousespleen cells stimulated by Con A was considerably reducedin the group irradiated at 200 mGy. This may appear contradictory to the enhanced cytotoxic T-cell response observedin the same study, but IFN-γ may also have other important
regulatory roles in the immune system [P11].
96. Evidence for the suppressive effect of LDR irradiation
on tumour growth, metastases and carcinogenesis has beenpresented. Ishii and colleagues reported a decreased incidenceof spontaneous thymic lymphoma in AKR mice as a resultof chronic fractionated low-dose whole-body X-irradiation[I1]. In another well-recognized model of thymic lymphoma
induced in C57BL mice by fractionated WBI (four acutedoses of 1.8 Gy, one per week), preirradiation with 75 mGygiven before each 1.8 Gy dose decreased the frequency oftumours from 90% to 63%. This level was further lowered to
43% by continuous WBI at 1.2 mGy/h for 450 days starting
35 days before the first 1.8 Gy dose. Interestingly, continuous irradiation to a total dose of 7.2 Gy over 258 days yieldedno thymic lymphoma. In parallel, CD4+ T-cells, CD40+
B-cells and plaque-forming-cell counts in the spleen weresignificantly increased by continuous 1.2 mGy/h irradiation
alone, indicating the involvement of immune activation intumour suppression by LDR irradiation [I9]. However, othermodifying factors, such as DNA repair and elimination of
injured cells by apoptosis, are involved in the mechanisms
for ­suppression of tumours. In addition, the complex natureof murine thymic lymphoma, with involvement of cell killing in the aetiology of the tumour, makes the interpretationof the data difficult [C34].
97. Significant suppression of the development of pulmonary tumour nodules was reported by Ju et al. [J8] andCai [C33], who irradiated mice with single doses of X‑rays­ranging from 50 to 150 mGy, 24 h before injection of B16
melanoma or Lewis lung cancer cells. These results were corroborated later by Cheda et al. [C21], who injected syngeneic

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

low-immunogenic sarcoma cells into BALB/c mice 2 h after
WBI with 100 or 200 mGy. This resulted in significantly
reduced pulmonary tumour colonies. The authors associatedthe effect with stimulation of NK-cell-mediated cytotoxicity
detected in splenocyte suspensions obtained from irradiatedmice but not from sham exposed mice.
98. A report of the French Academy of Sciences extensively reviewed published data concerning the dose–effectrelationship and carcinogenic risk of low doses of ionizing
radiation [F11]. A database of cancer induction by LDR
irradiation obtained from 472 different animal experiments
was analysed [D30]. The meta-analysis showed that the
spontaneous cancer rate fell significantly after LDR irradiation in only 40% of those experiments that could potentiallyhave revealed the effect. It was suggested that, together withother mechanisms, the finding could partly be explained by
the stimulation of immunological mechanisms. However,
the author states that the statistical strength of the overall
observations has not yet been determined. Although manyobservations show a reduction in the cancer rate and a longer
life in low-dose-irradiated animals, these studies should act
as a focus for further research in order to confirm or disprove
the generality of the effects.
99. The adaptive response to radiation is a biologicaldefence mechanism in which low-dose ionizing radiation (a“priming dose”) elicits cellular resistance to the genotoxic
effects of subsequent irradiation (the “challenge dose”)[S37]. The adaptive response to radiation in animal andhuman populations, as well as its effects on the immune
system, have been extensively considered in the UNSCEAR
1994 Report, annex B [U4].
100. The adaptive response has been observed after WBI.
The experiments show that a priming exposure to chronic
irradiation can induce radioresistance in mice. The manifestation of this resistance is reduced mortality (from the haematopoietic syndrome) of pre-exposed mice after a ­challenge
acute irradiation [S43]. Yonezawa et al. have reported thatpre-exposure of mice to 500 mGy two weeks before a lethal(7–8 Gy) WBI induced marked radioresistance and survivalof the mice [Y7, Y8]. Later, using the same priming doseand a challenge dose of 5 Gy for haematopoietic ­studies,
they investigated whether preirradiation favours recovery of pluripotent haematopoietic stem cells. They foundthat ­radiation-induced resistance to lethality appeared to
be closely related to the recovery of endogenous colony­forming units of the spleen (CFU-S), with a maximum
response when the priming dose was given 14 days before
the challenge dose [Y5]. In addition, they demonstrated thatthe adaptive response at a challenge dose of 5 Gy seemed to
be induced through a reduction of p53-dependent apoptosis
in haematopoietic stem cells [H29].
101. Gong and co-workers [G28] studied thymocyte
apoptosis and cell cycle progression induced by WBI in
Kumming mice, using priming doses of 25–200 mGy andchallenge doses of 1–2 Gy given 6 h after the priming dose.

113

Their results indicated that the percentage of thymocyte
apoptotic bodies decreased, the arrest of G1 and G2/M
phases diminished and the frequency of cells in S-phaseincreased. However, when the priming dose was 200 mGy,
the adaptive response was no longer induced. Furthermore, adose-dependent increase in thymocyte apoptosis was foundwith doses of 250 mGy or higher [M27]. The question ofthreshold dose for the immune-enhancing effects is critical.
It depends on the end point tested, but the dependence onother factors such as animal species and the radiation dose
rate is still an open question [S34].
102. Selective changes in the expression of proteins arereported to accompany LDR exposure [S17]. Increased levels of stress proteins were observed in mitogen-stimulated
splenocytes of mice exposed to LDR radiation. The biological relevance of this was supported by the demonstrationthat splenocytes that failed to elevate their constitutive levelsof heat shock proteins following LDR irradiation also wereunable to increase their capacity to proliferate [N20]. Later,
Chen et al. isolated a 10 kD protein from thymocytes after
LD WBI. This protein, named RIP10, potentiates spontaneous thymocyte and mitogen-induced splenocyte proliferation, and modulates apoptosis [C23]. In addition, changes incell cycle and apoptosis-related intracellular and extracellular proteins accompanying increased response to Con A inmouse lymphocytes following WBI were reported [S16].
103. Although growing evidence suggests that low-dose
WBI can be immunostimulatory, many of the questions
about immunoenhancement remain unanswered and require
further experimental studies. One important aspect is themolecular basis of the stimulatory effect of LDR irradiation.
Experimental data have been accumulating in this field. It
has been reported that the intracellular free Ca2+ concentration increases after LDR irradiation and that protein kinase
C (PKC) also increases in response to different doses of radiation, leading to the activation of early genes. Another signal
pathway involved is the cyclic adenosine monophosphate/
cyclic guanosine monophosphate protein kinase A (cAMP/
cGMP-PKA) cascade: the cAMP/cGMP ratio falls after LDR
irradiation, with PKA responding in the same ­pattern. A
third pathway is phospholipase 2-prostagalandin E2 (PLA2PGE2), which is also down-regulated. An adaptive response
mediated by a feedback signalling pathway involving p38
mitogen-activated protein (p38 MAP) kinase, phospholipase
C (PLC) and PKC has been demonstrated [L20].
2.

Human data

104. Although few data are available on the effects of
low-dose exposures on humans, some reports suggest thatchronic low-dose radiation exposure can lead to effects
on the human immune system. Chang et al. analysed theimmune status in residents of buildings constructed using
60
Co-contaminated steel rods [C7]. They evaluated CD3+,
CD4+, CD8+ and HLA-DR+ markers in lymphocyte subsets in 196 exposed subjects with a mean cumulative excess

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UNSCEAR 2006 REPORT: VOLUME IIdose of 169 mSv (range 8–1,662 mSv) protracted over 2–13
years. These results were compared with those obtained in
55 close relatives considered to be the non-exposed reference population. They analysis was restricted to individuals
with no apparent history of medical conditions that could
compromise their immune profile. The mean percentagesof CD4+ T-lymphocytes and HLA-DR+ lymphocytes andthe CD4+/CD8+ ratio in the exposed individuals were significantly lower than those in the reference population, while
total CD8+ cell counts in the exposed individuals were moderately increased compared with the reference population.
In addition, changes in the percentages of CD4+ T-cells and
HLA-DR+ activated T-cells were significantly associatedwith radiation dose, while CD4+/CD8+ ratios were only
moderately associated with dose [C7]. Low CD4+/CD8+
ratios are observed in primary or secondary immune deficiencies, and this ratio has been proposed as a method for
estimation of the cellular immune status [H25]. The resultspresented by Chang et al. suggest that protracted gamma
radiation exposure in a residential environment may induce
a dose-dependent decrease of cellular immunity. However,these findings should be interpreted cautiously, taking into
account the wide range of cumulative doses and their protraction among the exposed subjects. A new analysis of theseresults separating subgroups of people with narrower dose
ranges could allow higher-quality conclusions to be drawn.
105. Immune status was evaluated by Godekmerdan et al.
in 50 radiology workers [G26]. A decrease of CD4+ helper
T-cells with diminished levels of immunoglobulins (IgA,
IgG and IgM) and complement (C3 and C4) was found,suggesting impairment of cellular and humoral immunity.
The authors make reference to the fact that there was no
significant difference between subjects exposed for morethan or less than 5 years. This study does not provide data
concerning either cumulative doses or dose rates. There isno mention of the type of medical procedure performedby the subjects involved in this study or the area of theradiology department in which they worked. Thus it is notpossible to establish a relationship between these findings
and radiation dose.
106. Rees et al. did not find significant changes in the
immune profiles of 325 male workers occupationally
exposed to external low-LET radiation at the British Nuclear
Fuels facility at Sellafield, United Kingdom. The cumulative exposures were >200 mSv in a period of from 19.1 to45.7 years in one group and <27.5 mSv in a period of from
15.1 to 32.5 years in the other. No statistically significant differences in circulating T- and B-cell total counts, CD4+ andCD8+ T-cell subsets, CD4+/CD8+ ratio or CD3+/HLA-DR+
were observed [R3]. This study took account of possible
confounding factors such as age, sex and cigarette smoking,and the sample size was sufficient to substantiate the conclusion that occupational exposure to low doses does not affectthe immune profile of workers.
107. Similar findings were reported by Tuschl et al. in
employees working at the research reactor of the Austrian

Research Centre (Seibersdorf), exposed during the preceding 3 months to very low doses of gamma radiation(from 0.2 to 4.9 mSv). The percentages of CD2+, CD4+,
CD8+ and NK cells were investigated in peripheral blood
lymphocytes. Data were pooled in two groups of individual
doses: <0.5 mSv and >0.5 mSv. Except for a slight increasein the relative number of cells expressing CD2 (a marker
of T-cell activation), radiation-associated changes were notobserved [T8].
108. Previously, the same group of authors had reported
that lymphocytes of radiation workers exposed to 0.14–
0.98 mGy/month exhibited an enhanced capacity to repair
DNA damage inflicted by an in vitro challenge dose of ultraviolet (UV) radiation [T17]. More recently, Mohankumar etal. have analysed the UV-induced DNA repair capacity of thelymphocytes of 16 healthy, non-smoking radiation workers of
the Indira Gandhi Centre for Atomic Research, Kalpakkam,
India, who received whole-body gamma exposures ranging
between 1 and 6.3 mGy during a period of 3 months prior
to the study [M25]. At very low gamma doses (1–1.9 mGy),
they found higher UV-induced unscheduled DNA synthesis(UDS) levels in samples receiving gamma irradiation in vitro
than in control samples, but there was no such increase in theradiation workers’ samples, owing mainly to the large standard deviation values of the means. For doses of over 2 mGy,
both in vitro and in vivo irradiated samples show higher
UDS levels. De novo synthesis of repair enzymes induced
by low-dose ionizing radiation exposure was suggested as an
explanation for these results. Particularly in the dose range
3–7 mGy, the UV-induced DNA repair capacity of radiation
workers’ lymphocytes was higher than that of cells exposedin vitro. These authors tried to explain these findings as an
adaptive response of lymphocytes to radiation, due to cell
renewal mechanisms, that led to a shift in the lymphocyte
population in favour of a cell type with greater DNA repair
capacity. They also postulated a possible involvement of
the endocrinological system. However, the sample size wastoo small to confirm the observations and to sustain thesehypotheses.
109. Tuschl et al. [T9] investigated some immunologicalparameters in 10 nuclear power plant (NPP) workers exposed
during a 4-week period to external radiation (1.4–9.8 mSv)
and tritium inhalation (committed effective doses of 1.2–
2.8 mSv). Blood samples were taken 25 days after the startof this exposure period for quantification of lymphocyte subsets and evaluation of their mitogenic response to PHA. Data
were compared with reference values obtained in healthy
donors. CD4+/CD8+ ratios were increased in NPP workers
owing mainly to an increase in absolute numbers of CD4+
T-cells. The authors interpreted these findings as a potentiation of the immune response by low radiation doses andsuggested selective cell renewal of CD4+ T-cells as a possible underlying mechanism. Although the tritium burden inthese workers was very small (0.47–6.3 kBq/24 h in urine),
they postulated that the RBE of beta particles from tritium
may account for this effect, which was not observed in otherstudies of occupationally exposed workers. Nevertheless, theANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

sample under investigation was too small, and further studies
are needed to substantiate this hypothesis.
110. Beta particles from tritium are of greater biologicaleffectiveness than gamma rays and X‑rays. At low doses or
low dose rates, RBE values of 2–3 have been proposed forthe oxide form and even higher values when tritium is boundto organic molecules [S47]. However, depending on the end
point and the irradiation conditions, RBE values for beta
particles from tritium may greatly differ [M26, T10, T14].
The total number and percentage of leucocyte subpopulations were determined in 54 workers exposed to tritium inthe workplace. Tritium contamination was well below theannual limit on intake for occupationally exposed subjects(mean tritium activity in urine: 1.9 kBq/litre). The functional
status of leucocytes was evaluated by alkaline phosphatase(AP) and myeloperoxidase (MP) activity staining. While
total leucocyte counts did not differ from those of the control group, lymphocyte and eosinophil counts were higher
in radiation workers. AP and MP activities were lower in
exposed workers [M23]. The author interpreted the increasein lymphocyte counts as a stimulation of the immune system
by tritium and eosinophilia as a compensatory reaction of
the bone marrow, where tritium had entered and disturbed
enzyme synthesis in leucocyte precursors. The author statedthat the workers had no clinical manifestations of immunity disorders. The selected end points seem inappropriate for
evaluation of both innate and acquired immune response.
The biological significance of these data cannot be readily
discerned, and these results are inconclusive.
111. Few data have been published concerning the impact
on the immune system of people living in high-level natural radiation areas (HLNRAs). Comparison of cord blood
samples from newborns from the Kerala coast in India (average dose rates of greater than 1.5 mSv/a) with samples fromnewborns from areas with lower levels of natural radiation(less than 1.5 mSv/a) did not show any significant differencein the frequency of dicentrics, translocations, inversions orother types of aberration known to be associated with radiation exposure [C26]. Ghiassi-Nejad et al. reported in 2002
that no differences were found either in laboratory tests of
the immune system or in haematological parameters amongpeople living in Ramsar, an HLNRA in the Islamic Republicof Iran, where the mean dose rate is 260 mSv/a [G1]. Similar results had previously been reported for people living in
Yangjiang, an HLNRA (6.4 mSv/a) in China [Z1]. In thispreliminary study, Ghiassi-Nejad et al. did not observe significant differences in the basal frequency of chromosome
aberrations in peripheral blood lymphocytes between people
living in Ramsar and people living in normal backgroundareas. Following a dose of 1.5 Gy of gamma rays in vitro,
lymphocytes of Ramsar residents showed a significantly
reduced frequency of chromosome aberrations. The authorsinterpreted their findings as an adaptive response induced bychronic radiation exposure.
112. Two years later the same group published new results
showing a higher frequency of chromosome aberrations in

115

Ramsar residents [G20]. Concerning humoral immunity,
IgG and IgA levels were not different, whereas a significant
increase in IgE levels was observed in Ramsar residents.
The authors interpreted this finding as radiation-induced
immunostimulation due to a shift from a Th1 to a Th2
response. While no differences were found in the expressionof CD69 (a marker of lymphocyte activation) in unstimulated samples, the expression of CD69 was higher in PHA­stimulated CD4+ helper T-cells of Ramsar residents, a findingthat the authors considered as an indication of a higher risk of
proto-oncogene activation. However, taking into account thelack of consistency between these two papers [G1, G20], theresults are not conclusive, and these hypotheses appear rather
speculative. The frequency of chromosome aberrations was
also higher in residents from other HLNRAs in ­Brazil [B18]
and China [C22]. It has been reported that ­smoking plays amore significant role than natural radiation in the induction
rate of stable lymphocyte aberrations in those areas [Z2].
However, this statement should be interpreted with caution
since a recent meta-analysis from retrospective biologicaldosimetry data from seven European laboratories indicatedthat there was a strong variation of translocation yield withage, but no variation was detectable with sex or smoking
habits [W17].
3.

Remarks concerning low-dose/low-dose-rate irradiation

113. On the basis of the previous paragraphs, the following
remarks may be made concerning LD irradiation data. It has
been reported in some animal studies that under protracted
gamma ray exposure at low dose rates, the normally highly
radiosensitive haematopoietic system adapts and becomesradioresistant. Depending on the dose and dose rate, induced
the pattern of changes in leucocyte populations can be
described as an initial suppressive phase followed by a stableaccommodative phase. This pattern of changes is precededby similar changes in the haematopoietic progenitor cellcompartment. However, it was suggested that the recovery
of marrow precursors might be incomplete.
114. In animal experiments there is evidence demonstrating that LDR irradiation can produce activation of theimmune function. Enhancement of the proliferative responseof splenic and thymic lymphocytes to mitogens, enhancement of NK activity and increased secretion of cytokines
with regulatory effect on immune cells promoting theiractivation, inter alia, have been reported. Nevertheless, thedata are not entirely consistent, and the observed effects arehighly dependent on the range of dose and dose rate, andupon the animal and strain of animal studied.
115. Data demonstrating suppressive effects of LDR exposure on tumour growth, metastases and carcinogenesis havebeen reported. An association of these effects with enhanced
NK activity of splenocytes, higher antibody-dependent­cellular toxicity and increased levels of CD4+ cells, CD40+
B-cells and plaque-forming cells in the spleen has beenfound.

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UNSCEAR 2006 REPORT: VOLUME II

116. An adaptive response to radiation is another pheno­menon observed in many systems. Interestingly, radiation­induced resistance to lethality after WBI with a high­challenge dose in mice appeared to be closely related to
the recovery of CFU-S after the priming dose. It was also
related to the reduction of apoptosis in the haematopoietic
stem cells, giving insight into the possible mechanisms bywhich these adaptive processes occur.
117. Regarding human data, while some authors havereported evidence for effects after chronic LDR irradiation,others have not found such evidence. A dose-­dependent
decrease of cellular immunity, mainly evaluated by theCD4+/CD8+ ratio and HLA-DR+ activated T-cells, wasdescribed for residents of buildings constructed with60
­ Co-contaminated materials, although these findings should
be interpreted cautiously. In contrast, no significant changes
were observed in the same parameters of workers occupationally exposed to external low-LET radiation in nuclear
facilities.
118. Concerning tritium incorporation, it would appear
to have a higher RBE than external irradiation at the same
doses. This has been observed in both experimental studies
and human studies, but the results are inconclusive.
119. In the same way, when the impact on the immune
system of living in areas with high levels of natural radiation was analysed, the results were controversial, and the­significance of these findings remains unclear.
C.

Data concerning high-dose irradiation

1. High-dose-induced immunosuppression
120. The effects of radiation on the immune system generally intensify with the dose received. Massive cell death,inflammation and infection are the acute effects of high-doseradiation exposure. Human data concerning the effects on the
immune system of WBI have been widely studied in victimsof radiation accidents and in patients undergoing WBI as aconditioning regime for bone marrow transplantation. The
effects of high doses of ionizing radiation upon immune system function were reviewed by the Committee in 1988 [U6].
121. Acute radiation syndrome (ARS) occurs after WBI
or substantial partial-body irradiation of greater than 1 Gy,
delivered at a relatively high dose rate [G22]. With the
exception of the haematopoietic syndrome, the other clinicalcomponents of ARS (gastrointestinal and cerebrovascular)
are not the subject of this annex, and they are reviewed elsewhere [K45, W9]. Since granulocytes and lymphocytes arean essential part of the immune system, profound abnormalities of immune function are expected as a consequence ofhigh-dose WBI.
122. A patient who receives acute external WBI in therange 0.5–1 Gy is generally asymptomatic, and blood counts

may be normal or minimally depressed below baseline ­levels
3–5 weeks after exposure [G23]. The haematopoietic syndrome may be seen following doses of >1 Gy. Acute wholebody doses of below 2 Gy induce mild cytopenia without
significant bone marrow damage. Laboratory analysis incases with WBI of greater than 2 Gy can show an initial
granulocytosis, with pancytopenia evident within the firstmonth after exposure [G23]. Mitotically active haemato­
poietic progenitors are unable to divide after a whole-bodydose of >2–3 Gy, resulting in haematological crisis in thefollowing weeks [G22]. During this symptom-free period of
ARS (latency phase), the blood-producing cells in the bonemarrow begin to diminish and are not replaced, leading to asevere shortage of white blood cells, followed by a shortageof platelets and then red blood cells. The shortage of whiteblood cells can lead to severe immunodeficiency, increasing
the risk of infectious complications and impairing woundhealing [D1, G23].
123. The rate of decrease for different leucocytes in the
blood after WBI is dependent on their particular cell cycle
kinetics. Neutrophils have a relatively short lifespan, andthus they have a tendency to be depleted over a matter of days
following acute WBI, owing to radiation-induced ­damage totheir progenitor cells. They show an initial increase within
the first few days after doses of >2 Gy; this increase is greater
after higher doses. This first “abortive rise” may be due toa cytokine-dependent transient mobilization from bone­marrow or extramedullar sites and to accelerated maturationof granulocyte precursors. A progressive neutropenia thenoccurs, the rate and extent of which are dose-­dependent; thismay be followed by a second abortive rise following dosesof <5 Gy as a result of haematopoiesis recovering from precursor cells. This second abortive rise is not seen following doses of >5 Gy, indicating the failure of haematopoiesis
to recover permanently after very high doses, a finding that
may be clinically helpful as a prognostic indicator [G22].
The duration of neutropenia may be long, requiring prolonged administration of haematopoietic growth factors,
blood product support and antibiotics.
124. In non-uniform exposures, evaluation of cyto­penia
may be somewhat misleading because the cumulative curveof the granulocytes “averages” the actual production by­different portions of the bone marrow that have received different doses. Temporal parameters in such cases are more
relevant to the magnitude of the dose, and blood counts are
more correlated to the volume of damaged bone marrow.
Lymphopenia in non-uniform WBI is more prolonged thanin uniform WBI [G34]. When the ARS is associated withcutaneous radiation syndrome, the lymphohaematopoietic
suppression impairs wound healing and increases the risk ofwound bleeding and infection [B16].
125. A follow-up of neutrophil values for several days
post-irradiation was found to correlate well with dose. The
time to reach the critical level of 500 granulocytes/mL has
been proposed as a dosimetric bioindicator [B30]. However,in many cases of overexposure, an earlier approximation of

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

dose is required for efficient medical intervention. This canbe achieved by counting the decrease of lymphocytes, as
their nadir is reached much earlier than for other cell types.
The predictability of lymphocyte depletion following highdoses of ionizing radiation, which may be recognized within
hours of exposure, has allowed the development of biodosimetric models. This approach was originally developed togive a rough categorization of the magnitude of exposure(figure VI).

of dosimetry [G3]. This technique was further extended
to include analysis of various types of criticality accident.
Lymphocyte depletion in high-level mixed gamma–neutron
accidents was found to be approximately equal, at a given
effective dose, to that for gamma ray accidents. This finding
indicates that, in terms of lymphocyte depression, the RBEof neutrons could be close to unity [G24].
2.

Figure VI. Classical Andrews lymphocyte depletion curves
and clinical severity ranges.
Whole-body doses: curve (1), 3.1 Gy; curve (2), 4.4 Gy; curve (3),5.6 Gy; curve (4), 7.1 Gy [G3].
Patterns of early lymphocyte
response in relation to dose

LYMPHOCYTE COUNT (µL-1)

3000

Normal
range
2000
(1)

(2)

Moderate(3)

Severe(4)

Verysevere1000
Injury

500

100
0

0

1

2

TIME (DAYS)

126. A mathematical biodosimetric method for evaluating
uniform WBI by peripheral blood lymphocyte and neutrophil
counts was widely used and validated following the Chernobyl accident [B31, U6]. The doses evaluated by peripheral
blood cell counts, chromosome aberrations and electron spinresonance of tooth enamel were highly correlated [B30].
127. A mathematical model for lymphocyte depletion following gamma irradiation, intended only for providing a first
approximation of dose, was developed on the basis of accident cases with recorded haematological data and physicallyreconstructed doses. During the first 8 hours after exposure,the decrease in lymphocytes followed a single-term exponential curve, and the rate constant for this decrease correlated well with dose estimates obtained from other sources

117

Immune reconstitution

128. Reconstitution of the immune system after radiationinduced bone marrow aplasia has been widely studied inpatients undergoing bone marrow grafting. Bone marrowtransplantation is characterized by a subsequent period of
immunodeficiency, the duration and severity of which vary
according to graft manipulation, choice of graft type (donor
and source), development of graft-versus-host disease andlevel of residual thymic activity.
129. During the first month, T-lymphocytes reconstitute by peripheral expansion of the T-cells present in thegraft. Thereafter, starting from 100 days after transplantation, the production of substantial numbers of new naive
T-cells by the thymus can be detected [D9]. Rapid early
expansion of transferred or residual mature T-lymphocytesof extrathymic origin results in inversion of the CD4/CD8
ratio, which persists primarily as a result of delayed CD4+
T-cell recovery. Normalization of the CD8+ subset after
60 days was reported, while persistent CD4+ reduction has
been observed after 2 years, and normalization of the CD4+
subset was achieved only after 6 years in a long-term study[L4]. The different behaviour in this immune reconstitution may be explained by an extrathymic origin of CD8+
cells, while the CD4+ subset recovery, which is thymusdependent, is impaired in the adult population. In children,
who are characterized by having greater amounts of active
thymic tissue and more effective thymopoiesis than adults,
there is a more rapid recovery of CD4+ T-cells, which
express a naive phenotype (CD45RA+). This finding may
have significant implications for attempts to generate protective immunity against pathogens and clinically ­relevant
antitumour responses by vaccination strategies in the
post-transplantation period [P7].
130. Oligoclonal B-lymphocyte repopulation can be demonstrated in the early post-transplantation period, achieving
normal values after 90–120 days [L4]. Serum immunoglobulin levels usually decrease post-transplantation, followed bya gradual increase and normalization in a sequential ­patternsimilar to that identified in neonates. Recovery initiallyoccurs in IgM levels (2–6 months), followed by IgG levels(3–18 months) and finally IgA levels (6–36 months), the timedepending to some degree on conditioning and graft charac­
teristics [P7]. Cooperation between T-cells and B-cells isnecessary for antibody production. Thus, although B-cells
transferred with the graft may confer temporary protection
against pathogens, antigen-specific T-cells must be regenerated in order to ensure sustained B-cell competence [L4].

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131. Reconstitution of innate immunity following transplantation is characteristically more rapid than for acquired
immunity. Most studies have shown early normalization
or even rebound increases in NK cell numbers in the earlymonths [P7]. NK cells might provide an efficient defence
against pathogens and residual tumour cells, especially
immediately after transplantation, where the lack of cooperation between T-cells and B-cells results in an inability to
produce antibodies.
132. The results presented all support the conclusion that
normalization of immunological function is achieved withinseveral years after transplantation. The functional capacityof the recipient thymus appears to be the dominant influenceon thymus-dependent reconstitution. Thymus-independent
reconstitution, which accounts for the majority of the earlyreconstitution, might be predicted to depend more heavily
on stem cell sources.

3. Remarks concerning high-dose irradiation
133. As discussed in the preceding paragraphs, acute
WBI in the range 0.5–1 Gy is generally asymptomatic,
and leuco­cyte counts may be minimally depressed or evennormal. Acute radiation syndrome (ARS) occurs after
acute whole-body or substantial partial-body exposure of>1 Gy. While mild cytopenia is observed within the range
1–2 Gy, initial granulocytosis (first abortive rise) followedby pancyto­penia within the first month result from wholebody doses of greater than 2 Gy. A second granulocyte
abortive rise may be seen when the whole-body dose isbelow 5 Gy. In non-uniform exposures, temporal blood
cell parameters are more relevant for dose estimation thanthe magnitude of cytopenia. Mathematical models havebeen developed for correlating the dose with the kinetics of lymphocyte depletion during the first hours after
exposure.
134. Acquired immune reconstitution after radiationinduced bone marrow aplasia includes both thymus-­dependentand thymus-independent pathways. ­T-lymphocytes reconstitute during the first month by peripheral expansion, and,­during the following months, new naive T-cells begin toappear from the thymus. However, an inversion of the CD4/
CD8 ratio persists for several years. While CD8+ T-cells
normalize within two months, the recovery of CD4+ T-cells
may be achieved within 6 years. Central T-cell recovery
in adults is delayed relative to that in children, probably
owing to differences in thymic function. B-­lymphocyte
repopulation takes place during the first 4 months. Following an initial decrease of immunoglobulin levels, recovery
gradually occurs in IgM levels (2–6 months), IgG levels (3–18 months) and Ig A levels (6–36 months). Innate
immune reconstitution is more rapid than reconstitution of
acquired immunity. NK cells normalize or even increase in
the early months.

D. Influence of dose rate and radiation
quality on immune response
135. Several studies have examined the immunomodulating effects of whole-body exposure to different qualities ofradiation. The driving forces for these investigations are thechallenges created by exposures in the space flight environment (which are dominated by charged particles [S21, S28]),
clinical use of proton radiation in the management of cancer[L9, S23] and exposures due to radon and its progeny [N1].
1.

