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Ortiz de Mendivil A, Martín-Medina P, García-Cañamaque L, Jiménez-Munarriz B, Ciérvide R, Diamantopoulos J. Challenges in radiological evaluation of brain metastases, beyond progression. RADIOLOGIA 2024; 66:166-180. [PMID: 38614532 DOI: 10.1016/j.rxeng.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/02/2023] [Indexed: 04/15/2024]
Abstract
MRI is the cornerstone in the evaluation of brain metastases. The clinical challenges lie in discriminating metastases from mimickers such as infections or primary tumors and in evaluating the response to treatment. The latter sometimes leads to growth, which must be framed as pseudo-progression or radionecrosis, both inflammatory phenomena attributable to treatment, or be considered as recurrence. To meet these needs, imaging techniques are the subject of constant research. However, an exponential growth after radiotherapy must be interpreted with caution, even in the presence of results suspicious of tumor progression by advanced techniques, because it may be due to inflammatory changes. The aim of this paper is to familiarize the reader with inflammatory phenomena of brain metastases treated with radiotherapy and to describe two related radiological signs: "the inflammatory cloud" and "incomplete ring enhancement", in order to adopt a conservative management with close follow-up.
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Affiliation(s)
- A Ortiz de Mendivil
- Servicio de Radiodiagnóstico, Sección de Neurorradiología, Hospital Universitario HM Sanchinarro, Madrid, Spain.
| | - P Martín-Medina
- Servicio de Radiodiagnóstico, Sección de Neurorradiología, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | | | - B Jiménez-Munarriz
- Servicio de Oncología Médica, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - R Ciérvide
- Servicio de Oncología Radioterápica, Hospital Universitario HM Sanchinarro, Madrid, Spain
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Sakai A, Ebisumoto K, Iijima H, Yamauchi M, Maki D, Fukuzawa T, Okami K. Abscopal effect in maxillary sinus cancer: Insights from two case reports and a literature review. Cancer Rep (Hoboken) 2024; 7:e1994. [PMID: 38351554 PMCID: PMC10864721 DOI: 10.1002/cnr2.1994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/07/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The abscopal effect is a rare phenomenon in which localized radiation therapy triggers tumor reduction in nontargeted areas. Although this phenomenon has been observed in various cancer types, it remains infrequent and not fully understood. CASE Two patients with maxillary sinus cancer with distant metastases were treated with radiotherapy after immune checkpoint inhibitor (ICI) therapy. The patients demonstrated abscopal effects following ICI therapy and radiotherapy, showing shrinkage in metastatic areas not directly targeted by radiation. CONCLUSION This report was reviewed to examine the synergistic effects of ICI and radiotherapy and to identify optimal strategies to enhance the abscopal effect in clinical practice. It has also touched on various ongoing debates and clinical trials aimed at understanding and exploiting this effect to improve cancer treatment. The exact mechanisms and optimal treatment protocols remain areas for future research.
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Affiliation(s)
- Akihiro Sakai
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Koji Ebisumoto
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Hiroaki Iijima
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Mayu Yamauchi
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Daisuke Maki
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Tsuyoshi Fukuzawa
- Department of Radiation OncologyTokai University, School of MedicineIseharaJapan
| | - Kenji Okami
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
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3
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de Bruyn DP, van Poppelen NM, Brands T, van den Boom SC, Eikenboom E, Wagner A, van Veghel-Plandsoen MM, Geeven G, Beverloo B, van Rij CM, Verdijk RM, Naus NC, Bagger MM, Kiilgaard JF, de Klein A, Brosens E, Kiliç E. Evaluation of Circulating Tumor DNA as a Liquid Biomarker in Uveal Melanoma. Invest Ophthalmol Vis Sci 2024; 65:11. [PMID: 38319670 PMCID: PMC10854420 DOI: 10.1167/iovs.65.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/14/2023] [Indexed: 02/07/2024] Open
Abstract
Purpose Uveal melanoma (UM) has a high propensity to metastasize. Prognosis is associated with specific driver mutations and copy number variations (CNVs), but limited primary tumor tissue is available for molecular characterization due to eye-sparing irradiation treatment. This study aimed to assess the rise in circulating tumor DNA (ctDNA) levels in UM and evaluate its efficacy for CNV-profiling of patients with UM. Methods In a pilot study, we assessed ctDNA levels in the blood of patients with UM (n = 18) at various time points, including the time of diagnosis (n = 13), during fractionated stereotactic radiotherapy (fSRT) treatment (n = 6), and upon detection of metastatic disease (n = 13). Shallow whole-genome sequencing (sWGS) combined with in silico size-selection was used to identify prognostically relevant CNVs in patients with UM (n = 26) from peripheral blood retrieved at the time of diagnosis (n = 9), during fSRT (n = 5), during post-treatment follow-up (n = 4), metastasis detection (n = 6), and metastasis follow-up (n = 4). Results A total of 34 patients had blood analyzed for ctDNA detection (n = 18) and/or CNV analysis (n = 26) at various time points. At the time of diagnosis, 5 of 13 patients (38%) had detectable ctDNA (median = 0 copies/mL). Upon detection of metastatic disease, ctDNA was detected in 10 of 13 patients (77%) and showed increased ctDNA levels (median = 24 copies/mL, P < 0.01). Among the six patients analyzed during fSRT, three (50%) patients had detectable ctDNA at baseline and three of six (50%) patients had undetectable levels of ctDNA. During the fSRT regimen, ctDNA levels remained unchanged (P > 0.05). The ctDNA fractions were undetectable to low in localized disease, and sWGS did not elucidate chromosome 3 status from blood samples. However, in 7 of 10 (70%) patients with metastases, the detection of chromosome 3 loss corresponded to the high metastatic-risk class. Conclusions The rise in ctDNA levels observed in patients with UM harboring metastases suggests its potential utility for CNV profiling. These findings highlight the potential of using ctDNA for metastasis detection and patient inclusion in therapeutic studies targeting metastatic UM.
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Affiliation(s)
- Daniel P. de Bruyn
- Department of Ophthalmology, Erasmus MC, Rotterdam, The Netherlands
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
- Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Natasha M. van Poppelen
- Department of Ophthalmology, Erasmus MC, Rotterdam, The Netherlands
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
- Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Tom Brands
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | | | - Ellis Eikenboom
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Anja Wagner
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | | | - Geert Geeven
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Berna Beverloo
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Caroline M. van Rij
- Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
- Department of Radiation Oncology, Erasmus MC, Rotterdam, The Netherlands
| | - Robert M. Verdijk
- Department of Pathology, Section Ophthalmic Pathology, Erasmus MC, Rotterdam, The Netherlands
- Department of Pathology, LUMC, Leiden, The Netherlands
| | - Nicole C. Naus
- Department of Ophthalmology, Erasmus MC, Rotterdam, The Netherlands
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Mette M. Bagger
- Department of Ophthalmology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
- Department of Clinical Genetics, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Jens F. Kiilgaard
- Department of Ophthalmology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Annelies de Klein
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
- Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Erwin Brosens
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
- Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Emine Kiliç
- Department of Ophthalmology, Erasmus MC, Rotterdam, The Netherlands
- Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
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Lu Q, Yan W, Zhu A, Tubin S, Mourad WF, Yang J. Combining spatially fractionated radiation therapy (SFRT) and immunotherapy opens new rays of hope for enhancing therapeutic ratio. Clin Transl Radiat Oncol 2024; 44:100691. [PMID: 38033759 PMCID: PMC10684810 DOI: 10.1016/j.ctro.2023.100691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/04/2023] [Accepted: 10/15/2023] [Indexed: 12/02/2023] Open
Abstract
Spatially Fractionated Radiation Therapy (SFRT) is a form of radiotherapy that delivers a single large dose of radiation within the target volume in a heterogeneous pattern with regions of peak dosage and regions of under dosage. SFRT types can be defined by how the heterogeneous pattern of radiation is obtained. Immune checkpoint inhibitors (ICIs) have been approved for various malignant tumors and are widely used to treat patients with metastatic cancer. The efficacy of ICI monotherapy is limited due to the "cold" tumor microenvironment. Fractionated radiotherapy can achieve higher doses per fraction to the target tumor, and induce immune activation (immodulate tumor immunogenicity and microenvironment). Therefore, coupling ICI therapy and fractionated radiation therapy could significantly improve the outcome of metastatic cancer. This review focuses on both preclinical and clinical studies that use a combination of radiotherapy and ICI therapy in cancer.
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Affiliation(s)
- Qiuxia Lu
- Foshan Fosun Chancheng Hospital, P.R. China
- Junxin Precision Oncology Group, P.R. China
| | - Weisi Yan
- Baptist Health System, Lexington, KY, United States
- Junxin Precision Oncology Group, P.R. China
| | - Alan Zhu
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, United States
| | - Slavisa Tubin
- Albert Einstein Collage of Medicine New York, Center for Ion Therapy, Medaustron, Austria
| | - Waleed F. Mourad
- Department of Radiation Medicine Markey Cancer Center, University of Kentucky - College of Medicine, United States
| | - Jun Yang
- Foshan Fosun Chancheng Hospital, P.R. China
- Junxin Precision Oncology Group, P.R. China
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5
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Walker K, Simister SK, Carr-Ascher J, Monument MJ, Thorpe SW, Randall RL. Emerging innovations and advancements in the treatment of extremity and truncal soft tissue sarcomas. J Surg Oncol 2024; 129:97-111. [PMID: 38010997 DOI: 10.1002/jso.27526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
In this special edition update on soft tissue sarcomas (STS), we cover classifications, emerging technologies, prognostic tools, radiation schemas, and treatment disparities in extremity and truncal STS. We discuss the importance of enhancing local control and reducing complications, including the role of innovative imaging, surgical guidance, and hypofractionated radiation. We review advancements in systemic and immunotherapeutic treatments and introduce disparities seen in this vulnerable population that must be considered to improve overall patient care.
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Affiliation(s)
- Kyle Walker
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
| | - Samuel K Simister
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
| | - Janai Carr-Ascher
- Department of Hematology and Oncology, University of California, Davis, Sacramento, California, USA
| | - Michael J Monument
- Department of Surgery, The University of Calgary, Calgary, Alberta, Canada
| | - Steven W Thorpe
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
| | - R Lor Randall
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
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6
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Averbeck D. Low-Dose Non-Targeted Effects and Mitochondrial Control. Int J Mol Sci 2023; 24:11460. [PMID: 37511215 PMCID: PMC10380638 DOI: 10.3390/ijms241411460] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Non-targeted effects (NTE) have been generally regarded as a low-dose ionizing radiation (IR) phenomenon. Recently, regarding long distant abscopal effects have also been observed at high doses of IR) relevant to antitumor radiation therapy. IR is inducing NTE involving intracellular and extracellular signaling, which may lead to short-ranging bystander effects and distant long-ranging extracellular signaling abscopal effects. Internal and "spontaneous" cellular stress is mostly due to metabolic oxidative stress involving mitochondrial energy production (ATP) through oxidative phosphorylation and/or anaerobic pathways accompanied by the leakage of O2- and other radicals from mitochondria during normal or increased cellular energy requirements or to mitochondrial dysfunction. Among external stressors, ionizing radiation (IR) has been shown to very rapidly perturb mitochondrial functions, leading to increased energy supply demands and to ROS/NOS production. Depending on the dose, this affects all types of cell constituents, including DNA, RNA, amino acids, proteins, and membranes, perturbing normal inner cell organization and function, and forcing cells to reorganize the intracellular metabolism and the network of organelles. The reorganization implies intracellular cytoplasmic-nuclear shuttling of important proteins, activation of autophagy, and mitophagy, as well as induction of cell cycle arrest, DNA repair, apoptosis, and senescence. It also includes reprogramming of mitochondrial metabolism as well as genetic and epigenetic control of the expression of genes and proteins in order to ensure cell and tissue survival. At low doses of IR, directly irradiated cells may already exert non-targeted effects (NTE) involving the release of molecular mediators, such as radicals, cytokines, DNA fragments, small RNAs, and proteins (sometimes in the form of extracellular vehicles or exosomes), which can induce damage of unirradiated neighboring bystander or distant (abscopal) cells as well as immune responses. Such non-targeted effects (NTE) are contributing to low-dose phenomena, such as hormesis, adaptive responses, low-dose hypersensitivity, and genomic instability, and they are also promoting suppression and/or activation of immune cells. All of these are parts of the main defense systems of cells and tissues, including IR-induced innate and adaptive immune responses. The present review is focused on the prominent role of mitochondria in these processes, which are determinants of cell survival and anti-tumor RT.
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Affiliation(s)
- Dietrich Averbeck
- Laboratory of Cellular and Molecular Radiobiology, PRISME, UMR CNRS 5822/IN2P3, IP2I, Lyon-Sud Medical School, University Lyon 1, 69921 Oullins, France
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7
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Yu B, Zhang J, Fu Q, Han Y, Zhang J, Gao F, Jing P, Zhang P, Zheng G. Successful targeting in situ of an oncogenic nuclear antigen by hapten induced tumor associated autoantibodies (iTAA). Sci Rep 2023; 13:9902. [PMID: 37336938 DOI: 10.1038/s41598-023-36757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 06/09/2023] [Indexed: 06/21/2023] Open
Abstract
The abscopal is a hypothesis for treating of non-irradiated tumors after localized radiation therapy. It is associated with the products of tumor-associated gene as autoantibodies (aTAAs) in reaction to the tumor-associated antigens (TAAs), with increasing of anti-MAGEA3 and an relationship between the abscopal effect and immune response. The hapten enhanced local chemotherapy (HELC) was studied to kills tumor and release tumor TAAs, then hapten modify the TAAs to neu-TAAs, to produce tumor autologous antibodies, called induced tumor-associated autoantibodies (iTAAs) that is different from natural TAAs. Since the iTAAs and complement (C) are associated with cancer therapy Immunofluorescence (IF) was applied to evaluate the expression of the iTAAs and C3, C5, C9. Traces resulted in a partial staining of the nucleus in C3's perinuclear reaction. The iTTAs of Survivin, C-MYC, and IMP1 increased significantly in the tumor cells' intranuclear regions (P = 0.02, P = 0.00, P < 0.0001). Koc, zeta, RalA, and p53 had a similar trend in the perinuclear regions (P < 0.0001, P = 0.004, P < 0.0001, P = 0.003). Therefore, we can propose that tumor antigens inside the cancer cells' nuclei are targeted by the iTAAs since the iTAAs binding levels are higher after HELC. The iTAA tagging oncogenic nuclear antigens may play a distinctive role in regulating tumor cell growth.
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Affiliation(s)
- Baofa Yu
- TaiMei Baofa Cancer Hospital, Dongping, 271500, Shandong Province, China.
- Jinan Baofa Cancer Hospital, Jinan, 250000, Shandong Province, China.
- Beijing Baofa Cancer Hospital, Beijing, 100010, China.
- Immune Oncology Systems, Inc, San Diego, CA, 92102, USA.
- South China Hospital of Shenzhen Univisity, 518055, Shenzhen, China.
| | - Jian Zhang
- Jinan Baofa Cancer Hospital, Jinan, 250000, Shandong Province, China
| | - Qiang Fu
- Jinan Baofa Cancer Hospital, Jinan, 250000, Shandong Province, China
| | - Yan Han
- Jinan Baofa Cancer Hospital, Jinan, 250000, Shandong Province, China
| | - Jie Zhang
- Shandong University, Jinan, 250000, Shandong Province, China
| | - Feng Gao
- TaiMei Baofa Cancer Hospital, Dongping, 271500, Shandong Province, China
| | - Peng Jing
- TaiMei Baofa Cancer Hospital, Dongping, 271500, Shandong Province, China
| | - Peicheng Zhang
- TaiMei Baofa Cancer Hospital, Dongping, 271500, Shandong Province, China
| | - Guoqin Zheng
- TaiMei Baofa Cancer Hospital, Dongping, 271500, Shandong Province, China
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8
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Guan H, Zhou Z, Hou X, Zhang F, Zhao J, Hu K. Safety and potential increased risk of toxicity of radiotherapy combined immunotherapy strategy. Asia Pac J Clin Oncol 2023; 19:35-50. [PMID: 35538049 DOI: 10.1111/ajco.13688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/14/2021] [Accepted: 09/23/2021] [Indexed: 01/20/2023]
Abstract
Accumulating interest has emerged in exploring the toxicity profiles of the combination strategy of radiotherapy (RT) and immune checkpoint inhibitors (ICIs). Much remains unknown regarding safety and the potential increased risk of toxicity of a combined treatment. ICI prolongs survival but can induce immune-related adverse events as well. To increase awareness of adverse effect and support immediate and successful management, we go over the literature on the safety of RT combined immunotherapy strategy. Representative evidence relevant to RT combined with ICI in the brain, lung, head and neck, and pelvic malignance was reviewed respectively. Given radiation doses and fractionation, the irradiated volume, the timing of RT, and ICI would significantly affect the safety and efficiency of ICI+RT combination therapy, and no consensus had been reached about how to arrange RT delivery in the combined contexture, we went over the available literature and tried to address these challenges including the timing of RT, optimal dose and fractionations, RT target and target volume, and potential biomarkers to predict toxicity. We found even though RT+ICI combination therapy might augment toxicities, the majority of patients experienced grade 4 or 5 AE are relatively rare and no significant difference could be found between combination group and monotherapy group. Sometimes the acute toxicity with ICI is much less predictable and often life threatening and in some can give rise to permanent effects. Clinicians across disciplines should be aware of these uncommon lethal complications induced by ICI+RT. Early recognition is the key to successful treatment, reversibility of organ dysfunction, and in some cases even prevention of fatal outcome. If recognized early, managed properly, and no fatal AE occurs, the development of irAE indicates a good prognosis. It should be noted that nothing is known about potential late effects because very few studies have 5-year follow-up. The nature of irAE is the attack of activated immune cells on normal tissues. The nature of RT-induced AE is the DNA damage on normal tissue, which is related with the dose delivered and volume irradiated and the tolerance of surrounding normal tissues. The immune-modulating effect of SBRT may augment the damage on normal tissues. To maximize the antitumor immune response, 8-12 Gy/fraction is preferred when conducting RT. The available clinical evidence suggest RT of this dose/fractionated strategy combined with ICI have a tolerable AE profile, which need further validation by more clinical trials in the future. The combination strategy of RT with anti-PD1/PDL1 anti-body is supposed to be concurrent or RT followed by anti-PD1/PDL1 antibody. Although RT and ipilimumab combination sequence is controversial, ipilimumab prior to or concurrent with RT might be proper, which need more clinical validation. Under the concept of immunological dose painting, SBRT work as a trigger of immune response. It has been observed that SBRT of partially radiated tumors combined with ICI could induce similar tumor control compared with total tumor irradiation. The side effects of RT may be mitigated potentially due to the reduction of irradiated volume. The antitumor efficiency and safety profile of immunological RT dose painting+ICI deserve further investigation. Clinical predictive factors for irAE risk remain unclear, and more investigation deserves to be conducted about the irAE prediction.
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Affiliation(s)
- Hui Guan
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ziqi Zhou
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaorong Hou
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Fuquan Zhang
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Zhao
- Department of Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ke Hu
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Oh SW, Suh M, Cheon GJ. Current Status of PSMA-Targeted Radioligand Therapy in the Era of Radiopharmaceutical Therapy Acquiring Marketing Authorization. Nucl Med Mol Imaging 2022; 56:263-281. [PMID: 36425273 PMCID: PMC9679068 DOI: 10.1007/s13139-022-00764-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/11/2022] [Accepted: 07/11/2022] [Indexed: 10/15/2022] Open
Abstract
Prostate-specific membrane antigen (PSMA) is highly expressed in PCa, which gradually increases in high-grade tumors, metastatic tumors, and tumors nonresponsive to androgen deprivation therapy. PSMA has been a topic of interest during the past decade for both diagnostic and therapeutic targets. Radioligand therapy (RLT) utilizes the delivery of radioactive nuclides to tumors and tumor-associated targets, and it has shown better efficacy with minimal toxicity compared to other systemic cancer therapies. Nuclear medicine has faced a new turning point claiming theranosis as the core of academic identity, since new RLTs have been introduced to clinics through the official new drug development processes for approval from the Food and Drug Administration (FDA) or European Medical Agency. Recently, PSMA targeting RLT was approved by the US FDA in March 2022. This review introduces PSMA RLT focusing on ongoing clinical trials to enhance our understanding of nuclear medicine theranosis and strive for the development of new radiopharmaceuticals.
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Affiliation(s)
- So Won Oh
- Department of Nuclear Medicine, Seoul National University Boramae Medical Center, Seoul, 07061 Korea
| | - Minseok Suh
- Department of Nuclear Medicine, Seoul National University Hospital, Seoul, 03080 Korea
| | - Gi Jeong Cheon
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, 03080 Korea
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10
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Zhu S, Wang Y, Tang J, Cao M. Radiotherapy induced immunogenic cell death by remodeling tumor immune microenvironment. Front Immunol 2022; 13:1074477. [PMID: 36532071 PMCID: PMC9753984 DOI: 10.3389/fimmu.2022.1074477] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022] Open
Abstract
Emerging evidence indicates that the induction of radiotherapy(RT) on the immunogenic cell death (ICD) is not only dependent on its direct cytotoxic effect, changes in the tumor immune microenvironment also play an important role in it. Tumor immune microenvironment (TIME) refers to the immune microenvironment that tumor cells exist, including tumor cells, inflammatory cells, immune cells, various signaling molecules and extracellular matrix. TIME has a barrier effect on the anti-tumor function of immune cells, which can inhibit all stages of anti-tumor immune response. The remodeling of TIME caused by RT may affect the degree of immunogenicity, and make it change from immunosuppressive phenotype to immunostimulatory phenotype. It is of great significance to reveal the causes of immune escape of tumor cells, especially for the treatment of drug-resistant tumor. In this review, we focus on the effect of RT on the TIME, the mechanism of RT in reversing the TIME to suppress intrinsic immunity, and the sensitization effect of the remodeling of TIME caused by RT on the effectiveness of immunotherapy.
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11
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Isobe T, Takei H, Mori Y, Ide Y, Kobayashi D, Tomita T, Sugaya K, Nagai Y, Sakae T. [Biological Effects of Low Dose and Low Dose Rate Radiation]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2022; 78:1376-1380. [PMID: 36403971 DOI: 10.6009/jjrt.2022-2114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
| | - Hideyuki Takei
- Quantum Life and Medical Science Directorate, National Institute for Quantum Science and Technology
| | | | - Yasuwo Ide
- Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | | | | | - Keito Sugaya
- Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | - Yoshiaki Nagai
- Department of Radiological Technology, Tsukuba International University
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12
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Jungles KM, Holcomb EA, Pearson AN, Jungles KR, Bishop CR, Pierce LJ, Green MD, Speers CW. Updates in combined approaches of radiotherapy and immune checkpoint inhibitors for the treatment of breast cancer. Front Oncol 2022; 12:1022542. [PMID: 36387071 PMCID: PMC9643771 DOI: 10.3389/fonc.2022.1022542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/27/2022] [Indexed: 12/05/2022] Open
Abstract
Breast cancer is the most prevalent non-skin cancer diagnosed in females and developing novel therapeutic strategies to improve patient outcomes is crucial. The immune system plays an integral role in the body’s response to breast cancer and modulating this immune response through immunotherapy is a promising therapeutic option. Although immune checkpoint inhibitors were recently approved for the treatment of breast cancer patients, not all patients respond to immune checkpoint inhibitors as a monotherapy, highlighting the need to better understand the biology underlying patient response. Additionally, as radiotherapy is a critical component of breast cancer treatment, understanding the interplay of radiation and immune checkpoint inhibitors will be vital as recent studies suggest that combined therapies may induce synergistic effects in preclinical models of breast cancer. This review will discuss the mechanisms supporting combined approaches with radiotherapy and immune checkpoint inhibitors for the treatment of breast cancer. Moreover, this review will analyze the current clinical trials examining combined approaches of radiotherapy, immunotherapy, chemotherapy, and targeted therapy. Finally, this review will evaluate data regarding treatment tolerance and potential biomarkers for these emerging therapies aimed at improving breast cancer outcomes.