Low-LET exposures136. The effects on the immune system of radiation, suchas gamma rays or X‑rays, have been extensively investigated and reviewed [A13, S1, U8, U10]. Variability in the
biological response may reflect differences in the total dose,
dose rate, end points measured and time of evaluation postexposure. Analysis of the influence of each of these variables
is of importance not only in radiation therapy but also forenvironmental or occupational radiation exposure [G8].
137. Pecaut et al. [P6] investigated early effects on mice of
gamma ray doses of up to 3 Gy at low and high dose rates.
They observed a significant dose-dependent loss of spleen
and thymus mass, which was somewhat independent of dose
rate. Decreasing lymphocyte and leucocyte numbers in the
blood and the spleen with increasing dose, as well as dosedependent decreases in lymphocyte subpopulations (CD4+helper T-cells, CD8+ cytotoxic T-cells and CD19 B-cells)
were observed at both dose rates. While the percentages of
CD4+ increased with increasing dose (with some ­differences
between blood and spleen), the percentages of the CD8+
population remained stable in both compartments, andCD19+ cells declined markedly with high or low dose rate.
The number and proportion of NK cells remained stable.
Because of the differences in phenotypic radiosensitivities,
a decrease in lymphocyte counts sometimes results in a proportional enrichment of specific cell types. Overall, thesedata indicate that the changes observed were highly dependent on dose but not on dose rate, and that cells in the spleen
are affected more by dose rate than those in the blood.
138. Similar data have been reported for high-dose treatment under comparable experimental conditions [H11, W5].
A more pronounced dose-rate effect was seen in spleenmass, probably owing to a change in homing receptors in circulating populations of splenic endothelial cells [P6]. It has
been demonstrated that ionizing radiation can up-­regulate
the expression of ICAM-1 and E-selectin, both of which
are important in leucocyte trafficking. CD44, a molecule
involved in the migration and homing of immune cells, wasaltered in irradiated lymphoid cells [H3, N1].
139. Using the same animal model, the functional characteristics of splenocytes and cytokine expression was evaluated after WBI at various total doses and at low and highdose rates [G8]. An assay of spontaneous blastogenesis inANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

leucocytes is sometimes performed in order to determine
the proliferative capacity and activation of lymphocytes.
Mitogen-induced cell proliferation is employed extensively to assess the general responsiveness of lymphocytes
to stimulating agents. The data showed that at 4 days postirradiation, increasing doses resulted in a rise in spontaneous
blastogenesis in blood and spleen leucocytes. This finding
was correlated with a reduction in white blood cells [P6],and suggested that cell regeneration was in progress. Splenocyte response to LPS (bacterial lipopolysaccharide), a potent
non-specific stimulator of B-cells, was inversely related toradiation dose. This finding is consistent with the demonstration that B-cells are the most radiosensitive lymphocyte
subpopulation [C6, P6, W14]. Lymphocyte responsivenessto T-cell mitogens (PHA and Con A) was shown to dependon experimental conditions. A decreased ability of splenocyte mononuclear cells to respond to mitogens after WBI(0–7 Gy) was described by Harrington et al. [H5].
140. Acute doses of some centigrays, as well as chronic
WBI, can enhance mouse splenocyte response to these­mitogens [L15, N13]. Furthermore, WBI induced changes
in expression of CD25 (IL-2 receptor) and CD71 (transferring receptor) activation markers [M7]. IL-2 secretion by­PHA-activated splenocytes was reduced in a dose-­dependent
manner. Plasma levels of transforming growth factor
β1 (TGF-β1) and splenocyte secretion of tumour necrosis
factor α (TNF-α) were not affected by either the dose or thedose rate of radiation [G8]. The data demonstrate that the
responses of the blood and the spleen for the immune para­
meters studied were largely dependent upon the total dose ofradiation and that dose rate was not a significant factor.
141. Even though the quantity of energy deposited isminimal, a repetitive irradiation inflicts a series of small
insults on the tissue. Each delivered fraction contributes tothe development of inflammation. For a repetitive radiation
exposure with low to medium doses, the amount of the cumulative dose is more important than the number of fractionateddoses. Gremy et al. [G32] showed a modulation of expressionof inflammation mediators during fractionated gamma radiation restricted to a colorectal zone in the rat (5 Gy 3 times aweek, maximum dose 45 Gy). The IL-1β mRNA showed an
overexpression from a cumulative dose of 20 Gy. The levelof IL-10 mRNA was highly repressed at 45 Gy. The monocyte chemoattractant protein 1 (MCP-1) chemokine expression progressively increased with the cumulative dose, while
IL-8, less overexpressed, went to a maximum expression at
20 Gy. Some signalling pathways were altered, exacerbatedor ­suppressed, triggering a neutrophil recruitment to the
inflammatory site at the end of the irradiation protocol.
2. High-LET exposures(a)

Neutrons

142. Neutrons have been shown to have high values ofrelative biological effectiveness (RBE) for some biological119

end points, including chromosome aberration induction inhuman lymphocytes. Immediate early death of lymphocytes
and thymocytes after neutron irradiation seems to be comparable to that for low-LET gamma rays and X-rays whenassayed by apoptosis, suggesting that the neutron RBE
is close to unity for this end point. Moreover, the route tocell death is independent of dose rate. These observations
are in marked contrast to the much larger RBE values anddose-rate effects typically seen in many systems of clonogenic survival, replicative death and chromosome aberration
formation.
143. Warenius and Down compared apoptosis in mousethymocytes following exposure to low doses of fast neutrons(62.5 MeV) and photons (4 MeV). Both the time course
and the radiation dose–response curves were similar for
high- and low-LET radiation modalities [W16]. Vral et al.
examined the effectiveness of fast neutrons compared with60
Co gamma rays for inducing apoptosis in human lympho­
cytes. Doses ranging from 0.05 to 5 Gy were applied at
0.2 Gy/min (fast neutrons) or 1.5 Gy/min (gamma rays).
To investigate the role of DNA repair in apoptosis induction, they also performed irradiations at low dose rates(0.006 Gy/min). They found that apoptosis induction was
independent of LET and dose rate (the calculated RBE forfast neutrons was close to unity), suggesting that the initial DNA damage, as opposed to DNA repair, dominates
the induction of apoptosis in resting lymphocytes [V7].
Ryan et al. examined apoptosis in human lymphocytes following doses of between 0.25 Gy and 5 Gy of low-energy
fast neutrons (280 keV mean energy) and of 137Cs gamma
radiation. They found that neutrons are equally as effective
as gamma radiation at inducing apoptosis in lymphocytes[R23]. Goans et al. analysed lymphocyte depletion kinetics
in various types of criticality accident (high-level mixed
gamma/neutron fields). The results were approximately
equal, at a given effective dose, to those for gamma accidents, suggesting that the RBE of neutrons could be close
to unity for this end point, regardless of the structure of
their energy spectra [G24].
144. Huiskamp et al. compared the effect of WBI withfission neutrons (1 MeV mean energy) and 300 kVp X-rayson the supportive role in T-cell differentiation of thethymic stroma of neonatal CBA-H mice, after transplantation to athymic nude mice. Doses varied from 2.75 Gy to
6.88 Gy (0.1 Gy/min) for neutrons and from 6 to 15 Gy(0.3 Gy min) for X-rays. Although irradiation had no effecton the stromal and T-cell composition of grafts, the graft
size decreased in a dose-dependent manner with an RBEof 2.1 for fission neutrons [H32]. Holl et al. evaluated theeffect of WBI with 65 MeV neutrons or 15 MeV X-rays
on spleen cells of BALB/c mice following doses ranging
from 0.2 to 3 Gy. Their results indicated that the RBE ofneutrons differs depending on the end point selected, since
they found that the level of apoptosis was equal for highand low-LET radiation (RBE = 1), whereas spleen weightand cellularity were reduced to a greater extent by fastneutrons (RBE = 2) [H31].

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(b)

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Protons145. Since cells of the immune system are among themost radiosensitive in the body, an investigation of theeffect of proton radiation on these cells would support more
realistic estimates of the risks associated with space flight.
Furthermore, a better understanding is needed of the biological ­interactions following exposure to protons, in viewof the increasing number of patients undergoing proton
radiotherapy.
146. Both early and long-term effects on the immune system of mice undergoing whole-body proton irradiation havebeen reported [G9, K2, P4]. Gridley et al. drew attention tolymphoid organs and specific leucocyte populations of micereceiving WBI with 0.5–3 Gy of 250 MeV protons at two
dose rates: 1 cGy/min and 800 mGy/min [G9]. Four days
post-irradiation, highly significant dose-dependent reductions were observed in the mass of the thymus and the spleen,
and in the numbers of leucocytes and CD3+ T-cells, CD4+
helper T-cells, CD8+ cytotoxic T-cells and CD19+ B-cells
in both blood and spleen. A less pronounced dose effectwas noted for NK cells in the spleen. Monocyte (but not
granulocyte) counts in blood were highly dose-­dependent;
the numbers for each population tended to be lower withhigh-dose-rate than with low-dose-rate irradiation. Increases
in the percentage of CD3+, CD4+ and NK cells, and in theCD4+/CD8+ ratio, were noted with increasing doses. A significant dose-rate effect was found in the percentages of Tand B-cell monocytes and granulocytes, and in the CD4+/
CD8+ ratio. The majority of the dose-related decreases inthe spleen were highly linear. Results from gamma- andproton-irradiated groups were similar, although proton
irradiation gave consistently lower values in some measurements. Very rough calculations of RBE for protons ranged
from 0.82 (based on percentage of B-cells in the spleen) to
1.55 (based on percentage of NK cells in the spleen) [G9].
RBE values for CD4+ T-cells ranging from 0.9 to 1.4 andfor CD8+ T-cells from 0.7 to 0.9 were reported by Radojcic
and Crompton, who compared the induction of apoptosis in
human peripheral lymphocytes following irradiation with
300 kVp X‑rays or 138 MeV protons [R18].
147. In other studies [K2, K3] that also directly compared
the effects of these two forms of radiation at the same dose
(dose: 3 Gy; proton dose rate: 0.4 Gy/min and 1 Gy/min;photon dose rate: 0.3 Gy/min), CD19+ B-cells were the mostradiosensitive, although recovery back to normal levels wasobserved by day 15. T-cell (CD3+) and CD4+ helper T-cellrecovery was evident by day 29, while CD8+ cytotoxic
T-cell counts remained significantly below normal. Plasma
TGF-β1 was elevated on day 7 in the 60Co-irradiated but notin the proton-irradiated mice. However, few differences inassay results were seen between animals exposed to protons
versus photons.
148. Pecaut et al. [P5] assessed the functional characteristics of mouse leucocytes following whole-body proton
irradiation at doses of between 0.5 and 3 Gy (dose ratesof 10 mGy/min or 800 mGy/min). Treatment with protons
caused a significant dose-dependent increase in spontaneous
blastogenesis in the blood and the spleen, suggesting that
acute cell death had stabilized by day 4 post-­irradiation,and that DNA synthesis and regenerative mechanisms
were increasingly stimulated by an increasing magnitude
of cell depletion. The authors also observed a greater effectof irradiation by protons than by gamma rays at the same
doses. A dose-dependent decrease in the response to T- andB-cell mitogens was observed, and the splenocyte response
to Con A was significantly lower than that of the gammairradiated group. The underlying mechanism for this effect is
not known. The authors suggest that it may have been due togreater impairment of DNA synthesis in the T-cells capableof responding to Con A. Although the dose rates employed
represented a range within which dose-rate-dependent­changes in sublethal damage do occur, no dose-rate effects
were observed.
149. Although a large number of studies have provided
experimental results of long-term effects of radiation on the
immune response [C16, V1], there are few data on effects
following proton irradiation. Pecaut et al. [P4] studied theimmune status of mice exposed to 3 or 4 Gy of 250 MeV
protons and sacrificed at day 122 post-irradiation. The main
points that emerged are the following:− There were no effects on thymus, spleen or liver
mass;− There were significant dose-dependent decreases
in macrophage, CD3+ CD8+ cytotoxic T-cell, NK
cell, platelet and red blood cell populations;− In contrast, dose-dependent increases were observedin spontaneous, but not in mitogen-induced,
blastogenesis;− Effects of radiation were more evident in leucocytes
in the spleen than in the peripheral circulation.
(c)

Densely ionizing particles

150. Laboratory studies with mice have provided evidence for acute and chronic effects of high-LET particles
on the immune system. Utilizing carbon ions, Erofeeva et
al. [E4] and Grigorenko et al. [G12] reported changes in thecell architecture and distribution of lymphoid cells in boththe spleen and the thymus that persisted at 60 days post­irradiation. Gridley et al. [G10] evaluated the effects of 56Fe
and 28Si irradiation on the lymphoid cells and organs of miceat days 4 and 113 after whole-body exposure. In the shortterm, dose-dependent decreases were noted in spleen andthymus masses, but there was a greater dependence on dose
for thymus mass than for spleen mass. With low-LET radiation, in contrast, the spleen mass is more linearly dependenton dose than is the thymus mass [G10]. This suggests thatthe response of different lymphoid organs may be dependent
on radiation quality. Irradiation resulted in a marked reduction in the number of lymphocytes and granulocytes on day 4

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

post-irradiation. Interestingly, it was observed that high-LET
radiation might shift the nadir of peripheral neutropenia to an
earlier point. The radiosensitivities of lymphocyte subpopulations were consistent with those obtained using gamma
rays or protons. There were no significant differences in the
response to T- and B-cell mitogens or secretion of IL-2 andTNF-α by PHA-stimulated splenocytes. In contrast, proton
irradiation induced significant depression in the response
to all three mitogens [P5]. Overall, the radiation-inducedchanges on day 4 were significantly more pronounced in the
blood than in the spleen.
151. By day 113 post-irradiation, most of these radiationinduced changes were no longer evident. However, B-lympho­
cyte numbers and percentages in blood were significantly
increased. The percentages of total T-cells and CD8+ T-cells
were low in both blood and spleen. According to the authors[G10], these findings suggest that 56Fe irradiation may havecompromised cell-mediated or acquired immune responses.
These long-term effects seen with 2 Gy 56Fe irradiation were
not observed following exposure to 2 Gy 28Si ions. ­Exposure
to 28Si ions did, however, result in increased responsiveness to PHA and LPS, and in lower numbers and percentages of NK cells in both blood and spleen. Thus it appears
that exposure to 28Si ions, which have a depth–dose profile
considered to be optimal for maximizing high-LET particle
effects, may result in chronic immune dysfunction.
152. The above observations differ somewhat from thosereported from examination of the long-term effects of exposures to 250 MeV monoenergetic protons, where irradiatedanimals had significantly increased basal DNA synthesis andno differences in mitogen-induced blastogenesis. These datasuggest that different immunomodulatory consequences may
be induced by densely ionizing particles.
(d)

121

total cellularity of most lymphoid organs (such as the thymus, spleen, peripheral lymphoid nodes and lung-associatedlymph nodes) was observed compared with controls. The
percentage of T-cells increased while that of non-T-cells
decreased in peripheral lymphoid organs at both doses. It
was interesting to note that in the thymus at 2,500 WLMs, adramatic decrease in the number of CD4+ CD8+ T-cells andan increase in CD4– CD8– T-cells were observed.
155. The exact mechanism by which radon affects T-celldifferentiation in the thymus is not clear. Radon exposure led
to differential expression of CD44 in lung-associated lymph
nodes. CD44 is an adhesion/homing receptor involved inlymphocyte and macrophage homing to lymphoid and otherorgans. These data suggest that lymphocytes and macrophages may migrate in different patterns to other organs. In
the lung-associated lymph nodes, where one would predictthe largest number of damaged cells to be present, there wasa significant decrease in T-cell responsiveness to mitogens,while the B-cell response was not affected. This may be dueto the fact that in lung-associated lymph nodes there may
be a marked loss of macrophages, the accessory functionsof which are essential for T-cells to respond to mitogens.
Interestingly, radon exposure caused an increase in the Tand B-cell responsiveness to mitogens in the spleen and­peripheral lymph nodes.
3.

Remarks concerning the influence ofdose rate and radiation quality

156. Overall, the data presented in the preceding paragraphs show that both high and low dose rates of sublethal
gamma radiation induce significant depression in the majority of the parameters evaluated at early times after irradiation. The changes observed were highly dependent on total
dose but not on dose rate.

Radon

153. Data concerning health effects of radon exposure arereviewed in annex E, “Sources-to-effects assessment forradon in homes and workplaces”. Only some data concerning the effects of radon exposure on the immune system will
be reviewed here. Since previous studies have demonstrated
that exposure to radon can trigger genotoxic damage in rat
macrophages and deep-lung fibroblasts [K10], it is possiblethat lymphocytes migrating through the blood or the lymphatic circulatory systems of the lung may be exposed toalpha particles from radon progeny.
154. The effect of radon on the immune response was­studied by Nagarkatti et al. [N1]. Mice were exposed 18 h/dfor 10 (or 25) days to a concentration of radon and its progeny giving a total cumulative exposure of 1,000 (or 2,500)
working level months (WLMs)1. A marked decrease in the1
A working level (WL) is a unit of concentration in air of the potential alphaenergy released from the decay of radon and its daughter products. The
WL is defined as any combination of the short-lived radon daughters in one

157. The RBE of neutrons differs depending on the end
point considered. The level of lymphocyte apoptosis isalmost equal for neutron and photon exposures, whereas
immune organ weight and cellularity are reduced to a greater
extent by neutron irradiation.
158. The response of mononuclear cells following proton
irradiation is highly dependent on the total dose but not on
dose rate, at least in the range of doses and dose rates analysed. Some cell types exhibited differences in the response
to proton versus photon radiation, proton irradiation ­giving
consistently lower values. Significant depressions in somelymphocyte subpopulations were observed after longlitre of air that results in the ultimate release of 1.3 × 105 MeV of potentialalpha energy. Exposure of a worker to this concentration for 170 hours (aworking month) results in an exposure of one working level month (WLM).
However, while the cumulative exposure expressed in working level months
provides an estimate of the exposure to radon and its decay products (primarily of the bronchial epithelial tissues of the lung), it does not provide
a direct measure of the dose to lymphoid tissues. (See annex E for further
discussion of the dose due to radon and its decay products.)

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term evaluation. Increased spontaneous blastogenesis is a­relatively persistent phenomenon throughout short-term tolong-term evaluations.
159. Lymphoid cells and tissues are markedly affectedby high-LET radiation at relatively low doses, and somerearrange­ments persist long after exposure. Depression in
the percentage of cytotoxic T-cells, and enhancement in the
total number of lymphocytes and B-cells, were observed atlong times post-irradiation. Increased basal DNA synthesis
is a persistent phenomenon.
160. Radon exposure induces marked changes in thymus
subpopulations and alters the expression of CD44, a mole­cule
involved in the migration and homing of immune cells. A significant decrease has been observed in T-cell ­responsivenessto mitogens in lung-associated lymph nodes.
E.

Radiosensitivity of lymphocyte subsets
1. General considerations

161. The dose required to induce a defined percentage
of cell death in a given cell population defines the levelof radiosensitivity of that cell population [N19]. Although
the sensi­tivity of different lymphocyte subsets to ionizing
radiation has been extensively studied, there are still controversial results in the literature. The radiosensitivity oflymphocytes is related to the population under study. For
B-lymphocytes it depends on their degree of differentiation, and for each subset of T-lymphocytes it depends ontheir state of activation. Activated lymphocytes have long
been known to be more resistant to ionizing radiation thantheir resting (non-activated) counterparts [A13]. The radiosensitivity of lymphocyte subsets is higher when irradiationis performed on sorted purified lymphocyte subp opulations rather than on unsorted peripheral blood lymphocytes­irradiated as a whole [M29].
162. Radiation-induced apoptosis in lymphocytes is triggered by two pathways: the mitochondrial pathway (intrinsic
pathway) and the death receptor pathway (extrinsic pathway).
Apoptosis via both pathways is mediated by the activation ofa series of cysteine proteases, the caspases. Although both
pathways of apoptosis involve activation of common effector
or executioner caspases, they differ in the activation of apical or initiator caspases. The first one, through Bax protein,induces cell death by acting on mitochondria and accounts
for the differential radiosensitivity among lymphocyte subpopulations. The second one is mediated by plasma membrane signals via interaction of the tumour necrosis factor
receptor (TNFR) with its ligand (tumour-necrosis-factorrelated apoptosis-inducing ligand—TRAIL) and does notseem to be related to intrinsic radiosensitivity of lymphocyte
subsets [M29]. Interactions between TRAIL and ceramide
signalling pathways in regulating apoptotic death have beenreported [L25]. Apoptosis of lymphocytes through the death
receptor pathway also occurs in physiological conditions.

Activation-induced cell death is a form of apoptosis in which
activation of T-cells occurs through proper engagement of
TCRs by specific antigen bound to an HLA molecule, andinfluenced by antigen concentration and co-stimulatory signals. Activation-induced cell death plays an essential role inboth central and peripheral deletion (clonal deletion) events
involved in self tolerance and homeostasis [Z4].
2.

Review of published data

163. In 30 patients who were treated with 12 Gy(fractionated) of WBI, it has been reported that T- and­B-lymphocytes showed a sharp radiation-induced decrease,with ­B-lymphocytes being the most sensitive population[C11]. CD3+ CD4+ CD45RO+ (memory helper T-cells),
CD3+ CD4+ CD45RA+ (naive helper T-cells), CD4+
and CD8+ cells appeared equally sensitive. The CD34+
cell ­subset (progenitor/stem cells) remained basicallyunchanged, and the CD3– CD56+ CD16+ (an NK cellsubset) was relatively radioresistant compared with theother lymphocyte subsets. This study provides evidence
that T- and B-cell subsets seem to be highly radiosensitive in vivo, while progenitor/stem cells and NK cells seemto be more radioresistant. Similar findings were reported
in eight patients undergoing external beam radiotherapy
to the pelvis [L21]. NK cells were the most radioresistantand B-cells the most radiosensitive lymphocytes. No significant differences between helper T-cells and suppressor/
cytotoxic T-cells were observed.
164. Data concerning the radiosensitivity of CD4+ helper–
inducer and CD8+ cytotoxic T-cells are controversial. Several factors (e.g. the radiation dose, the end point selected
and the time period over which this end point is evaluated)
could modify the findings. The tendency to spontaneousand radiation-induced apoptosis of lymphocyte subpopulations differs among individuals. In addition, age and sex
are ­factors that may influence the apoptotic response [S8].
Nakamura et al. did not find any difference in the radiosensitivity of CD4+ and CD8+ cells [N4]. By using an in vitro
lymphocyte colony assay, they demonstrated that D10 (thedose required to reduce the surviving fraction to 10%) was
similar for these two types of cell: 3.13 ± 0.10 Gy (mean± SD) for CD4+, 3.34 ± 0.50 Gy (mean ± SD) for CD8+ and3.14 ± 0.17 Gy (mean ± SD) for unsorted cells.
165. Several studies have considered B-cells to be moreradiosensitive than T-cells [P12, R5, S8, V1, W14]. However,taking into account the spontaneous apoptosis of each different lymphocyte subpopulation, Wilkins et al. [W4] arrived
at a different conclusion. Using the modified neutral cometassay (MNCA) they demonstrated that, following 1 Gy of
low-LET radiation, CD8+ T-cells had the highest radiationinduced apoptotic fraction, followed by CD4+ T-cells.
166. Crompton and Ozsahin [C17], using a method basedon assessment of DNA internucleosomal degradation
through flow cytometry, demonstrated that CD8+ T-cells

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

were the most radiosensitive population, followed by
CD19+ B-cells. For interpreting these results, it should betaken into account that the frequency of radiation-induced
apoptosis was calculated by subtracting the fraction of apoptotic cells at 0 Gy (spontaneous apoptosis) from the fraction
induced by the radiation treatment of samples. Although
the results were identical to those reported by Stewart et al.
[S30], it is important to keep in mind that the latter studies
were ­performed using high-dose-rate irradiation.
167. Reports concerning the effects of ionizing radiation
on NK cells have been contradictory. As NK cells exhibit
so large a degree of interindividual variability, it is difficult to reach firm conclusions concerning the effect ofionizing radiation on this lymphocyte subpopulation. Sekiet al. [S11] reported that NK cells were the most radio­
sensitive in vitro and that CD8 cells and B-cells showed
lower susceptibility to radiation, whereas CD4+ cells wererelatively radioresistant. On the other hand, Mori and
Desaintes reported that, among peripheral blood lymphocyte subpopulations, NK cells are more highly resistantin vitro to ionizing radiation than are T- and B-lympho­
cytes [M28]. In exploring the potential radioprotective
effect of different types of cytokine on radiation-induced
apoptosis, it was shown that IL-2 inhibited the apoptosisof NK and that IL-2, IL-4 and IL-7 were able to rescue
both CD4+ and CD8+ T-cells from radiation-induced
cell death [S11]. The viability of B-cells in culture wasmaintained by the presence of IL-4 but not by other cytokines. The authors speculated that the protective effect byeach cytokine might be attributed in part to an enhancement of cellular induction of the expression of the bcl-2
protein family. However, while overexpression of bcl-2
leads to the inhibition of cell death [V5], it is important toremember that there exist in the immune system apoptotic
pathways unaffected by bcl-2 expression, such as the
CD-95-mediated pathway [S31].
168. Fuggetta et al. have shown impaired NK activity invitro after gamma irradiation (20 Gy) [F6]. IFN-β (200 IU/mL) was able to completely reverse this inhibitory radiationinduced effect, but was not able to modify the number of
CD16+ and CD56+ cells that died by apoptosis after irradiation. Concerning in vivo radiation exposure, no changes
in NK cell activity were found in 1,341 atomic bombing­survivors residing in Hiroshima [B5].
169. The molecular basis of the differential radiation sensitivity among lymphocyte subpopulations remains unclear[M29]. It has been proposed that the higher radiosensitivity of B-lymphocytes is due to a lower activity of DNA­dependent protein kinase (DNA-PK) in these cells [M14].
Also, the radiosensitivity of lymphocyte subsets has been
related to intrinsic differences in basal expression level of
specific genes, particularly those related to Bcl-2 family
genes such as Bax, Bcl-2 and Bcl-X [I11].
170. However, a recent study using microarray analysis demonstrated that basal gene expression does not

123

account for differential lymphocyte radiosensitivity. Moriet al. [M29] investigated the profile of gene expressionin peripheral lymphocytes 8 hours after in vitro X‑ray
irradiation. Cell suspensions of magnetically purified
lymphocyte subpopulations were irradiated with a doseof 1 Gy at a dose rate of 0.3 Gy/min. A total of 18,433
unique sequences were screened for their transcriptional response to ionizing radiation. The authors found
102 genes whose expression was modulated by radiation exposure: 75 were up-regulated and 27 were downregulated. The most strongly activated genes belonged to
apoptosis, cell cycle and DNA repair functional classes,with a clear predominance of the p53 pathway. The authors reported no difference in the basal level of expressionof the proapoptotic genes among lymphocyte subsets. In
contrast, their levels of activation following exposure to
X-rays differed among cell subtypes. For example, Bax
expression levels increased in lymphocytes in the following order: NK cells < CD4+ T-cells < CD8+ T-cells <CD19+ B-cells, reflecting their differential radiosensi­
tivity [M29]. On the other hand, the expression level of
the TNFR gene in irradiated cells did not differ among
these lymphocyte subsets.

3.

Remarks concerning the radiosensitivity
of lymphocyte subsets

171. The data presented in the preceding paragraphs indicate that the radiosensitivity of lymphocyte subsets, in termsof the radiation dose required to induce a defined percentage
of cell death, depends on several factors:− Lymphocyte subset under study;− Irradiation performed on resting or activatedlymphocytes;− Degree of differentiation;− Irradiation performed on sorted or unsorted
subpopulations;− Influence of cytokines;− Spontaneous apoptosis exhibited by the subset
under study;− Age and sex of the donors
172. B-lymphocytes (CD19+) seem to be the most radiosensitive subset, both in vivo and in vitro. However, whenestimation of radiation-induced apoptosis is performed bysubtracting spontaneous apoptosis, CD8+ T-cells exhibit
higher radiosensitivity. Most of the data show no difference
in radiosensitivity between CD4+ and CD8+ T-cells. WhileNK cells are relatively radioresistant in vivo, particularly theCD56+ CD16+ NK subset, data concerning in vitro irradiations are more controversial. The level of radiation-induced
activation of apoptosis-related genes differs among these
subsets, probably reflecting their differential radiosensitivity, as follows: NK cells < CD4+ T-cells < CD8+ T-cells <CD19+ B-cells.

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F.

Alterations of the immune response
after prenatal irradiation

173. Radiation-induced impairment of both humoral antibody and cell-mediated responses have been reported innumerous experimental and epidemiological studies. However, very few data are yet available concerning radiation
effects on the immune system following in utero exposure.
These data mainly concern numerical or structural changes,
and thus they cannot be directly related to effects on the
immune function. The developing haematopoietic system isvery sensitive to ionizing radiation. The mammalian embryonic haematopoietic system becomes functional in the yolksac during organogenesis; in parallel, additional haematopoietic activity takes place in the aorta, gonads and mesone­
phros. Later the function shifts to the foetal liver and spleen,
and finally to the bone marrow [T11, U16]. Foetal liver
haematopoiesis is first detectable at about the sixth week ofgestation in humans. Although the spleen has largely ceased
haematopoiesis in humans by the time of birth, it may regainhaematopoietic function in abnormal situations [H27].
1.

Animal data

174. Grande and Bueren irradiated mice at different stagesof development with a single dose of 500 mGy of X-rays.
Mice irradiated on days 13 and 17 post-conception showed asignificant reduction in the proportion of femoral bone marrow granulocyte–macrophage colony-forming units (CFUGM) one year after irradiation. This effect was manifested
neither in mice irradiated on day 4 post-conception nor inthose irradiated in early post-natal life (2 days, 8 days and
12 weeks old) [G6]. The effects of ionizing radiation on theembryo/foetus may differ according to the developmental
stage at which the exposure takes place. In this study, theimpairment in the CFU-GM population was observed whenmice were irradiated after midgestation. As seen in figure VI,
this is the period of haematopoetic progenitor cell expansion(day 13) and bone marrow and thymus colonization (day 17)
in rodents. This study indicates that, for most stages of development in the mouse, a single acute dose of X-irradiation of
500 mGy is below the threshold dose capable of inducing
deterministic effects in the mouse haematopoietic system,
although it reveals the induction of a significant impairment
in the CFU-GM population when irradiation is given at thelate stages of embryonic development.
175. Haematopoiesis is the product of two components:
the haematopoietic tissue and the regulatory stromal microenvironment in which it resides. The role of both components in radiation-induced haematopoietic effects remains
controversial. Yang et al. [Y3] proposed that irradiation at
midterm gestation damages the developing regulatory microenvironment but not the haematopoietic stem cell populationthat it hosts. To demonstrate this, the authors used an experimental model of prenatal irradiation in combination withcross-transplantation experiments. They found that 1.8 Gyof gamma irradiation given to mice at midgestation caused

a 40% reduction in the haematopoietic stem cell population(CFU-S), which persisted up to at least 6 months of age.
Spleen colony formation after sublethal doses of gamma
rays reflected this reduced complement of endogenous stem
cells. The regulatory haematopoietic microenvironment,
measured as fibroblastoid colony-forming cells (CFU-F),
was similarly depleted. The quality of the stem cell population in the offspring of irradiated mothers was not affected,
since normal growth of the CFU-S population was observed
after transplantation into standard recipients. In contrast,
when used as recipients of a bone marrow transplant fromeither normal or irradiated offspring, the offspring of irradiated mothers were unable to support normal growth. Compared with ­normal offspring, there were 70% fewer CFU-F in
the femur 1 month after bone marrow transplantation when
the offspring of irradiated mothers were used as transplant
recipients. This confirmed a reduced capacity to host normal
stem cells and also indicated that CFU-F in the transplant
were unable to compensate for the poor microenvironmentin irradiated ­offspring hosts.
176. The developing haematopoietic tissues are very sensitive to 239Pu contamination. Mason et al. [M1] studied postnatal haematopoietic function in the offspring of pregnant
mice injected with 30 kBq/kg of 239Pu at 13 days of gestation. The maximum dose (10–14 mGy) was absorbed in
the liver. A long-term deficit in the number of haematopoietic colony-forming cells (CFU-S) in the spleen, liver andbone marrow was observed. The development of the stromal
microenvironment was also deficient, suggesting sublethal
damage in those cells destined to become the precursors of
the supportive haematopoietic microenvironment.
177. Platteau et al. [P9] looked for medium-term effects in
the immune system of rats following 0–2 Gy prenatal or earlypost-natal WBI. They did not find changes in the histology ofthe spleen, profiles of lymphocyte subpopulations or serum
immunoglobulin levels. At an age of 10 weeks, rats were
immunized with a T-dependent or a T-independent dinitrophenylated carrier antigen. T-dependent response was higher inrats irradiated between days 6 and 20 of gestation; however, thisincrease was significant only for IgM and IgG1 responses.
178. Nold et al. [N14] demonstrated that dogs irradiatedprenatally with 1.5 Gy (60Co gamma irradiation) on day
35 of gestation exhibited lower primary humoral antibody
responses to a T-dependent antigen (sheep red blood cells),
with a decrease in helper T-lymphocyte subpopulations inperipheral blood. Moreover, they found defects in epitheliostromal development of the thymus and concluded that theobserved immune alterations could be related to radiationinduced prenatal thymic injury.
179. Thymocytes are either negatively selected as poten­
tially autoreactive and deleted, or positively selected to
become mature cells. In addition to the signal mediated by
the T-cell receptor (TCR), other signalling pathways also
regulate this developmental selection. It has been demonstrated [N12] that the CD28 receptor, which plays a role inANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

enhancing the survival and expansion of peripheral T-cells, isalso involved in negative selection in the thymus. Developing
thymocytes of CD28-deficient and wild-type mice displayed
similar radiosensitivity in terms of apoptosis, but negative selection was significantly reduced in the former, thus
suggesting that CD28 receptor involvement in thymus
development is not related to regulation of cell survival.

in haematopoiesis in the growing foetus. Post-natal, thebone marrow becomes the main haematopoietic organ; thespleen and liver have ceased their function by the time ofbirth or soon after.
182. During the intrauterine ontogenesis of the immune
system, apoptosis plays a central role in thymus development. A distinction should be made between developmental
and radiation-induced lymphocyte apoptosis. While apoptosis during T-cell maturation is p53-independent, p53 protein
is a critical mediator of apoptosis in response to genotoxic
agents such as ionizing radiation. Immature cortical thymocytes are characterized by a double-positive immunophenotype, CD4+ CD8+ TCRlow. The interaction between immature thymocytes and thymic reticuloendothelial cells induces
positive selection of T-lymphocytes that are not activatedby self HLA molecules, thus promoting tolerance induction. T-lymphocytes that do not undergo positive selection
are killed by apoptosis. Immature thymocytes also undergo
negative selection when thymic stromal cells eliminate selfreactive T-lymphocytes by apoptosis [K1].

180. Miller and Benjamin [M6] have studied radiationinduced alterations in prenatal thymic development in the
beagle dog. They found that injury to both thymic cortices
and medullas was greater following exposures earlier in gestation. Damage to medullas was relatively more severe thanin cortices following exposure at any given age. The degreeof reduction of medullar volume reflected thymic epithelial injury, which is surprising since the thymic epithelium isconsidered in the adult to be radioresistant. Such injury may
have serious post-natal consequences, as normal differentiation of T-cell subpopulations is dependent upon the integrity of the thymic microenvironment. Damage to the thymic
microenvironment could result in immunodeficiencies anddefects in immunological regulation.
2.

183. As seen in animals, the effects of ionizing radiation on
the human embryo/foetus may differ according to the developmental stage at which the exposure takes place. The definitionof critical windows in the development of the immune system
may allow identification of periods of special vulnerability. On
the basis of known developmental changes occurring within
the immune system, Dietert et al. proposed a relative timeline
for critical windows in the developing human immune system[D5]. A parallel approach for the development of rodent andhuman immune systems is shown in figure VII.

Human data

181. Human foetuses are thought to be highly sensitive
to ionizing radiation. However, human data concerning
the effects of prenatal irradiation on the immune system
are scarce. In humans, haematopoietic activity begins in
the liver by six weeks of gestation and continues until one
week of post-natal life. The spleen also plays a major role

Figure VII. Critical windows of toxic exposure for the developing immune system in rodents and humans.
Gestation: 21 days for rodents, 38 weeks for humans (adapted from reference [D5]).