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Affiliation(s)
- Kassidy M. Jungles
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, United States
| | - Erin A. Holcomb
- Graduate Program in Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Ashley N. Pearson
- Graduate Program in Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Kalli R. Jungles
- Department of Biology, Saint Mary’s College, Notre Dame, IN, United States
| | - Caroline R. Bishop
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Lori J. Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
| | - Michael D. Green
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, United States
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, United States
- *Correspondence: Michael D. Green, ; Corey W. Speers,
| | - Corey W. Speers
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Case Comprehensive Cancer Center, Cleveland, OH, United States
- *Correspondence: Michael D. Green, ; Corey W. Speers,
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13
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G JM, P P, Dharmarajan A, Warrier S, Gandhirajan RK. Modulation of Reactive Oxygen Species in Cancers: Recent Advances. Free Radic Res 2022; 56:447-470. [PMID: 36214686 DOI: 10.1080/10715762.2022.2133704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Oxidation-reduction reactions played a significant role in the chemical evolution of life forms on oxygenated earth. Cellular respiration is dependent on such redox reactions, and any imbalance leads to the accumulation of reactive oxygen species (ROS), resulting in both chronic and acute illnesses. According to the International Agency for Research on Cancer (IARC), by 2040, the global burden of new cancer cases is expected to be around 27.5 million, with 16.3 million cancer deaths due to an increase in risk factors such as unhealthy lifestyle, environmental factors, aberrant gene mutations, and resistance to therapies. ROS play an important role in cellular signalling, but they can cause severe damage to tissues when present at higher levels. Elevated and chronic levels of ROS are pertinent in carcinogenesis, while several therapeutic strategies rely on altering cellular ROS to eliminate tumour cells as they are more susceptible to ROS-induced damage than normal cells. Given this selective targeting potential, therapies that can effectively modulate ROS levels have been the focus of intense research in recent years. The current review describes biologically relevant ROS, its origins in solid and haematological cancers, and the current status of evolving antioxidant and pro-oxidant therapies in cancers.
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Affiliation(s)
- Jeyasree M G
- Department of Human Genetics, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra University, Porur, Chennai 600116, India
| | - Prerana P
- Department of Human Genetics, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra University, Porur, Chennai 600116, India
| | - Arun Dharmarajan
- Department of Biomedical Sciences, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra University, Porur, Chennai 600116, India.,Stem Cell and Cancer Biology Laboratory, Curtin University, Perth, WA, Australia.,School of Pharmacy and Biomedical Sciences, Curtin University, Perth, WA 6102, Australia.,Curtin Health and Innovation Research Institute, Curtin University, Perth, WA 6102, Australia
| | - Sudha Warrier
- Division of Cancer Stem Cells and Cardiovascular Regeneration, School of Regenerative Medicine, Manipal Academy of Higher Education (MAHE), Bangalore 560065, India.,Cuor Stem Cellutions Pvt Ltd, Manipal Institute of Regenerative Medicine, Manipal Academy of Higher Education (MAHE), Bangalore 560065, India
| | - Rajesh Kumar Gandhirajan
- Department of Human Genetics, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra University, Porur, Chennai 600116, India
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14
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Xie L, Song W, Dong W, Li Y, Chen S, Sun X, Huang M, Cheng Y, Gao Y, Yang S, Yan X. Indirect Application of Intense Pulsed Light Induces Therapeutic Effects on Experimental Murine Meibomian Gland Dysfunction. Front Med (Lausanne) 2022; 9:923280. [PMID: 35721080 PMCID: PMC9201038 DOI: 10.3389/fmed.2022.923280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose To investigate the indirect effects of intense pulsed light (IPL) on morphological and pathological changes of the meibomian glands (MGs) in apolipoprotein E knockout (ApoE–/–) mice and explore the underlying mechanisms. Methods ApoE–/– mice were treated with or without IPL three times below the lower eyelids and MGs were not directly exposed to irradiation. The eyelids and ocular surface were observed under a stereoscope. The morphology of MGs was examined by photographing and hematoxylin and eosin staining. Lipid droplets in MGs were examined by Oil Red O staining. The ultrastructure of meibocytes and mitochondria was observed under transmission electron microscopy. The relative gene and protein expression in MGs of upper eyelids was determined by immunostaining, Western blot, and qRT–PCR. Results Three IPL treatments decreased the toothpaste-like plugging of orifices and thickening and irregularity of the upper and lower eyelid margins in ApoE–/– mice. The morphology of some MGs improved after IPL treatments, accompanied by increased proliferation of acinar basal cells and decreased ductal keratinization. Furthermore, the accumulation of hyperchromatic lipid droplets in the acini increased, and the lipid droplets distributed in the cells around the acini were round and small. Compared with untreated ApoE–/– mice, oxidative stress and apoptosis were downregulated by IPL treatment, accompanied by the improvements in mitochondrial structure. Further research showed that IPL treatments reduced the levels of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-17A, IL-6 in MGs and inactivated nuclear factor kappa B (NF-κ B). Conclusion Collectively, the results demonstrate that indirect effects of IPL can improve the structure and function of MGs and mitigate the progression of MGD, which may be related to the indirect effects of photobiomodulation.
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15
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The Significance of Lymph Node Ratio and Total Lymph Nodes Examined in Determining the Indications of Adjuvant Radiation in pN2 Non-Small Cell Lung Cancer. Clin Lung Cancer 2022; 23:e384-e393. [DOI: 10.1016/j.cllc.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/20/2022]
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16
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Salom F, Prat F. Current role of endoscopic ultrasound in the diagnosis and management of pancreatic cancer. World J Gastrointest Endosc 2022; 14:35-48. [PMID: 35116098 PMCID: PMC8788172 DOI: 10.4253/wjge.v14.i1.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/03/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) has emerged as an invaluable tool for the diagnosis, staging and treatment of pancreatic ductal adenocarcinoma (PDAC). EUS is currently the most sensitive imaging tool for the detection of solid pancreatic tumors. Conventional EUS has evolved, and new imaging techniques, such as contrast-enhanced harmonics and elastography, have been developed to improve diagnostic accuracy during the evaluation of focal pancreatic lesions. More recently, evaluation with artificial intelligence has shown promising results to overcome operator-related flaws during EUS imaging evaluation. Currently, an appropriate diagnosis is based on a proper histological assessment, and EUS-guided tissue acquisition is the standard procedure for pancreatic sampling. Newly developed cutting needles with core tissue procurement provide the possibility of molecular evaluation for personalized oncological treatment. Interventional EUS has modified the therapeutic approach, primarily for advanced pancreatic cancer. EUS-guided fiducial placement for local targeted radiotherapy treatment or EUS-guided radiofrequency ablation has been developed for local treatment, especially for patients with pancreatic cancer not suitable for surgical resection. Additionally, EUS-guided therapeutic procedures, such as celiac plexus neurolysis for pain control and EUS-guided biliary drainage for biliary obstruction, have dramatically improved in recent years toward a more effective and less invasive procedure to palliate complications related to PDAC. All the current benefits of EUS in the diagnosis and management of PDAC will be thoroughly discussed.
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Affiliation(s)
- Federico Salom
- Department of Gastroenterology, Hospital Mexico, Uruca 1641-2050, San Jose, Costa Rica
| | - Frédéric Prat
- Servide d'Endoscopie, Hopital Beaujon, Université Paris et INSERM U1016, Clichy 92118, Paris, France
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Franzese O, Torino F, Giannetti E, Cioccoloni G, Aquino A, Faraoni I, Fuggetta MP, De Vecchis L, Giuliani A, Kaina B, Bonmassar E. Abscopal Effect and Drug-Induced Xenogenization: A Strategic Alliance in Cancer Treatment? Int J Mol Sci 2021; 22:ijms221910672. [PMID: 34639014 PMCID: PMC8509363 DOI: 10.3390/ijms221910672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
The current state of cancer treatment is still far from being satisfactory considering the strong impairment of patients' quality of life and the high lethality of malignant diseases. Therefore, it is critical for innovative approaches to be tested in the near future. In view of the crucial role that is played by tumor immunity, the present review provides essential information on the immune-mediated effects potentially generated by the interplay between ionizing radiation and cytotoxic antitumor agents when interacting with target malignant cells. Therefore, the radiation-dependent abscopal effect (i.e., a biological effect of ionizing radiation that occurs outside the irradiated field), the influence of cancer chemotherapy on the antigenic pattern of target neoplastic cells, and the immunogenic cell death (ICD) caused by anticancer agents are the main topics of this presentation. It is widely accepted that tumor immunity plays a fundamental role in generating an abscopal effect and that anticancer drugs can profoundly influence not only the host immune responses, but also the immunogenic pattern of malignant cells. Remarkably, several anticancer drugs impact both the abscopal effect and ICD. In addition, certain classes of anticancer agents are able to amplify already expressed tumor-associated antigens (TAA). More importantly, other drugs, especially triazenes, induce the appearance of new tumor neoantigens (TNA), a phenomenon that we termed drug-induced xenogenization (DIX). The adoption of the abscopal effect is proposed as a potential therapeutic modality when properly applied concomitantly with drug-induced increase in tumor cell immunogenicity and ICD. Although little to no preclinical or clinical studies are presently available on this subject, we discuss this issue in terms of potential mechanisms and therapeutic benefits. Upcoming investigations are aimed at evaluating how chemical anticancer drugs, radiation, and immunotherapies are interacting and cooperate in evoking the abscopal effect, tumor xenogenization and ICD, paving the way for new and possibly successful approaches in cancer therapy.
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Affiliation(s)
- Ornella Franzese
- School of Medicine, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (O.F.); (G.C.); (A.A.); (I.F.); (L.D.V.)
| | - Francesco Torino
- Department of Systems Medicine, Medical Oncology, University of Rome Tor Vergata, 00133 Rome, Italy; (F.T.); (E.G.)
| | - Elisa Giannetti
- Department of Systems Medicine, Medical Oncology, University of Rome Tor Vergata, 00133 Rome, Italy; (F.T.); (E.G.)
| | - Giorgia Cioccoloni
- School of Medicine, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (O.F.); (G.C.); (A.A.); (I.F.); (L.D.V.)
- School of Food Science and Nutrition, University of Leeds, Leeds LS29JT, UK
| | - Angelo Aquino
- School of Medicine, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (O.F.); (G.C.); (A.A.); (I.F.); (L.D.V.)
| | - Isabella Faraoni
- School of Medicine, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (O.F.); (G.C.); (A.A.); (I.F.); (L.D.V.)
| | - Maria Pia Fuggetta
- Institute of Translational Pharmacology, Consiglio Nazionale delle Ricerche (CNR), Via Fosso del Cavaliere, 00133 Rome, Italy; (M.P.F.); (A.G.)
| | - Liana De Vecchis
- School of Medicine, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (O.F.); (G.C.); (A.A.); (I.F.); (L.D.V.)
| | - Anna Giuliani
- Institute of Translational Pharmacology, Consiglio Nazionale delle Ricerche (CNR), Via Fosso del Cavaliere, 00133 Rome, Italy; (M.P.F.); (A.G.)
| | - Bernd Kaina
- Institute of Toxicology, University Medical Center, D-55131 Mainz, Germany
- Correspondence: (B.K.); (E.B.)
| | - Enzo Bonmassar
- School of Medicine, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (O.F.); (G.C.); (A.A.); (I.F.); (L.D.V.)
- Institute of Translational Pharmacology, Consiglio Nazionale delle Ricerche (CNR), Via Fosso del Cavaliere, 00133 Rome, Italy; (M.P.F.); (A.G.)
- Correspondence: (B.K.); (E.B.)
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Choucair K, Radford M, Bansal A, Park R, Saeed A. Advances in immune therapies for the treatment of microsatellite instability‑high/deficient mismatch repair metastatic colorectal cancer (Review). Int J Oncol 2021; 59:74. [PMID: 34396449 PMCID: PMC8360619 DOI: 10.3892/ijo.2021.5254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/23/2021] [Indexed: 11/29/2022] Open
Abstract
Microsatellite instability-high/deficient mismatch repair colorectal cancer (MSI-H/dMMR CRC) is a molecular subtype characterized by high-frequency mutations within DNA mismatch repair genes. Defects in the DNA mismatch repair machinery lead to subsequent frame-shift mutations, resulting in the generation of frame-shift peptides that serve as neoantigens. This has translated into exquisite sensitivity to immune checkpoint inhibitors (ICIs) and a significant clinical benefit from immune therapies in this patient population. The present article provides a comprehensive review of the advances in the field of immune therapies for MSI-H/dMMR metastatic CRC, with a focus on the major randomized clinical trials that led to Food and Drug Administration approval of specific ICIs for this population, a detailed review of the molecular background responsible for tumor response, as well as the mechanisms of resistance to ICI therapy. Finally, ongoing investigations of other immunotherapeutic strategies to address and overcome the challenges that currently limit response and long-term response to ICIs were presented.
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Affiliation(s)
- Khalil Choucair
- Department of Medicine, Kansas University School of Medicine, Wichita, KS 67214, USA
| | - Maluki Radford
- Department of Medicine, Kansas University Medical Center, Kansas City, KS 66205, USA
| | - Ajay Bansal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Kansas Medical Center and Kansas Cancer Institute, Kansas City, KS 66205, USA
| | - Robin Park
- Department of Medicine, MetroWest Medical Center/Tufts University School of Medicine, Framingham, Massachusetts, MA 01702, USA
| | - Anwaar Saeed
- Department of Medicine, Division of Medical Oncology, Kansas University Cancer Center, Kansas City, KS 66205, USA
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19
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Mouabbi JA, Chand M, Asghar IA, Sakhi R, Ockner D, Dul CL, Hadid T, Aref A, Rimawi MF, Hoyos V. Lumpectomy followed by radiation improves survival in HER2 positive and triple-negative breast cancer with high tumor-infiltrating lymphocytes compared to mastectomy alone. Cancer Med 2021; 10:4790-4795. [PMID: 34080777 PMCID: PMC8290225 DOI: 10.1002/cam4.4050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE The goal was to compare the 5-year DFS and 5-year OS in patients with early-stage human epidermal growth factor receptor 2 breast cancer (HER2+ BC) and triple-negative breast cancer (TNBC) in relation to the amount of stromal tumor-infiltrating lymphocytes (TILs) after locoregional management by either mastectomy without radiation or lumpectomy and whole-breast radiotherapy (RT). METHODS This was a retrospective review of HER2+ BC and TNBC patients' charts and histopathology slides with clinical stage of T1-T2 N0 who presented at our facility between January 2009 and December 2019. Locoregional treatment included either mastectomy without RT (M) or lumpectomy with RT (L+R). TILs were assessed by three pathologists using the guidelines of the 2014 TILs working group. A competing risk model and Kaplan-Meier analysis were used to analyze correlations between TILs levels and clinical outcome. RESULTS We reviewed 211 patients' charts. Of them, 190 proceeded to the final analysis. Patients were split into groups of "low TILs" and "high TILs" based on a 50% TILs cut-off. Of them 26% had high TILs, 48% received RT, 97% received chemotherapy, all HER2+ BC patients received HER2-directed therapy and all HER2+ BC that were also hormone receptor positive (HR+) received endocrine therapy (ET). In patient with low TILs, L+R did not improve outcomes compared to M. Moreover, patients with high TILs had a significant improvement of their DFS and OS with L+R when compared to M. CONCLUSION The results of our study reflect that a selected group of HER2+ BC and TNBC with elevated TILs, L+R is associated with improvement of 5-year DFS and 5-year OS.
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Affiliation(s)
- Jason A. Mouabbi
- Dan L Duncan Comprehensive Cancer CenterBaylor College of MedicineHoustonTXUSA
| | | | | | | | | | | | | | - Amr Aref
- Ascension St John HospitalDetroitMIUSA
| | - Mothaffar F. Rimawi
- Dan L Duncan Comprehensive Cancer CenterBaylor College of MedicineHoustonTXUSA
| | - Valentina Hoyos
- Dan L Duncan Comprehensive Cancer CenterBaylor College of MedicineHoustonTXUSA
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20
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Hendricks-Wenger A, Hutchison R, Vlaisavljevich E, Allen IC. Immunological Effects of Histotripsy for Cancer Therapy. Front Oncol 2021; 11:681629. [PMID: 34136405 PMCID: PMC8200675 DOI: 10.3389/fonc.2021.681629] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/10/2021] [Indexed: 12/11/2022] Open
Abstract
Cancer is the second leading cause of death worldwide despite major advancements in diagnosis and therapy over the past century. One of the most debilitating aspects of cancer is the burden brought on by metastatic disease. Therefore, an ideal treatment protocol would address not only debulking larger primary tumors but also circulating tumor cells and distant metastases. To address this need, the use of immune modulating therapies has become a pillar in the oncology armamentarium. A therapeutic option that has recently emerged is the use of focal ablation therapies that can destroy a tumor through various physical or mechanical mechanisms and release a cellular lysate with the potential to stimulate an immune response. Histotripsy is a non-invasive, non-ionizing, non-thermal, ultrasound guided ablation technology that has shown promise over the past decade as a debulking therapy. As histotripsy therapies have developed, the full picture of the accompanying immune response has revealed a wide range of immunogenic mechanisms that include DAMP and anti-tumor mediator release, changes in local cellular immune populations, development of a systemic immune response, and therapeutic synergism with the inclusion of checkpoint inhibitor therapies. These studies also suggest that there is an immune effect from histotripsy therapies across multiple murine tumor types that may be reproducible. Overall, the effects of histotripsy on tumors show a positive effect on immunomodulation.
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Affiliation(s)
- Alissa Hendricks-Wenger
- Graduate Program in Translational Biology, Medicine and Health, Virginia Tech, Roanoke, VA, United States
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA, United States
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
| | - Ruby Hutchison
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
| | - Eli Vlaisavljevich
- Graduate Program in Translational Biology, Medicine and Health, Virginia Tech, Roanoke, VA, United States
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
- Institute for Critical Technology and Applied Sciences Center for Engineered Health, Virginia Tech, Blacksburg, VA, United States
| | - Irving Coy Allen
- Graduate Program in Translational Biology, Medicine and Health, Virginia Tech, Roanoke, VA, United States
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA, United States
- Institute for Critical Technology and Applied Sciences Center for Engineered Health, Virginia Tech, Blacksburg, VA, United States
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
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Yin T, Xin H, Yu J, Teng F. The role of exosomes in tumour immunity under radiotherapy: eliciting abscopal effects? Biomark Res 2021; 9:22. [PMID: 33789758 PMCID: PMC8011088 DOI: 10.1186/s40364-021-00277-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022] Open
Abstract
As a curative treatment of localized tumours or as palliative control, radiotherapy (RT) has long been known to kill tumour cells and trigger the release of proinflammatory factors and immune cells to elicit an immunological response to cancer. As a crucial part of the tumour microenvironment (TME), exosomes, which are double-layered nanometre-sized vesicles, can convey molecules, present antigens, and mediate cell signalling to regulate tumour immunity via their contents. Different contents result in different effects of exosomes. The abscopal effect is a systemic antitumour effect that occurs outside of the irradiated field and is associated with tumour regression. This effect is mediated through the immune system, mainly via cell-mediated immunity, and results from a combination of inflammatory cytokine cascades and immune effector cell activation. Although the abscopal effect has been observed in various malignancies for many years, it is still a rarely identified clinical event. Researchers have indicated that exosomes can potentiate abscopal effects to enhance the effects of radiation, but the specific mechanisms are still unclear. In addition, radiation can affect exosome release and composition, and irradiated cells release exosomes with specific contents that change the cellular immune status. Hence, fully understanding how radiation affects tumour immunity and the interaction between specific exosomal contents and radiation may be a potential strategy to maximize the efficacy of cancer therapy. The optimal application of exosomes as novel immune stimulators is under active investigation and is described in this review.
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Affiliation(s)
- Tianwen Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Huixian Xin
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Feifei Teng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, China.
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22
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Chairmadurai A, Jain SK, Jain A, Prakash H. Rapid Arc-SBRT: Non-invasive immune adjuvant for advanced stage Non-Small Cell Lung Carcinoma. Anticancer Agents Med Chem 2021; 22:202-205. [PMID: 34225640 DOI: 10.2174/1871520621666210322105641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 11/22/2022]
Abstract
In conjunction with Radio-chemotherapy, pulmonary resection is recommended for early-stage Non-small-cell lung carcinoma but not for advanced-stage NSCLC patients with having high-grade metastatic lesions. In these cases, Rapid Arc-Stereotactic body radiotherapy (Ra-SBRT) technique offers a therapeutic advantage by delivering focal irradiation to metastatic lung lesions and reduces the bystander toxicity to normal tissues. We have previously demonstrated that Ra-SBRT ablates metastatic lesions and induces tumor immune rejection of metastatic tumors by promoting in situ programming of M2 TAM towards M1-TAM and infiltration of Siglec-8+ Eosinophils. Most interestingly, Ra SBRT has very low abscopal impact and spares normal tissues, which are the significant limitations with conventional radiotherapy. In view of this and Immune adjuvant potential of Ra SBRT, it promotes normalization of aberrant vasculature and inhibits the metastatic potential of NSCLC lesions. In view of this we here propose that Ra-SBRT indeed represents an immunogenic approach for the effective management of advanced-stage NSCLC.
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Affiliation(s)
| | | | - Aklank Jain
- Department of Zoology, Central University of Punjab, Bathinda, Punjab, India
| | - Hridayesh Prakash
- Amity Institute of Virology and Immunology, Amity University, Uttar Pradesh, Sector -125, NOIDA, India
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23
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The role of connexin proteins and their channels in radiation-induced atherosclerosis. Cell Mol Life Sci 2021; 78:3087-3103. [PMID: 33388835 PMCID: PMC8038956 DOI: 10.1007/s00018-020-03716-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 02/08/2023]
Abstract
Radiotherapy is an effective treatment for breast cancer and other thoracic tumors. However, while high-energy radiotherapy treatment successfully kills cancer cells, radiation exposure of the heart and large arteries cannot always be avoided, resulting in secondary cardiovascular disease in cancer survivors. Radiation-induced changes in the cardiac vasculature may thereby lead to coronary artery atherosclerosis, which is a major cardiovascular complication nowadays in thoracic radiotherapy-treated patients. The underlying biological and molecular mechanisms of radiation-induced atherosclerosis are complex and still not fully understood, resulting in potentially improper radiation protection. Ionizing radiation (IR) exposure may damage the vascular endothelium by inducing DNA damage, oxidative stress, premature cellular senescence, cell death and inflammation, which act to promote the atherosclerotic process. Intercellular communication mediated by connexin (Cx)-based gap junctions and hemichannels may modulate IR-induced responses and thereby the atherosclerotic process. However, the role of endothelial Cxs and their channels in atherosclerotic development after IR exposure is still poorly defined. A better understanding of the underlying biological pathways involved in secondary cardiovascular toxicity after radiotherapy would facilitate the development of effective strategies that prevent or mitigate these adverse effects. Here, we review the possible roles of intercellular Cx driven signaling and communication in radiation-induced atherosclerosis.