Rodents
Days 7–9

Days 9–13

Day 13–birth

Birth–30 days

30–60 days

HumansWeeks 8–10

Weeks 10–16

Week 16–birth

Birth–1 year

1–18 years

Stem cell
formation

Progenitor
cell expansion
and tissue
migration

Bone marrow
and thymus
colonization

Perinatal
immunematuration

Immunememory isestablished

Conception

125

Birth

Sexualmaturity

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184. Prenatal events can affect the immune response at birthand, depending on gestational timing, can result in widely
varied outcomes. The potential outcomes of toxic exposures
to the developing immune system may derive from suppression, perturbation or up-regulation of the immune response,
leading to immunodeficiencies, autoimmunity or hypersensitivity reactions, respectively. Moreover, prenatal damage to the thymus would have a more profound effect thanpost-maturational damage. Similarly, prenatal destruction ofabundant pluripotent stem cells may have a more harmful
outcome than destruction of single lineages or differentiatedcells, which predominate in adults [H14, H27].

− Prenatal radiation-induced damage in the thymus
is more severe for the medulla than for the cortex;

185. Ohtaki et al. evaluated the frequency of stable aberrations (translocations) in blood samples from 150 survivors of
the atomic bombings at Hiroshima and Nagasaki who were
exposed in utero to doses of ≥5 mSv and from 181 controls(dose < 5 mSv). Foetal doses were approximated by the doseto the maternal uterus. The mean age of subjects at the timeof sampling was 40 ± 0.7 years. The investigators did not finda dose response but did find a small increase in translocation frequency at doses of <100 mSv, with a peak response at~30 mSv, at which the net increase in translocation frequency
was ~0.4%. There was no evidence for an effect of gestational age in the estimated coefficients. These findings wereexplained with the hypothesis that the human foetal lymphoidprogenitor pool comprises two subpopulations with different
radiosensitivity. A major fraction exhibits radiation resistance.
The other subpopulation, small in number, was consideredsensi­tive to the induction of both translocations and cell killing,and ­diminished rapidly ­following doses of >50 mSv [O9].

187. As seen, DNA recombination processes not only
account for immune diversification but also constitutea major checkpoint in the development of lymphocytes[D26]. Defects in V(D)J recombination lead to immunodeficiency, and a deregulation of this process may result inhigher sensitivity to genotoxic agents and increase the risk ofmalignancies.

3.

Remarks concerning the effects of prenatal irradiation

186. On the basis of the preceding paragraphs, the following remarks may be made concerning the effects of prenatal
irradiation on the immune system:− The developing immune system is very sensitive
to ionizing radiation;− There are critical windows of special vulnerability of the prenatal immune system;− The effects differ according to the developmental stage at which the irradiation takes place; forexample, a dose of 500 mGy given to mice inearly pregnancy has no effect, whereas the same
dose given after midgestation results in significant
depletion of bone marrow precursors 1 year later;− Developing haematopoietic tissues are very sensitive to 239Pu contamination: even doses of around
10 mGy are capable of inducing a long-term­haematopoietic deficit;− Radiation-induced impairment of the developing
stromal microenvironment accounts, at least inpart, for these long-lasting effects;− Prenatal thymic injury is greater following­irradiation in early pregnancy;− Human foetal lymphoid progenitors include amajor subpopulation that is relatively radioresis­
tant and a minor subpopulation that is very radiosensitive to the induction of both translocations
and cell killing.

G. Immune dysfunction and hypersensitivity
to ionizing radiation

188. The understanding of the mechanisms involved in thedevelopment of human pathologies exhibiting immune dysfunction and higher radiosensitivity may be relevant in thecontext of the effects of ionizing radiation on the immune­system. There exist a number of human genetic disorders characterized by chromosomal instability that are associated witha higher incidence of cancer. Both the chromosomal instabilities and the neoplastic outcomes are related to abnormalities
of DNA metabolism, DNA repair, cell cycle regulation orcontrol of apoptosis. Among them there are several disorders
associated with defects in the immune system and increased
susceptibility to radiation, including UV and ionizing radiation [B9]. These observations are especially relevant because
they are at the crossroads of basic cellular mechanisms,
combining immunodeficiency, increased rate of cancer, anddefects in DNA repair and pathways known to be associatedwith hypersensitivity to radiation. Other pathological conditions involving immune dysfunction, such as autoimmune
diseases and acquired immunodeficiency ­syndrome (AIDS),
could be also associated with higher radio­sensitivity. Becauseof the double condition of hypersensitivity to radiation andimmunodeficiency, the radiation effects on the immune­system may be more severe in these patients.
1.

Human genetic disorders

189. Abnormal DNA repair and cell death regulation may
result in higher vulnerability to ionizing radiation. Several
human genetic disorders associated with defective DNA
repair present functional abnormalities in the immune ­system.
Some of them exhibit increased susceptibility to radiation. If
individuals with such disorders undergo radiotherapy, they
may develop adverse side effects in normal tissues, such asacute effects appearing during or shortly after treatment, or
late effects developed months or years later. Some of thesegenetic disorders are reviewed below and are summarized intable 10.

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127

Table 10 Human genetic disorders with immune system defects and increased susceptibility to radiation
Disease

Defective
mechanisma

Mutated gene

Xeroderma pigmentosum

NER(+/– TCR)

Trichothiodystrophy

Sensitivity tob
UV

Ionizing radiation

XP-A, XP-B, XP-C, XP-D, XP-E,
XP-F, XP-F/ERCC1, XP-G

(+++)

?

NER/TCRTFIIH-related XP-D and XP-B

(++)

?

TLS

hRAD30(+)(+)

Ataxia telangiectasia
homozygote

DSB cell signalling

ATM (–/–)(++++)

Ataxia telangiectasia
heterozygote

DSB cell signalling

ATM (+/–)(+)

Ataxia-telangiectasia-like
disorderDSB cell signallinghMRE11(++++)

Nijmegen breakage syndrome

DSB cell signalling

NBS1 (nibrin)(++++)

Fanconi anaemia

Cross-linking repair and HR

FANC-A, FANC-B, FANC-C,
FANC-D1/BRCA2, FANC-D2,
FANC-E, FANC-F, FANC-G(++)

Bloom’s syndrome

HR/TLSBLM RecQ helicase

Wiedemann–Rautenstrauch
syndrome

Neonatal progeria

WRS

Hutchinson–Gilford syndrome

Progeria infantum

HGPS (lamin A)

(++)

(++)

Cockayne syndrome

NER/TCR (youthful progeria)

CS-A and CS-B

(++)

(?)

Werner’s syndrome

HR/TLS (adult progeria)

WRN RecQ helicase

(+)

(+)

Severe combined
immunodeficiency (SCID)

V(D)J/NHEJ

Artemis(+++)(SCID with increased
radiosensitivity)

Immunodeficiency withmicrocephaly

NHEJ

Ligase IV
Cernunnos/XLF(++++)

Seckel syndrome

DSB cell signalling

ATR

(+++)

Dyskeratosis congenita

Telomere metabolism

Dyskerin/hTR(++)

Hyper-IgM syndromes

Class switch recombination

Uracil-N-glycosylase (UNG)(++)

Xeroderma pigmentosum
variant(+)?
?

a	NER = nucleotide excision repair; TCR = transcription-coupled repair; DSB =double-strand break; HR = homologous recombination; TLS = translesion
synthesis; NHEJ = non-homologous end joining.

b	Increasing number of + symbols means increasing degree of radiosensitivity. Query symbol (?) means probably radiosensitive but radiosensitivity notdemonstrated.

190. Xeroderma pigmentosum (XP) is an autosomal recessive disease with defective nucleotide excision repair (NER)
characterized by severe sensitivity to all types of UV radiation. The NER pathway recognizes and removes UV-induced
DNA lesions. XP is characterized by cutaneous and ocularabnormalities, predominantly on sites exposed to sunlight,
and in some cases by neurological features resulting fromprogressive neuronal loss. Expression in skin includes disposition for sunburn, pigmentary abnormalities, telangiectasia, dryness, scarring, and susceptibility to multiple benign
and malignant neoplasms, including basal and squamouscell carcinomas and melanomas [L7]. A variety of immune
abnormalities have been described in XP patients: decreased

delayed-type hypersensitivity reactions, decreased T-cellproliferative responses to mitogens, decreased CD4/CD8
ratio and impairment of NK cell activity [G19, L6, N21,
N22, W15]. XP is categorized in at least eight genetic subtypes labelled A to G, plus the F/ERCC1 group. While both
XP-A and XP-C can be attributed entirely to defects in
NER, the other complementation groups involve defects inother DNA repair mechanisms [L6]. Some XP patients incomplementation group E (XP-E) lack UV-damaged-DNAbinding protein (UV-DDB), which is present in healthy individuals and in patients in other XP complementation groups.
UV-DDB protein is composed of two subunits, DDB1 and
DDB2. In vivo, UV-DDB protein plays an important role

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in the ­p53-dependent response of mammalian cells to DNA
damage. When cells are exposed to UV, the resulting accumulation of p53 activates DDB2 transcription, which leads
to increased levels of UV-DDB. A linear dose response foractivation of DDB2 and XPC genes has been demonstrated
following exposure of peripheral blood lymphocytes to dosesof gamma rays as low as 0.2 Gy [A21].
191. The cells of xeroderma pigmentosum variant ­(XP-V)
patients are only slightly more sensitive than normal cells
to the killing action of UV radiation. The XP-V cells are
NER-proficient but present a deficit in translesion DNA
synthesis, with an increased probability of being blocked
at a DNA lesion [C31]. Defects in translesion synthesis(TLS) due to mutations in the damage-specific polymerase hRAD30 (polymerase η) are responsible for the UVhypermutability of XP-V cells leading to skin cancers[K38]. It has been proposed that sunlight carcinogenesis in
XP-V patients may be associated with increased genomic
rearrangements that result from double-strand breaks andrejoining in cells of the skin in which p53 is inactivated by
UV-induced mutations [L12].
192. Trichothiodystrophy (TTD) refers to several autosomal recessive diseases whose diagnostic hallmark is short,brittle hair low in sulphur and cysteine because of impaired
synthesis of high-sulphur matrix protein [L7, S38]. The clinical symptoms associated with TTD, such as ichthyotic skin,neurodegeneration and developmental disorders, represent avariable range of abnormalities in organs derived from theectoderm [L7]. The majority of TTD patients exhibit photosensitivity because their NER pathway does not remove UVinduced DNA lesions efficiently. Although their deficiencies
result mainly from mutations in either XP-B or XP-D, TTD
patients do not present skin cancer susceptibility [C27, S38]
and also do not exhibit hypersensitivity to ionizing radiation. Although some abnormal immune parameters havebeen found in TTD patients [C19, N22, R10], immune deficiency is not a common feature of TTD. However, the finding of additional TTD patients combining features of XP and
Cockayne syndrome indicates that there may be considerable clinical heterogeneity with phenotypic overlap.
193. Bloom’s syndrome belongs to a family of hereditarydiseases caused by defects in genes belonging to the RecQ
family of DNA helicases, which play a role in regulatinghomologous recombination. Bloom’s syndrome patients,
who exhibit a mutation in the BLM gene, are hypersensitive
to UV and exhibit abnormal replication patterns following
DNA damage. They present sun-induced rash, immuno­
deficiency, subfertility and cancer predisposition [K4]. Oneof the defining features of cells from Bloom’s syndrome
individuals is chromosomal instability, characterized bychromosomal breaks, deletions and rearrangements, as wellas elevated levels of sister chromatid exchange.
194. Ataxia telangiectasia (AT) is an autosomal recessive
multisystem disorder with early-onset cerebellar ataxia, conjunctival and cutaneous telangiectasia, and immunodeficiency

as its main clinical features. AT patients are prone to cancer
development and are unusually sensitive to ionizing radiation. They carry a mutation in a gene involved in DNA damage signalling [J9], called the ataxia-telangiectasia-mutated(ATM) gene. Only homozygous AT patients present the typical clinical features described above. Homozygous AT is themost common cerebellar ataxia in children under 5 yearsof age, with a prevalence of 1 in 100,000 live births [S48].
Progressive cerebellar ataxia becomes apparent as early as
the first year of life. Oculomotor abnormalities may also be
seen. Telangiectases appear after onset of the neurologicalsyndrome and are progressive.
195. AT affects both TCR and Ig genes, thus explaining theimmunodeficiency observed in AT patients. Moderate cellular and humoral immunodeficiency, with low levels of certain
Ig classes, in conjunction with difficulties in swallowing, leadto frequent pulmonary infections in AT patients. Peripheral
lymphocytes from AT homozygotes show elevated chromosomal rearrangements, which preferentially involve chromosomal breakpoints within TCR genes, mainly at 14q11(TCR-α and -δ), 7q14 (TCR-γ) and 7q35 (TCR-β) [T2]. Telomere shortening and fusions, with normal telomerase activity,
have been observed in peripheral blood lymphocytes of thesepatients [T2]. AT patients show progeroid features, such as
strands of grey hair or keratoses, which have been related toaccelerated telomere shortening [P2]. Endocrine defects typically result in gonadal abnormalities and retardation in somatic growth. Some patients develop ­insulin-resistant diabetes,
which has been attributed to antibodies directed against insulin receptors [S48]. Many homozygous AT patients develop
cancer, mostly lymphoid malignancies of both B-cell andT-cell origin, including Hodgkin’s lymphoma, non-­Hodgkin’s
lymphoma and leukaemias [B8].
196. Solid tumours, mainly breast and stomach cancer,
occur more commonly as the AT patient matures, and arebeing seen in greater numbers as these patients are living
longer [H23]. Although plausible, the hypothesis of a higher
risk of radiogenic cancer in homozygous AT patients is notsupported by solid data. In contrast, the hypersensitivity todeterministic effects from ionizing radiation, around three
to fourfold compared with the general population, is wellestablished. Indeed, the treatment of cancer in AT patientswith conventional doses of ionizing radiation may induce
extremely high radiotoxicity, resulting in life-threatening
sequelae. The frequency of heterozygous ATM mutations
among the general population is around 1%. Heterozygous
carriers are neurologically normal. Although some authors
have not found any evidence of abnormal radiotoxicity inheterozygous AT patients [W12], other epidemiologicalstudies have suggested that heterozygous AT women havea predisposition to breast cancer and may exhibit higher
clinical radiosensitivity [A24].
197. Ataxia-telangiectasia-like disorder (ATLD) is due tomutations in the hMre11a gene, involved in DNA doublestrand-break repair. ATLD shares many clinical features with
AT. While abnormalities in B-lymphocytes have not been

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

reported in ATLD, T-lymphocytes show an increased levelof translocations involving the TCR. Both lymphocytes andfibroblasts from these patients exhibit higher radio­sensitivity
in vitro [T2].
198. Nijmegen breakage syndrome (NBS) is a rare autosomal recessive condition characterized by chromosomal
instability, growth retardation, microcephaly, characteristic
facial features, radiosensitivity, immunodeficiency, gonadal
dysgenesis and cancer predisposition. A high proportion of
NBS patients develop lymphoid malignancies, most of B-cellorigin. Fibroblasts and lymphocytes from NBS patients are
3–5 times more sensitive to ionizing radiation and radiomimetic drugs than normal cells, and display radioresistant
DNA synthesis due to an inability to retard S‑phase progression after exposure to ionizing radiation. NBS also involves
inversions and translocations in peripheral T-cells affecting
the genes for the heavy chain of immunoglobulins and theTCR, thus accounting for the immunodeficiency characteristic of this syndrome [D6]. NBS patients carry a mutationin the NBS1 gene, which codes for a protein called NBS-1/
Nibrin, involved in DNA double-strand-break repair.
199. Fanconi anaemia (FA) is a recessive disorder characterized by bone marrow failure, multiple congenitalabnormalities and predisposition to cancer, particularly
to acute myeloid leukaemia and squamous cell carcinoma[R8, T2]. Although FA is considered a genetically and clinically heterogeneous disorder, the genes mutated in FA are
all involved in recruiting and organizing other proteins tocope with DNA damage and participate in the regulationof homologous recombination. FA patients are unusuallysensitive to a variety of clastogens, most prominently DNA
cross-linking agents such as mitomycin C. Moderate to highsensitivity to ionizing radiation and other oxidative stressinducers has been reported in FA patients [D10]. Djuzenova
et al. [D8] observed high initial and residual DNA damage
rates and elevated repair half-time in peripheral blood mononuclear cells from FA patients exposed to X-rays.
200. Human progeria syndromes are rare disorders characterized by premature ageing. Some of these syndromes areassociated with defects in DNA repair pathways and with ahigher susceptibility to DNA damage agents, such as ionizing radiation. According to the age at the onset of symptoms,
human progeria syndromes may be classified as neonatal,
infantum, youth and adult progeria.
201. Neonatal progeria (Wiedemann–Rautenstrauch syndrome) is a rare autosomal recessive disorder usually lethalby 7 months. It is characterized by a triangular, aged-looking
face with prominent veins and sparse scalp hair, and nearly
total absence of subcutaneous fat. These features are apparent at birth and therefore differ from congenital generalized
lipodystrophy.
202. Progeria infantum (Hutchinson–Gilford progeria
syndrome—HGPS) is a rare genetic disorder characterized
by prominent scalp veins, the absence of hair, maxillary

129

hypoplasia, delayed tooth eruption, facial cyanosis, insulindependent diabetes, accelerated ageing and early death, frequently from coronary artery disease. HGPS is caused bymutations in the lamin A gene, placing this syndrome within
the group of “laminopathies” [B29]. The main functions ofA-type lamins include high-order chromatin organization,
nuclear structure maintenance and gene expression control.
Hypersensitivity to gamma radiation has been describedin these patients [W7]. Concerning immune dysfunction,a decreased CD4/CD8 ratio and decreased T-cell response
have been associated with HGPS [H19].
203. Youth progeria (Cockayne syndrome—CS) patientsshow many developmental defects, including mental retardation, microcephaly, long limbs, birdlike face, pigmented
retinopathy, gait defects and sun sensitivity due to a failureof RNA synthesis to recover following UV irradiation [L16],
but without an increased incidence of skin cancer. Two complementation groups (A and B) have been identified in CS
depending on which gene is mutated (CS-A or CS-B); thesegenes encode proteins involved in the transcription-coupled
repair pathway of NER [L16]. Cells from CS patientsaccumulate oxidative-induced DNA lesions after exposure
to ionizing radiation [T16]. Decreased T-cell proliferative
response and decreased serum levels of thymic hormone
have been observed in these patients [B22].
204. Adult progeria (Werner’s syndrome—WS) patientsdisplay age-related disorders, including greying and thinningof the hair, bilateral cataracts, type II diabetes, atherosclerosis, osteoporosis and increased incidence of sarcomas. The
incidence of epithelial cancer and mesenchymal sarcoma is
10 times that of the general population. The incidence of WS
is extremely high in Japan compared with other countries[Y6]. WS patients carry a mutation in the WRN gene, which
encodes a protein belonging to the RecQ family of DNA heli­cases. WS cells exhibit genomic instability, premature senescence, defects in telomere metabolism, and hypersensitivity
to DNA cross-linkers and to ionizing radiation [C25, M17].
The WRN protein is recruited in the radiation-induced DNA
double-strand breaks and collocalizes with the Mre11 andγH2AX complex via binding to NBS1. NBS1 is the genemutated in the Nijmejen breakage syndrome, thus suggestinga functional link between these two genetic syndromeswith partially overlapping phenotypes [C24, C25]. Immune­dysfunction has been found in WS patients [G29, G30, N16].
205. Severe combined immune deficiency (SCID) is themost severe inherited immunological disorder and is caused
by a variety of molecular defects, all affecting at least the
T-lymphocyte population [F16]. Human SCID is characterized by the absence of the T- and B-lymphocytes owing to a
defect in V(D)J rearrangement of TCR and Ig genes [D26].
Mutations in the Artemis gene, which encodes a protein
essential for V(D)J recombination and DNA double-strandbreak repair, cause a variant of human SCID with increased
radiosensitivity (RS-SCID) [L28, M19]. Hypomorphic­Artemis mutations are associated with the development ofB-cell lymphomas [M13].

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206. Immunodeficiency with microcephaly patients, presenting with various degrees of immunodeficiency andgrowth delay, display mutations in the DNA ligase IV
gene, which encodes a protein essential for DNA repair
through non-homologous end-joining (NHEJ) and V(D)J
recombination [B33, O2]. This clinical phenotype closely
resembles Nijmegen breakage syndrome, and cells fromthe patients show pronounced radiosensitivity [O2]. A
new NHEJ factor, Cernunnos, was identified through thesurvey of similar patients with SCID and microcephaly[B34]. This resemblance is not surprising, given the interactions of Cernunnos and DNA ligase IV in a same protein
complex [A26].
207. Hyper-IgM syndromes are primary immunodeficiencies characterized by normal or increased serum IgM levels
contrasting with low or absent IgG IgA, and IgE. They arecaused by a defect in the class switch recombination [D31].
A subset of these patients display defects in DNA repair
genes such as Uracil-N-glycosylase [I12].
208. Seckel syndrome shares features with the above disorders involving impaired DNA damage repair and elevatedradiosensitivity. Seckel syndrome patients have a mutation in ATR, the gene encoding ataxia telangiectasia andRad3-related protein, resulting in failed checkpoint arrest­following exposure to genotoxic agents [A9, O3].
209. Dyskeratosis congenita (DC) is a rare syndromecaused by defective telomere maintenance characterized
by atrophy and reticular pigmentation of the skin, nail dystrophy, leucoplasia of mucosa membranes, hypotricosis,
dysphagia, skeletal abnormalities, mental retardation, bonemarrow failure and predisposition to malignancies [C29].
The major X-linked form of DC is due to mutations in a
nucleolar protein, dyskerin, found in the telomerase complex [D23]. An autosomal dominant form is due to mutations in the RNA component of telomerase (hTR) [S46].
Patients with this form of the disease are more severely
affected in later generations that carry the mutations, possibly owing to the inheritance of shortened telomeres, disguising the inherited nature of the disease, which in somecases is classified as aplastic anaemia. Increased sensitivityof DC cells to ionizing radiation and alkylating agents has
been described [D24]. It was demonstrated that fibroblasts
from DC patients are highly susceptible to X-irradiationinduced chromatid breakage [D18], and hypersensitivity toradiation therapy has been described in these patients [C20].
A severe infantile variant of X-linked DC called Hoyeraal–
Hreidarsson syndrome exhibits increased in vitro sensitivity
to radiation and alkylating agents in circulating lymphocytes
and fibroblasts. Accelerated telomere shortening was also
reported in these patients [M24]. Severe B-lymphopenia
with decreased IgM levels and moderate T-lymphopenia
were observed in autosomal dominant form, probably as
a consequence of replicative failure and premature senescence of lymphocytes, supporting a role of telomerase inimmune homeostasis [K41].

2.

Autoimmune diseases and radiation response

210. DNA damage and its defective repair could be important in the pathogenesis of autoimmune diseases. Impaired
response to oxidative stress has been postulated as anothercondition found in autoimmune diseases [H17, K51]. Bhusate et al. demonstrated that the spontaneous number of DNA
strand breaks in peripheral blood mononuclear cells frompatients with rheumatoid arthritis is significantly increased
compared with those from healthy donors [B24]. Neutrophils
from systemic lupus erythematosus (SLE) patients display
increased spontaneous DNA damage and defective repairof oxidative DNA damage [M20]. Higher sensitivity to oxidative stress has been also described in lymphocytes frompatients with SLE, vasculitis and Behcet’s disease [B20].
211. McCurdy et al. studied DNA repair of peripheral
blood lymphocytes from patients with autoimmune diseases,
irradiated with 1.5 Gy. By using single-cell alkaline gel electrophoresis (comet assay) they observed that lymphocytes
from patients with systemic lupus erythematosus, juvenile
rheumatoid arthritis and systemic sclerosis exhibited delayed
repair of radiation-induced DNA damage compared withlymphocytes from healthy donors [M21]. These findings
were in accordance with a previous study by Harris et al.,who evaluated the lymphocyte responsiveness to mitogens(Con A) following irradiation and found that lymphocytes
from patients with rheumatoid arthritis, systemic lupus erythematosus and polymyositis were more radiosensitive thanthose from healthy volunteers or patients with conditions not
associated with autoimmunity [H6].
212. Cossu et al. evaluated the proliferative responsivenessfollowing irradiation with doses of between 0 and 10 Gy
in peripheral blood lymphocytes from patients affected bysystemic lupus erythematosus in the active and remissive
phases. They compared their results with those found in agroup of normal subjects. Patients in the clinically active
phase of the disease exhibited a decreased responsiveness ofthe total lymphocyte population as well as of the subpopulations of T- and B-cells. Responsiveness from patients in theremissive phase was similar to that of normal subjects. They
concluded that the lymphocytes of patients affected by thisautoimmune disease in the active phase are more radiosensitive than those of patients in the remissive phase of these
diseases [C15]. Greater toxicity from radiation therapy has
been described in patients with collagen diseases, such assystemic lupus erythematosus, polymyositis, dermatomyos­
itis and scleroderma, manifested as significant acute toxicity
and severe late effects [M12].
3.

Ionizing radiation and acquired
immune deficiency syndrome

213. A higher incidence of several cancers, e.g. Kaposi’s
sarcoma, non-Hodgkin’s lymphoma, conjunctival squamous
carcinoma and Hodgkin’s disease, has been observed inpatients with acquired immunodeficiency syndrome (AIDS).

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

Since there is accumulating evidence that AIDS patients
exhibit higher radiosensitivity, the effects of ionizing radiation on the immune system may be relevant in medical practice when radiotherapy is administrated to AIDS patientswith cancer [S53].
214. Enhancement of the human immunodeficiency virus
type 1 (HIV-1) by heterologous viral, chemical and physicalagents has been shown both in vitro and in vivo. Exposureof AIDS patients to ionizing radiation (for example during radiation therapy) could play a role in activating HIV-1
in vivo. Faure et al. demonstrated in lymphoid cell linesthat HIV long-terminal-repeat-directed gene expression is
activated by X-irradiation in a dose- and time-dependent
manner [F2].
215. Stress agents such as ionizing radiation could directly
activate HIV-1 virus replication or reporter gene expression. The kappa B regulatory elements seem to be involvedin this up-regulation [F1]. Antioxidant drugs inhibit thiseffect, which suggests that reactive oxygen species (ROS)
are involved. Taher et al. found that ionizing radiation, at
both low and high doses, stimulates HIV gene expression
to a lesser extent and with different kinetics than does UV
radiation [T1]. While UV activation was completely blockedby p38 MAP kinase inhibition, activation by ionizing radiation was reversed by MAP kinase/MEK inhibition. Thisfinding suggests that ionizing radiation modulates HIV gene
­expression by this latter signalling pathway.
216. Integrase-induced host DNA damage associated with
HIV-1 infection elicits DNA damage signalling. Waninger et
al. have established that the DNA-PK is involved in HIV-1
replication, suggesting that the NHEJ pathway, involved inrepair of radiation-induced DNA double-strand breakage,is required to support efficient retroviral infection [W8]. In
addition to DNA-PK, Lau et al. have recently presented evidence that ATM kinase activity has an important role in HIV-1
infection. By using a specific ATM inhibitor (KU-55933),
they demonstrated that ATM is required for HIV-1 replication in NHEJ-proficient cells [D14, L24]. A direct correlation exists between apoptosis and HIV gene expression in
T-cells in response to ionizing radiation exposure. Caspases
seem to be involved in ionizing-radiation-induced activationof HIV, since caspase inhibitors abolish both apoptosis andHIV gene expression [O1]. However, triggering of apoptosis is not sufficient to induce HIV gene expression, since inother cell types (e.g. carcinoma cells), ionizing radiationinduces apoptosis but does not enhance HIV expression.
217. Higher morbidity associated with radiation therapy
has been reported in HIV-1+ patients [S25], although themechanisms involved in this response remain controversial. It has been postulated that the pattern of immune dysregulation present in these patients could play a role in theirabnormal response to ionizing radiation. Cells infected with
HIV-1 exhibit down-regulation of the DNA repair gene DNAPKcs and other cell-cycle-related genes, suggesting that
impairment of DNA repair and dysregulation of cell cycle

131

checkpoints may be involved in the higher radiosensitivityof AIDS patients [S53]. Decreased levels of major endogenous antioxidant systems have been seen in HIV-1 disease,including lower levels of glutathione and decreased levelsof superoxide dismutase and catalase [B13]. The state ofchronic immune activation secondary to HIV-1 infection andthe ­frequent secondary or opportunistic infections (as well
as reactions to other antigenic products) lead to a constantstate of oxidative stress. ROS generated by ionizing radiation
might trigger additional oxidative stress in these patients.
4.

Remarks concerning human pathologies with immune
dysfunction and hypersensitivity to ionizing radiation

218. As described in the preceding paragraphs, the identification of human pathologies in which immunodeficiency is
associated with higher radiosensitivity is relevant, because
the effects of ionizing radiation on the immune system may
be more severe in these patients. Table 10 summarized themain human genetic disorders in which immune dysfunction
is associated with hypersensitivity to ionizing radiation. The
mutated genes and the defective mechanisms that accountfor these disorders are also presented in this table. The data
indicate that ataxia telangiectasia, ataxia telangiectasia-likedisorder, Nijmegen breakage syndrome, severe combined
immune deficiency, ligase IV and Cerunnos deficiencies,
and Seckel syndrome are the disorders exhibiting a very highradiosensitivity. To a lesser extent, higher radiosensitivity
has been proven for xeroderma pigmentosum variant, Fanconi anaemia, progeria infantum and adult, and dyskeratosis
congenita. Concerning the other conditions described, theirprobable hypersensitivity to ionizing radiation has not yet
been demonstrated.
219. Defective DNA damage repair and impaired responseto oxidative stress seem to be involved in the pathogenesis of
autoimmune diseases. Lymphocytes of patients in the active
phase are more radiosensitive than those of patients in theremissive phase of these diseases.
220. Concerning AIDS, ionizing radiation activates humanimmunodeficiency virus (HIV-1) replication. Higher radiotoxicity is observed in AIDS patients, probably owing not
only to immune dysregulation but also to impairment of DNA
repair combined with a chronic state of oxidative stress.
H. Summary
221. This section has summarized the influence of dose,
dose rate and radiation quality on radiation effects on the
immune system. Data concerning the radiosensitivity oflymphocyte subsets and the immune effects of prenatal­irradiation were reviewed. Human immune pathologies
associated with radiosensitivity were summarized.
222. Activation of the immune function by low-dose
irradiation has been mainly demonstrated in splenic and132

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thymic lymphocytes from some strains of animals. Lowdose enhancement of the immune response is mainly seen
in T-lymphocytes, particularly in CD8+ T-cells. This effect,
which has not yet been demonstrated in humans, seems totake place within a very narrow dose range. While a doseof 20 mGy (acute exposure) induces immunoenhancement
in rodents, changing the dose to 200 mGy induces a shift
towards immunosuppression. The same dose (200 mGy)administered using a protracted schedule exhibits immuno­
enhancing properties. However, this effect may vary according to the age and strain of the animal. The suppressive effectof low-dose irradiation on tumour growth has been reported
in animal models. An adaptive response to radiation in the
immune system seems to be related to a reduction of apoptosis and an enhanced capacity to repair DNA ­damage. Evenat very low doses, tritium incorporation appears to havea higher RBE. The long-term impact of low doses on the
immune functions related to human health remains to be
determined.
223. Concerning high doses, minimal depression of leucocyte counts may be observed following acute WBI in therange 0.5–1 Gy. Acute radiation syndrome occurs after acute
whole-body or significant partial-body exposure of >1 Gy.
The kinetics and severity of immunosuppression depend on
the whole-body dose. In non-uniform exposures, temporal
blood cell parameters are more relevant for dose estimation
than the magnitude of cytopenia. Reconstitution of innate
immunity is more rapid than that of acquired immunity.
Humoral recovery precedes T-cell reconstitution, which
includes both thymus-dependent and thymus-independent
pathways.
224. Radiation-induced changes in immune parameters
seem to be more dependent on total dose than on dose rate.

The RBE of high-LET radiation differs, depending on theend point considered. Some cell types exhibited differencesin the response to proton versus photon radiation, proton
irradiation inducing more significant immunosuppression.
Lymphoid cells and tissues are markedly affected by highLET radiation at relatively low doses in terms of cell depletion and organ size, whereas neutron RBE is close to unity
for the induction of lymphocyte apoptosis. Radon exposure
induces marked changes in thymus subpopulations and alters
molecules involved in the migration and homing of immune
cells.
225. Although the radiosensitivity of lymphocyte subsets
depends on several factors related to the experimental conditions, the data reviewed indicate that B-lymphocytes are
the most radiosensitive subset and that NK cells are moreradioresistant.
226. There are critical windows of special vulnerability forprenatal irradiation of the immune system, and the effects
differ according to the developmental stage at which the irradiation takes place. Radiation-induced damage to the developing thymus and haematopoietic stromal micro­environment
account, at least in part, for the observed effects.
227. The identification of human pathologies in which
immunodeficiency is associated with higher radiosensitivity
is relevant, because the effects of ionizing radiation on the
immune system may be more severe in patients with these
disorders. Delayed repair of radiation-induced DNA damage
and increased lymphocyte radiosensitivity have been foundin patients with autoimmune diseases. AIDS patients exhibit
higher radiotoxicity. Ionizing radiation activates HIV-1 replication, and bystander effects involving reactive oxygen
species seem to be involved in this activation.