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Radiation, a two-edged sword: From untoward effects to fractionated radiotherapy. Radiat Phys Chem Oxf Engl 1993 2021. [DOI: 10.1016/j.radphyschem.2020.108994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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25
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Tubin S, Gupta S, Grusch M, Popper HH, Brcic L, Ashdown ML, Khleif SN, Peter-Vörösmarty B, Hyden M, Negrini S, Fossati P, Hug E. Shifting the Immune-Suppressive to Predominant Immune-Stimulatory Radiation Effects by SBRT-PArtial Tumor Irradiation Targeting HYpoxic Segment (SBRT-PATHY). Cancers (Basel) 2020; 13:cancers13010050. [PMID: 33375357 PMCID: PMC7795882 DOI: 10.3390/cancers13010050] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/19/2022] Open
Abstract
Simple Summary This review presents and summarizes the key components and outcomes of a novel, unconventional radiation approach aimed to exploit immune-stimulatory radiation effects which, being added to direct radiation tumor cell killing, may improve the therapeutic ratio of radiotherapy. This technique, as a product of translational oncology research, was intentionally developed for the induction of immune-mediated bystander and abscopal effects in the treatment of unresectable bulky tumors which have much fewer therapeutic options and show poor prognoses after conventional treatments. This review offers insights into a unique unconventional radiotherapy technique which, due to its higher immunogenic potential, may improve the prognosis of patients affected by highly complex malignancies, providing additional opportunities for future research in terms of combining novel immuno-modulating agents with more modern radiotherapy approaches. Abstract Radiation-induced immune-mediated abscopal effects (AE) of conventional radiotherapy are very rare. Whole-tumor irradiation leads to lymphopenia due to killing of immune cells in the tumor microenvironment, resulting in immunosuppression and weak abscopal potential. This limitation may be overcome by partial tumor irradiation sparing the peritumoral immune-environment, and consequent shifting of immune-suppressive to immune-stimulatory effect. This would improve the radiation-directed tumor cell killing, adding to it a component of immune-mediated killing. Our preclinical findings showed that the high-single-dose irradiation of hypoxic tumor cells generates a stronger bystander effect (BE) and AE than the normoxic cells, suggesting their higher “immunogenic potential”. This led to the development of a novel Stereotactic Body RadioTherapy (SBRT)-based PArtial Tumor irradiation targeting HYpoxic segment (SBRT-PATHY) for induction of the immune-mediated BE and AE. Encouraging SBRT-PATHY-clinical outcomes, together with immunohistochemical and gene-expression analyses of surgically removed abscopal-tumor sites, suggested that delivery of the high-dose radiation to the partial (hypoxic) tumor volume, with optimal timing based on the homeostatic fluctuation of the immune response and sparing the peritumoral immune-environment, would significantly enhance the immune-mediated anti-tumor effects. This review discusses the current evidence on the safety and efficacy of SBRT-PATHY in the treatment of unresectable hypoxic bulky tumors and its bystander and abscopal immunomodulatory potential.
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Affiliation(s)
- Slavisa Tubin
- MedAustron Ion Therapy Center, Marie Curie-Straße 5, 2700 Wiener Neustadt, Austria; (P.F.); (E.H.)
- Correspondence: ; Tel.: +43-676-9021-687
| | - Seema Gupta
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20057, USA; (S.G.); (S.N.K.)
| | - Michael Grusch
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria; (M.G.); (B.P.-V.)
| | - Helmuth H. Popper
- Diagnostic and Research Institute of Pathology, Medical University of Graz, 8010 Graz, Austria; (H.H.P.); (L.B.)
| | - Luka Brcic
- Diagnostic and Research Institute of Pathology, Medical University of Graz, 8010 Graz, Austria; (H.H.P.); (L.B.)
| | - Martin L. Ashdown
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne 3010, Australia;
| | - Samir N. Khleif
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20057, USA; (S.G.); (S.N.K.)
| | - Barbara Peter-Vörösmarty
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria; (M.G.); (B.P.-V.)
| | - Martin Hyden
- Institute for Pathology, Kabeg Klinikum Klagenfurt, 9020 Klagenfurt am Wörthersee, Austria;
| | - Simone Negrini
- Internal Medicine, Clinical Immunology and Translational Medicine Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Piero Fossati
- MedAustron Ion Therapy Center, Marie Curie-Straße 5, 2700 Wiener Neustadt, Austria; (P.F.); (E.H.)
| | - Eugen Hug
- MedAustron Ion Therapy Center, Marie Curie-Straße 5, 2700 Wiener Neustadt, Austria; (P.F.); (E.H.)
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Kolberg HC, Hoffmann O, Baumann R. The Abscopal Effect: Could a Phenomenon Described Decades Ago Become Key to Enhancing the Response to Immune Therapies in Breast Cancer? Breast Care (Basel) 2020; 15:443-449. [PMID: 33223988 DOI: 10.1159/000511431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/08/2020] [Indexed: 01/18/2023] Open
Abstract
Background The term "abscopal effect" was defined in 1953. In oncology the term is used to describe systemic antitumor effects triggered by local irradiation (nontarget effect). Although the mechanism of the abscopal effect is not completely understood yet, it has been demonstrated that in situ tumor vaccination, and the resulting antitumor immune response, is one of the key factors. Summary The development of immune therapies has recently led to concepts combining local radiotherapy and immune therapy with the aim of enhancing the response to immune therapy by the immunological mechanisms summarized in the term abscopal effect. This concept has also been investigated in less immunogenic tumors such as breast cancer. Initial data are promising but the hypothesis that the combination of checkpoint inhibitors and local radiotherapy could be an effective combination in breast cancer has to be proven by ongoing trials. Substitution of local radiotherapy by local hyperthermia could be an option in selected cases. Key Messages Combination of checkpoint inhibitors with local radiation or hyperthermia in breast cancer is a promising approach and could enhance the response rates generated by immune therapy alone through the antitumor immune response initiated by the abscopal effect.
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Affiliation(s)
| | - Oliver Hoffmann
- Department of Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
| | - René Baumann
- Department of Radiation Oncology, St. Marien-Hospital, Siegen, Germany
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D'Andrea MA, Reddy GK. Systemic Effects of Radiation Therapy-Induced Abscopal Responses in Patients with Advanced Lung Cancer. Oncology 2020; 99:1-14. [PMID: 33221794 DOI: 10.1159/000510287] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Out-of-field tumor regression effects of radiation therapy (abscopal response) have been sporadically observed in the past, but they have only recently gained significant importance due to the use of innovative high-precision radiation delivery devices for the treatment of various cancers including non-small cell lung cancer (NSCLC). In this study, we provide a detailed overview of the current state of knowledge and clinical experience of radiation therapy-induced abscopal effects in patients with advanced NSCLC. SUMMARY Peer-reviewed published clinical evidence on the abscopal effect of radiation therapy was collected using electronic databases such as MEDLINE via PubMed and Google Scholar. The clinical data on the abscopal effect of radiation therapy were reviewed and the outcomes have been summarized. Most studies describing the abscopal effects of radiation therapy in patients with advanced NSCLC have been in the form of either case reports or small cohort studies. Although the exact molecular mechanisms for the abscopal effect are yet to be established, current evidence indicates that tumor cell destruction induced by local radiation therapy releases tumor antigens, which stimulate the immune system of the host to activate the body's immune effector cells systemically and trigger the regression of distant nonirradiated cancer cells. These off-target antitumor effects of radiation therapy provide an opportunity to explore the use of the radiation therapy in combination with novel immunotherapy agents to maximize treatment outcomes in patients with advanced NSCLC and other cancers. Key Message: The findings suggest that radiation therapy has the ability to induce abscopal effects with an increased potential to boost these effects when it is used in combination with immunotherapy for the treatment of patients with advanced NSCLC and other cancers. Clinical trials investigating radiation therapy-induced abscopal effects may lead to a dramatic change in its use especially when it is combined with immunotherapy for the treatment of patients with advanced NSCLC.
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Affiliation(s)
- Mark A D'Andrea
- University Cancer and Diagnostic Centers, Houston, Texas, USA
| | - G Kesava Reddy
- University Cancer and Diagnostic Centers, Houston, Texas, USA,
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Radiotherapy-Mediated Immunomodulation and Anti-Tumor Abscopal Effect Combining Immune Checkpoint Blockade. Cancers (Basel) 2020; 12:cancers12102762. [PMID: 32992835 PMCID: PMC7600068 DOI: 10.3390/cancers12102762] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/19/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Radiotherapy (RT) is a conventional method for clinical treatment of local tumors, which can induce tumor-specific immune response and cause the shrinkage of primary tumor and distal metastases via mediating tumor infiltration of CD8+ T cells. Ionizing radiation (IR) induced tumor regression outside the radiation field is termed as abscopal effect. However, due to the mobilization of immunosuppressive signals by IR, the activated CD8+T cells are not sufficient to maintain a long-term positive feedback to make the tumors regress completely. Eventually, the "hot" tumors gradually turn to "cold". With the advent of emerging immunotherapy, the combination of immune checkpoint blockade (ICB) and local RT has produced welcome changes in stubborn metastases, especially anti-PD-1/PD-L1 and anti-CTLA-4 which have been approved in clinical cancer treatment. However, the detailed mechanism of the abscopal effect induced by combined therapy is still unclear. Therefore, how to formulate a therapeutic schedule to maximize the efficacy should be took into consideration according to specific circumstance. This paper reviewed the recent research progresses in immunomodulatory effects of local radiotherapy on the tumor microenvironment, as well as the unique advantage for abscopal effect when combined with ICB, with a view to exploring the potential application value of radioimmunotherapy in clinic.
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Mehnati P, Baradaran B, Vahidian F, Nadiriazam S. Functional response difference between diabetic/normal cancerous patients to inflammatory cytokines and oxidative stresses after radiotherapy. Rep Pract Oncol Radiother 2020; 25:730-737. [PMID: 32684862 DOI: 10.1016/j.rpor.2020.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/23/2020] [Indexed: 02/06/2023] Open
Abstract
Diabetes, which is considered as a chronic metabolic disorder leads to an increase in inflammatory cytokines and oxidative stresses. Studies have shown several functional differences in the oxidative stress and inflammatory cytokines responses in diabetic/normal cancerous patients candidate for radiotherapy. Also, radiotherapy as a cancer treatment modality is known as a carcinogen due to oxidative damage via generation of reactive oxygen metabolites and also causing inflammation of the tissue by increasing the inflammatory cytokines. Therefore, the consequence of diabetes on oxidative stress and increased inflammatory factors and synergistic effects of radiotherapy on these factors cause complications in diabetics undergoing radiotherapy. It is considered as one of the most interesting objectives to control inflammation and oxidative stress in these patients. This review aims to concentrate on the influence of factors such as MPO, MDA, IL-1β, and TNF-α in diabetic patients by emphasizing the effects related to radiation-induced toxicity and inflammation by proposing therapeutic approaches which could be helpful in reduction of the complications.
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Affiliation(s)
- Parinaz Mehnati
- Department of Medical Physics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Vahidian
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sousan Nadiriazam
- Department of Medical Physics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Radiation-induced bystander and abscopal effects: important lessons from preclinical models. Br J Cancer 2020; 123:339-348. [PMID: 32581341 PMCID: PMC7403362 DOI: 10.1038/s41416-020-0942-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 03/10/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022] Open
Abstract
Radiotherapy is a pivotal component in the curative treatment of patients with localised cancer and isolated metastasis, as well as being used as a palliative strategy for patients with disseminated disease. The clinical efficacy of radiotherapy has traditionally been attributed to the local effects of ionising radiation, which induces cell death by directly and indirectly inducing DNA damage, but substantial work has uncovered an unexpected and dual relationship between tumour irradiation and the host immune system. In clinical practice, it is, therefore, tempting to tailor immunotherapies with radiotherapy in order to synergise innate and adaptive immunity against cancer cells, as well as to bypass immune tolerance and exhaustion, with the aim of facilitating tumour regression. However, our understanding of how radiation impacts on immune system activation is still in its early stages, and concerns and challenges regarding therapeutic applications still need to be overcome. With the increasing use of immunotherapy and its common combination with ionising radiation, this review briefly delineates current knowledge about the non-targeted effects of radiotherapy, and aims to provide insights, at the preclinical level, into the mechanisms that are involved with the potential to yield clinically relevant combinatorial approaches of radiotherapy and immunotherapy.
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Tubin S, Yan W, Mourad WF, Fossati P, Khan MK. The future of radiation-induced abscopal response: beyond conventional radiotherapy approaches. Future Oncol 2020; 16:1137-1151. [PMID: 32338046 DOI: 10.2217/fon-2020-0063] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Advances in the immunological pharmaceuticals, such as checkpoint inhibitors and agonists, have positive implications for the future of the radiotherapy abscopal response. A once rare phenomenon, whereby distant nonirradiated tumor sites regressed after radiotherapy alone, may become more common when combined with the immune modulating agents. Radiotherapy can increase neoantigen expression, increased tumor PD-L1 expression, increase MHC class I expression, reverse exhausted CD8 T cells and increase tumor-infiltrating tumors within the tumor microenvironment. These changes in the tumor and the tumor microenvironment after radiotherapy could potentiate responses to anti-CTL-4, anti-PD-L1/PD-1 and other immunotherapy agents. Thus, advances in checkpoint inhibitors have increased interest in re-evaluation of the role of conventional radiotherapy approaches on the immune system. We reviewed newer nonconventional approaches such as SBRT-PATHY, GRID, FLASH, carbon ion and proton therapy and their role in eliciting immune responses. We believe that combining these novel radiation methods may enhance the outcome with the newly US FDA approved immune modulating agents.
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Affiliation(s)
- Slavisa Tubin
- MedAustron Center for Ion Therapy and Research, Marie Curie Strasse 5, A-2700 Wiener Neustadt, Austria
| | - Weisi Yan
- Department of Radiation Oncology, Thomas Jefferson University, 11th St, Philadelphia, PA 19107, USA
| | - Waleed F Mourad
- Department of Radiation Medicine, Markey Cancer Center, University of Kentucky, Medical Center, MN 150 - Lexington, KY 40536-0298, USA
| | - Piero Fossati
- MedAustron Center for Ion Therapy and Research, Marie Curie Strasse 5, A-2700 Wiener Neustadt, Austria
| | - Mohammad K Khan
- Department of Radiation Oncology, Emory University School of Medicine, Winship Cancer Institute, 1365-C Clifton Road, Atlanta, GA 30322, USA
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Ellerin BE, Demandante CGN, Martins JT. Pure abscopal effect of radiotherapy in a salivary gland carcinoma: Case report, literature review, and a search for new approaches. Cancer Radiother 2020; 24:226-246. [PMID: 32192840 DOI: 10.1016/j.canrad.2020.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 12/12/2022]
Abstract
We report the case of an 84-year-old woman with poorly differentiated non-small cell carcinoma of the right parotid who presented with headache, was found to have a primary right parotid gland cancer as well as metastatic disease, and underwent palliative radiotherapy to the primary site. The patient received no chemotherapy or immunotherapy, but both the primary site and several non-irradiated foci in the lungs regressed or completely resolved. The patient remained free of disease for about one year before progression. The case is a rare instance of abscopal regression of metastatic disease in the absence of pharmacologic immunomodulation. A literature review surveys the history of the abscopal effect of radiation therapy, attempts to understand the mechanisms of its successes and failures, and points to new approaches that can inform and improve the outcomes of radioimmunotherapy.
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Affiliation(s)
| | | | - J T Martins
- UT Health HOPE Cancer Center, Tyler, TX 75701, USA
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Intraoperative Boost Radiotherapy with 50 kV X-Rays Versus External Radiotherapy in Breast Cancer: Single-Center Experiences. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2020. [DOI: 10.5812/ijcm.98561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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34
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D’Andrea MA, Reddy GK. Systemic Antitumor Effects and Abscopal Responses in Melanoma Patients Receiving Radiation Therapy. Oncology 2020; 98:202-215. [DOI: 10.1159/000505487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 12/10/2019] [Indexed: 11/19/2022]
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Akbor M, Hung KF, Yang YP, Chou SJ, Tsai PH, Chien CS, Lin LT. Immunotherapy orchestrates radiotherapy in composing abscopal effects: A strategic review in metastatic head and neck cancer. J Chin Med Assoc 2020; 83:113-116. [PMID: 31834023 DOI: 10.1097/jcma.0000000000000234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The treatment of metastatic head and neck squamous cell carcinoma (HNSCC) with a combination of radiotherapy (RT) and immunotherapy can augment treatment response and symptomatic relief. Combination therapy can also trigger a non-targeted tumor control event called the abscopal effect. This effect can be demonstrated by treatment with anti-programmed death 1/programmed death ligand 1 (PD-L1) and anti-cytotoxic T-lymphocyte-associated antigen 4 antibodies in combination with hypofractionated RT. Individual studies and clinical trials have revealed that combination radio-immunotherapy improves overall treatment response by successful initiation of the abscopal effect, which extends the treatment effects to non-targeted lesions. Growing attention to the abscopal effect may inspire innovations in current RT toward more effective and less toxic radiobiological treatment modalities for advanced HNSCC. We review the latest findings on the abscopal effect with emphases on therapeutic modalities and potential applications for treating metastatic HNSCC.
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Affiliation(s)
- Mohammady Akbor
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Kai-Feng Hung
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yi-Ping Yang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Pharmaceutical Sciences, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Shih-Jie Chou
- School of Pharmaceutical Sciences, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ping-Hsing Tsai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chian-Shiu Chien
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Liang-Ting Lin
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
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Fu J, Zhu L, Tu W, Wang X, Pan Y, Bai Y, Dang B, Chen J, Shao C. Macrophage-Mediated Bystander Effects after Different Irradiations through a p53-dependent Pathway. Radiat Res 2019; 193:119-129. [PMID: 31841081 DOI: 10.1667/rr15354.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The goal of this work was to elucidate the mechanisms of bystander effects outside the localized irradiation field and their potential hematological toxicity. In this study, an in vitro multicellular co-culture system was used to investigate the intercellular commutation and related signaling pathways between either irradiated A549 cells or Beas-2B cells and bystander lymphoblast TK6 cells with or without macrophage U937 cells as an intermediator. Results showed that the proliferation ability of bystander TK6 cells was inhibited after co-culture with A549 cells irradiated with γ rays rather than carbon ions. When macrophages were contained in the co-culture system, the cell viability damage to the bystander TK6 cells were further enhanced. However, the proliferation inhibition of bystander TK6 cells after co-culture with irradiated Beas-2B cells was observed only when intermediator macrophages existed in the cell co-culture system. More serious cell injury was detected after carbon-ion irradiation compared with γ-ray irradiation. The p53-relevant apoptosis pathway was activated in both irradiated A549 and Beas-2B cells, each to a different extent. When the p53 pathway of irradiated cells was inhibited by PFT-α, PFTµ or p53 siRNA, the bystander damage to TK6 cells were clearly alleviated. In conclusion, the bystander lymphoblast damage was induced in different cells using different LET radiations. An amplified bystander response was modulated by the intermediator macrophage. The underlying molecular mechanisms of these bystander effects were dependent on the activation of p53 and its relevant apoptosis pathway in the irradiated cells. These results suggest that the bystander and macrophage-mediated bystander effects contribute to the common acute side effect of lymphocytopenia after local irradiation.
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Affiliation(s)
- Jiamei Fu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, 200433, China.,Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Lin Zhu
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Wenzhi Tu
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Xiangdong Wang
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Yan Pan
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Yang Bai
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Bingrong Dang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou 730000, China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chunlin Shao
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
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Sun X, Gan L, Na A, Ge L, Chen B, Liu J. Combination with Stereotactic Body Radiotherapy Offers a Promising Strategy to Overcome Resistance to Immunotherapy in Advanced Renal Cell Cancer. JOURNAL OF ONCOLOGY 2019; 2019:1483406. [PMID: 31871454 PMCID: PMC6906880 DOI: 10.1155/2019/1483406] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/24/2019] [Accepted: 10/26/2019] [Indexed: 02/05/2023]
Abstract
Immunotherapy for renal cell cancer (RCC) has witnessed several developments for more than two decades. Checkpoint inhibitors, including anti-CTLA-4 and anti-PD-1/PD-L1 blockers, have changed the treatment landscape for patients with advanced RCC in the past 3 years. Despite these advances, more than 55% RCC patients become resistant to different immunotherapies without other treatment combination. Among various attempts at overcoming resistance to immunotherapy, stereotactic body radiotherapy (SBRT) has been found to potentiate the activity of immunotherapy agents through several potential mechanisms, including normalization of microvessels to alleviate tumor hypoxia, improvement in efficient delivery of drugs, abundant neoantigen exposure, and recruitment of antitumor immune cells to alter the immunosuppressive tumor microenvironment. Preclinical studies and clinical case reports have predicted that the combination of SBRT, an immunotherapy, may lead to remarkable results. This review aims to provide the biological basis for the feasibility of combining SBRT to overcome immunotherapy resistance and to review the currently available clinical evidence of this combination therapy in patients with advanced RCC.
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Affiliation(s)
- Xiaowen Sun
- Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Lu Gan
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Aru Na
- Department of Obstetrics and Gynecology, West China Second Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Lingling Ge
- West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Baoqing Chen
- Department of Radiation Oncology, State Key of Oncology in South China, Collaborative Innovation Center for Cancer Medcine, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, China
| | - Jiaming Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Tubin S, Khan MK, Salerno G, Mourad WF, Yan W, Jeremic B. Mono-institutional phase 2 study of innovative Stereotactic Body RadioTherapy targeting PArtial Tumor HYpoxic (SBRT-PATHY) clonogenic cells in unresectable bulky non-small cell lung cancer: profound non-targeted effects by sparing peri-tumoral immune microenvironment. Radiat Oncol 2019; 14:212. [PMID: 31771654 PMCID: PMC6878646 DOI: 10.1186/s13014-019-1410-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/30/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Radiotherapy-induced lymphopenia may be limiting the success of therapy and could also negatively affect the ability of immune system in mediating the bystander (BE) and abscopal effects (AE). A novel SBRT-based PArtial Tumor irradiation of HYpoxic clonogenic cells (SBRT-PATHY) for induction of the tumoricidal BE and AE by sparing the peritumoral immune microenvironment and regional circulating lymphocytes has been developed to enhance the radiotherapy therapeutic ratio of advanced lung cancer. The aim of this retrospective review of prospectively collected mono-institutional phase 2 study was to compare the outcomes between unconventional SBRT-PATHY and standard of care in unresectable stage IIIB/IV bulky NSCLC. MATERIALS AND METHODS Sixty patients considered inoperable or unsuitable for radical radio-chemotherapy were enrolled and treated using the following 3 regimens: SBRT-PATHY (group I, n = 20 patients), recommended standard of care chemotherapy (group II, n = 20 patients), and institutional conventional palliative radiotherapy (group III, n = 20 patients). RESULTS Median follow-up was 13 months. The 1-year overall survival was 75, 60, and 20% in groups 1, 2 and 3, respectively (p = 0.099). The 1-year cancer specific survival was 90, 60, and 20% in groups 1, 2, and 3, respectively (p = 0.049). Bulky tumor control rate was 95% for SBRT-PATHY compared with 20% in the other two groups. BE and AE were seen by SBRT-PATHY in 95 and 45% of patients, respectively. Multi-variate analysis for cancer specific survival was significant for treatment effect with SBRT-PATHY (p < 0.001) independent of age, sex, performance status, histology, stage, treated bulky site and tumor diameter. SBRT-PATHY resulted in lower toxicity (p = 0.026), and improved symptom control (p = 0.018) when compared to other two treatment options. CONCLUSION SBRT-PATHY improved treatment outcomes in unresectable NSCLC and should be investigated in larger trials. Present study has been retrospectively registered on 8th of August 2019 by the ethic committee for Austrian region "Kärnten "in Klagenfurt (AUT), under study number A 31/19.