III.

possible MECHANISMS INVOLVED AND IMPLICATIONS

228. In order to better understand the findings described in
section IV (Epidemiological studies), this section ­summarizes
some mechanisms that are probably involved in radiationinduced alterations of the immune system. Mechanisms ofcancer development and the possible roles of the immune
system are also discussed.

during which the morphological and biochemical features of
apoptosis become apparent [K20].
231. There are at least two pathways for radiation-induced
apoptosis: one is mediated by mitochondrial factors and is
p53-dependent, and the other is mediated by cell surface
receptors (Fas/CD95) [S16]. The latter pathway may beacidic-sphingomyelinase-dependent and ceramide-mediated[K46]. ROS generated by ionizing radiation result in oxidative damage to the cell membrane, and lymphocytes are
known to be sensitive to oxidative stress because of theirhigh mitotic potential and the content of polyunsaturated
fatty acids in their cell membranes [S51]. In recent years,
evidence has accumulated suggesting that the damage to thecell membrane contributes to radiation cell killing [R14]. It
has been demonstrated that activation of membrane-boundsphingomyelinase after irradiation produces ceramide,
which strongly induces expression of Fas ligand (FasL/
CD95L), cleavage of caspases and apoptosis [D22]. These
data demon­strate that ceramide links cellular stress responses
induced by gamma irradiation or anticancer drugs to the Fas
pathway of apoptosis.

229. The pathways activated by ionizing radiation thathave been investigated in the greatest depth are those dealing
with the responses to DNA damage. These pathways involve
sensor molecules linked to primary downstream componentsthat integrate and process the signals. As a result of this
response to DNA damage, the cell cycle arrests, DNA repair
takes place and the cell may survive or die. However, not
all the effects of ionizing radiation on the immune system
can be ascribed to cytotoxicity. An additional outcome ofradiation exposure, which is not often considered, concerns
the production of “danger signals” that may also influence
the classical cellular responses normally related to DNA­damage [M2]. The following possible mechanisms involved
in radiation-induced alterations of the immune system will
be summarized:− Lymphocyte apoptosis;

232. Radiation-induced apoptosis in lymphocytes may
be initiated by the Fas/FasL system. Radiation induces thesynthesis of the death ligand FasL. Ligand-mediated crosslinking of the Fas receptor initiates signalling pathways toapoptosis. Anti-Fas or anti-FasL antibodies reduced the levelof radiation-mediated cell killing [B3]. Furthermore, ionizing radiation up-regulates the surface expression of Fas,
thus increasing the sensitivity of those cells to FasL. The Fas
receptor stimulates a variety of molecules, including several
members of the caspase family and the acidic sphingomye­linase. Brenner et al. [B10] described a signalling cascadefrom the Fas receptor via caspases to acidic sphingomye­linase, release of ceramide and activation of Jun N-terminal
kinase (JNK) and p38-K kinases (phospho-p38 mitogenactivated protein kinase). Fas-mediated apoptosis could be
prevented in CD4+ or CD8+ T-cells by several proteaseantagonists, suggesting the involvement of the interleukin1β-converting-enzyme-related cysteine protease in CD4+
T-cell death, and of both a CPP32-related cysteine protease
and a calpaine protease in CD8+ T-cell death triggered by
Fas [E5].

− TCR mutations;− Modification of Th1 and Th2 balance;− Bystander effects and genomic instability;− Shift towards an inflammatory profile;− Acceleration of immunological ageing;− Modification of antigen presentation;− Autoimmune reactions;− Perturbation of the immunological homeostasis;− Other possible mechanisms involved.

A.

Lymphocyte apoptosis

1. Review of published data
230. Apoptosis plays a crucial role within the immune system, in particular in negative regulation, and is a key mechanism in the response to ionizing radiation. Lymphocytes die
by apoptosis immediately after exposure (interphase death)[J5] or by reproductive cell death [M22]. The apoptotic
process can be divided into three phases: a death-stimulusdependent induction phase; an effector phase during which
the “decision to die” is taken; and a degradation phase,

233. In contrast, Ogawa et al. [O4] demonstrated that­peripheral blood mononuclear cells irradiated with 5 or
10 Gy of gamma radiation showed positivity to apoptosis ­markers but displayed no increase in surface Fas
expression or caspase-3 activity relative to non-irradiated
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cells, suggesting a Fas-independent mechanism. A Fas­independent mechanism was also reported by Kuida et al.
[K35] in thymocytes from ICE mice that were sensitive to
apoptosis induced by dexamethasone or ionizing radiation
but resistant to apoptosis induced by Fas antibody. In addition, TCR stimulation of CD8+ T-cells led to a different
Fas-independent death process [E5].
234. A p53-dependent, mitochondria-mediated apoptotic pathway was proposed. The p53 molecule is a key
modulator of radiation-induced apoptosis in several cell
types [L22]; however, it has also been shown that ionizing radiation can induce apoptosis in human lymphocytes independently of p53 status. Radiation-inducedup-­regulation of FasL protein defines a p53-independent
pathway to apoptosis, since apoptosis induced by FasL
does not require p53. In fact, radiation-induced p53dependent and p53-independent apoptotic pathways areboth present in different cell types of the immune system.
Seki et al. [S10] demonstrated that p53 protein was inducible in TCR αβ T-cells (CD4 and CD8 cells) and B-cells,
but not in TCR γδ T- and NK cells after gamma irradiation. Cycloheximide was able to inhibit radiation-induced
cell death in TCR αβ T-cells and B-cells, indicating arequirement for protein synthesis, including p53 protein.
235. Mitochondria serve to integrate and amplify upstream
cell death signals, clarifying the cellular reaction to a go/
no-go response. These signals include proteins, reactive species and divalent cations. The protein signals include theproapoptotic members of the Bcl-2 family, such as Bax, Bad
and Bak. Anti-apoptotic members of the Bcl-2 family include
bcl-2 and bcl-xL. Reactive compounds include reactive oxygen species (ROS) and reactive nitrogen species (RNS). If
the stress is sufficient, mitochondria respond by releasing aseries of protein factors. These factors include cytochrome cand Smac/DIABLO, which act to initiate and facilitate thedownstream stages of the caspase-dependent cascade. Other
factors released include apoptosis-inducing factors andendonuclease G, which then initiate the downstream stagesof the caspase-independent cascade [K20, S29].
236. Cui et al. [C13, C18] found an increased expressionof Bax protein in thymic lymphocytes of mice 3 hours after
exposure to lethal doses of gamma radiation. On the other
hand, the expression of bcl-2 and bcl-xL proteins was reduced
at 3 hours after irradiation, reaching their lowest level at 24hours. However, a Fas-mediated pathway unaffected by bcl-2
has been described [S31].
237. The role of ROS in radiation-induced apoptosis ofhuman peripheral T-cells was studied by Ogawa et al. [O5].
They found that ROS formation occurred immediately after
irradiation, continued for several hours and resulted in oxidative DNA damage. Early (13 hours post-irradiation) andlate (23 hours post-irradiation) apoptotic changes were correlated. Therefore the origin of the hyperradiosensitivity of
T-lymphocytes seems to be the high production of ROS in
the mitochondrial DNA following irradiation. Ogawa et al.

recently described the possible existence of a new apoptotic
cascade involving early lysosomal membrane destabilization. Therefore possible involvement of lysosomal proteaseleakage caused by hydroxyl radical formation in lysosomes(possibly resulting in mitochondrial membrane dysfunction)is considered to play an important role in radiation-induced
T-cell apoptosis [O6]. Moreover, in a recent study, Sharma
et al. [S51] investigated the immunomodulatory effect ofchlorophyllin (CHL), a water-soluble mixture of salts ofchlorophyll that had earlier been shown to reduce the level of
intracellular ROS. CHL significantly inhibited apoptosis in
Con-A-stimulated spleen cells from BALB/c mice, whereas
the expression of anti-apoptotic genes bcl-2 and bcl-xL was
up-regulated in lymphocytes of CHL-treated mice compared
to controls.
238. Down-regulation of mitochondrial transmembranepotential by inhibitors of electron transport and adenosine
triphosphate (ATP) synthesis prevented stress-induced p53
protein accumulation and eliminated p53-dependent apoptosis in a wild-type p53 leukaemia cell line (MOLT-3) andin normal T-lymphocytes, identifying mitochondrial activity
and ROS levels as critical intracellular determinants of the
p53 activity [K7]. On the other hand, Chen et al. [C8] demon­
strated that nitric oxide, a key RNS, protects thymo­cytes
from gamma-irradiation-induced apoptosis. The mechanism
may involve inhibition of p53 up-regulation and reduction of
mitochondrial damage, with subsequent ­inhibition of downstream caspase activation.
239. The apoptotic response of lymphocytes may differ following low-dose irradiation. Data recently communicated by
Shankar and Sainis in whole-body gamma-irradiated mice(cumulative dose 200 mGy at 40 mGy/day) demonstrated
that such very low doses enhanced the mitogen responsiveness to Con A of spleen lymphocytes, reduced expression of
p53 and down-regulated apoptosis. This anti-apoptotic effect
was associated with a higher expression of cyclin D1 andproliferating cell nuclear antigen (PCNA), two critical proteins for cell cycle transition and cell proliferation. Interestingly, these authors also demonstrated that down-regulationof apoptosis was not mediated by the Fas/FasL pathway
but rather through the mitochondrial pathway [S16]. These­findings suggest that those apparently opposite effects ofionizing radiation on some immune responses observed following moderate to high doses compared with low doses,
e.g. immunosuppression versus immunostimulation, may berelated to signal transduction pathways involving cell cycle
regulatory proteins such as p53, cyclins and PCNA.
2.

Remarks concerning lymphocyte apoptosis

240. The preceding paragraphs indicate that apoptosis plays
a crucial role within the immune system, in particular in negative regulation, and is also a key mechanism in the response
to ionizing radiation. It is accepted that there are at least two
pathways for radiation-induced apoptosis: DNA-damagemediated and p53-dependent, and ceramide-mediated.

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

241. Radiation-induced apoptosis in lymphocytes may beinitiated by the Fas/FasL system. Radiation induces the synthesis of the death ligand FasL and up-regulates the surface
expression of the Fas receptor, which stimulates the releaseof ceramides and members of the caspase family. Radiationinduced up-regulation of FasL protein is a p53-independent
pathway to apoptosis.
242. A p53-dependent, mitochondria-mediated apoptotic
pathway has been proposed. Radiation-induced p53 apoptosis and p53-independent pathways are both present in different cell types of the immune system. Mitochondria integrate and amplify upstream cell death signals. These signals
include proteins, reactive species and divalent cations. The
proteins include proapoptotic and anti-apoptotic membersof the Bcl-2 family, and mitochondria respond by releasingprotein factors that initiate the caspase-dependent cascade.
Reactive compounds include ROS and RNS, and divalentcations are mainly Ca2+ and Mg2+.
243. The apoptotic response may differ following low-dose
irradiation. Protracted exposure to radiations at low dose rate
reduces the expression of p53 and down-regulates apoptosis.
This effect was associated with a higher expression of cyclin
D1 and PCNA, two critical proteins for cell cycle transitionand cell proliferation. These findings suggest that the apparently opposite effects observed in the immune system athigh and low doses might be related to signalling pathways
involving cell cycle regulatory proteins such as p53, cyclins
and PCNA.
B. TCR mutations
1.

Review of published data

244. It has been well established that ionizing radiationinduces somatic mutations in a dose-dependent manner bothin vivo and in vitro. Radiation-induced mutations in TCR
genes could result in the phenotypic expression of TCRdefective T-cells. Since the TCR/CD3 complex is involved in
the first step of a variety of other T-cell-dependent immune
functions, loss or alteration of TCR expression in surviving
cells may contribute to radiation-induced impairment of the
T-cell response [K34].
245. A considerable volume of literature is available
describing the defective expression of TCR gene α or β.
A marginally significant (p = 0.051) dose-related increasein the TCR mutation frequency has been detected among
survivors of the atomic bombings in Japan. The presenceof TCR mutation is dependent on the in vivo selection that
occurred soon after exposure, and TCR mutants were almost
completely eliminated in vivo during the first decades following the exposure to radiation from the atomic bombings.
The half-life of TCR mutants is quite short, between two andthree years. Similar results were found in patients treatedwith Thorotrast and with 131I [A7, K34, U19]. An increased
frequency of TCR mutations was found among persons

135

exposed to effluents of the Techa River in the ­Russian­Federation [A17].
246. On the other hand, a positive correlation has beenfound between TCR mutation frequencies and dicentricchromosome frequencies in lymphocytes from patients who
had previously received a full course of radiation therapy for
gynaecological disorders. By comparing mutation frequencies of hypoxanthine-guanine phosphoribosyltransferase(HPRT) and TCR using flow cytometry, it was possible todemonstrate that the frequency of TCR mutants correlated
well with that of dicentric chromosomes [I4].
247. Although the TCR in vivo somatic mutation assay has
been proposed as a sensitive indicator of ionizing radiation
exposure, this assay cannot be applied immediately, since
the mutant phenotype may require as long as several months
to express. Ishioka et al. [I3], using IL-2 after PHA pulse
stimulation, demonstrated a dose-dependent increase of
mutation frequency in CD4+ cells during the first seven days
post-irradiation.
248. In 2002, Smirnova et al. described the mutation frequency of TCR genes in lymphocytes from 165 individuals
exposed to ionizing radiation [S24]. The cohort was divided
into three groups depending on the type of irradiation andtime elapsed since exposure: group 1, analysis performed
16–40 years after acute irradiation; group 2, 13 years after
acute irradiation; and group 3, 9–13 years after prolonged
irradiation. Elevated frequencies of TCR mutant cells weredetected in all three groups: 36%, 25% and 15% in the first,
second and third group, respectively. The same authors haverecently found elevated frequencies of TCR mutant cells in
nuclear chemical plant workers chronically exposed to low
doses of external and internal irradiation [S44]. In both studies, the frequency of mutant cells was significantly higher
than in control groups.
249. Although several papers have provided strong evidence for mutation of the TCR, the question concerning
the lifespan of human memory cells in the absence of TCR
signalling remained open. The long-term kinetics of TCR/
CD3 mutation between CD4+ CD45RA+ naive and CD4+
CD45RA– memory T-cell fractions was studied in cancer
patients receiving radiotherapy [U17]. Both the proportionand the number of mutant cells decayed exponentially withtime following radiotherapy. The results indicated that thelifespan of mature CD4+ T-cells is limited regardless of theirmemory or naive phenotype, suggesting that continued cell
receptor signalling is required for lifetime maintenance ofhuman memory cells.
250. Moreover, in vivo models to establish the spontaneousand radiation-induced TCR mutation frequency showed that
the TCR mutation frequency dose response fitted a linear–quadratic or quadratic function. The general trend wasthat radiation-induced TCR mutation frequency started toincrease 3 days after WBI with X‑rays, reached a peak at
2–3 weeks and then gradually decreased, with a half-life

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of about 2 weeks. The coefficients of the quadratic term in
BALB/c mice were significantly higher than for C57BL/6 or
C3H/He mice, suggesting that genetic factors may control
the susceptibility of somatic genes to both spontaneous andradiation-induced mutagenesis [U18].
251. Studies involving TCR mutation frequencies in p53deficient mice have clarified the important role of the p53
protein in the repair of radiation-induced mutagenic ­damage
to the immune system. In p53 (-/-) mice, the TCR mutation
frequency did not decline significantly with time. It was
concluded that complete repair of mutagenic damage in
irradiated tissues requires the integration of DNA repair and­p53-dependent apoptotic mechanisms [K8, S32].
252. In order to explore the ability of ionizing radiation to
induce rearrangements in TCR leading to TCR βγ variants(hybrids) in human lymphocytes, peripheral blood lymphocytes from healthy donors were exposed in vitro to 3 Gy ofeither X- or gamma rays. The TCR βγ frequency was not
significantly different in irradiated versus control samples up
to 55 days after PHA stimulation, suggesting that low-LET
radiation is not able to induce this type of TCR ­rearrangementin vitro [M4].
2. Remarks concerning TCR mutations
253. Some remarks may be made on the basis of theinformation presented in the preceding paragraphs.
­Radiation-induced mutations in TCR genes could resultin the phenotypic expression of TCR-defective T-cells
and thus contribute to radiation-induced impairment of
the T-cell response. A significantly increased frequency of
TCR mutation has been detected among survivors of theatomic bombings, in patients treated with Thorotrast and131
I, and among the Techa River cohort. It must be emphasized that the presence of mutation is dependent on thein vivo selection, and that the half-life of TCR mutants is
between two and three years. Elevated frequencies of TCR
mutant cells were also observed in chronically exposed
workers at nuclear plants.
254. In vivo models to establish the spontaneous andradiation-induced TCR mutation frequency showed thatthe dose–response function fitted a linear–quadratic or
quadratic function. The coefficients were dependent on
the strain of mouse studied, suggesting that genetic factors may control the susceptibility of somatic genes to bothspontaneous and radiation-induced mutagenesis. Likewise,
in a p53 (-/-) mouse model it was observed that the TCR
mutation frequency did not decline significantly with time,leading to the conclusion that repair of mutagenic damage
in irradiated tissues requires the integration of DNA repair
and p53-dependent apoptotic mechanisms.
255. To date, there are no definitive data demonstratingthat low levels of TCR mutation frequency have induced
immunodeficiency.

C. Modification of Th1/Th2 balance
1.

Review of published data

256. As described earlier, two distinct functional cytokine secretion patterns, designated Th1 and Th2, have been
defined for helper T-cells. While Th1 cytokines promotecell-mediated immunity, Th2 cytokines favour humoral
immunity, providing B-cell assistance for antibody production. Controversial results have been published concerning
the effects of ionizing radiation on the Th1/Th2 balance andits impact on human health. Th1 and Th2 helper T-cells arecross-regulatory in vitro, and the balance of these cells invivo determines the character of the cell-mediated immune
and inflammatory response [N10]. An imbalance between
Th1 and Th2 may be responsible both for the progression ofseveral diseases and their resultant complications. Patientswith advanced cancer often have impaired cell-mediatedimmunity associated with a switch from Th1 to Th2. Whileorgan-specific autoimmune diseases have been related to an
overreactive Th1 pathway, the Th2 pathway may underlie
allergy and systemic autoimmune diseases [G13, K11]. On
the other hand, shifting from one cytokine pattern to anothermay be highly beneficial in certain physiological conditions; for instance, IL-10 (a Th2-type cytokine) may play arole in pregnancy-associated immune tolerance through the­establishment of a Th2 cytokine bias at the maternal–foetal
interface [S20].
257. The impairment of cell-mediated immunity associated with the increase in the B-cell component and humoral
immunity observed in atomic bombing survivors led to the
hypothesis that radiation exposure could induce an imbalance towards a Th2 profile. The observed increase in percentage of CD4– CD8– αβ+ double-negative T-cells, known
to produce primarily Th2-type cytokines, supported the ideathat ionizing radiation could induce a shift from a Th1 to a
Th2 response [K23]. Reduced IL-2 production in response to
Con A in survivors was reported to be caused by a reduced
number of naive CD4+ T-cells [K31]. However, a dosedependent increase in TNF-α and IFN-γ production wasobserved in atomic bombing survivors, suggesting that Th2
does not dominate over Th1 [N3].
258. Interaction between cytokines and their receptors
leads to the activation of multiple signalling molecules,
including the family of “signal transducer and activator oftranscription” (STAT) proteins. Different STAT proteinsare capable of regulating the activity of diverse types ofcytokine. It has been reported that mice with a disrupted
STAT gene have impaired IL-12 responsiveness of NK
and T-cells, a lack of Th1 responsiveness and enhanced
Th2 function [K5]. Gamma radiation has been shown to
reduce STAT1 phosphorylation. In contrast, mRNA levels
for IL-5 were only slightly increased by gamma radiationcompared with non-irradiated samples, suggesting that ionizing radiation induces a polarized Th2 response by interfering with STAT signals, thereby causing suppression of
the Th1 response [H4].

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

259. In addition to the STAT protein family, the transcription factor NF-κB is one of the key regulators of the genes
implicated in the immune inflammatory response. In a rat
abdominal gamma irradiation model, Linard et al. [L26] haveshown that genesis of the inflammatory process involved thetranslocation/activation of the NF-κB/Rel p65 subunit in theintestine. This activation was inhibited by a specific NF-κB
inhibitor (caffeic acid phenethyl ester) that contributed to a
reduction in the expression of TNF-α, IL-6 and IL-6 receptors. The cytokine signalling is under negative feedback
regulation by intracellular proteins such as the suppressorof cytokine signalling (SOCS) gene. The differentiation into
Th1 and Th2 is accompanied by a preferential expression of
distinct SOCS (SOCS1 is highly expressed by Th1, whereas
Th2 expresses high levels of SOCS3). Reports indicatedthat Th1 responses are likely to be negatively regulated by
SOCS3 in vivo, rather than Th2 responses being attenuatedby SOCS1 [I7]. Irradiation induced an intestinal overexpression of SOCS3 and a repression of SOCS1 in the first week.
The inhibition of NF-κB activation reduced the SOCS3
expression [L27]. These data suggested that the polarized
Th2 response induced by ionizing radiation involved thetranscription factor NF-κB.
260. Bass et al. [B2] studied the ratio of Th1 and Th2 clones
in the spleens of mice 4–6 weeks following total lymphoid
irradiation by high-dose X‑rays (5.5 and 8.5 Gy). The Th1/Th2 ratio was 1/0.6 in control mice, whereas the ratio in
total lymphoid irradiated mice was approximately 1:7, supporting a conclusion that radiation exposure enhances Th2type cytokine production [B2]. In contrast, it has been shownthat low-dose WBI with 0.075 Gy X‑rays is able to generatechanges in IL-12 p35/p40 mRNA and IL-12 p70 protein levels, while IL-10 decreased significantly in splenocytes, andmRNA levels for both IL-12 p35 and p40 subunits increasedin macrophages following WBI. The suppression of IL-10
expression and stimulation of IL-12 expression were interpreted as representing a shift of the immune response infavour of Th1 differentiation [L19].
261. The prevalence of a radiation-induced Th2 response
has been verified in irradiated lung. Enhanced lymphocyte
reactivity, dominated by Th2 cells, was shown in radiationinduced pneumonitis and subsequent pulmonary fibrosis.
The kinetics was studied in T-cell lymphocytes isolated fromlungs irradiated with 20 Gy. A selective increase of CD4+
T-cells was observed, peaking four weeks after irradiationof the lungs. When the rats were depleted in CD4+ T-cells,
post-irradiation thickening of the parenchyma was significantly reduced, as determined by morphometric analysis.
The CD4+ cell subtype of the T-lymphocyte population
was analysed by measuring different cytokine mRNAs by
RT-PCR (reverse transcription polymerase chain reaction).
It was found that IL-4 mRNA was selectively increased in
the CD4+ cells isolated from irradiated lungs, which indicates a lymphocyte reactivity by Th2 cells. The authors
suggested a critical role for Th2 CD4+ cells in the pathogenesis of radiation-induced pneumonitis preceding lungfibrosis [W3].

137262. Pharmacological improvement of the impaired Th1
function after irradiation has been used as an indirect way
to investigate the radiation-induced enhancement of Th2
response. Ginsan (an acidic polysaccharide from Panex ginseng) is able to induce proliferation of lymphokine-activatedkiller cells, to increase the mitogen activity in different systems and to induce the production of several cytokines (suchas IL-1, IL-6, IFN-γ and IL-12) that are required for haematopoietic recovery. In an experimental model of WBI, ginsan
was injected in vivo and its action was evaluated by measuring its effect on CFU-S bone marrow cells and cytokine generation. Ginsan was shown to enhance Th1 function whileinterfering with the radiation-induced Th2 response [S27].
263. Interestingly, the cytokines characteristically expressedin Th1 cells seem to be regulated by cell-mediated suppression. The induction of TNF-β mRNA in lymphoid cells isgreatly enhanced by gamma radiation. However, the level of
TNF-β mRNA expressed in response to radiation and otherstimuli, whether by mitogen or antigen, is strongly reduced byconcomitant activation of suppressive cell subsets. Removalof CD8+ or CD11b+ cells leads to a substantial induction of
TNF-β mRNA in the depleted cell population; this induction
precedes the appearance of suppressive cell activity, allowing
for temporary suppression. TNF-β, as well as other Th1
cytokines such as IFN-γ and IL-2, is suppressed by CD8+ orCD11b+ cells [A1].
264. IL-4 and IL-5 synthesis in lymph node cells primed
by keyhole limpet haemocyanin (KLH) was greatly diminished after irradiation. In addition, the capacity of irradiatedKLH-primed lymph node cells to induce IgG, IgM and IgEsynthesis in hapten-primed cells was studied. Irradiation was
not able to modify IgG synthesis in these cells, but their capacity to induce IgE was significantly reduced. Thus irradiation greatly inhibited the capacity of Th2 clones, but only
minimally inhibited the capacity of Th1 clones, to induce
IgG synthesis in primed B-cells. By adding IL-4 and IL-5,
the capacity of Th2 cells to produce IgE was completely
restored [D2].
2.

Remarks concerning modification of Th1/Th2 balance

265. As discussed in the preceding paragraphs, two distinct
functional cytokine secretion patterns have been defined forhelper T-cells: Th1 and Th2. While Th1 cytokines promotecell-mediated immunity, Th2 cytokines favour humoral
immunity. The balance of Th1 and Th2 helper cells in vivo
determines the character of cell-mediated immunity andinflammatory response, the imbalance being responsible
for the progression of several diseases and their resultant
complications.
266. The results concerning the effects of ionizing radiation on Th1/Th2 balance are controversial. In survivorsof the atomic bombings, the impairment of cell-mediatedimmunity associated with the increase in the B-cell component and humoral immunity suggests an imbalance towards a

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Th2 profile induced by the radiation exposure. The observed
increase in the percentage of CD4– CD8– αβ+ T-cells,
known to produce mainly Th2-type cytokines, supports the
hypothesis of a shift from Th1 to Th2. Nevertheless, a dosedependent increase in TNF-α and IFN-γ secretion suggeststhat Th2 does not dominate over Th1.
267. The prevalence of a radiation-induced Th2 response
has been verified in experimental studies, for example of thespleens of mice irradiated with high-dose X-rays and thelungs of rats irradiated with 20 Gy, where it was found thatTh2CD4+ cells might play a critical role in the pathogenesisof radiation-induced pneumonitis. In contrast, after low-dose
WBI, 0.075 Gy, the changes observed might contribute to ashift in favour of Th1 differentiation.
268. STAT proteins are key molecules in the regulationof the activity of different types of cytokine, and mice with
disrupted STAT genes have a lack of Th1 responsivenessand enhanced Th2 function. It has been shown that radiation reduces STAT phosphorylation, inducing suppressionof Th1 response. The transcription factor NFκB is anotherkey regulator of the genes implicated in the immune inflammatory response, and the action of specific NFκB ­inhibitors
after irradiation in a rat model contributed to a reductionof Th2 cytokine expression. In addition, the cytokines
expressed in Th1 cells seem to be regulated by cell-mediatedsuppression.
D.

Bystander effects and genomic instability
1. Review of published data

269. Bystander effects and genomic instability are twogeneral mechanisms possibly involved in the effects of ionizing radiation on the immune system. The general featuresof these two mechanisms are reviewed in annex C, “Nontargeted and delayed effects of exposure to ionizing radiation”. Thus this section reviews only observations of these
non-targeted and delayed effects that relate to the immune
system.
270. Irradiation has been shown to induce leukaemic transformation of non-irradiated stem cells transplanted into syngeneic mice [D13]. These findings may reflect the alteredcharacteristics of the stem cell microenvironment after
irradiation, since irradiated haematopoietic stromal cells
release mutagenic ROS, produce different sets of adhesion
molecules and growth factors, and alter the overall growthand phenotypic characteristics of co-cultured non-irradiatedstem cells [G7].
271. Haematopoietic tissues exposed to ionizing radiation
have been shown to exhibit increased macrophage activation[L8]. Activated macrophages are able to induce apoptosis inneighbouring cells [B12, D12] and produce gene mutations[W2], DNA base modifications [D7], DNA strand breaks[S14] and cytogenetic damage [W1] in neighbouring cells.

These various end points have all been demonstrated as nontargeted effects of ionizing radiation. Many properties ofactivated macrophages are consistent with in vitro studies
that implicate free radical generation in non-targeted radiation effects [N5], and with other studies in which oxidative
processes and nitric oxide have been implicated as having
roles in the mechanisms [C12, G4, L11]. Nitric oxide canbe either proapoptotic or anti-apoptotic, can either downregulate or up-regulate p53 activity [B11], and can be either
pro-inflammatory or weakly anti-inflammatory [G13, N6],
depending on context.
272. A stimulatory bystander effect can be induced in
immune cells by low-dose irradiation. When a mouse macrophage cell line (J774A.1) was exposed to a low dose
(0.075 Gy) and co-cultured with a non-irradiated mouse
T-lymphocyte cell line (EL-4), the irradiated macrophages
exerted a stimulatory effect on the EL-4 cells, as shown by
increased proliferation. At a high dose (2 Gy), irradiated
J774A-1 cells exerted an inhibitory effect on the proliferation of the non-irradiated EL-4 cells. Preliminary mechanistic studies show that changes in CD48 expression and nitricoxide production by the J774A.1 cells after high- and lowdose irradiation might be important factors underlying thedifferential bystander effects elicited by different doses ofradiation [L13].
273. There are few data on bystander effects in whole animals. However, prior to the recent interest in non-targeted
effects, there were numerous reports that a transferable clastogenic activity capable of causing chromosome breaks in
non-irradiated lymphocytes was present in the plasma of
patients after radiotherapy, though with considerable interindividual variation in both production and response [M15].
Clastogenic factors in plasma have also been obtained fromatomic bombing survivors and Chernobyl liquidators [P3,
W6], and from patients with a variety of chromosomal
instability syndromes and inflammatory disorders. The­chromosome-damaging effects of clastogenic factors are
mediated by the superoxide anion. Their clastogenic activity
may be related to the formation of lipid peroxidation products and cytotoxic cytokines, which are possible agents formediating radiation-induced bystander effects. A body ofclinical and experimental radiotherapy data exists concerning the “abscopal effects” of radiation, where responses arenoted in unrelated organs or tissues that had not been irradiated [C2]. However, it is far from clear whether bystander
killing contributes to the curative potential of radiotherapy
and whether inducible instability is an important componentof late adverse effects.
274. Xu et al. demonstrated that low doses of radiation(0.25–10 mGy) stimulate expression of IL-2 receptors(CD25) on the surface of peripheral blood lymphocytes
taken from normal human donors [X1]. Clastogenic factors
can also stimulate CD25 surface expression in non-­irradiatedcells, suggesting that this radiation-stimulated surface
expression is a bystander effect resulting from the secretion
into the medium of a soluble factor from the irradiated cells.

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

2.

Stimulation of CD25 expression by ionizing radiation showsa triggered-type response rather than being proportional todose.
275. Persistent subclinical inflammation has recently beenreported among survivors of the atomic bombings in Japan[N7], and it was suggested that radiation-induced enhancement of inflammatory reactions might contribute, as an­epigenetic and/or bystander effect, to the development ofseveral radiation-induced disorders.
276. Thymic stromal cell cultures are able to support T-cell precursor proliferation and differentiation in
the presence of IL-7 and stem cell factor. By exposing
thymic stromal cell cultures to 10 Gy of gamma irradiation before the seeding of T-cell precursors, it was possible to demonstrate a reduction of these T-cell precursors
without changes in their differentiation. The effect could
be reproduced by the addition of supernatants from irradiated stromal cell cultures on to sham-irradiated cultures,
which suggests that gamma irradiation induces the production of soluble factors by thymic stromal cells, which
in turn modify their ability to support proliferation ofT-cell precursors [B4].
277. Radiation-induced overexpression of IL-7 fromthymic stromal cells is key to understanding the radiationinduced differentiation of CD8+ TCR γδ T-cells. When­double-negative foetal thymocytes were co-cultured withfoetal thymus irradiated with 25 Gy of low-LET radiationin the absence of direct contact or mitogen stimulation,induction of TCR γδ T-cells was observed, reaching 50%
after 4 days of co-culture. Supernatants of the irradiatedfoetal thymus were also able to induce the differentiationfrom double-negative thymocytes to CD8+ TCR γδ T-cells
after 3 days of culture, suggesting a radiation-induced production of soluble factors by thymic cells. It was possibleusing RT-PCR to detect an increased expression of IL-7mRNA in the foetal thymus 24 hours after irradiation, andantibodies against IL-7 inhibited the radiation-induced
differentiation [T7].
278. Shankar et al. studied bystander effects and adaptive response induced by gamma radiation in murine lymphocytes, using irradiated conditioned medium (ICM)from lymphocytes exposed to 0.1 Gy, 0.5 Gy and 1 Gy.
They found that ICM enhanced the proliferation responseof non-irradiated lymphocytes to Con A, with increased
expression of IL-2 receptor and cyclin D, two proteinsthat drive progression through the cell cycle. ICM alsoenhanced intracellular ROS content and nitric oxide generation in non-irradiated lymphocytes. Apoptosis was significantly lower in lymphocytes exposed to a challengedose of 1 Gy when they were preincubated with ICM.
The results of these authors suggest that soluble factors
released by irradiated lymphocytes trigger signalling
pathways that result in increased response to mitogens
and resistance to radiation exposure in non-irradiatedlymphocytes [S50].

139

Remarks concerning bystander
effects and genomic instability

279. Some remarks may be made on the basis of the data
presented above. Delayed effects and genomic instability in the immune system have been demonstrated in vitro
and in vivo after exposure to ionizing radiation. Chromosomal instability in haematopoietic cells can be induced bya bystander-type mechanism, providing a link between these
two untargeted effects, as well as other radiation responses
that are consistent with the microenvironment contributing tocell damage as a consequence of an inflammatory responseto radiation-induced injury.
280. Activated macrophages after irradiation are able toinduce apoptosis, gene mutations, DNA base modifications,
DNA strand breaks and chromosome-damaging effects inneighbouring cells. Intercellular signalling and free radical
generation are implicated in these non-targeted effects ofionizing radiation. Nitric oxide emerges as a key mediator in
the bystander effects elicited by high- and low-dose irradiation. Likewise, the superoxide anion has been described asa mediator of clastogenic factors in chromosome-damaging
effects.
281. Long-lasting inflammation has been reported among
the atomic bombing survivors, and it was suggested thatradiation-induced enhancement of inflammatory reactions
might contribute as an epigenetic and/or bystander effect tothe development of several disorders. However, the potential
impact of such delayed effects in humans is not known.
E.

Shift towards an inflammatory profile
1.

Review of published data

282. Ionizing radiation may induce a persistent inflammatory status that could increase the risks of both cancer andnon-cancer diseases [N3]. Higher risks of hepatic, cardiovascular and thyroid pathologies have been observed among
atomic bombing survivors, and several authors have investigated the relationship between these chronic diseases andimpairment of the immune system.
283. One of the main functions of cytokines is to mediate interactions between the immune and the inflammatory
response. Chronic immune inflammatory diseases might becaused in part by dysregulation of cytokine production [B14].
TNF-α, IFN-γ, IL-6 and IL-10 coordinate the inflammatory
response [H10]. The stimulus for production of acute phase
proteins in response to tissue injury is likely to be mediatedby these inflammatory cytokines. Thus the cytokine profile
as well as the level of acute phase proteins may be usefulmarkers of inflammation.
284. Exposure to high doses of ionizing radiation, such as
those delivered during radiotherapy or in cases of accidental
irradiation, can induce fibrosis in many tissues as a late effect.

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Formation of the fibrotic tissue requires chronic activation ofseveral cell types, including myofibroblasts, that secrete thecollagenous matrix. The origin of the chronic activation ofthese cells is still a matter of debate. TGF-β1 has been proposed as a master switch for the fibrotic programme [M18].
This cytokine can be secreted by the inflammatory cells thatchronically invade the irradiated tissue and locally by themyofibroblasts. Antioxidant treatment that reduces established fibrotic tissues in patients can act on both of these cell
populations [D19, D20].
285. Neriishi et al. [N7] investigated the status of several
inflammation parameters in atomic bombing survivors. They
demonstrated a positive association between radiation doseand erythrocyte sedimentation rate, total leucocyte counts,
alpha-1 and alpha-2 globulin, and sialic acid.
286. Hayashi et al. [H8] found increased plasma levels of
C-reactive protein (CRP) and IL-6 in atomic bombing survivors. This increase was significantly related to radiationdose, by about 30% Gy–1 for CRP and 10% Gy–1 for IL-6,
and was associated with a decrease in the percentage of­peripheral CD4+ T-cells.
287. Inflammatory parameters were analysed in blood
samples from atomic bombing survivors, including 180 nonexposed subjects and 90 subjects from each of the following dose groups: low dose (0.0005–0.7 Gy), medium dose
(0.7–1.5 Gy) and high dose (>1.5 Gy). The levels of TNF-α,
IFN-γ and IL-10 were significantly increased with radiationdose, as was the erythrocyte sedimentation rate. There wasa radiation-dose-dependent increase in plasma levels of IL-6
and CRP. IL-6 stimulates the synthesis of acute phase proteins (such as CRP) involved in complement activation. A
dose-dependent increase was also observed in total immunoglobulin levels. While the levels of IgA and IgM increased
significantly with radiation dose, those of IgG and IgE did
not [H10]. Increased serum levels of TNF-α [S13] and IgM[K21, S13] with higher functional complement activity[K21] were reported in Chernobyl emergency and cleanup workers. Higher serum levels of both IgG and IgM were
found in children resident in contaminated areas around theChernobyl nuclear power plant [K15, T5].
288. These observations provide evidence of a persistent inflammatory profile as a long-term effect after radiation exposure. Preclinical inflammatory status is linked insome way to a decrease in CD4+ T-cells, suggesting that­radiation-associated immunological changes may cause
long-lasting inflammation [K36]. This T-cell impairment
may generate age-associated chronic inflammation, which
may be responsible for an increased risk of various lifestyleassociated diseases, such as atherosclerosis, coronary heartdisease, diabetes and several cancers [K36, N3].
2. Remarks concerning the shift
towards an inflammatory profile289. As reviewed in the paragraphs above, a ­persistent
inflammatory status induced by ionizing radiation has been
associated with impairment of the immune system andwith cancer and non-cancer diseases. Since TNF-α, ­IFN-γ,
IL-6 and IL-10 coordinate the inflammatory response,
immune inflammatory diseases might be attributed in part to­dysregulation of cytokine production.
290. Significant dose-dependent increases of TNF-α,
IFN-γ and IL-10 in parallel with the erythrocyte sedimentation rate as a biomarker of inflammation were observed fromblood analysis of atomic bombing survivors. Total immuno­
globulin levels were also enhanced in a dose-dependent
manner. On the other hand, increased serum levels of TNF-α
and IgM with higher functional complement activity werereported in Chernobyl emergency and clean-up workers.
291. Preclinical inflammatory status may be linked to
impairment of cellular immunity, e.g. a decrease in CD4+
T-cells observed after radiation exposure, suggesting thatradiation-associated immunological changes could accountfor long-lasting inflammation.
F.

Acceleration of immunological ageing
1. Review of published data

292. It has been proposed that acceleration of immunological ageing may be associated with radiation effects inhumans. Immunosenescence has been described in section II
above. As illustrated in table 11, comparison of the mainfeatures of immunosenescence with the experimental andepidemiological findings concerning radiation effects on the
immune system supports this hypothesis.

Table 11 Comparison between the main features of normal immunosenescence and observed radiation effects on
the immune system
Parameter

Normal ageing

Irradiation

Renewal capacity of stem cells and haematopoietic
progenitor cells

Decreased [H1, L1]

Decreased [G5]Total CD4+ T-cells

Decreased, about 4% per 10 years [K29]

Decreased [C7, C9, G9, K21, K33, P5, S8, T6, Y4],
about 2% Gy–1 [K29] Increased [T9, V9]ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

Parameter

Normal ageing

141

Irradiation

CD4+ naive T-cells

Decreased [H16], about 7.5% per 10 years [K36]

Decreased [K25, K29, K37, Y2], about 4.5% Gy–1
[K36]

CD4+ memory T-cells

No significant changes [K36]No significant changes [K36, Y2]

CD4+ naive/memory T-cell ratio

Decreased [H1, L5, V2, V4]

Decreased [K24, K25, K37, Y2]

Total CD8+ T-cells

No significant changes [K36]No significant changes [K36]CD8+ naive T-cells

Decreased, more than 40% per 10 years [K36]

Decreased [Y2], about 7.7% Gy–1 [K36]CD8+ memory T-cells

Increased, about 7.3% per 10 years [K36]

Increased [Y2], about 5.6% Gy–1 [K36]CD8+ naive/memory T-cell ratio

Decreased [U21]

Decreased [Y2]

Double-negative CD4– CD8– αβ+ T-cells

Increased [H15]

Increased [A6, K37, N1]

Available TCR repertoire

Reduced [H1, V2, V4]

Reduced [K25]CD8+ CD28– (effector) T-cells

Increased proportion of CD8+ CD28– T-cells [E2,H16]

CD28 expression: up-regulation(low doses) and down-regulation(high doses) [L14]T-cell responsiveness to mitogens

Lower [B6, B15, V2]

High doses: lower [A4, A5, K26, K31, P5]
Low doses: higher [J6, L17, L18, N20, P11, S16,
S17, Y1]

Thymus mass and cellularity

Decreased [H16]

Decreased [G8, N1, P6]

B-lymphocytes

Decreased, about 7.3% per 10 years [K36]; less ability
to generate antibody responses [B15, F3, H1, L5]

Increased [K29, Y1], about 8.5%
Gy–1 [K36]
Decreased [G9, K24, P6]
Hyporesponsiveness to LPS [C10, P6]

Lymphocyte oxidative status

Oxidative stress [V2]Oxidative stress [C10]IL-2 production

Decreased [E1, H16]High doses: decreased [A2, B5, G8, K31]
Low doses: increased [J8, L18]

TNF-α release

Increased [B6, E1], about 15% per 10 years [N3]

Increased [S13], about 7% Gy–1 [H10, N3]

IL-10

Increased, about 8% per 10 years [N3]

Increased, about 6% Gy–1 [H10, N3]

IL-6 release

Increased [B6, E1], about 24% per
10 years [H10, N3]

Increased [H5], about 13% Gy–1 [H10, N3]

C-reactive protein level

Increased, about 25% per 10 years [H10, N3]

Increased [H5], about 39% Gy–1 [H10, N3]

IgA

Increased, about 5% per 10 years [H10, N3]

Increased [T5], about 8% Gy–1 [H10, N3]
Increased in females [F4]No change [K21]IgG–

Decreased [K21]
Increased [K15, T5]
No change [F4, H10]

IgM–

Increased [F4, H10, K15, K21, T5]

IgE–

Increased [K15]No change [F4, H10]

Total Ig

Increased, about 3% per 10 years [H10]

Increased [K14], about 3% Gy–1 [H10]Erythrocyte sedimentation rate

Increased, about 15% per 10 years [H10, N3]

Increased [N7], about 17% Gy–1 [H10, N3]

Th1/Th2 imbalance

Shift from Th1 to Th2 [R1, S7]

Shift to Th2 [A1, B2, H4, K23, S27, T5, W3]
Shift to Th1 [D2, L19, N3]

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Parameter

Normal ageing

Irradiation

Production of autoantibodies

Increased [H13]

Increased [T6, Y1, Y4]
No change [F4]Neutrophils

Impaired function [G25]

Impaired function [K21]

Monocytes/macrophages

Impaired function [B15, H1]

Impaired function [G18, K33]
Macrophage activation [C21, I6, L8, N24, P11]
Increased proportion of peripheral monocytes [S13]Absolute number of NK cells

Increased [B15], about 20% per 10 years [K36]

Increased [K24, K33]
No significant change [K29, K36]

NK cell function

Impaired [H1]

Impaired [K15]
Enhanced [C21, K18, Y1]
No significant change [B5, P6]

CD3+ CD56+ CD16+ (NKT) cells

Increased [M9]

Increased [K33]

Immunoproteasome function

Impaired [M8]Impaired [L10]293. Kusunoki et al. [K29] tested the hypothesis that ionizing radiation may accelerate ageing by using the proportion of
CD4+ T-cells as an index. They reported that the normal agerelated decrease of CD4+ T-cells was about 4% per 10 years
and that the radiation-induced decrease of CD4+ T-cells was
about 2% Gy–1. These findings suggest that exposure to 1 Gy
is equivalent to about a 5-year increase in age.
294. In 442 atomic bombing survivors without a history of cancer or inflammatory diseases, Nakachi’s group[H10, N3] found that both age and radiation exposure were associated with increases in selected plasma
inflammation markers. Their findings indicated that the­r adiation effect might be estimated in terms of acceleration of ageing by applying a multivariate model (table 12).
The per cent increments in TNF-α, IL-10, IL-6, CRP,
IgA and erythrocyte sedimentation rate observed in
atomic bombing survivors ranged from 6% Gy –1 to
39% Gy –1, corresponding on average to an increase inage of 10 a/Gy.

Table 12 Multivariable model of the effects of age at time of irradiation and of radiation dose on inflammatory biomarkers
and ageinga
Adapted from reference [N3]
Variableb

Change in per cent (95% CI)
TNF-α

IL-10

IL-6

CRP

ESR

IgA

Age at time of irradiation (per centper 10 years)

15 (9, 20)

8 (4, 13)24 (19, 30)

25 (13, 38)

15 (9, 20)

5 (2, 9)Radiation dose(% Gy–1)

7 (1, 15)

6 (0, 12)13 (6, 20)

39 (20, 62)

17 (9, 24)

8 (3, 13)

Estimated ageing effect of radiation(a Gy–1)

5 (0, 10)6 (–1, 14)c

5 (2, 8)14 (4, 24)

11 (5, 17)

15 (1, 29)a	Subjects were a total of 442 atomic bombing survivors who did not have ahistory of cancer or inflammatory-associated disease (e.g. chronic bronchitis,
collagen disease, arthritis, myocardial infarction).

2. Remarks concerning the accelerationof immunological ageing
295. The preceding paragraphs indicate that comparison of themain features of immunosenescence with the epidemiologicalb	TNF-α = tumour necrosis factor α; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.
c Estimated by the δ-method.

and experimental findings on radiation effects on the immune
system supports the hypothesis that acceleration of immunological ageing may be involved in radiation effects in humans.
No demonstrable relationship with cancer or inflammatory­diseases in atomic bombing survivors has been found.

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

G.

Modification of antigen presentation
1. Review of published data

296. “Danger” signals affect antigen-presenting cells(APCs), and the dendritic cells are the most powerful. Functional antigen presentation by dendritic cells requires thatthe cells mature under the influence of different danger signals. However, in addition to the maturation of dendritic
cells being essential for lymphocyte activation, immaturedendritic cells themselves maintain a state of immunologicaltolerance. Cells dying by necrosis are more potent at inducing dendritic cell maturation than cells dying by apoptosis(the latter may even block maturation). However, cells thathave undergone apoptosis in response to stressors such asheat or ionizing radiation may be more effective for inducing dendritic cell maturation than cells that have undergone
natural physiological apoptosis.
297. Although dendritic cells are relatively radioresistant,ionizing radiation affects their functions. Liao et al. demonstrated that non-cytotoxic effects of ionizing radiation
might account for the impairment of antigen processing andpresentation following irradiation of dendritic cells. Cell
viability was not significantly affected over a 24 h culture
period following 10 Gy of gamma irradiation at 4.5 Gy/min.
However, immunoproteasome activity was down-regulated
in irradiated cells by 50–60% [L10].
298. It has been reported that ionizing radiation may cause
a generalized decrease in proteasome functions in mammalian cells [M3]. Immunoproteasomes are responsible for theprocessing of antigens for presentation by the class I HLA
pathway. Alterations of immunoproteasome function havebeen proposed as a signal of immunosenescence [M8]. Proteasomes are direct redox-sensitive targets for the action ofionizing radiation [M2]. Using microarray analysis, Snyder[S26] has studied gene expression profiles of cells exhibiting
radiation-induced genomic instability. Two of the genes thatwere underexpressed belonged to the proteasome/­ubiquitin
pathway. These findings suggest that ionizing radiation could
impair immune function by altering antigen ­processing at
the immunoproteasome level.
299. Findings concerning the effect of ionizing radiation
on HLA molecules are controversial. Liao et al. did not findsignificant changes in the expression of class I and class II
HLA molecules on dendritic cells following gamma irradiation with a single dose of 10 Gy [L10]. Reits et al. found thatcell surface expression of class I HLA molecules increased
in a radiation-dose-dependent manner on murine colon
adenocarcinoma cells [R19]. Radiation-induced enhancement in the expression of class I HLA molecules has beenreported by Hauser et al. in a murine melanoma cell line
following fractionated gamma irradiation (50 Gy in 25 fractions) [H7]. In contrast, a decrease in the expression of class
I HLA molecules was found in a human melanoma cell line
following gamma irradiation with a single dose of 20 Gy[G35]. These discrepancies may be due to the pathways

143

activated by ionizing radiation in different cell types as wellas to ­different dose protraction and total doses.
300. HLA mutant lymphocytes are induced by radiation
exposure and eliminated by NK cells [K30]. Autologous
NK cells are responsible for the elimination of mutant lymphocytes that have lost the ability to express self class I HLA
molecules in vivo [K27], and therefore may explain why it
has not been possible to detect increased frequencies of HLA
mutants in blood samples from atomic bombing survivors.
2.

Remarks concerning modification of antigen presentation

301. The data reviewed indicate that dendritic cells, themost powerful APCs, are relatively radioresistant, but thatradiation may affect their function. Down-regulation of
immunoproteasome activity has been reported. Immunoproteasomes are responsible for the processing of antigens forpresentation by the class I HLA pathway; consequently, ionizing radiation could impair immune function by modification of antigen processing at the immunoproteasome level.
This was also proposed as a sign of immunosenescence.
302. Concerning the effects of ionizing radiation on
HLA molecules, controversial results are presented. Non­significant changes were found in the expression of class I
and class II HLA molecules following irradiation of dendritic
cells. Enhancement in the expression of class I HLA molecules after fractionated irradiation of a murine melanoma cellline, as well as down-regulation of their expression following
acute irradiation of a human melanoma cell line, have beenreported. Different dose protraction and total doses, as well
as different cell types, may account for the discrepancies.
H.

Autoimmune reactions

1.

Review of published data

303. Ionizing radiation can produce functional alteration
the immune system and break self tolerance. Autoimmune
diseases are characterized by the activity of autoreactive
lymphocytes that produce antibodies targeting self tissues ororgans for destruction. Autoimmunity may be seen as a caseof “mistaken identity”, in which the immune system mistakes
part of the body for a foreign invader. One explanation for
why the immune system attacks self tissues in some people
is molecular mimicry, which means that a part of a mole­cule of a given protein closely resembles a part of another,
totally different protein. It has been shown that peptides invarious infectious agents resemble parts of various self proteins. Therefore, if these protein fragments are presented toT-cells, the activated immune system will not only attack all
foreign invaders with the same pattern but could also attacka very similar pattern in a self protein [O10]. The significant
dose-dependent impairment of the immune system demonstrated in irradiated populations [K14, K21, K29, K31, V9]
could lead to many of these persons being less responsive to144

UNSCEAR 2006 REPORT: VOLUME II

infectious agents. These individuals are at a higher risk forviral or microbial infection, and are therefore more prone todeveloping autoimmune diseases by molecular mimicry.
304. It was not proved that autoimmune reactions wereinvolved in the pathogenesis of thyroid diseases in atomic
bombing survivors [I8]. However, the immune system has
been demonstrated to be involved in the pathogenesis of thyroid diseases in victims of the Chernobyl accident. These
apparently contradictory results may be due to the different thyroid exposure conditions (acute external irradiation
versus internal exposure from radioiodine). It is possiblethat thyroid damage induced by internal exposure fromradioiodine sets into motion antigenic mechanisms that lead
to autoimmune responses. Epidemiological data from children exposed to radioiodine during the Chernobyl accident
indicate signs of autoimmune thyroid disorder and impaired
NK-related elimination of tumour cells, both of which may
be contributing to the promotion of thyroid neoplasia in thispopulation.
305. Sakaguchi et al. [S6] demonstrated that high-dose
fractionated total lymphoid irradiation (42.5 Gy in 17 fractions) caused various organ-specific autoimmune diseases inmice. Irradiation of the target organs alone failed to elicit
the autoimmunity, and shielding the organs from irradiation
failed to prevent it, suggesting that radiation-induced tissue
damage is not the primary cause of the autoimmune disease.
A significant decrease in mature thymocytes and peripheral
T-cells was observed for one month post-irradiation. Thesefindings suggest that high-dose fractionated total lymphoid
irradiation can cause autoimmune disease by affecting the
T-cell immune system (rather than the target self antigens),
presumably by altering T-cell-dependent control of selfreactive T-cells.
306. In a further paper, Sakaguchi [S3] demonstrated thatelimination of CD4+ CD25+ T-regulatory cells (Treg) led
to the development of various organ-specific autoimmune
diseases in mice. Reconstitution of the Treg population prevented the development of autoimmunity. Moreover, elimination or reduction of the Treg population by environmental
agents also induced autoimmune diseases in normal mice,suggesting that radiation-induced CD4+ T-cell alterations
may cause autoimmunity without altering the antigenicity of
the host organs concerned [K23].

from fractionated total lymphoid irradiation showed that thedevelopment of autoimmunity was related to the alterationof T-cell-dependent control of self-reactive T-cells.
I.

Perturbation of immunological homeostasis
1.

Review of published data

308. Immunological homeostasis is the mechanism bywhich the immune system responds to foreign antigens (e.g.
an infectious organism) and then returns to its original state,although retaining memory cells that will protect the hostagainst subsequent infection by the same organism. Thishomeostasis is achieved in the T-cell system by the balance
between renewal and death of naive and memory T-cells.
The ability to maintain both naive and memory T-cell pools,
which declines with age, is critical for immune function. An
immunostatic mechanism exists that controls the proportionsof immune cell types, the production of cytokines and thelevel of expression of functional immune cell molecules.
309. Exposure to ionizing radiation is thought to affect T-cell
homeostasis. Both experimental and epidemiological data
have demonstrated that ionizing radiation may perturb T-cell
homeostasis by reducing the ability of the immune system toproduce new naive T-cells and by disturbing the regulationand maintenance of memory T-cell pools. A diverse pool ofnaive T-cells is necessary to produce immune responses to
new antigens. Exposed atomic bombing survivors showed
lower numbers of naive CD4+ and CD8+ T-cells. Althoughmemory T-cell pools were either normal (CD4+) or evenlarger (CD8+) in size [Y2], their TCR repertoire was significantly reduced with radiation dose [K25], probably due
to clonal expansion of memory T-cells. Alterations in T-cell
subpopulations were also described in ­Chernobyl clean-up
workers [T6, Y4].
310. Radiation-induced perturbation of T-cell homeostasis
may have important health implications. The reduction of
the naive T-cell pool may lead to reduced ability of the hostto defend against new pathogens, and the clonal expansionof memory T-cells associated with TCR repertoire deviation
may compromise the ability of the host to control recurrent
and latent infections [K36].

2. Remarks concerning autoimmune reactions

2.

Remarks concerning perturbationof immunological homeostasis

307. As discussed in the preceding paragraphs, self tolerance breaking may be among the alterations on the immune
system induced by radiation. No radiation-induced auto­
immune reactions were involved in the pathogenesis of
thyroid diseases observed in atomic bombing survivors. In
contrast, the immune system was involved in the pathogenesis of thyroid diseases in people exposed to radiation fromthe Chernobyl accident. This may be due to the different
thyroid exposure conditions. Experimental data obtained

311. The data reviewed indicate that immunologicalhomeostasis is the mechanism by which the immune system responds to foreign antigens and returns to its originalstate, but retaining memory cells to protect against subsequent infection by the same agent. This homeostasis isachieved by the balance between renewal and death of naiveand ­memory T-cells. Experimental and epidemiological data
have demonstrated that radiation alters T-cell homeostasis by
reducing the ability of the immune system to produce newANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

naive T-cells and by disturbing the maintenance of memory
T-cells. The perturbation of T-cell homeostasis may have
health implications in terms of decreased defences against
new pathogens and compromised ability to control recurrent
and latent infections.
J.

Other possible mechanisms involved
1. Review of published data

312. Liu et al. [L16] proposed that catecholamines mediate the increase in proliferative reactivity of splenic andthymic lymphocytes that has been observed in mice irradiated at a low dose (75 mGy). In a similar model, they
demonstrated the involvement of intracellular calcium andprotein ­kinase C in the facilitation of signal transduction
in lymphocytes and suggested that this facilitation was
implicated in the mechanism of immune enhancement
after low-dose irradiation [L17].
313. Modulation of oxidative status has been postulated
as another mechanism for radiation-induced immune stimulation following low-dose irradiation. Kojima et al. [K16]found an increase of immune function in mouse splenocytesthat correlated with endogenous glutathione (GSH) accumulation within the first six hours after irradiation. This effectwas enhanced by exogenous addition of precursors of GSH
synthesis and was completely blocked by inhibition of GSH
synthesis, suggesting that low-dose exposure to ionizing
radiation enhances immune function through the inductionof GSH [K16, K17, K18].
314. Indirect effects of local radiotherapy on tumour
cells outside the radiation field have been reported inmany malignancies [A14, C2, E3, K13, N11, O7, R2, S15,
U20]. It has been proposed that this phenomenon, originally described as the “abscopal effect”, may be related to­radiation-induced effects on the immune system. Several
factors could influence this effect, such as the immunological state of the tumour-bearing host and the immunogenicity of the tumour cells, as well as the schedule andoverall dose of radiotherapy.
315. In an experimental mammary carcinoma model,
Demaría et al. [D3] demonstrated that the growth of tumours
outside the radiotherapy field was impaired by the combination of radiotherapy and Flt3 ligand, a haematopoietic
cytokine that has been shown to facilitate the expansion ofdendritic cells and the generation of an antitumour immune
response. Importantly, in this experimental model Flt3 ligand
alone had no effect on the growth of primary or secondary
tumours, indicating that ionizing radiation was involved in
the abscopal phenomenon. In addition, this abscopal effect
was absent in nude mice (i.e. in mice lacking T-cells). In
contrast to immunocompetent mice, the addition of Flt3 ligand did not result in any abscopal effect in nude mice. Thesefindings indicate that the abscopal effect triggered by local
irradiation was T-cell dependent [D3].

145316. In a recent paper, Van der Meeren et al. [V3] investigated the radiation-induced inflammatory response after
total-abdominal or whole-body irradiation of mice at adose of 15 Gy. A comparison with WBI was used to take
into account haematopoietic involvement in the inflammatory process. The authors found a systemic inflammatory
reaction after both abdominal irradiation and WBI, with anincreased cytokine and chemokine production at the intestinal and lung levels, indicating a possible abscopal effectof radiation. They postulated that the effects observed in thelungs after irradiation of the abdominopelvic region may becaused by circulating inflammatory mediators due to the gut
inflammatory response.
317. One question that remains unanswered is whether the
immunogenetic background may be involved in disease risksof irradiated subjects. There are large individual variationsin the level of immunological parameters and inflammatory markers. Only some individuals with reduced immune
function and/or elevated inflammatory biomarkers develop­particular diseases [K36]. Thus it may be postulated that individual immunogenetic background may determine individual
susceptibility to certain diseases. One particularly important
genetic factor that can affect host immune response appears
to be the HLA gene. Higher risks of type 2 diabetes were
found between heavily exposed atomic bombing survivors
with different class II HLA DQA1 and DRB1 alleles [H12],
suggesting that certain class II HLA genes regulate one ormore components of the immune system that are related withthe risk of diabetes development in irradiated people.
318. Ionizing radiation exhibits immunomodulatory properties. The “danger” model of immunity describes antigenspecific cellular immunity engendered by an inflammatory
milieu, where an important role is played by dendritic cells.
Ionizing radiation may create an inflammatory setting via
induction of apoptosis, necrosis, cell surface molecules andsecretory molecules. Radiation may influence the expression of immunomodulatory surface molecules (MHC,­co-­stimulatory molecules, adhesion molecules, death receptors, heat shock proteins) as well as secretory molecules(cytokines, inflammatory mediators), in both tumour andnormal cells. Experimental data indicate possible radiation­mediated modulation of tumour antigen-specific immunity [F5]. Radiation-mediated immunomodulation currently
remains unquantified and poorly understood. A major
research effort will be required to better elucidate the­mechanisms involved.
2. Remarks concerning otherpossible mechanisms involved
319. Other possible mechanisms involved are:− Involvement of catecholamines in the proliferative activity of splenic and thymic lymphocytes,
as well as intracellular calcium and protein kinase
C in the signalling of immunoenhancement after
low-dose irradiation;

146

UNSCEAR 2006 REPORT: VOLUME II− Modulation of oxidative status following lowdose irradiation;− Indirect effects of local radiotherapy, outside theradiation field, described originally as “abscopal
effects”;− Possible involvement of immunogenetic background in disease risks of irradiated subjects.

K.

Immune mechanisms and cancer
1.

General considerations

320. That cancer may result as a stochastic effect fromexposure to ionizing radiations has been well known for along time, and mechanisms of radiation carcinogenesis havebeen extensively reviewed [U2, U4, U5, U6]. In the context
of this annex, it is most important to understand the mechanisms of cancer development and especially to investigate
the possible roles of the immune system.
321. Cancer is a multifactorial disease for which a genetic
susceptibility and environmental factors—chemical, physical or viral—can be responsible. It is worth noting that somespecific cancers are usually linked to specific exposures toenvironmental or infectious factors [N3, W18]. Some evidence has been recorded of a possible connection between
haematological malignancies and exposure to ionizing radiation, although nitrates, pesticides, HTLV1 or Epstein–Barrvirus infections, and immunodeficiency are other possible
risk factors [D27]. The increased cancer incidence observedin organ transplant recipients has been related to immunosuppressive treatments that must be maintained to preventand treat acute rejection [A11, A30, O11].
322. Cancers are not merely autonomous masses of mutant
cells, but are composed of multiple cell types such as fibro­
blast and epithelial cells, cells that form blood and lymphatic
vasculature, specialized mesenchymal cells that are uniqueto each tissue environment, and indeed innate and acquired
immune cells [C35]. While tissue homeostasis is maintainedby collaborative interactions between these diverse cell
types, cancer development is enhanced when mutant cells
neutralize homeostatic growth constraints and hijack thenormal physiological processes to favour their own survival.
Furthermore, tumours can develop an angiogenic phenotype which gives them a potential of growth and metastatic­migration [F14].
323. It is recognized that each stage of cancer development
can be exquisitely susceptible to modulation by immune
cells. In essence, there is a complex relationship between
immune cells and developing tumours with the following
paradox: full activation of immune cells in response to thetumour may result in eradication of malignant cells and conversely an inefficient immune response may leave tumour
cells with the possibility to grow, whereas chronic activation of various types of innate immune cell in or aroundpremalignant tissues may actually promote tumour development. In cancers, the abundance of infiltrating lymphocytes,
which are the predominant cells involved in the acquired
response, correlates with a favourable prognosis. On theother hand, an abundance of infiltrating innate immune cells,such as macrophages, mast cells and neutrophils, correlateswith increased angiogenesis and/or a poor prognosis [D17],
although clusters of macrophages around tumours are often
associated with tumour regression [G27].
324. Therefore, with regard to the role of the immune system in cancer development, it could be inferred that ionizing radiation might modify cancer risk not only by acting
as a carcinogen per se but also by modulating host immune
response. Genotoxic stress and stalled DNA replication
forks induce the expression of ligands for the NKG2D
receptor found in NK and certain T-cells, cell types that areable to attack tumour cells [G36]. This activation depends
on proteins involved in DNA damage-sensing pathways andcell cycle regulation. This might explain how DNA damage
response participates in altering the immune response to thepresence of potentially dangerous cells.
2.

Immune surveillance theory

325. The fact that so many persons die each year of cancer
suggests that their immune response to tumour cells is inefficient. Indeed the immune system may respond only if novel
antigens are expressed on the cell surface by tumour cells andare subsequently recognized as non-self neoantigens [L29].
A number of alterations occur in the cell during tumori­genesis: depression of some genes, expression of ­othersor alteration of genes via mutations. Thus genetic changes
related with carcinogenesis may result in the expression of“aberrant” molecules by transformed cells (reappearance ofembryonic proteins not expressed in adult life, expression ofunique antigens not expressed by normal cells). However,the prevalence of an antigen expression can vary, meaningthat not all tumours of a particular type may express the antigen at all. Many antigens have heterogeneous expression,
with the result that the proportion of cells that express theantigen within each tumour may vary from patient to patient.
Indeed, antigen expression depends on the status of the cellular machinery; for example, antigen expression would
be reduced in the case of proteasome deficiency [D28].
It is worth noting that most tumours induced by physical,
chemical or viral agents express neoantigens [S52], while
in contrast, spontaneously occurring tumours are only often
weakly immunogenic or are non-immunogenic.
326. In the immune surveillance theory of cancer, tumours
can develop only when cancer cells can escape from theimmune surveillance either by reducing the expression oftumour antigens or by modifying immune recognition andactivation [Z3]. As an example, the down-regulation of thesynthesis of class I HLA molecules in tumours and meta­
stases is a potential mechanism by which cancer cells canescape from class I HLA restricted lysis by cytotoxic T-cells.

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

In addition, the expression of the non-classical class I HLA
molecule HLA-G on the cell surfaces of various cancers(melanomas, kidney cancers, breast cancers) inhibits boththe cytotoxic activity of NK lymphocytes and the antigenspecific cytotoxic lymphocyte response [R22].
327. In support of the immune surveillance theory is thefact that the incidence of cancers is significantly increased
in immunodepressed patients whatever the cause of theirimmunodepression. This is well documented in patientswith AIDS due to viruses of the HIV family. These patients,
who present with an unusually high frequency of Kaposi sarcoma, are also more sensitive to radiation. Unlike the classical Kaposi sarcoma, where radiation therapy is associatedwith minimal toxicity, radiotherapy treatment of this tumourin AIDS patients is associated with very high morbidity[C32, H30, R11].
328. A higher incidence of cancers is also observed intransplant patients who receive immunosuppressive treatments [A11, O11]. This higher incidence concerns not only
tumours associated with latent infections [N3], but also
tumours commonly observed in the general population, suchas digestive, respiratory, endocrine and breast cancers. The
increased incidence of these tumours can be associated with
the immunosuppressive treatment [L3], although some confounding factors such as tobacco and alcohol certainly playa role [C28, F13, H26].
329. The immune system can produce significant anti­
tumour effects, for example after allogenic bone marrowgrafting. T-cells from the donor recognize the tumour as
non-self and develop impressive antitumour effects (graftagainst-tumour effects).
330. Natural antibodies are not very efficient at destroying
tumour cells. However, it has been suggested that the immune
system may eliminate tumour cells that carry tumour-­specificantigens, leaving room for the tumour to grow cells with alow level of these antigens or with antigens that differ only
very slightly from those of normal cells [G27]. On the other
hand, monoclonal antibodies can be ­successful in controlling tumours when they have a high affinity for the tumourand can be used in large quantities. The most successful
examples are the treatments of B-lymphoma with antiCD20 monoclonal antibodies and of some breast cancers
with ­anti-human epidermal growth factor receptor 2 (HER2)
monoclonal antibodies.
331. Against the immune surveillance theory, it has been
observed that the relative risk for some common non-virusassociated solid tumours of epithelial origin (breast, prostate and bladder) is decreased in some immune-suppressed
patients [F12, G17]. This finding has not yet been completely
explained, although it has been suggested that immuno­
suppressive drugs could have a direct antitumour effect.
332. In order to test the validity of the immune surveillance theory, experiments can be carried out in animals.