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Affiliation(s)
- Slavisa Tubin
- KABEG Klinikum Klagenfurt, Institute of Radiation Oncology, Feschnigstraße 11, 9020, Klagenfurt am Wörthersee, Austria.
| | - Mohammad K Khan
- Department of Radiation Oncology, Emory University School of Medicine, Winship Cancer Institute, 1365-C Clifton Road, 30322, Atlanta, NE, Georgia
| | - Gerardo Salerno
- Department of Neurosciences, Mental Health and Sensory Organs / Department of Clinical and Molecular Medicine, Universita' La Sapienza Roma, Ospedale Sant' Andrea, Via di Grottarossa, 1035, 00189, Rome, RM, Italy
| | - Waleed F Mourad
- Markey Cancer Center, Department of Radiation Medicine, University of Kentucky Lexington ky, UK Medical Center MN 150, Lexington, KY, 40536-0298, USA
| | - Weisi Yan
- Department of Radiation Oncology, Thomas Jefferson University, 111 S 11th St, Philadelphia, PA, 19107, USA
| | - Branislav Jeremic
- BioIRC, R&D Center for Biomedical Research, Kragujevac, SERBIA and Research Institute of Clinical Medicine, 13 Tevdore Mgvdeli St, 0112, Tbilisi, Georgia
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Weaver BD, Goodman JR, Jensen R. Concurrent Radiosurgery and Systemic Therapies for Melanoma Brain Metastases: A Systematic Review. Cureus 2019; 11:e6147. [PMID: 31886081 PMCID: PMC6907724 DOI: 10.7759/cureus.6147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Intracranial metastatic melanoma is a major challenge for neuro-oncological teams. Historically, treatment has focused on surgical or radiosurgical treatment of appropriate lesions, mostly for palliative purposes. Immunotherapies and other targeted therapies (BRAF/mitogen-activated protein kinase kinase inhibitors (BRAFi/MEKi)) are mainstays of advanced melanoma therapy, yet the optimal timing and synergistic properties of concurrent combinations of these systemic therapies and stereotactic radiosurgery (SRS) are poorly understood. We performed a systematic review of the MEDLINE and Scopus databases focused on outcomes after therapy using SRS and either immunotherapies or targeted therapies in an effort to define the optimal timing. We defined concurrent therapy as SRS within three months of treatment with any systemic therapy. End points included local control, distant control, overall survival, and toxicities. We identified five retrospective cohort studies from the literature. These studies found that concurrent SRS plus immunotherapy or BRAFi/MEKi is well tolerated by most patients and generally improved local control, distant control, and overall survival. Importantly, no significant increases in toxicities were noted with concurrent therapy. Combining concurrent SRS with immunotherapy or BRAFi/MEKi may offer important advances for patients with intracranial metastatic melanoma. To address interstudy heterogeneity, we propose reporting two major time intervals defining “concurrent treatment”: concurrent-SRS (≤4 weeks) and peri-SRS (≤3 months). Future large-scale, prospective trials considering truly concurrent SRS therapies with systemic therapies are desperately needed.
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Affiliation(s)
| | - James R Goodman
- Anesthesiology, Oregon Health & Science University, Portland, USA
| | - Randy Jensen
- Neurosurgery, University of Utah, Salt Lake City, USA
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Relevance of Non-Targeted Effects for Radiotherapy and Diagnostic Radiology; A Historical and Conceptual Analysis of Key Players. Cancers (Basel) 2019; 11:cancers11091236. [PMID: 31450803 PMCID: PMC6770832 DOI: 10.3390/cancers11091236] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/16/2019] [Accepted: 08/18/2019] [Indexed: 11/17/2022] Open
Abstract
Non-targeted effects (NTE) such as bystander effects or genomic instability have been known for many years but their significance for radiotherapy or medical diagnostic radiology are far from clear. Central to the issue are reported differences in the response of normal and tumour tissues to signals from directly irradiated cells. This review will discuss possible mechanisms and implications of these different responses and will then discuss possible new therapeutic avenues suggested by the analysis. Finally, the importance of NTE for diagnostic radiology and nuclear medicine which stems from the dominance of NTE in the low-dose region of the dose–response curve will be presented. Areas such as second cancer induction and microenvironment plasticity will be discussed.
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Tumor Microenvironment as A "Game Changer" in Cancer Radiotherapy. Int J Mol Sci 2019; 20:ijms20133212. [PMID: 31261963 PMCID: PMC6650939 DOI: 10.3390/ijms20133212] [Citation(s) in RCA: 276] [Impact Index Per Article: 55.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/19/2019] [Accepted: 06/25/2019] [Indexed: 12/24/2022] Open
Abstract
Radiotherapy (RT), besides cancer cells, also affects the tumor microenvironment (TME): tumor blood vessels and cells of the immune system. It damages endothelial cells and causes radiation-induced inflammation. Damaged vessels inhibit the infiltration of CD8+ T lymphocytes into tumors, and immunosuppressive pathways are activated. They lead to the accumulation of radioresistant suppressor cells, including tumor-associated macrophages (TAMs) with the M2 phenotype, myeloid-derived suppressor cells (MDSCs), and regulatory T cells (Tregs). The area of tumor hypoxia increases. Hypoxia reduces oxygen-dependent DNA damage and weakens the anti-cancer RT effect. It activates the formation of new blood vessels and leads to cancer relapse after irradiation. Irradiation may also activate the immune response through immunogenic cell death induction. This leads to the "in situ" vaccination effect. In this article, we review how changes in the TME affect radiation-induced anticancer efficacy. There is a very delicate balance between the activation of the immune system and the immunosuppression induced by RT. The effects of RT doses on immune system reactions and also on tumor vascularization remain unclear. A better understanding of these interactions will contribute to the optimization of RT treatment, which may prevent the recurrence of cancer.
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Lockney NA, Zhang M, Morris CG, Nichols RC, Okunieff P, Swarts S, Zhang Z, Zhang B, Zhang A, Hoppe BS. Radiation-induced tumor immunity in patients with non-small cell lung cancer. Thorac Cancer 2019; 10:1605-1611. [PMID: 31228354 PMCID: PMC6610279 DOI: 10.1111/1759-7714.13122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 01/19/2023] Open
Abstract
Background Radiation‐induced tumor immunity (RITI) influences primary tumor growth and development of metastases in preclinical cancer models with conventional radiotherapy. Antigen‐specific immune responses have also been shown for prostate cancer treated with radiotherapy. We examined whether RITI can be induced in patients with non‐small cell lung cancer (NSCLC) following proton radiotherapy. Methods Pre‐ and post‐radiotherapy plasma samples from 26 patients with nonmetastatic NSCLC who received radiotherapy between 2010 and 2012 were evaluated by western blotting for IgG and IgM bands to assess RITI response to tumor antigens from lung cancer cell lines. Statistical analysis was used to evaluate any correlation among IgG or IgM and clinical outcomes. Results Twenty‐one patients received proton therapy at 2 GyRBE/fraction (n = 17) or 6–12 Gy/fraction (n = 4); five received photon therapy at 2–2.5 GyRBE/fraction. Compared with the pretreatment baseline, new IgG or IgM binding was detected in 27% and 50% of patients, respectively. New IgG bands were detected in the 25–37 kD, 50–75 kD, and 75–100 kD ranges. New IgM bands were detected in the 20–25 kD, 25–37 kD, 37–50 kD, 50–75 kD, and 75–100 kD ranges. There was no difference in IgG and/or IgM RITI response in patients treated with photons versus protons, or in patients who received SBRT compared to standard fractionation (P > 0.05). There was no difference in overall survival, metastasis‐free survival, or local control based on IgG and/or IgM RITI response (P > 0.05). Conclusion RITI can be induced in patients with NSCLC through upregulated IgG and/or IgM. RITI response was not associated with proton versus photon therapy or with clinical outcomes in this small cohort and should be examined in a larger cohort in future studies.
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Affiliation(s)
- Natalie A Lockney
- Department of Radiation Oncology, University of Florida, Gainesville, USA
| | - Mei Zhang
- Department of Radiation Oncology, University of Florida, Gainesville, USA
| | | | | | - Paul Okunieff
- Department of Radiation Oncology, University of Florida, Gainesville, USA
| | - Steven Swarts
- Department of Radiation Oncology, University of Florida, Gainesville, USA
| | - Zhenhuan Zhang
- Department of Radiation Oncology, University of Florida, Gainesville, USA
| | - Bingrong Zhang
- Department of Radiation Oncology, University of Florida, Gainesville, USA
| | - Amy Zhang
- Department of Radiation Oncology, University of Florida, Gainesville, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida, Gainesville, USA
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The systemic immunostimulatory effects of radiation therapy producing overall tumor control through the abscopal effect. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s13566-019-00391-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Kovács A, Stenmark Tullberg A, Werner Rönnerman E, Holmberg E, Hartman L, Sjöström M, Lundstedt D, Malmström P, Fernö M, Karlsson P. Effect of Radiotherapy After Breast-Conserving Surgery Depending on the Presence of Tumor-Infiltrating Lymphocytes: A Long-Term Follow-Up of the SweBCG91RT Randomized Trial. J Clin Oncol 2019; 37:1179-1187. [DOI: 10.1200/jco.18.02157] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The effects of radiotherapy (RT) on the basis of the presence of stromal tumor infiltrating lymphocytes (TILs) have not been studied. The purpose of this study was to analyze the association of TILs with the effect of postoperative RT on ipsilateral breast tumor recurrence (IBTR) in a large randomized trial. METHODS In the SweBCT91RT (Swedish Breast Cancer Group 91 Radiotherapy) trial, 1,178 patients with breast cancer stage I and II were randomly assigned to breast-conserving surgery plus postoperative RT or breast-conserving surgery only and followed for a median of 15.2 years. Tumor blocks were retrieved from 1,003 patients. Stromal TILs were assessed on whole-section hematoxylin-eosin–stained slides using a dichotomized cutoff of 10%. Subtypes were scored using immunohistochemistry on tissue microarray. In total, 936 patients were evaluated. RESULTS Altogether, 670 (71%) of patients had TILs less than 10%. In a multivariable regression analysis with IBTR as dependent variable and RT, TILs, subtype, age, and grade as independent variables, RT (hazard ratio [HR], 0.42; 95% CI, 0.29 to 0.61; P < .001), high TILs (HR, 0.61; 95% CI, 0.39 to 0.96, P = .033) grade (3 v 1; HR, 2.17; 95% CI, 1.08 to 4.34; P = .029), and age (≥ 50 v < 50 years; HR, 0.55; 95% CI, 0.38 to 0.80; P = .002) were predictive of IBTR. RT was significantly beneficial in the low TILs group (HR, 0.37; 95% CI, 0.24 to 0.58; P < .001) but not in the high TILs group (HR, 0.58; 95% CI, 0.28 to 1.19; P = .138). The test for interaction between RT and TILs was not statistically significant ( P = .317). CONCLUSION This study shows that high values of TILs in the primary tumor independently seem to reduce the risk for an IBTR. Our findings further suggest that patients with breast cancer with low TILs may derive a larger benefit from RT regarding the risk of IBTR.