147

This is the case in nude mice with no thymus, which do notdevelop more cancers than normal mice though this would
be expected given the lack of T-cells. On the other hand, it
has been observed in some tumour grafting experiments thatthe tumour does not develop after injection of intermediate
doses of cancer cells, while tumour development is observed
after injection of low and high doses of cancer cells; thisfinding is difficult to reconcile with the immune surveillance
theory.
3.

Immune response against tumours

333. Cancer immune surveillance involves innate andacquired responses. Innate responses for transformed cells
are associated mainly with NK cells, and the function isbalanced between activating and inhibitory receptors. Thisbalance significantly influences the efficacy of the immune
response and consequently of tumour progression [S12].
Activating NK receptors may respond to stress-inducible
proteins overexpressed by tumour cells. Conversely, the lostor down-regulated expression of class I HLA molecules intransformed cells (“missing self”) may suppress the inhibitory signalling in other NK receptors. NK cells can protect
against experimental tumour growth, in part by producing mediators with anti-angiogenic properties [H22, S45].
NK cell deficiency as observed in the Chediak–Higashi­syndrome in humans and in Beige mice results in some­circumstances in an excess of cancers.
334. Tumour cells may express HLA-G, a non-classicalclass I HLA molecule involved in immunotolerance. The
expression of HLA-G by malignant cells prevents theirelimination, and constitutes a newly described mechanism by which tumour cells may evade immune surveillance [C4]. Through the interaction with specific inhibitory
receptors, HLA-G can protect tumour cells lacking ­classicalclass I HLA expression from cytotoxicity mediated by
NK and T-cells [S12]. Through the inhibition of MICA
­signals, HLA-G may lead to tumour escape from immune­surveillance [R9].
335. Genotoxic stress and stalled DNA replication forks
induce the expression of ligands for the NKG2D receptor
found in NK and certain T-cells, cell types that are able
to attack tumour cells [G36]. This activation depends onproteins involved in DNA damage-sensing pathways andcell cycle regulation. This may explain how DNA damage
response participates in altering the immune response topotentially dangerous cells.
336. Activated macrophages can play a significant rolein the immune response against tumours. Their antitumour
activity is probably linked to lytic enzymes and the generation of free radicals. Furthermore, macrophages produce
TNF-α, a cytotoxin with a powerful antitumour activity.
337. Acquired immunity involves the recognition by
T-cells of the products of mutated genes, oncogenic virus

148

UNSCEAR 2006 REPORT: VOLUME II

products or normal proteins aberrantly expressed. Moreover,interactions between T- and B-cells mediated by cytokines,
as well as minor T-cell subsets such as NKT cells andγδ T-cells, may act in eliminating transformed cells.
4.

Immunologic promotion of tumours

338. Exposure to ionizing radiation may impair the
immune system and, on some occasions, result in lowgrade chronic inflammation. It has been proposed that persistent inflammation could play a role in promoting theproliferation of initiated cells through the generation of
ROS, the production of inflammatory cytokines and theinduction of genetic instability. During chronic inflammatory processes there is an excess production of free radicals, which deregulate cellular homeostasis and can drive
normal cells to malignancy [B1]. Recent findings haveprovided evidence suggesting that persistent inflammation
involving repeated infection could be a key step in carcinogenesis. Indeed, the long-term inhibition of chronic
inflammation by aspirin and selective cyclooxygenase-2(COX-2) inhibitors in patients with ­premalignant disease,or who are predisposed to cancer development, has significantly reduced cancer risk [D15]. Figure VIII showsa model proposed by de Visser et al. [D17] for explaining innate and acquired immune cell functions during­inflammation-associated cancer.

Figure VIII. Model of innate and acquired immune cell functions during inflammation-associated cancer.
Tumour antigens are presented by dendritic cells (DCs) to activate acquired immune responses, which may result in both antitumour (direct)
effects and tumour-promoting effects (via innate immune response) [D17].
Neoplastic progession
Initiation

Pro-inflammatory
cytokines

Tumour-promoting
Pro-growth
Tissue expansion
Malignant conversion

DC migration andantigen presentation
Innate immune
response

T- and Blymphocyte
activation

Serum proteins

Secondary lymphoid organs
Adaptive immune response

339. Chronically activated innate immune cells can also
contribute indirectly to cancer development through suppression of antitumour escape from immune surveillance.
For example, myeloid suppressor GR+CD11b+ cells, e.g.
a subset of innate immune cells, induce T-lymphocyte
dysfunction by direct cell–cell contact and by productionof immunosuppressive mediators, and therefore actively
inhibit antitumour acquired immunity [G16, S42, Z3].

Cell-death inhibition
Genomic instability
Fibroblast activation
Matrix metabolism
Angiogenesis
Anti-tumour
T-cell-mediated cytotoxicity(FAS, perforin and/or cytokine pathways)
Antibody-dependent cell-mediated cytotoxicity
Antibody-induced complement-mediated lysis

340. Immunological activation of tumour growth by tumour
cells has been observed in experimental animals. In many
circumstances, attempts to protect animals against tumour
growth by active immunization by tumour-specific antigens
or by passive immunization by specific tumour antibodies
have, surprisingly, yielded tumour growth. This is interpreted
as being due to the existence of blocking factors. either theantibody itself, which after binding the antigen hides it from

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

cytotoxic T-cells, or the antibody–antigen complex, which
inhibits the antibody-dependent cell-mediated cytotoxicity
by binding to the Fc receptors on the surface of NK cells ormacrophages and blocking their activity.
5.

Remarks concerning immune mechanisms
and cancer

341. On the basis of the preceding paragraphs, some
remarks may be made concerning immune mechanisms andcancer. A complex relationship giving rise to a paradox isobserved between immune cells and developing tumours:
full activation of immune cells in response to the tumour
may result in the elimination of tumour cells, whereas aninefficient immune response allows their growth. In addition, chronic activation of various types of innate immune
cells in or around premalignant tissues may actually promotetumour development.
342. The immune surveillance theory suggests thattumours can develop only when cancer cells can escapefrom the immune surveillance either by reducing the tumour
antigens or by modifying the immune response to them. A
large body of evidence in favour of the immune surveillance theory comes from immunodepressed patients, who
present a higher incidence of cancer. Evidence has also been
seen in transplant patients who receive an immunosuppressive treatment. In contrast to these observations, it has beenreported that the relative risk for some common non-virusassociated solid tumours of epithelial origin is decreased insome immuno­depressed patients. An anti­tumour effect of
the immunosuppressive drugs was suggested in these cases.
343. The capability of the immune system to develop
antitumour effects involves innate and acquired responses.
The innate response is mainly associated with NK cells.
Its function is balanced between activating and inhibitory receptors. NK cell deficiency as observed in humanand mice syndromes results in some circumstances inan excess of cancers. A newly described mechanism bywhich malignant cells avoid their elimination is throughthe expression of HLA-G, a non-classical class I HLA
molecule that can protect tumour cells lacking classicalclass I HLA expression from cytotoxicity mediated by NK
and T-cells. Similarly, activated macrophages play an antitumour role linked to lytic enzymes and the generation offree radicals along with the release of cytokines with apowerful antitumour activity.
344. Acquired immunity involves the recognition by
T-cells of the products of mutated genes, oncogenic virus
products and normal proteins aberrantly expressed.
345. Finally, long-lasting inflammation could play a rolein promoting the proliferation of initiated cells throughthe generation of free radicals, the release of inflammatory
cytokines and the induction of genetic instability, because ofalterations of immune cells.

L.

149

Summary346. There are many mechanisms potentially involved inradiation-induced alterations of the immune system:− Radiation-induced apoptosis is a key mechanism,
well established for blood-circulating white cells,
mostly lymphocytes.
− Mutations of TCR genes is a radiation-dosedependent mechanism which can produce defective TCRs and alter the discrimination between“self” and “non-self”.
− There is still some controversy regarding the functional cytokine secretion pattern of helper T-cells
following exposure to ionizing radiation, although
it is likely that the homeostatic balance between
Th1 pattern (cell-mediated immunity) and Th2
pattern (humoral immunity) is shifted towards a
pro-inflammatory profile.
− Delayed effects, e.g. bystander effects and genomic
instability, have been demonstrated after exposureof the immune system to ionizing radiation. However, the potential impact of such delayed effects
in humans is not known.
− Inflammation resulting from the effects of ionizing radiation can be observed at the microscopic
level and involves immune cells within and aroundtumours, but inflammation may be large enoughto produce significant alterations of parameters inblood samples. Inflammation may be associatedwith chronic diseases.
− There is a vast literature showing that immune
cells after exposure to ionizing radiation show
abnormalities that are quite similar to thoseobserved in normal ageing. These observations at
the biological level have so far not been linked todiseases.
− Alterations of the process of antigen presentation at the level of the immunoproteasome havebeen demonstrated and are possibly a signal of
immunosenescence after exposure to ionizing
radiation.
− Ionizing radiation can contribute to a disturbanceof self tolerance and consequently can pave theway towards autoimmunity.
− Finally, the immunological response against­foreign antigens implies T-cell homeostasis, which
is disturbed after exposure to ionizing radiation.
347. Besides apoptosis, which is a key mechanism within
the immune system, it is rather difficult to classify the othermechanisms according to their importance after exposure
to ionizing radiation. It likely that these mechanisms areinterlinked, e.g. microscopic inflammation, propagated by atype of bystander mechanism and contributing to the ageing of tissues and promotion of cancer. Three hypotheses
to further explore the mechanisms involved in the effects of150

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ionizing radiation on the immune system and their impact inhuman health have been postulated by the Radiation Effects
Research Foundation (RERF) (see section IV):
− Ionizing radiation may accelerate immunologicalageing by perturbing T-cell homeostasis;− Ionizing radiation may induce long-lasting inflammation that may lead to disease development;− Individual immunogenetic background may determine individual susceptibility to succumbing todisease.

348. Immune surveillance is different for the various cancer
entities and has not been reported for all of them. The immune
surveillance theory of cancer development remains controversial. Although the immune system has the capability todevelop impressive antitumour effects, it is not very clear thatcancer results from a deficiency of the immune system, andtumours can be promoted through low-level chronic inflammation because of alterations of immune cells. The potential effects of low doses of ionizing radiation on the critical­balance existing in the immunological network (promoting or
suppressing antitumour immunological response arising in thetumour microenvironment) has been insufficiently studied.

IV.
A.

EPIDEMIOLOGICAL STUDIES

Atomic bombing survivors
1.

3.

352. In an early paper investigating T-cell immunity among
the atomic bombing survivors, Akiyama et al. [A5] lookedat the responsiveness of peripheral blood lymphocytes
to allogenic antigens in mixed lymphocyte cultures from
139 atomic bombing survivors. This study revealed a significant decrease in mixed lymphocyte culture response withincreasing radiation dose. The decline was most marked in
the survivors who were more than 15 years old at the timeof the initial exposure. These results were interpreted as an
impaired thymic function.

General considerations

349. Epidemiological studies of the survivors of the atomic
bombings in Japan are currently the most important single
source of radiation risk estimates for humans. Most of theinformation on the health effects of ionizing radiation available to date comes from long-term studies of survivors of theatomic bombings in Hiroshima and Nagasaki. Almost sixty
years after exposure to radiation, survivors of the atomic
bombings still exhibit increased risks of developing solid
tumours. Immune mechanisms have consistently been associated with either resistance to or development of numerous
tumours. Also, an association between non-cancer mortality and radiation dose has been observed among survivors,
cardiovascular, thyroid and liver diseases being the more
frequently reported causes. Long-lasting inflammation may
be considered an important contributory factor for the development of some of these diseases [K36]. Knowledge of the
impact of radiation on the immune system is therefore critical to assessing radiation-induced effects on the long-term
health of survivors [K23, K36].

2.

Long-term effects

353. In 1983 Akiyama et al. [A4] described functional
defects in T-cell response to mitogens such as PHA. IL-2 isknown to have different actions regarding T-cell proliferation and T-cell development. CD4+ T-cells are those primarily responsible for producing IL-2 in response to mitogens
such as concanavalin A (Con A). Decreased production of
IL-2 has been implicated as a potential factor in radiationinduced impaired immunity [B5]. To elucidate the biologicalsignificance of the T-cell abnormalities observed in atomic
bombing survivors long after exposure, Kusunoki et al.
investigated the percentage of T-cells capable of responding
to PHA or Con A or that could produce IL-2. The study used
a limiting dilution assay method to evaluate the responsiveness of the T-cell population to these mitogens. The subjects
in this study were 251 atomic bombing survivors exposed
to <0.005 Gy and 159 survivors exposed to >1.5 Gy.
The percentage of CD2+ cells (activated T-lymphocytes)
capable of proliferating in response to PHA in the presence of exogenous IL-2 did not differ substantially between
distally and more heavily exposed survivors. In contrast,
T-cell capacity in response to Con A was lower in the more
exposed individuals. Moreover, heavily exposed survivors
possessed fewer T-cells with the capability of producing
IL-2. It was concluded that peripheral blood samples fromheavily exposed survivors contained significantly fewer­IL-2-producing CD4+ T-cells than did similar samples fromthose distally exposed to radiation from the atomic bombings. Radiation might have a long-lasting negative effecton the capacity of the CD4+ T-cell populations involved in
IL-2 production [K31].

Short-term effects

350. It has been estimated that around 114,000 people
in Hiroshima (an additional 20,000 military personnel notincluded) and 74,000 people in Nagasaki died before theend of 1945, in total about 210,000 deaths, as a direct resultof the bombings. These deaths are referred to as “acutedeaths”. The short-term effects of the bombings have been
extensively described, and include thermal, mechanicaland radiation injuries (in particular radiation-induced bone­marrow depletion).
351. At the time of the bombings, the haematopoietic systems of survivors underwent a level of damage for which
the severity and persistence were dose-dependent. The mostserious effects were those related to radiation-induced cell
death resulting in the development of symptoms of acuteradiation syndrome. Several months after exposure, thehaematolymphoid function of many survivors had almost
completely recovered [O8]. Studies initiated soon after thebombings showed little evident dose-dependent effects on
the immune system [A6]. However, even several decades
later, it was still possible to detect long-term alterations in
the immune system of exposed survivors.

354. A decreased proportion of mature CD3+ T-cells wasfound in peripheral blood lymphocytes among the atomic
bombing survivors exposed to >1.5 Gy, particularly in the
proportion of the CD4+ CD45RA+ naive T-cell subset. The
frequency of a rare T-lymphocyte subpopulation bearing
CD3 surface antigen and TCR (α and β chains), but lacking
151

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UNSCEAR 2006 REPORT: VOLUME IIboth CD4 and CD8 (double-negative CD4– CD8– αβ+), wasstudied in 409 atomic bombing survivors (160 who had been
exposed to ≥1.5 Gy and 249 controls). The frequency of
CD4–CD8– αβ+ T-cells was significantly elevated in individuals exposed to >1.5 Gy [K37]. The authors interpreted
this finding as a result of altered differentiation and development of T-cells. This rare T-cell population may be differentiated through a pathway different from that of conventional
CD4+ or CD8+ αβ+ T-cells [K32].
355. Alterations of T-cell population subsets were confirmed in further studies. The proportions of subsets of T-,
B- and NK cells in peripheral blood lymphocytes of atomic
bombing survivors were studied by flow cytometry analysis[K29]. Blood samples from 159 survivors estimated to havereceived >1.5 Gy and from 252 controls were evaluatedusing multiple combinations of monoclonal antibodies tolymphocyte differentiation antigens. The findings revealed
that the proportion of CD4+ T-cells was decreased significantly in the heavily exposed survivors and that a similartendency was apparent for the CD4+ CD45RA+ naive T-cell
subset. No significant changes were found in the proportionof CD8+ T-cell subsets between exposed individuals andcontrols. Also, a dose-dependent increase in the frequencyof PHA-stimulated lymphocytes bearing chromosome­aberrations was reported in 1975 [A15].
356. The high sensitivity of CD4+ CD45RA+ naive
T-cells to ionizing radiation in long-term studies appears
to involve functional defects in T-cell response or demonstrable impairment in CD4+ T-cell immunity. In T-cells
from 723 atomic bombing survivors, almost uniformly
distributed with respect to age, sex and dose, the ability ofT-cells to proliferate in vitro was tested after a challenge
by each of the Staphylococcus aureus toxins SEB, ­SEC-2,
SEC-3, SEE and TSST-1. The results revealed that the
proliferative responses of the T-cells of the atomic bombing survivors became progressively weaker as the radiation dose increased, and that they did so in a manner that
correlated with the decrease in the percentage of CD4+
CD45RA+ (naive) T-cells, but not with that of CD4+
CD45RA– (memory) T-cells. These findings indicatedthat irradiation from the atomic bombings led to impairment of the ability of exposed individuals to maintain theirnaive T-cell pools, explaining why they responded poorly
to ­toxins encoded by common pathogens [K26].
357. A dose-dependent increase in the relative risk of myocardial infarction has been observed in RERF’s Adult HealthStudy cohort of atomic bombing survivors [K43]. The effectsof ionizing radiation on conditions other than cancer havepreviously been reviewed in the UNSCEAR 1982 [U8] and1993 [U5] Reports. This subject is now extensively reviewed
in annex B, “Epidemiological evaluation of cardiovascular disease and other non-cancer diseases following radiation exposure”. However, some data will be discussed here
concerning the hypothesis of a causal relationship between
immune dysfunction and myocardial infarction in atomic
bombing survivors.

358. The T-cells of survivors with a history of myocardial
infarction responded poorly to Staphylococcus aureus toxins, and these individuals had proportionally fewer CD4+
CD45RA+ (naive) T-cell populations than survivors with no
myocardial infarction in their history [K26]. It had previously been reported that among 1,006 survivors uniformly
distributed with respect to age, sex and dose, 18 persons had
a history of myocardial infarction; the proportion of CD4+
cells was significantly decreased with increased dose andhistory of this disease. Further, the prevalence of myocardial
infarction was significantly greater in those individuals who
had a lower proportion of CD4+ helper T-cells [K28].
359. Kusunoki et al. suggested that myocardial infarction in atomic bombing survivors may be due at least inpart to their having diminished ability to mount an immune
response against certain infections that may be implicated in
the aetiology of cardiovascular disease [K36]. However, thisinference may be premature. Blood samples for determination of the proportion of CD4+ and CD8+ T-cells were taken
between 1992 and 1995, while histories of myocardial infarction were recorded from 1958 to 1990. Although Kusunoki
et al. assumed that measurements of T-cell subsets before
disease onset would have shown similar values to thoseobtained in their study, in order to demonstrate a causal relationship they had to carry out a prospective study to record
newly diagnosed cases and compare the incidence between
subjects exhibiting low and normal CD4+ T-cell proportions. Changes in the proportion of CD4+ T-cells have been
described in patients with acute myocardial infarction andpost-myocardial-infarction syndrome without antecedents ofradiation exposure [A19, B26, K53, T15]. Although someof these changes were exhibited only temporarily, long-term
effects may also exist. It is thus possible that CD4+ T-celldeficiencies in survivors with myocardial infarction history
are, at least in part, of a fundamental nature rather than being
totally attributable to radiation exposure.
360. Kusunoki’s observation is reminiscent of an earlier
report by Roberts-Thomson et al. [R7], who examined thenumber of positive delayed-type hypersensitivity reactions
and the number of deaths among study participants aged
over 80 years. They found that those who manifested fewer
than two positive reactions had significantly greater mortality over the two-year period of study than those who showed
two to five positive reactions. Bronchopneumonia, cerebrovascular accidents and cardiac failure were the most commonly recorded causes of death; no deaths were attributed
to cancer, suggesting that reduced T-cell-mediated immune
responsiveness resulting from earlier exposure to radiation
could cause diseases other than cancer related to old age by
as yet unknown mechanisms.
361. No dose–response relationship was found between
anti-hepatitis-C-virus (HCV) seropositivity and radiationdose in atomic bombing survivors. The relative risk ofchronic liver diseases among anti-HCV-positive individuals
was marginally increased with radiation dose. The authorsinterpreted their findings with the hypothesis that radiation

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

exposure may accelerate the progress of chronic liver diseaseassociated with HCV infection [F8]. The rates of seropositivity for hepatitis B surface antigen (HBsAg), which indicatescurrent hepatitis B virus (HBV) infections, and anti-HBVcore antibody, which indicates either cured or current infections, increased with radiation dose among 6,121 atomic
bombing survivors. However, no relationship was observed
between radiation and anti-HBV surface antibody, indicating cured infection, suggesting a lower likelihood of clearance after HBV infection among those who were more likely
to have been infected with HBV as adults after irradiationfrom the atomic bombings [F7]. Taking into account thatTh1 responses are able to clear hepatitis virus infections
very efficiently, these findings could be interpreted to be theresult of a persisting radiation-induced Th1/Th2 imbalance­promoting chronic infection [K23].
362. As discussed earlier, a large and diverse TCR repertoire, necessary for recognition of the many antigenic
peptides possible, is a critical feature of T-cell populations.
Kusunoki et al. [K25] evaluated whether the recovery of
CD4+ T-cell populations in atomic bombing survivors was
associated with a long-term reduction in the diversity of the
TCR repertoire. Using a panel of monoclonal antibodies
against 13 TCR V β families, they employed flow cyto­
metry to analyse peripheral blood samples from 710 survivors, distributed almost uniformly with respect to age, sex
and dose (controls, <0.0005 Gy; exposed, ≥0.0005 Gy).
They defined a parameter referred to as “repertoire deviation”, which expressed the extent to which the TCR V βrepertoires of T-cells from a given individual deviated fromthe mean for the whole population. The naive helper T-cell
pools (CD4+ CD45RA+) of exposed individuals showeda dose-­dependent decline without changes in their TCR
V β repertoires. In contrast, the percentages of memory
helper T-cells (CD4+ CD45RA–) did not decline, but their
TCR V β reper­toires were skewed in a dose-dependent­manner among individuals who were at least 20 years ofage at the time of the bombings.
363. Normally, since fewer new T-cells emerge from thethymus in the elderly, naive T-cell pools gradually become
smaller with age. In contrast, memory T-cells that are lost
tend to be replaced through clonal expansion. Thus the memory T-cell pool remains almost constant in size but graduallyloses the diversity of TCR repertoire with age. Recovery ofT-cell populations after radiation-induced depletion involves
two different pathways: the production of new T-cells fromthymus stem cells and the proliferation of peripheral mature
cells that have managed to survive. The observations by
Kusunoki et al. [K25] lead to the conclusion that restoration of the peripheral T-cell pools of atomic bombing survivors involved these two different pathways, and suggestthat ionizing radiation accelerated the normal processes of­immunological ageing.
364. Radiation exposure from the atomic bombings wasdemonstrated to be associated with long-lasting deficits inboth naive CD4+ and CD8+ T-cell populations. Statistically153

significant dose-dependent decreases in the percentages ofnaive CD4+ and CD8+ T-cells were found in the peripheral
blood lymphocyte populations of 533 Hiroshima atomic
bombing survivors. In contrast, while the percentages ofmemory CD8+ T-cell subsets were found to increase withradiation dose, no changes were observed in the percentagesof memory CD4+ T-cell subsets [Y2].
365. The numbers of peripheral blood lymphocytes
belonging to different subsets were studied in 1,328 atomic
bombing survivors using immunocytochemistry (fluorescentantibodies) [K24]. A decreasing trend in the numbers of
CD4+ and CD8+ T-cells and in CD19+ B-cells was observedwith increasing age. The CD5 molecule has an important role in T-cell/B-cell interactions [B25]. The number ofCD5+ B-lymphocytes was significantly lower in those persons exposed to >1 Gy within the group exposed at the ageof 30 years or later. A similar tendency towards decreased
numbers of CD4+, CD8+ and CD19+ cells was observed inthese older survivors, although the differences were not statistically significant. These results suggest that ageing of the
T-cell-related immune system is accelerated in people irradiated at an advanced age. Owing to the age-related decreasein thymic function, subjects who were older at the time of
the bombing may have decreased functional capability of theimmune system for recovery after radiation injury.
366. In a further paper reporting flow cytometric analysesof the lymphocyte subsets from atomic bombing survivors,
Kusunoki et al. [K29] demonstrated a significant increasein the proportion of B-lymphocytes in heavily exposed survivors. The increase was evident in both positive and negative cells for CD5 antigen (a marker of mature B-cells), as
well as in both positive and negative cells for CD23 antigen(a marker of stimulated B-cells). The discrepancy between
these results and those from earlier studies [K24] may be due
to a difference in the measurement method.
367. NK cell numbers were studied in atomic bombing survivors using immunocytochemistry. The NK cell population
was found to be increased significantly in the older comparedwith the younger age group, but there was little dependence
on dose [K24]. These results are in good agreement with afurther study carried out using flow cytometry that did not
find any effect of radiation dose on the proportion of NK cellsubsets [K29]. Concerning NK cell activity, no significant
changes were observed in a study of 1,341 atomic bombing
survivors [B5].
368. Several studies have been carried out since 1968 concerning serum immunoglobulin levels. Data published byHall et al. [H2] and by King et al. [K12] in 1973 showedno relationship between radiation dose and serum immunoglobulin levels in the cohort of atomic bombing survivors
at that time. Fujiwara et al. [F4] determined the levels of
autoantibodies and immunoglobulins among 2,061 individuals exposed to radiation from the atomic bombings in Hiroshima and Nagasaki for whom dose estimates ranged from0 to 5.6 Gy. They found: a significant increase in IgA levels

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in females, a significant increase in IgM levels in both sexes,
and no changes in the prevalence of antinuclear antibody,
antithyroglobulin antibody and antithyroid microsomal antibody, or in levels of IgG and IgE. These results were recently
confirmed by Hayashi et al. [H10].
369. In 1994 Nagataki et al. reported an increase in theprevalence of antibody-positive hypothyroidism among
atomic bombing survivors in Nagasaki [N2]. In contrast, theAdult Health Study by the Atomic Bomb Casualty Commission/RERF reported a lack of dose–effect relationship on
the prevalence of autoantibodies [F4]. Imaizumi et al. haverecently re-evaluated these observations and found that theprevalence of hypothyroidism with autoantibodies marginally increased among moderately exposed survivors but notamong highly exposed survivors in Nagasaki. They concluded
that there is no statistically significant dose response in theprevalence of antithyroid autoantibodies or hypothyroidismwith autoantibodies in atomic bombing survivors [I8].
370. In their studies of somatic mutations, Kushiro et al.
[K22] used a flow cytometric assay to identify both genemutation and somatic recombination. In 168 Adult HealthStudy participants and 58 employees of RERF, the frequency
of variant lymphocytes lacking expression of HLA-A2 or
HLA-A24 allele products was about 10-4 in heterozygous
donors and increased with donor age. Possible mutant cells
lacking expression of HLA-A2 or HLA-A24 were isolated
and clonally propagated. Molecular analysis of 164 clones
derived from six donors revealed that 71–100% were defective in expression of the selected HLA-A alleles. On theother hand, 80% of the clones consisted of CD4+ T-cells,
and the remainder were CD8+ T-cells. The effect of exposure to radiation from the atomic bombings was not statistically significant. However, while 1 out of 50 mutants invivo derived showed a possible small deletion at the HLAlocus without any chromosomal abnormality, the majority ofmutants derived from in vitro X-irradiated peripheral bloodmononuclear cells bore important deletions [K22].
371. As already discussed, the HLA gene seems to be a particularly important genetic factor that can affect host immune
response. Significant differences in type 2 diabetes prevalence
were found between heavily exposed (>1.5 Gy) and low-doseor non-exposed Hiroshima atomic bombing survivors withdifferent class II HLA DQA1 and DRB1 alleles [H12]. The
prevalence was higher for heavily exposed individuals who
were less than 20 years old at the time of the bombing and who
presented DQA1*0401 and DRB1*08 alleles or DQA1*0301
and DRB1*09. These results suggest that certain class II HLAgenes regulate one or more components of the immune system related with the risk of diabetes development among theyounger and more heavily exposed survivors. This was thefirst report suggesting that the development of a particulardisease can be affected by radiation exposure in individuals
with different genetic backgrounds.
372. The possibility of various degrees of radiation­associated immune suppression being dependent on HLA

type has been addressed. To investigate the possibility ofdiffering frequency distributions of HLA type in the Hiroshima cohorts, HLA-DQA1 alleles and HLA-DR antigens
were typed for 201 survivors exposed to >1.5 Gy, 339
exposed to between 0.005 and 1.5 Gy, and 388 in a distally
exposed group (<0.005 Gy). Although no dose-related differences were found, when the subjects were grouped by
the presence of a specific allele or antigen, males carrying
DQA1*0103 in at least one of their two HLA-DQA1 lociexhibited frequency distributions that decreased as radiationdose increased [H9].
373. In earlier work, Kusunoki et al. [K27] had demonstrated that mutant lymphocytes lacking expression of class
I HLA molecules were eliminated by autologous NK cells.
In an attempt to explain the inability to detect any increase
in HLA-A2 negative cell number in HLA-A2 heterozygous
individuals exposed to irradiation from the atomic bombings,
the hypothesis was tested that HLA mutant lymphocytes
might well have been induced by radiation exposure but
eliminated by strong negative selection associated with theiralmost inevitable exposure to autologous NK cells [K30].
The results strongly supported the hypothesis that autologous NK cells are responsible for the elimination of mutant
lymphocytes that have lost the ability to express self class
I HLA molecules in vivo, and therefore might explain why
it has not been possible to detect increased frequencies of
HLA-A2 mutants in samples from any of the 164 atomic
bombing survivors whose HLA-A2 heterozygote status
made their lymphocytes suitable for such a test.
374. Kodama et al. wanted to investigate whether radiation
exposure had induced chromosomal instability in peripheral lymphocytes. Ordinary cytogenetics was not expected
to help them solve this problem, as lymphocyte stable aberrations (mainly translocations) induced at the time of thebombings would not be distinguishable from those that may
have arisen later as a result of the instability. Therefore theystudied clonally expanded T-cell populations, e.g. cells bearing identical translocations, because they are descendants
of a single progenitor cell which acquired aberrations as aresult of radiation exposure. By determining the frequencyof additional translocations among clonal cells, the authors
found that clonally expanded T-cell populations of atomic
bombing survivors do not exhibit increased chromosomal
instability [K44].
375. It has been argued that chronic low-level inflammatory responses induced by radiation could be a significant
risk factor in the well-documented increase of non-cancer
disease occurring in atomic bombing survivors. Hayashi etal. investigated the long-term effects of ionizing radiationon the levels of two markers of inflammatory response,
C-reactive protein (CRP) and IL-6, in blood samples from453 participants in an epidemiological cohort of atomic
bombing survivors [H8]. Blood lymphocyte subpopulations
were identified by flow cytometry, using monoclonal antibodies to CD3, CD4 and CD8. CRP levels were significantly
increased, by about 35% Gy–1 (p = 0.0001). After adjustment

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

for confounding factors (sex, age, etc.), CRP levels were still
increased significantly with dose, by 28% Gy–1 (p = 0.0002).
IL-6 levels also increased with radiation dose, by 9.3% Gy–1
(p = 0.0003) and, after multiple adjustments, by 9.8% at
1 Gy (p = 0.0007). Elevated CRP and IL-6 levels were associated with decreases in the percentages of CD4+ T-cells in
the peripheral blood lymphocyte population [H8]. Hayashi
et al. recently reported long-term effects of radiation doseon inflammatory markers in atomic bombing survivors. They
found that erythrocyte sedimentation rate, IFN-γ, TNF-α andIL-10 increased significantly with radiation dose [H10].
4.