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Affiliation(s)
- Anikó Kovács
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Axel Stenmark Tullberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Malmström
- Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
| | | | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Aznar MA, Planelles L, Perez-Olivares M, Molina C, Garasa S, Etxeberría I, Perez G, Rodriguez I, Bolaños E, Lopez-Casas P, Rodriguez-Ruiz ME, Perez-Gracia JL, Marquez-Rodas I, Teijeira A, Quintero M, Melero I. Immunotherapeutic effects of intratumoral nanoplexed poly I:C. J Immunother Cancer 2019; 7:116. [PMID: 31046839 PMCID: PMC6498680 DOI: 10.1186/s40425-019-0568-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 03/15/2019] [Indexed: 12/30/2022] Open
Abstract
Poly I:C is a powerful immune adjuvant as a result of its agonist activities on TLR-3, MDA5 and RIG-I. BO-112 is a nanoplexed formulation of Poly I:C complexed with polyethylenimine that causes tumor cell apoptosis showing immunogenic cell death features and which upon intratumoral release results in more prominent tumor infiltration by T lymphocytes. Intratumoral treatment with BO-112 of subcutaneous tumors derived from MC38, 4 T1 and B16-F10 leads to remarkable local disease control dependent on type-1 interferon and gamma-interferon. Some degree of control of non-injected tumor lesions following BO-112 intratumoral treatment was found in mice bearing bilateral B16-OVA melanomas, an activity which was enhanced with co-treatment with systemic anti-CD137 and anti-PD-L1 mAbs. More abundant CD8+ T lymphocytes were found in B16-OVA tumor-draining lymph nodes and in the tumor microenvironment following intratumoral BO-112 treatment, with enhanced numbers of tumor antigen-specific cytotoxic T lymphocytes. Genome-wide transcriptome analyses of injected tumor lesions were consistent with a marked upregulation of the type-I interferon pathway. Inspired by these data, intratumorally delivered BO-112 is being tested in cancer patients (NCT02828098).
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Affiliation(s)
- M Angela Aznar
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain.
| | | | | | - Carmen Molina
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain
| | - Saray Garasa
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain
| | - Iñaki Etxeberría
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain
| | - Guiomar Perez
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain
| | - Inmaculada Rodriguez
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain
| | - Elixabet Bolaños
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain
| | | | - Maria E Rodriguez-Ruiz
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain
| | - Jose L Perez-Gracia
- Clínica Universidad de Navarra, Pamplona, Spain.,CIBERONC, Madrid, Spain.,IDISNA, Instituto de investigación de Navarra, Pamplona, Spain
| | - Ivan Marquez-Rodas
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alvaro Teijeira
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain.,CIBERONC, Madrid, Spain.,IDISNA, Instituto de investigación de Navarra, Pamplona, Spain
| | | | - Ignacio Melero
- Center for Applied Medical Research (CIMA), University of Navarra, Avenida Pio XII, 55, 31008, Pamplona, Spain. .,Clínica Universidad de Navarra, Pamplona, Spain. .,CIBERONC, Madrid, Spain. .,IDISNA, Instituto de investigación de Navarra, Pamplona, Spain.
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The Combination of Stereotactic Body Radiation Therapy and Immunotherapy in Primary Liver Tumors. JOURNAL OF ONCOLOGY 2019; 2019:4304817. [PMID: 31182960 PMCID: PMC6512065 DOI: 10.1155/2019/4304817] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023]
Abstract
Treatment recommendations for primary liver malignancies, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), are complex and require a multidisciplinary approach. Despite surgical options that are potentially curative, options for nonsurgical candidates include systemic therapy, radiotherapy (RT), transarterial chemoembolization (TACE), and radiofrequency ablation (RFA). Stereotactic Body Radiation Therapy (SBRT) is now in routine use for the treatment of lung cancer, and there is growing evidence supporting its use in liver tumors. SBRT has the advantage of delivering ablative radiation doses in a limited number of fractions while minimizing the risk of radiation-induced liver disease (RILD) through highly conformal treatment plans. It should be considered in a multidisciplinary setting for the management of patients with unresectable, locally advanced primary liver malignancies and limited treatment options. Recently, the combination of immunotherapy with SBRT has been proposed to improve antitumor effects through engaging the immune system. This review aims at shedding light on the novel concept of the combination strategy of immune-radiotherapy in liver tumors by exploring the evidence surrounding the use of SBRT and immunotherapy for the treatment of HCC and CCA.
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47
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Biermann J, Langen B, Nemes S, Holmberg E, Parris TZ, Werner Rönnerman E, Engqvist H, Kovács A, Helou K, Karlsson P. Radiation-induced genomic instability in breast carcinomas of the Swedish hemangioma cohort. Genes Chromosomes Cancer 2019; 58:627-635. [PMID: 30938900 DOI: 10.1002/gcc.22757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 02/06/2023] Open
Abstract
Radiation-induced genomic instability (GI) is hypothesized to persist after exposure and ultimately promote carcinogenesis. Based on the absorbed dose to the breast, an increased risk of developing breast cancer was shown in the Swedish hemangioma cohort that was treated with radium-226 for skin hemangioma as infants. Here, we screened 31 primary breast carcinomas for genetic alterations using the OncoScan CNV Plus Assay to assess GI and chromothripsis-like patterns associated with the absorbed dose to the breast. Higher absorbed doses were associated with increased numbers of copy number alterations in the tumor genome and thus a more unstable genome. Hence, the observed dose-dependent GI in the tumor genome is a measurable manifestation of the long-term effects of irradiation. We developed a highly predictive Cox regression model for overall survival based on the interaction between absorbed dose and GI. The Swedish hemangioma cohort is a valuable cohort to investigate the biological relationship between absorbed dose and GI in irradiated humans. This work gives a biological basis for improved risk assessment to minimize carcinogenesis as a secondary disease after radiation therapy.
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Affiliation(s)
- Jana Biermann
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Britta Langen
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Szilárd Nemes
- Department of Orthopedics, Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Regional Cancer Center Western Sweden, Gothenburg, Sweden
| | - Toshima Z Parris
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Hanna Engqvist
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology and Genetics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Khalil Helou
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Lemdani K, Mignet N, Boudy V, Seguin J, Oujagir E, Bawa O, Peschaud F, Emile JF, Capron C, Malafosse R. Local immunomodulation combined to radiofrequency ablation results in a complete cure of local and distant colorectal carcinoma. Oncoimmunology 2019; 8:1550342. [PMID: 30723580 PMCID: PMC6350685 DOI: 10.1080/2162402x.2018.1550342] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Katia Lemdani
- EA4340 BCOH, Versailles University, Paris-Saclay University, Boulogne, France
- Department of Surgery and Oncology, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France
- CNRS, UTCBS UMR 8258, Paris, France
- Paris Descartes University, Sorbonne-Paris-Cité, Paris, France
- INSERM, UTCBS U1022, Paris, France
| | - Nathalie Mignet
- CNRS, UTCBS UMR 8258, Paris, France
- Paris Descartes University, Sorbonne-Paris-Cité, Paris, France
- INSERM, UTCBS U1022, Paris, France
- Chimie ParisTech, PSL Research University, Unité de Technologies Chimiques et Biologiques pour la Santé (UTCBS), Paris, France
| | - Vincent Boudy
- CNRS, UTCBS UMR 8258, Paris, France
- Paris Descartes University, Sorbonne-Paris-Cité, Paris, France
- INSERM, UTCBS U1022, Paris, France
- Chimie ParisTech, PSL Research University, Unité de Technologies Chimiques et Biologiques pour la Santé (UTCBS), Paris, France
- Innovation in Pharmaceutical Formulation Department, Agence Générale des Equipements et des Produits de Santé (AGEPS), AP-HP, Paris, France
| | - Johanne Seguin
- CNRS, UTCBS UMR 8258, Paris, France
- Paris Descartes University, Sorbonne-Paris-Cité, Paris, France
- INSERM, UTCBS U1022, Paris, France
- Chimie ParisTech, PSL Research University, Unité de Technologies Chimiques et Biologiques pour la Santé (UTCBS), Paris, France
- Optical imaging platform LIOPA, Life imaging, PIV, Faculty of Pharmacy, Paris Descartes University, Paris, France
| | | | - Olivia Bawa
- Institut Gustave Roussy, Unité de pathologie expérimentale de l’IRCIV, Villejuif, France
| | - Frédérique Peschaud
- EA4340 BCOH, Versailles University, Paris-Saclay University, Boulogne, France
- Department of Surgery and Oncology, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France
| | - Jean-François Emile
- EA4340 BCOH, Versailles University, Paris-Saclay University, Boulogne, France
- Pathology Department, Ambroise Paré Hospital, AP-HP, Boulogne, France
| | - Claude Capron
- EA4340 BCOH, Versailles University, Paris-Saclay University, Boulogne, France
- Immunology and hematology Department, Ambroise Paré Hospital, Boulogne, France
| | - Robert Malafosse
- EA4340 BCOH, Versailles University, Paris-Saclay University, Boulogne, France
- Department of Surgery and Oncology, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France
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de Andrade Carvalho H, Villar RC. Radiotherapy and immune response: the systemic effects of a local treatment. Clinics (Sao Paulo) 2018; 73:e557s. [PMID: 30540123 PMCID: PMC6257057 DOI: 10.6061/clinics/2018/e557s] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 10/23/2018] [Indexed: 12/14/2022] Open
Abstract
Technological developments have allowed improvements in radiotherapy delivery, with higher precision and better sparing of normal tissue. For many years, it has been well known that ionizing radiation has not only local action but also systemic effects by triggering many molecular signaling pathways. There is still a lack of knowledge of this issue. This review focuses on the current literature about the effects of ionizing radiation on the immune system, either suppressing or stimulating the host reactions against the tumor, and the factors that interact with these responses, such as the radiation dose and dose / fraction effects in the tumor microenvironment and vasculature. In addition, some implications of these effects in cancer treatment, mainly in combined strategies, are addressed from the perspective of their interactions with the more advanced technology currently available, such as heavy ion therapy and nanotechnology.
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Affiliation(s)
- Heloisa de Andrade Carvalho
- Departamento de Radiologia e Oncologia, Divisao de Radioterapia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Servico de Radioterapia, Centro de Oncologia, Hospital Sirio-Libanes, Sao Paulo, SP, BR
| | - Rosangela Correa Villar
- Departamento de Radiologia e Oncologia, Divisao de Radioterapia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Servico de Radioterapia, Centro Infantil Boldrini, Campinas, SP, BR
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50
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Gajiwala S, Torgeson A, Garrido-Laguna I, Kinsey C, Lloyd S. Combination immunotherapy and radiation therapy strategies for pancreatic cancer-targeting multiple steps in the cancer immunity cycle. J Gastrointest Oncol 2018; 9:1014-1026. [PMID: 30603120 PMCID: PMC6286952 DOI: 10.21037/jgo.2018.05.16] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/16/2018] [Indexed: 12/13/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a deadly disease, with its mortality rate approaching its incidence rate every year. Accordingly, much interest has been generated in harnessing the immune system in order to improve survival outcomes for these patients. Pancreatic cancer is not thought to be as immunogenic as other cancers that have seen promising results with immune checkpoint inhibitors alone, therefore likely several targets within the cancer-immunity cycle will need to be employed for successful treatment. We sought to investigate both the current state of the field in immunotherapy in PDAC with a special emphasis on combined approaches with radiation therapy (RT). We also summarized ongoing clinical trials that are examining the use of radiotherapy with other immune-stimulating agents in the treatment of PDAC. A PubMed and clinicaltrials.gov search was conducted using the following search terms, either alone or in combination: "pancreatic cancer", "immunotherapy", and "abscopal effect". Open clinical trials were reviewed and included if they involved both RT and other immune-stimulating agents. Pancreatic cancers tend to reside within immune-suppressive tumor microenvironments (TME), express PD-L1, and secrete several immuno-suppressive agents, such as TGF-B, IL-10, indoleamine 2,3-dioxygenase, galectin-1. Whole-cell vaccine therapies, peptide and protein vaccines, dendritic cell vaccines, and vaccines with micro-organisms have been investigated by themselves with promising results. Open clinical trials are currently investigating the use of these vaccines, which increase antigen presentation, with treatments that stimulate release of tumor antigens including RT. There are currently at least 21 open clinical trials investigating the combination of RT with other immune-stimulating agents. The combination of RT and immunotherapy may be a promising avenue for PDAC treatment and deserves further research.
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Affiliation(s)
- Snehal Gajiwala
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Anna Torgeson
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ignacio Garrido-Laguna
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Conan Kinsey
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah, USA
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