Remarks concerning data on survivorsof the atomic bombings

376. The preceding review of data concerning atomic
bombing survivors shows that short-term effects ofradiation on the immune system were expressed mainly
as dose-dependent acute bone marrow depletion due toradiation-induced cell death. These effects were reversed
over several months, and studies initiated shortly after
the bombings showed few dose-dependent effects on the
immune system [A6].
377. Studies of the late effects of radiation on the immune
system commenced about 20 years after the atomic bombings. The most remarkable late effects of radiation werefunctional and quantitative abnormalities of T- and B-cells insurvivors exposed to high doses (≥1 Gy). The main findings
observed up to 1995 have been reviewed and summarized
by Akiyama [A6]. With respect to data published thereafter,
the most remarkable late effects of radiation on the immune
system of atomic bombing survivors are summarized in thefollowing paragraphs.
378. Effects on T-cell immunity:− Decreased proportion of CD3+ CD4+ TCRαβ +T-cells;− Decreased proportion of CD3+ CD8+ TCRαβ +T-cells;− Decreased proportion of CD3+ CD4+ CD45RA+
naive T-cells;− Non-significant changes in the proportion of
CD3+ CD4+ CD45RA– memory T-cells;− Skewed TCR repertoires of CD3+ CD4+
CD45RA– memory T-cells in individuals exposedin adult life;− Decreased proportion of CD3+ CD8+ CD45RA+
naive T-cells;− Increased proportion of CD3+ CD8+ CD45RA–
memory T-cells;− Increased frequency of CD4– and CD8– (doublenegative) αβ+ T-cells;− No change in the proportion of CD3+ TCR γδ+T-cells;155− Functional defects in T-cell responses to mitogens
and alloantigens.
379. Effects on B-cell immunity:− Significant increase in the proportion of B-cells;− Increase in serum IgA levels in females;− Increase in IgM levels in both sexes;− No changes in IgG and IgE levels.
380. Effects on innate immunity:− In contrast with acquired immunity, significant
dose effects were not observed on the number
and function of NK cells. However, some ­studies
showed an increase in the proportion of NK
cells in the peripheral blood of atomic bombing
survivors.
381. Other findings:− Increased frequencies of somatic mutations (TCR
and HLA) and chromosome aberrations;− Marginal increase with radiation dose in the prevalence of chronic liver diseases and hepatocellular
carcinoma among anti-HCV-positive individuals;− Decreased cellular immunity and enhanced
humoral immunity may have led to long-term
imbalance in Th1/Th2 responses, resulting inaltered cytokine expression profiles;− Qualitative and quantitative changes suggestinga radiation-induced acceleration of the normal
process of immunological ageing;− Radiation-associatedresponses;

chronic

inflammatory− Decreased proportion of CD4+ cells withincreased dose and history of myocardial­infarction, and higher prevalence of myocardial
infarction in those survivors who had a lower
proportion of CD4+ cells;− Differences in type 2 diabetes prevalence in heavily exposed individuals with two particular classII HLA DQA1 and DRB1 alleles.

B.

Chernobyl workers and residents
1.

General considerations

382. The accident at the Chernobyl nuclear power plant(NPP) on 26 April 1986 resulted in both acute and long­lasting health effects. Early and late immune system changes
were among the key points studied after the accident. Acuteradiation effects in victims were extensively described in an
appendix to the UNSCEAR 1988 Report [U6]. Further information about the immunological effects of exposure to radiation from the Chernobyl accident as they were known up to156

UNSCEAR 2006 REPORT: VOLUME II

the year 2000 was provided by the Committee in reference[U2]. The Committee is currently updating its assessment of
the health consequences of the accident. However, some data
concerning immunological issues will be discussed here. A
broad spectrum of immune abnormalities had been reported
among Chernobyl victims; however, it has not been possible to interpret these results, since it was unclear whether all
possible confounding factors (such as heavy metal contamination, infections and diet) had been taken into account.
383. Early changes in immune parameters were characterized by alteration of the amount or function of peripheral
lymphocytes and changes in serum immunoglobulins. The
data indicate that radiation-induced effects on the immune
system remained detectable for a considerable period after
the accident. The available data vary widely, according to thecharacteristics of the populations studied, the dose received
and its protraction in time, the mode of exposure (external irradiation and/or internal contamination) and the time
elapsed since the accident.
384. Immunological monitoring of persons affected by the
Chernobyl accident comprised two main groups:− Individuals who worked at the NPP during the
emergency and/or participated in further clean-up
activities;− Residents of contaminated areas, particularly
children living in several settlements aroundthe NPP, who were included in the Children of
Chernobyl Project, as requested by the Ukrainian
Government.
Different parameters have been evaluated and several
phases may be identified in these two groups concerning the­temporal behaviour of the immunological effects.

2. Emergency and clean-up workers
385. The workers involved in the recovery and clean-up
after the Chernobyl accident were subjected not only to
external and internal radiation exposure but also to othernon-radiation factors that may have affected their health.
As a consequence of the accident, different heavy metals
were deposited at the reactor site, with a significant amountbeing vaporized and distributed in rain clouds. Higher bloodconcentrations of iron, zinc and lead have been found in­workers who took part in cleaning up after the accident [N9].
It could be hypothesized that some of the observed changes
in the immune status of clean-up workers might be due to a
­combined action of ionizing radiation and heavy metal contamination. [B19, G10]. Moreover, these workers sufferedstrong psychological stress, which may significantly affectthe immune system [G21].
386. Yarilin et al. [Y4] evaluated disorders in T-cell subpopulations 5 years after the accident in two groups ofworkers from the Chernobyl NPP accident, the first being

workers without manifestations of acute radiation syndrome(ARS), for which total doses from external irradiation were0.1–0.5 Gy (group 1), and the second being individuals who
survived ARS, for which total doses from external irradiation were 0.5–9 Gy (group 2). Decreases in the percentage
and absolute number of CD3+ T-cells were observed in bothgroups. A decrease in the percentage and absolute number ofCD8+ T-cells was observed only in group 1 (which had lower
doses). A decrease in the percentage and absolute number of
CD4+ T-cells was evident only in heavily exposed people
from group 2.
387. Titova et al. found that the mean number of CD8+
T-cells was decreased in personnel working in the 30 km
control zone around the NPP [T6]. The absolute numberof CD4+ T-cells was also decreased, but their percentage
remained higher. Kurjane et al. characterized the immune
status of a group of Latvian workers who received external radiation doses of 0.01–0.5 Gy [K21]; this study was
performed 10–14 years after the accident. A significant
decrease was observed in the number of CD3+ T-cells. This
study also demonstrated that both CD4+ and CD8+ T-cells
were decreased. A study performed by Kuzmenok et al.
[K33] 11–14 years after the accident did not, however, findsignificant changes in the phenotypic characterization of themain subpopulations of peripheral lymphocytes in a groupof Belarussian clean-up workers who received mean dosesof 0.15–0.5 Gy.
388. Other lines of evidence point to the role of serum
inhibitory factors that down-regulate T-cell surface antigen
expression and that could regulate T-cell differentiation invitro. It has been reported that the decreased percentage of
CD4+ helper–inducer T-lymphocytes of recovery operations
workers returned to normal values after 3 days of culture
without activation, suggesting that the phenotype may beunder the control of suppressive soluble factors in the bloodof these individuals [K33]. The fact that the percentage of
CD4+ T-cells in control samples did not change after culture
reinforces this hypothesis.
389. A decline in the number of CD3+ and CD4+ T-cells,with augmentation of the percentages of CD8+ T-cells andCD16+ CD56+/NK cells, was observed after 3 days of­culture with the polyclonal activator PHA at optimal concentration (10 μg mL–1). This activation-induced deviationin the maturation of T-cell subpopulations may be a consistent characteristic of impaired T-cell immunity in clean-up­workers [K33].
390. The functional status of T-cells plays a key role in
the immune regulation of human pathology. The proliferative response of lymphoid cells to mitogens was also alteredin recovery operations workers. Kuzmenok et al. [K33]reported a significant decrease of the response of peripheral blood mononuclear cells to PHA and the phorbol ester
PMA. ­Neither the TCR-restricted proliferative response of
T-cells nor the level of Con-A-induced proliferation was­significantly decreased.

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

391. The proliferative response of peripheral blood mononuclear cells to exogenous IL-2 was higher in recovery operations workers, which may indicate an up-regulation of the
IL-2 receptor CD25 in their cells [K33]. Interleukin-2 (IL-2)
is a cytokine responsible for a variety of immune stimulatory
and regulatory functions, including activation and stimulation of cytotoxic cells able to recognize and kill humantumour cells, and T-cell proliferation and differentiation.
Similar results had previously been obtained by Xu et al. inan experimental model of low-dose (0.25–10 mGy) in vitro
irradiation [X1].
392. Changes in cell subpopulations have been reported
as evidence of radiation-induced disturbance of the T-cellsystem [W5]. An increase in peripheral blood CD3+ CD16+
CD56+ NKT cells, a small subpopulation of lymphocytesthat exhibits certain characteristics of both T-cells and NK
cells and that can be the source of an abnormal pattern ofcytokines, was observed in Belarussian clean-up workers[K33].
393. One of the best described effects of the Chernobyl
accident on the immune system was the increased level ofmonocytes in peripheral blood. Senyuk et al. evaluated thelong-term effects of ionizing radiation in Chernobyl recovery operations workers [S13]. In many cases, the cumulative gamma radiation dose was >0.5 Gy. The authors found ahigh number of monocytes with an increase in plasma levelsof cytokines IFN-α and TNF.
394. Functional changes have been reported in the monocytes and macrophages of clean-up workers. T-cell activation implies cooperation between the APCs and T-cells.
The functions of monocytes as APCs were compared inclean-up workers and control individuals. Impaired function of monocytes as APCs was found in the T-cell proliferation assay. Indeed, allogenic monocytes purified fromclean-up workers significantly augmented the proliferative response to mitogens of T-cells from control individuals but inhibited proliferation of T-cells from clean-up
workers. In contrast, allogenic monocytes purified fromhealthy donors marginally augmented the proliferative
response to mitogens from both clean-up workers andcontrol individuals [K33].
395. Yarilin et al. evaluated the effect of ionizing radiation on the thymus and its role in radiation-induced T-celldisorders in victims of the Chernobyl NPP accident. A
decrease in serum concentration of thymosin alpha-1 andserum thymic activity (STA) level was found with increased
titres of autoantibodies to epithelial cells of the thymus[Y4]. This titre was higher in persons with lower levelsof thymosin alpha-1. The dynamics of post-irradiation
recovery of CD4+ and CD8+ cells were different. It had
been suggested previously that preferential CD4+ cell deficiency might result from radiation-induced damage to thethymus [A12]. The good correlation observed by ­Yarilin etal. between thymic hormone and CD4+ cell levels would
confirm this hypothesis [Y4].

157

396. Yarilin’s results are in good agreement with those of
Titova et al. [T6], who also found lower levels of thymosinalpha-1 and an increased serum level of antithymic epithelium autoantibodies in personnel from the 30 km control zone
around the Chernobyl NPP. The dose-dependent decreaseof the serum level of thymosin alpha-1 and STA observed
5 years after the accident indicates late impairment of thymic
function, which could be a result of a disturbance of thymic
epithelial cell renewal. Thymus dysfunction after low doses
could be due to the action of anti-epithelial autoantibodies
induced by the release of antigenic material from the cells
damaged, even minimally, by ionizing radiation.
397. Thomas et al. [T4] performed a multiple end point
study comparing hypoxantine phosphoribosyltransferase(HPRT) mutation frequency with chromosome translocations in peripheral blood lymphocytes of clean-up workers.
When adjusted for age, smoking status and year of sampling,
the authors demonstrated a significant increase in HPRT
mutation frequency in clean-up workers, with a dependence on time elapsed since radiation exposure (a decline of
4.4% per year). They found little difference in the overall
deletion spectra. However, they observed a decline in the
average size of deletions of clean-up workers as time after
exposure increased from 6 to 13 years. Jones et al. found anincrease, more than 5 years after the accident, of chromosome translocations and in HPRT mutation frequency inperipheral lymphocytes of clean-up workers with absorbed
doses of below 0.25 Gy [J4].
398. Chumak et al. demonstrated an accumulation of autoxi­
dized lipoxygenase products of polyunsaturated fatty acids inthe peripheral blood mononuclear cells of 23 clean-up ­workers
with absorbed doses of below 0.3 Gy [C10]. They observed
higher levels of free and esterified fatty acids, with a positive
correlation between the absolute number of CD4+ T-cells andthe amount of 15-hydroxyeicosatetraenoic acid (15-HETE)
in the phospholipid fraction. The percentage of CD4+ T-cells
was higher in heavily irradiated ­workers, and the percentage
of CD8+ T-cells tended to decrease with dose.
3. Residents of contaminated areas
399. Titov et al. investigated the production of immuno­
globulins in children living around the Chernobyl NPP. They
found a decrease in B-cell numbers, a transient decrease of
IgM and IgG and an increase of IgA levels (in both serumand saliva) during the first months following the accident.
Over a six-year period of living in contaminated areas,children exhibited increasing production of IgG and IgM.
A ­correlation was found between the changes in B-system
immunity and the levels of 137Cs contamination. There wasalso a strong correlation between the production of natural (heterophilic) antibodies and dose to the thyroid due toincorporation of 131I (in the range 0.1–1 Gy). Higher accumulation of 131I resulted in decreased titres of these anti­
bodies. High levels of heterophilic antibodies correlatedwith high levels of IgE. Altered production of subclasses

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of IgG associated with the increasing biosynthesis of IgEsuggests that T-cells may have been driven towards the Th2
profile [T5]. However, trying to find a causal association
between radiation exposure and these changes in Th2 profile would be speculative, because no data about confounding factors such as ­parasite infections in these children weretaken into account.
400. Chernyshov et al. examined peripheral blood lymphocyte subsets eight years after the accident in children living
around the Chernobyl NPP [C9]. They evaluated children
living in 15 contaminated settlements in Ukraine, with andwithout recurrent respiratory disease (RRD), and a control
group of children living in non-contaminated areas, again
with and without RRD. The average dose (internal plus
external contributions: 0.57–3.09 mSv) was calculatedon the basis of the average density of contamination with137
Cs and 90Sr; no data were included concerning thyroid
doses due to 131I incorporation. Lower percentages of CD3+
T-cells were observed in RRD children from contaminatedareas than in control RRD children. Lower percentages of
CD3+ CD4+ (helper) T-cells were observed in RRD children
from contaminated areas than in control RRD children. RRD
children from contaminated areas exhibited lower percentages of CD3+ T-cells and CD3+ CD4+ (helper) T-cells thanhealthy children. Healthy children (no RRD) from contaminated areas had the same mean values for lymphocyte subsets as control healthy children. However, a wider range ofpercentage levels of CD3+ CD4+ T-cells was found among
healthy children from contaminated areas, which allowed
them to be divided into three subpopulations: children withvery low, normal or very high percentage levels of CD3+
CD4+ T-cells. The other lymphocyte subsets studied did not
differ among groups.
401. Children from contaminated areas had a healthy
population (non-RRD) without major lymphocytic manifestations of immune disorders and an RRD populationthat exhibited lower percentages of total T-cells and helper
T-cells than RRD controls. This decrease was more marked
in RRD children with higher doses [C9]. This dose dependence provided strong evidence for a radiation-induced
effect. The question is what accounts for the difference inimmune response observed between exposed children who
are healthy and those with RRD. It may be that repeatedexposure to pathogenic or antigenic stimuli is necessary forthe development of radiation-induced immune disturbances.
Moreover, individual features (including genetic factors)
are involved in the sensitivity of immunocompetent cells toionizing radiation. It could be proposed that children predisposed to RRD have an impaired immune response andmay exhibit greater radiosensitivity. Although this study did
not consider thyroid doses, it is well known that the region
where the study was performed (northern Ukraine) had ahigh level of 131I contamination. It could be hypothesizedthat healthy children from contaminated areas exhibited ahigher percentage of CD3+ CD4+ T-cells owing to clinicaland subclinical autoimmune disorders related to radioiodine
incorporation.

402. The same group of researchers published further
results that confirmed previous findings and showed in addition that children with RRD from contaminated areas had
higher ­levels of CD3– CD56+ CD16+ NK cells than did
RRD children living in non-contaminated regions [V8]. It isinteresting to note that children examined 8–10 years after
the accident exhibited a more marked decrease in CD4+ cells
than those with the same dose but who were examined at
5 years after the accident. This finding shows that long-term
exposure to low doses (i.e. a time effect) rather than low-doseradiation exposure itself (i.e. a dose effect) altered the composition of peripheral blood lymphocyte subsets in child­renwith RRD living in contaminated areas. Although it has beensuggested that CD4+ T-cells are relatively radioresistant invitro [S8], it may be that the combination of repeated exposure to antigenic stimuli together with long-term exposure to
low doses of ionizing radiation leads to CD4+ T-cell depletion. Considering that NK cells have a lower in vivo radio­
sensitivity [C11, L21], their relative increase in children
with RRD from contaminated areas could also be an effectof long-term low-dose exposure. The different responses ofblood lymphocyte subsets could contribute to the lower riskof developing autoimmune thyroid abnormalities in children
with RRD living in contaminated areas.
403. Koike et al. compared NK activity in children living
in Gomel, a highly contaminated area, with that of children
living in non-contaminated areas [K15]. While children­living in non-contaminated areas exhibited a narrow rangeof NK cell cytotoxicity percentages, a wider range of NK
cell cytotoxicity (from 8.9% to 76%) was found in child­
ren from contaminated areas. The NK cell cytotoxicity ofthese children was correlated neither with NK cell number
nor with the amount of internal contamination by 137Cs. The
authors interpreted these findings as a loss of the normal
regulatory mechanisms that maintain a correlation between
cytotoxic activity and NK cell number. It seems a rather
speculative conclusion. Even if such dysregulation exists, itcannot be attributed to ionizing radiation. The lack of correlation between these abnormalities and the levels of internal contamination suggests that related factors, other thandirect internal exposure to 137Cs, may be responsible. Diet
and/or environmental exposure to some agent (such as heavy­metals) might be proposed. The effect of external ionizing
radiation from contaminated ground and the effect fromradionuclides other than 137Cs remain to be determined.
404. Mikhalevich et al. investigated cytogenetic and mutational effects in the lymphocytes of children living in a contaminated region of Belarus nine years after the accident[M5]. Their results indicated a doubling of the percentage of
micronuclei in the mononucleated lymphocytes of exposedchildren, while the same parameter studied in binucleatedlymphocytes showed no differences. No evidence was foundfor induction of HPRT mutations.
405. An adaptive response of lymphocytes to radiation has
been suggested by a number of in vitro studies indicatingthat cells can become less susceptible to radiation-induced

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

damage when a “challenge” exposure to ionizing radiation
is preceded by a very low “priming” dose. Padovani et al.
[P1] administered a challenge dose of 1.5 Gy to stimulated
peripheral lymphocytes of children chronically exposed incontaminated areas around Chernobyl. They did not findany decreased susceptibility for the two end points examined (chromosome and chromatid aberrations). An importantconsideration relates to the dose rate at which the priming
dose is delivered. Assuming a constant intake for 1 year, theaverage value of committed effective dose equivalent was
450 µSv (range 50–2,000 µSv); this dose rate is lower thanthat used in most published studies. Another point of concern
is that the priming dose in this study took place in resting
lymphocytes, and it has been reported that a radio-adaptive
response cannot be induced in the G0 stage of the cell cycle.
4. Radioiodine contamination, immune
status and thyroid diseases
406. A higher incidence of goitre has been reported among
the Chernobyl clean-up workers. Kurjane et al. [K21] analysed several parameters of the immune system in 385 male
Latvian residents who participated in the clean-up work at
the Chernobyl site. The results were compared with thosefrom 47 healthy age- and sex-matched controls. This groupof clean-up workers received external doses of 10–500 mGy.
No data were provided in this paper concerning thyroid doses
due to radioiodine incorporation. Workers were exposed
during 2–6 months, while working at Chernobyl, and thenthey lived in uncontaminated territories after they returned
to Latvia. The prevalence of non-cancer thyroid diseases
as determined in January 2000 was higher among clean-up
workers (47 cases among 385 workers; 121/1,000), than ina non-exposed Latvian population (30/100,000), with goitre
being the most frequent disorder. Diminished acquired cellular immunity (total CD3+ cells, CD4+ and CD8+ T-cells)
was found among the Latvian clean-up workers. The phagocyte activity of neutrophils was significant decreased. Lower
levels of IgG and higher levels of IgM, without changes in
IgA were also found in this group. The observed decrease in
the percentage of CD16+ NK cells contrasts with previous
reports suggesting that NK cells display radioresistance. It is
important to note that blood lead concentration was six times
higher in clean-up workers [K21].
407. Kurjane et al. [K21] also reported that some immune
parameters of workers with thyroid diseases differed fromthose observed in workers without thyroid disease: a lower
number of NK cells, higher IgG plasma concentrations andhigher activation of the classical pathway of complement.2

159

Complement split product C3d was higher in both groups(i.e. with and without thyroid disease) of clean-up workers.
Thyroid follicular cells are protected from lysis by locally
activated complement. Although the underlying mechanismof the complement activation in clean-up workers is unclear,
it may reflect a secondary radiation-induced inflammatory
response. The question of whether this mechanism is also
involved in the development of thyroid abnormalities among
these workers remains unanswered.
408. Considering that the immune system is a vulnerable
target for the effect of lead contamination [B19], the resultspresented for Kurjane et al. should be interpreted cautiously.
It has been reported that CD16+ NK cells and CD4+ T-cells
are vulnerable targets for the effects of lead [G10]. Elevatedblood and urine lead concentrations were found in Kurjane’sgroup of clean-up workers. It could be concluded that even
10–14 years after exposure, a combined impact of both
radiological and non-radiological factors could be observedon the immune system of Latvian workers: impairment ofphagocytic activity, reduction of cell-mediated immunity
parameters and a shift towards an inflammatory profile.
409. Kiseleva et al. reported an increase in serum ­levels of
antithyroglobulin and microsomal fraction auto­antibodies,with higher levels of circulating immune complexes inliquidators 11 years after the Chernobyl accident [K14].
­Vykhovanets et al. investigated the involvement of autoimmune mechanisms in the development of thyroid abnormalities in the context of radioiodine exposure of children
living around the Chernobyl NPP [V9]. The study, which was
carried out 8 years after the accident, included children living
in 15 contaminated settlements and control children living
in non-contaminated areas. Individual absorbed doses to thethyroid due to radioiodine (<1 Gy, 1–2 Gy and >2 Gy) andaverage doses (internal plus external; range 0.57–3.09 mSv)
due to 137Cs and 90Sr were estimated. A positive correlation
was found between thyroid 131I dose and serum AbTg levels, content of CD4+ T and CD4+/CD8+ ratio. In contrast,
a negative correlation was observed between thyroid 131I
dose and CD8+ T-cells and NK cells. The lack of correlation
between thyroid-stimulating hormone (TSH) levels and thyroid dose suggests that the higher levels of TSH found amongchildren living in contaminated areas may be due to iodine
deprivation in areas of endemic goitre. Children with individual absorbed doses of >2 Gy due to radioiodine have several
signs of autoimmune disorder: abnormal thyroid echogenicity, positive sera for AbTg, higher levels of CD4+ T-cells(which play a central role in immune response and are able toincrease immunoglobulin production by B-cells), lower levels of CD8+ T-cells and higher CD4+/CD8+ T-cell ratios, afrequent finding in autoimmune thyroid diseases [V9].

2

Note: These results are presented here as discussed by Kurjane et al. [K21]in the text of their paper. However, the Committee found a lack of correlation between these comments and the values presented by the authors intable 2 of their paper, which seem to be contradictory: a higher number ofNK cells, lower IgG plasma concentrations and lower functional activityof the classical pathway of complement in clean-up workers with thyroid
diseases. The Committee considered that this discrepancy might be due to a
mistake in typing column headings.

410. Two further studies [P10, V12] also reported a higher
prevalence of antithyroglobulin or antithyroperoxidase
antibodies in children living in contaminated areas; thiswas already apparent in individuals who were in utero or
newborn at the time of the accident. Autoimmune pheno­mena were limited to an increased prevalence of circulating

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thyroid autoantibodies, without evidence of significant thyroid dysfunction. It should be taken into account that children
involved in these geographical correlation (“ecological”)
studies may present a combined effect of iodine deficiency
and internal contamination with short-lived iodine isotopes.

to be necessary for the development of radiation-induced
immune disturbances. Individual features, including genetic
factors, are involved in the sensitivity of immuno­competentcells to ionizing radiation. Illnesses associated with bothradiation exposure and genetic factors could be ­determinantsof the immune status after the accident.

411. Koike et al. evaluated the immune status in children
with goitre living in the highly contaminated area of Gomel.
They found increased serum levels of IgG, IgM and IgE, anddepressed NK cell activity [K15]. Although IFN-γ and IL-2
enhanced the cytotoxicity of these NK cells, the response to
IFN-γ was still below control values. The other parameters
were within normal values.

414. The immunological effects of exposure to ionizing
radiation from the Chernobyl accident were mainly related
to changes in the amounts or function of peripheral lymphocytes and serum immunoglobulin levels. These effects
were detectable long after the accident. The immune ­systemseems to be involved in the pathogenesis of thyroid diseases
in victims of the Chernobyl accident, probably owing toantigenic mechanisms being triggered by radiation-induced
thyroid damage, leading to autoimmune responses. Neuro­
endocrine and other stress-related factors, respiratory­diseases, chronic infections, chemical contamination andautoimmune dysbalance could also be factors in some of theimmune ­disorders found in this population.

5. Remarks concerning data on Chernobyl
workers and residents
412. Some remarks may be made on the basis of the publications on the Chernobyl accident reviewed above. Even
many years after the accident, the impacts of both radiological and non-radiological factors on the immune systemwere observed in Chernobyl recovery operations (clean-up)
workers. Ionizing radiation accelerated the natural ageing of
the immune system due to a progressively declining thymic
function. The dynamics of post-irradiation recovery are different for CD4+ and CD8+ cells, and it has been suggested
that preferential CD4+ cell deficiency may result from­radiation-induced damage to the thymus.

C. Techa River study
1.

415. The Techa River study is seen as an excellent opportunity to obtain more reliable risk estimates for a general
population exposed over an extended period to low-doserate gamma rays. More than 25,000 inhabitants of Techa
riverside villages were exposed, predominantly during
the early 1950s, to external gamma radiation from fission
products associated with discharges of high- and mediumlevel wastes into the river from the Mayak nuclear facility.
In addition, residents incorporated, via drinking water andthrough the food chain, large activities of short-lived fission­products such as 89Sr, and subsequently long-lived activity,
especially from 90Sr and 137Cs. Mean and median doses to soft
tissue and bone marrow according to the earlier Techa River
Dosimetry System (TRDS-1996) and the revised dosimetry
system (TRDS-2000) are shown in table 13.

413. Short-term as well as long-term effects were detectable in B-cell and T-cell function profiles, as well as in thebiosynthesis of immunoglobulins in both serum and saliva,of children living in contaminated areas around the Chernobyl NPP. Some of these changes were dose-dependent
and were characterized by phases. Indeed, immune profiles
were different several months as opposed to several years
after the accident. The NK cell system of these children may
have lost the normal regulatory mechanisms that maintain acorrelation between cytotoxic activity and NK cell number.
Repeated exposure to pathogenic or antigenic stimuli seems
Table 13

General considerations

Mean and median doses to soft tissue and bone marrow in inhabitants residing near the Techa River [K9]
Dosimetry system

Soft tissue dose (mGy)

Bone marrow dose (mGy)

TRDS-1996
Mean

99

405

Median

17

267

Mean

35

353

Median7

253

TRDS-2000

2. Epidemiological data
416. In the early period, cases of chronic radiation sickness(CRS; 940 cases in total) were diagnosed. The diagnosis of

CRS was based on the occurrence of the following signs:
changes in blood parameters (leucopenia, thrombocytopenia, granulocytopenia); nervous system disorders; oste­
algia; cardio­vascular syndrome; and changes in immunity

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

161(inhibition of innate immunity, autoimmunity). At dose rates
in excess of 300–500 mSv/a to red bone marrow, a portionof the irradiated population developed post-irradiation reactions of the haematopoietic and immunological systems[A8]. Some of the residents exposed did not develop CRS,
but in the early years they manifested isolated reactions mostcommonly represented by haematological changes in peripheral blood studies. The dynamics of blood parameters clearly
manifested a reduction in the number of cellular elements at
the highest dose rates and a subsequent normalization with adecrease in dose rate. The average leucocyte counts for CRS
patients persisted at lower than 90% confidence intervalsof the reference value for three decades after the beginningof exposure. Only after 1970 did the difference in leuco­
cyte counts between followed-up patients and reference

values disappear (figure IX). The dynamics of segmented
neutrophils correlated with leucocyte dynamics, indirectly
corroborating the decrease in leucocyte counts as associatedwith the decreased number of granulocytes (figure X) [K19].
According to the data for individuals with CRS, there wasan increase in the fractions of myelocytes and metamyelocytes in the bone marrow, corresponding to the occurrence of
leucopenia and granulocytopenia in peripheral blood. Suchfindings can be interpreted as delayed maturation and differentiation of granulocytes at the final stage of cell development. The subjects who were initially exposed in utero or atage 1–2 years showed the greatest changes in the immune
system parameters already mentioned. Haematopoietic­disturbances developed almost at the same time as the signsof immune insufficiency [K19].

Figure IX. Mean leucocyte counts at different times after
the beginning of exposure [K19].

Figure X. Mean neutrophil counts at different times after
the beginning of exposure [K19].
4.0
SEGMENTED NEUTROPHIL COUNT (103 μL-1)

LEUCOCYTE COUNT (103 μL-1)

765
Normal
90% confidence intervals
4
1950

1960

1970

1980

CALENDAR YEAR

417. Recovery from these symptoms depended on exposure
rates, with greater exposure leading to longer recovery times.
Even after the cessation of external exposure and intakesof radionuclides, leucopenia and neutropenia ­persisted fora long period; this may have been due to incorporation of
long-lived strontium, which contributed to ­irradiation andmaintained a certain level of dose rate. The average duration of the disease was 7.35 years, but at doses in excess of
700 mSv to the red bone marrow, the repair process lasted
for more than 9 years [K19]. Complete recovery from thehaematological and neurological effects occurred within
13–16 and 14–20 years, respectively, following the beginning of exposure. The duration of the disease was presumably dependent on the patient’s age at exposure. Recovery

3.5

3.0

2.5
Normal
90% confidence intervals
2.0
1950

1960

1970

1980

CALENDAR YEAR

processes developed more slowly in children and teenagers
who received the highest doses, since a close dependenceof exposure dose on age was observed. The age dependence of the duration of CRS is shown in figure XI [K19].
Immunity disorders persisted for 30 years and longer afterthe ­exposures began. Long-term immunity changes involved
cellular immunity (decreased expression of differentiating
antigens of T-lymphocytes, T-lymphocyte blast transformation), natural toxicity (reduced counts of NK cells) and signsof immunological imbalance. At long times (43–48 years)
after the beginning of exposure, the status of haematopoiesis
and immunity was normal among most of the exposed subjects. However, the proportions of the exposed persons still
showed an increased frequency of chromosomal aberrations

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and CD3–CD4+ mutant T-lymphocytes in the peripheral blood [A18]. An increased frequency of TCR mutant
lympho­cytes was also noted [A17].
Figure XI. Dependence of CRS duration on age at time of
exposure [K19].

have since died, mainly owing to infectious and respiratory
diseases and trauma [K49]. A total of 75 cases of cancer
were detected. The most frequent cancer types were foundto be respiratory tract, malignant lymphoma and leukaemia.
The overall cancer incidence rate was 24.3 per 100,000, thiscomparatively low morbidity rate being attributed to the factthat the highest age attained was 45 years, with only 26% of
the cohort being over 40 years of age [K50].

143.

DURATION OF CRS (YEARS)

12
10
8
6
4
2
0

-1

20

40

60

80

AGE (YEARS)

418. CRS diagnosed in a number of residents of Techa river­side villages was found to be associated with higher death
rates from cancer and leukaemia. The Extended Techa River
Cohort (ETRC) includes 29,873 people born before 1950
who lived near the river sometime between 1950 and 1960.
Between the years 1950 and 1999, 1,842 solid cancer deaths
and 61 leukaemia deaths occurred. The maximum incidenceof leukaemia was observed 15–19 years after the exposure
began. The excess relative risk per unit dose for solid cancer was 0.92 (95% CI: 0.2, 1.7) Gy–1, while the values forleukaemia, including and excluding chronic lymphocytic leukaemia, were 4.2 (95% CI: 1.2, 13) Gy–1 and 6.5 (95% CI:
1.8, 24) Gy–1, respectively. It is estimated that about 2.5% of
the solid cancer deaths and 63% of the leukaemia deaths wereassociated with the radiation exposure [K52]. Clinical manifestations of immune insufficiency with respect to certain
infectious diseases (such as chronic pneumonia, pulmonary
tuberculosis and non-traumatic osteomyelitis) occurred withhigher frequency among exposed patients with tumours thanin exposed individuals without tumours [A8].
419. The Techa River Offspring Cohort (TROC) comprises
10,459 children at least one of whose parents lived along the
Techa River during the period 1950–1992. Of these children,
3,897 were born during the period of highest release, i.e.
between 1950 and 1956, and might thus have been exposed
in utero or during childhood. A total of 1,103 individuals

Remarks on the Techa River study

420. Some remarks may be made concerning the information reviewed above. Residents of Techa riverside villages
were exposed to external gamma radiation and internal
contamination with both short-lived and long-lived fission
products. Early effects on the immune system included
leuco­penia, neutropenia, inhibition of innate immunity andautoimmune disorders. Long-term effects include impaired
cellular immunity and a decrease of NK cells. A long-lasting
delayed maturation and differentiation of granulocytes wasobserved. Leucopenia and neutropenia persisted for aroundthree decades after the beginning of the exposure. Continuous
exposure from long-lived incorporated radionuclides may
account for this long-lasting effect. Greater exposures werecorrelated with longer recovery times. Subjects exposed inutero or during the first two years of post-natal life presented
more severe effects. Five decades after the beginning of the
exposure, immunological parameters had normalized, but anincrease in the frequency of chromosomal aberrations andmutations was found in the peripheral lymphocytes of residents of Techa riverside villages. Manifestations of immuno­
deficiency occurred more frequently among residents whodeveloped tumours.
D. Hanford nuclear site
1.

General considerations

421. As previously described, there is no statistically significant dose response in the prevalence of autoimmune
hypothyroidism or thyroid autoantibodies in atomic bombing survivors. On the other hand, it was suggested that theimmune system might be involved in the pathogenesis of
thyroid diseases in Chernobyl accident victims. It is thusinteresting to present here another epidemiological study
developed for evaluating thyroid diseases in people exposed
to ionizing radiation.
422. Approximately 2.73 × 1016 Bq of 131I were released tothe atmosphere from the Hanford nuclear site between theyears 1944 and 1957. This facility manufactured plutonium
for early nuclear weapons. This production process caused
the release of a variety of radioisotopes, which drifted on thewind and the river, settled on vegetation and were consumed
by grazing animals. The vast majority of radioactive releases
came in a single year. A study was recommended to estimate
radiation doses to area residents and another to examine theANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

feasibility of potential health effects of 131I, the radioisotopethat accounted for most of the exposures [R12].
2. Hanford Thyroid Disease Study
423. The Hanford Thyroid Disease Study was conducted
as a retrospective cohort study (1992–1997) to determine
if thyroid disease had increased among persons exposed as
children to these atmospheric releases of 131I. The cohort
included a sample of all births between the years 1940 and1946 to mothers whose usual residence was in one of sevencounties near the Hanford site. The thyroid doses ranged
from 0.0029 to 2,823 mGy (mean 174 mGy, median 97 mGy)
[K47]. Assessments of thyroid disease, including a thyroid
ultrasound, a physical examination, and a fine needle biopsy
if required to evaluate thyroid nodularity, were carried out in
3,440 individuals.
424. There was no evidence of a relationship between
radiation dose and the cumulative incidence of any of thefollowing outcomes: total neoplasia, thyroid cancer, benign­thyroid nodules, autoimmune thyroiditis and hypothyroidism. Although ultrasound abnormalities were observedin 55.5% of women and 37.4% of men, they were not significantly associated with the dose. The Hanford Thyroid
Disease Study has sufficient statistical power to test for
dose–response relationships between thyroid outcomes andradiation exposure [D16, K48, R12].
3. Remarks concerning the Hanford nuclear site425. As seen in the preceding paragraphs, 131I was theradioisotope that accounted for most of the dose received
by residents near the Hanford nuclear facility. Fifty years
after exposure, the Hanford Thyroid Disease Study did not
find evidence of a relationship between radiation dose andthyroid pathologies, including autoimmune thyroiditis. The
results of this study support the hypothesis that exposure
during infancy and childhood to 131I at these dose levels andin these exposure circumstances does not increase the risk ofthese forms of thyroid disease.
E.

Patients undergoing radiotherapy
1.

General considerations

426. Ionizing radiation is an important and often indispensable strategy for cancer treatment. More than 50% of ­people
with cancer undergo radiotherapy at some time during theirillness [F9]. Although more alternatives for fractionation are
now available, conventional fractionation schedules for local
external radiotherapy (9–10 Gy/week delivered at dose rates
of approximately 50 Gy/h over 5–6 weeks) continue to be themain modality. The potential for increased tumour ­control
with protocols combining low-dose-rate with high-doserate irradiation is now under discussion [G11]. The rapid163

expansion of the number of elderly individuals in the world
population will lead to a substantial increase in the prevalenceof cancer and hence in the number of individuals under­goingradiotherapy. Second primary malignancies among cancer
patients account for 16% of all cancer incidences [T13]. An
extensive body of literature concerning ­second cancers inpatients undergoing radiotherapy has recently been published[A20, D25, G33, R15, R16, R17]. However, papers concerning changes of immunological parameters after radio­therapy
are scarce, and the actual impact of these changes on healthhas not been well established.
2. Review of published data
427. Nakayama et al. investigated changes in peripheral
blood lymphocyte subsets of 15 lung cancer patients who
had undergone thoracic irradiation [N17]. After radiation therapy, the percentage and the absolute number of
CD4+CD45RA+ cells (naive T-cells) and CD56+ and/or
CD16+ cells (NK cells) decreased. The percentage of HLADR+ CD4+ cells (activated CD4+ T-cells) and HLA-DR+
CD8+ cells (activated CD8+ T-cells) increased, although theabsolute ­number did not change significantly. Changes inlocal inflammatory cells in bronchoalveolar lavage fluid wereanalysed by the same authors in a similar group of patients[N18]. The percentage of lymphocytes and eosinophils, thepercentage of HLA-DR+ CD4+ and CD8+ cells (activatedCD4+ and CD8+ T-cells, respectively) and the incidence of
ICAM-1+ T-cells was higher in lung cancer patients who had
undergone thoracic irradiation than in controls (lung ­cancer
non-irradiated patients). Naive T-cells seem to be more
selectively damaged than memory T-cells by thoracic irradiation. The reduction of NK cells may be disadvantageous for
antitumour immunity. On the other hand, thoracic irradiation
enhanced both peripheral and local T-cell activation, which
may promote antitumour effects. Nakayama’s results are ingood agreement with the findings of Ishida et al. in patients
who underwent thymectomy and post-operative radiation
therapy, which also indicated that irradiation was associatedwith a higher percentage of activated T-cell subsets [I10].
428. Van Mook et al. studied 24 B-cell chronic lymphocytic leukaemia patients after splenic irradiation. Radiation
treatment consisted of a weekly dose of 1 Gy up to a total
dose of 10 Gy to the spleen. Six weeks after splenic irradiation, total leucocytes decreased significantly, with a decreasein the fraction of lymphocytes and an increase in the neutrophil and platelet counts. The number of CD4+ and CD8+
cells decreased significantly without significantly changing
the CD4+/CD8+ ratio. No significant changes in immunoglobulin levels were observed [V11].
429. A long-term deficit in total CD4+ T-cell counts afterradiation treatment for Hodgkin’s disease (HD) was reported
many years ago [P14]. In patients who received mediastinal irradiation for HD, Watanabe et al. found a marked
depletion in both CD4+ and CD8+ naive T-cell counts that­persisted for up to 30 years after completion of treatment.

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In contrast, CD4+ and CD8+ memory T-cell subsets andtotal CD8+ T-cells recovered to normal or above normal
levels by five years post-treatment, with different kinetics(early expansion of CD8+ memory T-cells versus the gradual recovery of the others). Thus the long-term deficit in
total CD4 T-cell counts in irradiated HD patients was due tospecific depletion of the naive T-cell subset. Similarly, total
CD8+ T-cell counts returned to normal values by 5 years
post-treatment, particularly because CD8+ memory T-cells
expanded to higher than normal levels. As the thymus is
the main source of naive T-cells, these findings suggest thatmediastinal irradiation results in a long-term depletion of
the CD4+ naive cell pool, probably owing to thymus impairment. This dysregulation of T-cell subset homeostasis may
explain the altered T-cell function observed in treated HD
patients, including the poor response to immunization after
treatment. An extrathymic (peripheral) expansion of mature
T-cells may partially compensate for the loss of thymusderived T-cells, but this expansion is primarily restricted tothe memory population, thus resulting in a selective expansion of memory T-cells, while naive T-cell numbers remain
low [W10].
430. Safwat et al. [S35] studied immunological parametersin 35 non-Hodgkin’s lymphoma patients undergoing WBI
consisting of two cycles of four daily fractions of 0.2 Gy
separated by 2 weeks of rest (total dose of 1.6 Gy overfour weeks). WBI was associated with a significant decreasein the percentage of lymphocytes and a significant increasein the percentage of CD4+ T-cells, with a consequent signifi­
cant increase in the CD4+/CD8+ ratio. In terms of absolutevalues, WBI leads to a significant reduction in the absolute number of all the lymphocyte subsets. The significant
increase in the percentage of CD4+ cells in the peripheral
blood was interpreted as indicating a higher radiosensitivityof the CD8+ T-cell subset. This contrasts with previous data
published by Clave et al. [C11] for patients given WBI (total
dose 12 Gy) before bone marrow transplantation, which
revealed that all major T-lymphocyte subsets appeared
equally radiosensitive, while the NK cells were relatively
radioresistant. In that study, however, blood samples werecollected 6 h after a single dose of 2 Gy, while in Safwat’s
study the samples were collected 24 h after a total dose of
1.6 Gy delivered over 4 weeks.
3. Remarks concerning data on patients
undergoing radiotherapy
431. As presented in the preceding paragraphs, the effects
on the immune system observed in cancer patients undergoing local radiotherapy include decreases in the absolute
number of total leucocytes, total lymphocytes, CD8+ and/or CD4+ T-cells, and NK cells. Naive T-cells are more
selectively damaged than memory T-cells. While CD4+ andCD8+ memory T-cell subsets and total CD8+ T-cells returnto ­normal levels within 5 years after irradiation, CD4+
naive T-cell depletion may be long-lasting (recovery several decades after radiotherapy). This is particularly evident

following mediastinal irradiation, probably owing to thymus
impairment. Extrathymic (peripheral) expansion of memory
T-cells results in a lower naive/memory cell ratio.
432. Although reduction in the absolute number of all lymphocyte subsets is observed after therapeutic WBI, the effects
differ according to the fractionation schedule. While an early
increase of the CD4+/CD8+ ratio is observed after a total
whole-body dose of 1.6 Gy protracted over four weeks (lowdose fractions of 0.2 Gy), indicating a higher radiosensitivityof CD8+ T-cells, this effect was not observed after a total
whole-body dose of 12 Gy given over three days ­(high-dose
fractions of 2 Gy).
F.

Summary433. This section reviewed the effects observed on the
immune system of human populations exposed to ionizing
radiation in very different conditions. Diverse immunologicalparameters were evaluated in these populations, at different
times after exposure. There are similarities and differencesamong the results reported by different authors. The analysis
of similarities might aid identification of the predominant
effects of ionizing radiation on the human immune system.
However, findings should be interpreted taking account of
the specific characteristics of each population.
434. The detonation of the atomic bombs in Hiroshima
and Nagasaki in 1945 resulted in a short burst of external
neutron and gamma irradiation. Radiation-induced cell
death accounts for the short-term effects observed in the
immune system, mainly associated with the developmentof acute radiation syndrome. An almost complete recoveryof the haematopoietic system of atomic bombing survivors
took place within the first year after the exposure. Little evidence of dose-dependent effects on the immune system of
the survivors was found soon after the bombings. Studies ofthe long-term effects of ionizing radiation on the immune­system began about 20 years after the atomic bombings.
435. The Chernobyl accident released large amounts ofradionuclides into the environment over a period of around
10 days. External irradiation was predominant among emergency and recovery operations workers. Doses to residentsof contaminated areas resulted from external irradiation fromradionuclides deposited on the ground and from internal irradiation mainly due to ingestion of short-lived (e.g. 131I) andlong-lived (e.g. 137Cs) radionuclides present in foodstuffs.
Large quantities of radioiodine were internalized during theearly period. Ingested and inhaled radioiodine was preferentially incorporated into the thyroid, resulting in higher­levels of exposure to this gland compared with the rest of the
body. As seen in the atomic bombing survivors, short-term
effects on the immune system were mainly associated withthe symptoms of acute radiation syndrome.
436. The residents of Techa riverside villages were
exposed predominantly during the early 1950s to external

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

gamma irradiation from fission products and internal incorporation of short-lived (mainly 89Sr) and long-lived (mainly90
Sr and 137Cs) radionuclides via drinking water and foodstuffs. In the early period, chronic radiation sickness (CRS)
was diagnosed, including leucopenia, neutropenia, thrombo­
cytopenia, impaired innate response and autoimmunity. The
effects were more severe in children exposed in utero or at
1–2 years old. Normalization of haematological parametersin CRS patients was observed 30 years after the beginningof the exposure. Long-lived radionuclides contributing tochronic irradiation may explain why immunity disorders persisted for such a long period, even after cessation of external
exposure and intakes. Long-term effects included decreased
cellular immunity and reduced counts of NK cells.
437. Major radioactive releases into the air, water and soil
occurred at the Hanford nuclear site between 1944 and 1957.
Thyroid diseases were selected for the study of health effects
because the release of 131I caused the highest exposures in the
population. There is no evidence of a relationship between
radiation dose and the incidence of total neoplasia, thyroid
cancer, non-cancer thyroid diseases, hypothyroidism andautoimmune thyroiditis.
438. Most cancer patients undergoing radiotherapy receivea very localized high-dose irradiation protracted over several
weeks. Most of the published data concern mainly shortterm effects on the immune system: total leucocyte decrease,
total lymphocyte decrease, selective damage to naive T-cells
compared with memory T-cells, enhancement of local andperipheral T-cell activation and decrease of NK cells. Longterm effects described in Hodgkin’s disease patients show
long-lasting (30 years) depletion of naive T-cells with a more
rapid (5 years) recovery of memory T-cells. Studies concerning short-term effects of ionizing radiation on the immune
system of patients receiving WBI indicate that the fractionation regime influences the resulting effects. Althougha decrease in total lymphocytes is a common feature, thebehaviour of lymphocyte subsets differs according to the
WBI schedule.
439. The following findings may be considered as similareffects on the immune system observed in human populations exposed to ionizing radiation:− Impairment of T-cell immunity: decreased total
T-cells and CD4+ T-cells, lower T-cell responsiveness to mitogens and alloantigens;165− Increased humoral immunity: higher levels of
total Ig, IgA and IgM;
− Shift towards an inflammatory profile: inflammatory cytokines, activated complement.
440. Atomic bombing survivors presented with a reductionof naive CD8+ and CD4+ T-cell pool, and clonal expansionof memory CD8+ T-cells associated with TCR repertoire
deviation. This kind of perturbation of T-cell homeostasis
was not evident in Chernobyl workers and residents. While
total CD4+ T-cells were diminished in both populations,
total CD8+ T-cells were decreased only in the Chernobyl
population.
441. Findings concerning NK cells also differ: while significant changes were found in neither their number nor
their cytotoxic activity among atomic bombing survivors,
a decrease in both parameters was found in the Chernobyl
population. Many workers who took part in recovery operations after the Chernobyl accident were contaminated withheavy metals, which may account, at least in part, for theobserved changes in their immune status. An increase in the
NKT lymphocyte subset was observed in Belarussian recovery operations workers, an observation that was not reported
in atomic bombing survivors.
442. The development of autoimmunity is a relevant
finding among Chernobyl workers and residents. There
were regions with iodine deficiency in most affected terri­
tories of Belarus, the Russian Federation and Ukraine.
Ionizing radiation might have induced thyroid glandchanges affecting the expression of endemic goitre. These
factors should be considered in interpreting the increasein thyroid autoantibody levels and the development of
autoimmune thyroid diseases, which were not observedin the atomic bombing survivors or in residents near the
Hanford site.
443. Studies of the long-term effects of ionizing radiation on the immune system of atomic bombing survivors
began about 20 years after the bombings and continue tobe carried out. Because the Chernobyl accident occurredin 1986, data concerning long-term effects of ionizing
radiation on the immune system are today limited to thefirst 20 years after the event. These should be considered
for cross-comparison of the long-term effects observed in
the two populations.

V.

Final summary

444. The immune system is certainly one of the most complex systems of the body. It is composed of a large varietyof cells spread widely throughout the body and of different organs where stem cells can differentiate into one of the
major lineages. Immune cells communicate via cytokines,
which are soluble molecules that stimulate immune cell proliferation and/or differentiation. Consequently the immune
cells can differentiate towards specific cell types. Clusters
of differentiation (CD) are cell surface glycoproteins associated with specific functions; their expression may change
depending on cell environment, e.g. the effect of ionizing
radiation.

radiation-induced apoptosis. In addition to these cytotoxic
effects, ionizing radiation may induce “danger signals”,
which may in turn influence cell responses in the immune
system. Such evidence has led to the emerging notion thationizing radiation has much more to offer than its qualities as a powerful cytotoxic agent, and because of this, ionizing radiation is probably better considered an immuno­
modulatory agent rather than an immunosuppressive one.
449. Although many questions remain open, the role ofthe immune system with regard to cancer development isbetter understood. In the classical immune surveillance­theory, tumours may develop when cancer cells escape from
immune surveillance either by reducing the expression oftumour antigens or by modifying the immune response tothem. Although a strong antitumour activity can be efficiently developed as a result of the activation of both innate
and acquired immune responses, some immunological promotion of tumours may result from low-grade persistent
inflammation, chronic activation of innate immune cells or
the blocking of cell-mediated cytotoxicity by antibodies.

445. One of the main functions of the immune system isthe recognition of foreign antigens and the development ofsubsequent actions of protection, for example against infection and cancer. Autoimmune disease may result from thealteration of self tolerance mechanisms.
446. For protecting the body, the immune system can use
two different but interrelated forms of immunity, i.e. innate
and acquired. While innate immunity provides a rapid defence
because it is always ready for use, acquired immunity develops only after a pathogen has entered the body. Acquired
immunity is very antigen-specific and keeps the memoryof a previous exposure, yielding a stronger response at thetime of a subsequent exposure to the same antigen. Acquired
immunity can respond to the diversity of foreign antigens,
those antigens being processed by APCs. The major histocompatibility complex, in humans called human leucocyte
antigen (HLA), plays a fundamental role in the processing of
antigens by APCs and their presentation for recognition by
T-cells via specific receptors. HLA-G is a family of particular molecules involved in immunotolerance; cells expressing
HLA-G can escape from immune surveillance.

450. The effects of ionizing radiation on the immune system
at low doses (<200 mGy) and low dose rates (<100 mGy/h)remain controversial. In animals, although depletion of­different categories of immune cells is observed, as well
as changes in lymphocyte subsets, there is some evidence
that low-dose WBI can be immunostimulatory. Data concerning suppressive effects of low doses on tumour growth
have been reported. Such data have been obtained after lowLET radiation exposure, they are dependent on a number offactors and they are very variable. In humans, although adecrease of CD4+ T-lymphocytes, a decrease of HLA-DR+
lymphocytes and decrease of the CD4+/CD8+ ratio due toan increase in CD8+ are frequently reported, these numerical findings could not be directly related to a decrease of
immune function. Some studies regarding people living inareas with high levels of natural radiation suggest the existence of an adaptive response induced by chronic radiation
exposure.

447. The effects of ionizing radiation on each componentof the immune system (e.g. organs of the immune system,
cell populations, expression of CDs) have been documented.
Although significant changes occur, the results of the publications on these changes are difficult to compare, because
the circumstances and the protocols of exposure to ionizing radiation (dose, dose rate, quality of radiation, cell type)­differ considerably.

451. In atomic bombing survivors and the residents of
Techa riverside villages, the haematolymphoid system wasdamaged in a dose-dependent manner, although the groups
underwent different types of radiation exposure. Several
months or even years later, their systems regenerated, andhaematolymphoid function recovered almost completely.
However, even after several decades, with different effects inthe two populations, significant effects have been observedin the haematolymphoid systems.

448. The data reviewed in this annex indicate that ­exposure
to ionizing radiation often leads to immunosuppression,
particularly following high-dose irradiation. Immuno­
suppression is most often ascribed to lymphocytes being
highly radiosensitive, owing to their proclivity to undergo
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452. In atomic bombing survivors, long-lasting effects arestill observed more than a half-century after their radiation
exposure. These effects include an increase in the frequency
of somatic mutations and chromosome aberrations in lymphocytes, as well as significant changes in lymphoid cellcomposition and function. TCR-defective cells could resultin the impairment of the immune function. Although low frequencies of somatic mutations or chromosome aberrations
would not influence the regeneration or homeostasis of theimmune system, the extensive proliferation of a single cellbearing a radiation-induced mutation may result in clonal
expansion, particularly in haematopoietic stem cells, committed lymphoid precursor cells and memory T-lymphocytes.
With regard to changes of lymphoid cell composition andfunction, the main kinds of damage observed among atomic
bombing survivors include: impairment of T-cell immunity,
especially owing to a decreased proportion of CD4+ helper,
CD4+ naive and CD8+ cytotoxic T-cells; a dose-dependent
increase in the proportion of B-cells and of immunoglobulin production; and impairment of viral immunity and otherT-cell functions, such as PHA-dependent proliferation,ability to produce IL-2 and alloantigen responses.
453. In Techa riverside village populations chronically exposed to radiation, long-term immunity changes
involved decreased expression of differentiating antigens of­T-lymphocytes, reduced counts of cells involved in natural
cytotoxicity and signs of immunological imbalance. As in
the atomic bombing survivors, a preferential CD4+ cell deficiency was observed many years later in persons affected by
the Chernobyl accident. Proliferative response to mitogens
was also altered. The dynamics of post-irradiation recovery
of CD4+ and CD8+ were different, suggesting that radiation
may induce damage to the thymus, accelerating the naturalageing of the immune system by a progressive decline inthymic function. Both short-term and long-term effects weredetectable in the B- and T-cell function profiles, as well as in
the synthesis of immunoglobulins, depending on the population studied. Some of these changes were dose-dependentand characterized by phases. The immune system is involvedin the pathogenesis of the thyroid diseases observed in victims of the Chernobyl accident, probably owing to antigenic
mechanisms leading to autoimmune damage.
454. Animal data involving low-dose irradiation reinforced some of these results, for example the gradual reconstitution of peripheral blood and bone marrow patterns withpartial deficiency of haematopoietic and lymphopoietic precursors, suggesting that ineffective haematopoiesis could
cause restriction of myeloid and lymphoid cell reserves andconsequent disturbances of cellular and humoral immunity.
Enhancement of immunity may be observed under certain
circumstances, in particular following low-dose irradiation,and modulation of oxidative status seems to be involved inthis effect.
455. Recent developments in immunology have contributed to our understanding of how human diseases may berelated to abnormalities in the immune system. The studyof these disorders from an immunological viewpoint could
therefore provide further insight into the mechanisms
involved in ­certain radiation-associated diseases. Radiationinduced ­perturbation of T-cell homeostasis may have important implications for human health, not only by reducing theability of the immune system to fight against new pathogens
but also by compromising the control of recurrent and latent
infections. Increasing evidence indicates that persistent
exposure to infections leads to more rapid senescence of theimmune system. An association between non-cancer diseases and radiation dose has recently emerged among atomic
bombing survivors. This association has led to the hypothesis that radiation-induced effects on the immune system may
account at least in part for this phenomenon, although themechanisms involved remain incompletely understood.
456. Epidemiological findings suggest that the radiationinduced impairment of immunocompetence may increase
the risk of diseases that normally occur in elderly people.
The data reviewed in this annex reinforce the hypothesisthat ionizing radiation may accelerate immunosenescenceby perturbing T-cell homeostasis in the same direction thatageing does. Immunological homeostasis has critical implications for human health, for example with respect to therelationship between the immune system and disease susceptibility, and the possible interaction between hereditaryand environmental factors such as ionizing radiation.
457. A statistically significant dose–response relationshiphas been found for several inflammatory biomarkers in irradiated subjects. The persistent inflammatory status inducedby ionizing radiation may increase the risks of both cancer
and non-cancer diseases. The negative correlation between
plasma levels of inflammatory biomarkers and the percentage of CD4+ helper T-cells in peripheral blood indicates anassociation between radiation-induced impairment of cellmediated immunity and a preclinical inflammatory ­status that
could further promote the development of various diseases.
458. The proportion of CD4+ cells was significantly
decreased among atomic bombing survivors with increased
dose and history of myocardial infarction. It has been suggested that a diminished immune response against certain
infections implicated in the development of cardiovasculardiseases could account for this finding. Moreover, inflammatory biomarkers were significantly elevated in these patients,
indicating that inflammatory responses may be playing arole in the development of cardiovascular diseases, such as
myocardial infarction, in irradiated people.
459. In order to explain the possible links between­radiation-induced perturbation of immunological homeo­
stasis and human diseases, the “Th1/Th2 paradigm” has been
invoked. Experimental data, further reinforced by humandata, seem to sustain the hypothesis that ionizing radiation reduces cellular responses controlled by Th1 cells andincreases humoral responses controlled by Th2 cells by triggering a shift from Th1 towards Th2 (Th1/Th2 imbalance).
Recent findings demonstrated that radiation-dose-dependent

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

increases observed in irradiated individuals involved not
only Th2-related cytokines but also Th1-related cytokines.
This evidence leads to the postulate that ionizing radiation
might better be considered an agent that modulates the production of cytokines towards a pro-inflammatory response
rather than towards a Th2 response.
460. Programmed cell death (apoptosis) is essential forthe development and maintenance of cellular homeostasis of
the immune system. The functional balance of proapoptotic
versus anti-apoptotic influences determines whether a lymphocyte will live or die. Multiple molecules, often working
in concert, control serial stages of lymphocyte development
and homeostasis. Radiation-induced apoptosis is one of themechanisms by which ionizing radiation alters the homeo­
stasis of the immune system.
461. Evaluations of the human health risks associated withradiation exposure have been based primarily on the assumption that the effects of radiation occur in irradiated cells.
Non-targeted cellular responses to ionizing radiation, suchas bystander effects and genomic instability as well as adaptive responses, have also been demonstrated in the immune
system, although their implications for human health arestill poorly understood. These effects, which predominate at
the low doses of relevance to radiation protection, need to
be fully characterized; they pose new challenges to evaluating the risks associated with radiation exposure. In contrast,
local radiotherapy may facilitate the expansion of dendritic
cells and the generation of antitumour immune responses
outside the radiation field (abscopal effect).
462. The idea that the immune system functions by discriminating “self” from “non-self” has a long history inimmunology. The “self/non-self theory” proposes thatlymphocytes with reactivity against host constituents aredestroyed during development, and only those tolerant lymphocytes that are not self reactive are left to engage foreign antigens. Although the notion that the immune system
has evolved to recognize (dangerous) pathogens is not new,recent discussions have emerged concerning the notion that
antigenicity in the immune system may be seen as a question of degree, where “self” evokes one kind of response(tolerance) and “foreign” evokes another kind of response(destruction) based not on intrinsic foreignness but rather
on the immune system’s recognition of foreign antigens in169

the context of “danger signals”. Whichever theory is ­correct,
ionizing radiation has emerged as an agent capable of disturbing the ability of the immune system to deal with thissort of recognition. As a result of radiation-induced damage,the immune system may tolerate what should be destroyed
and, conversely, it may destroy what should be tolerated.
Examples of these two opposing consequences are thediminished ability to mount an immune response against
some infections and the development of autoimmune reactions as a consequence of radiation exposure, both of whichhave been demonstrated by experimental and human data.
463. Individual genetic susceptibility to ionizing radiation has been clearly demonstrated in patients. Some of themolecular and cellular mechanisms that determine sensitivity
to ionizing radiation have been elucidated, most of them representing a defect in the response to DNA ­damage. Researchon this subject will be relevant, since most of the human
genetic disorders involving such defects are also associatedwith alterations of immune system functioning.
464. Finally, the question of how radiation-induced effects
on the immune system may impact on human healthremains unanswered. There are many issues that need to be
more thoroughly investigated before firm conclusions canbe reached. Possible future directions for research concerning the effects of ionizing radiation on the immune ­systemthat should provide new insights about the underlying­mechanisms may include:− Effects of low-dose and low-dose-rate irradiation
versus intermediate- and high-dose irradiation;− Combined effects of ionizing radiation and otheragents;− Differential effects of external and/or internal
irradiation;− Immunomodulation and cancer;− Perturbation of T-cell homeostasis;− Immune function and disease development;− Immunogenetic background and disease susceptibility;− Immunological ageing and inflammatory response;− Effects on the skin immune system.

VII.

CONCLUding remarks

465. This annex reviews data related to radiation-induced
alterations of immune response, considers the possible mechanisms involved and reviews epidemiological studies of theeffects of ionizing radiation on the human immune system.

Lymphocytes are very radiosensitive, and their
reduction is currently used as an early indicator of the level of an accidental acute exposure.
­Radiation-induced changes in immune parameters
seem to be more dependent on total dose than ondose rate. Persisting effects on the immune ­systemhave been observed after exposure to ­ionizing
radiation.

466. The effects of ionizing radiation on the immune ­system
can be assessed by estimating changes in cell numbers or
by using a variety of functional assays. The impact of suchalterations in immune response depends on factors such as
the dose of radiation, its temporal relationship with immune
system challenge and individual genetic constitution.

− At low doses and dose rates, the effects of ionizing
radiation on the immune system may be suppressive or stimulatory. The long-term impact of low
radiation doses on the immune function in relation
to human health needs to be further evaluated.

− High doses of radiation produce immunosuppression mainly through the destruction of cells.

171

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

Abbreviations
AIDS

acquired immunodeficiency syndrome

AIRE

autoimmune regulatorAPalkaline phosphatase

APC

antigen-presenting cell

ARS

acute radiation syndromeAT

ataxia telangiectasia

ATLD

ataxia-telangiectasia-like disorderATMataxia-telangiectasia-mutated geneATPadenosine triphosphate

BCR

B-cell receptor

C

constant gene segmentcAMP

cyclic adenosine monophosphateCDcluster of differentiation

CFU

colony-forming unit

CFU-F

fibroblastoid colony-forming units

CFU-GM

granulocyte–macrophage colony-forming units

CFU-S

stem cell colony-forming units

cGMP

cyclic guanosine monophosphateCHheavy chain constant domainCLlight chain constant domain

Con A

concanavalin A

COX-2

cyclooxygenase-2

CRP

C-reactive protein

CRS

chronic radiation sickness

CS

Cockayne syndrome

CTLA-4

cytotoxic T-lymphocyte-associated antigen-4

DdiversityDCdyskeratosis congenita

DNA

deoxyribonucleic acid

DNA-PK

DNA-dependent protein kinase

DNF

dinitrofluorobenzene

DSB

double-strand break

DTH

delayed type hypersensitivity

ESR

erythrocyte sedimentation rate

ETRC

Extended Techa River Cohort

FA

Fanconi anaemia

Fas/CD95

Fas death receptor

FasL/CD95L

ligand for Fas death receptor

GM-CSF

granulocyte–macrophage colony-stimulating factor

GSH

glutathione

Gy

gray

HBsAg

hepatitis B surface antigen

HBV

hepatitis B virus

173

174

UNSCEAR 2006 REPORT: VOLUME IIHD

Hodgkin’s disease

HER2

human epidermal growth factor receptor 2

HETEhydroxyeicosatetraenoic acid

HGPS

Hutchinson–Gilford progeria syndromeHIVhuman immunodeficiency virus

HLA

human leucocyte antigen

HLNRA

high-level natural radiation area

HPRThypoxanthine-guanine phosphoribosyltransferaseHRhomologous recombination

HVC

hepatitis C virus

ICE

interleukin-converting enzyme

IFN

interferon

IFN-γ

interferon gammaIg

immunoglobulinIL

interleukin

ILT

immunoglobulin-like transcriptJjoining

JNK

Jun N-terminal kinase

KIR

killer cell immunoglobulin-like receptor

KLH

keyhole limpet haemocyanin

LC

Langerhans cellLD

low doseLDR

low dose rate

LET

linear energy transfer

LPB

lipopolysaccharide-binding protein

LPS

lipopolysaccharide

MALT

mucosa-associated lymphoid tissue

MAP kinase
MBP

mitogen-activated protein kinase
mannan-binding protein

MCP-1
MHC
MICA

monocyte chemoattractant protein 1
major histocompatibility complex
class I MHC chain-related A molecule

MNCA

modified neutral comet assay

MP

myeloperoxidase

mRNA

messenger ribonucleic acid

NBS

Nijmegen breakage syndrome

NCR

natural cytotoxicity receptor

NER

nucleotide excision repair

NHEJ

non-homologous end-joiningNK

natural killer (cell)

NKG2

lectin-like receptor

NKT

lymphocyte with certain characteristics of both T- and NK cells

NPP

nuclear power plant

p38 MAP

p38 mitogen-activated protein

PAMPpathogen-associated molecular pattern

ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

PCNA

proliferating cell nuclear antigen

PGE2

prostaglandin E2

PHA

phytohaemagglutinin

PKA

protein kinase A

PKC

protein kinase C

PLA2

phospholipase 2

PLC

phospholipase C

PRRs

pattern recognition receptors

RBE

relative biological effectivenessROS

reactive oxygen species

RRD

recurrent respiratory disease

RT-PCR

reverse transcription polymerase chain reaction

SCID
SIS

severe combined immune deficiency
skin immune system

SLE

systemic lupus erythematosus

SOCS

supressor of cytokine signalling gene

STAT proteins

signal transducer and activator of transcription proteinsTCR

T-cell receptor

TCR

transcription-coupled repair

TCR/CD3

T-cell receptor/CD3 complex

TGF-βtransforming growth factor βThlymphocyte T-helper

Th1lymphocyte T-helper subset or subclass 1

Th2

lymphocyte T-helper subset or subclass 2

TLR

Toll-like receptor

TLS

translesion synthesis

TNF

tumour necrosis factor

TNFR

tumour necrosis factor receptor

TRAIL

tumour-necrosis-factor-related apoptosis-inducing ligand

TRDS

Techa River Dosimetry SystemTreg

T-regulatory cells

TROC

Techa River Offspring Cohort

TSH

thyroid-stimulating hormone

TTD

trichothiodystrophy

UDS

unscheduled DNA synthesis

UV

ultraviolet

UV-DDBUV-damaged-DNA-binding protein

Vvariable

VH

heavy chain variable domain

VL

light chain variable domain

WBI

whole-body irradiation

WLM

working level monthWS

Werner’s syndromeXP

xeroderma pigmentosum

XP-V

xeroderma pigmentosum variant

175ANNEX D: EFFECTS OF IONIZING RADIATION ON THE IMMUNE SYSTEM

177

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