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Luo D, Zhong Q, Yue H, Wang J, Liang Q, Liu W, Zhu X. The predictors of lymphopenia and its effects on survival in locally advanced esophageal squamous cell carcinoma. Cancer Biol Ther 2024; 25:2371632. [PMID: 38946404 PMCID: PMC11218796 DOI: 10.1080/15384047.2024.2371632] [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: 12/15/2022] [Accepted: 06/19/2024] [Indexed: 07/02/2024] Open
Abstract
To investigate the impact of the effective radiation dose to immune cells (EDIC) and gross tumor volume (GTV) on lymphopenia and survival in patients with locally advanced esophageal squamous cell carcinoma (LAESCC). Between January 2013 and December 2020, 272 LAESCC patients were treated with definitive radiotherapy in two institutions. Based on radiation doses to the lungs, heart, and body region scanned, EDIC was calculated as an equal uniform dose to the total blood considering blood flow and fraction effect. The radiotherapy plan was used to calculate the GTVs. Lymphopenia was graded based on the lowest lymphocyte count during RT. The overall survival (OS), progress-free survival (PFS), and local recurrence-free survival (LRFS) were analyzed statistically. The lowest lymphocyte count was significantly correlated with EDIC (r= -0.389, p < .001) and GTV (r= -0.211, p < .001). Lymphopenia, EDIC, and GTV are risk factors for patients with ESCC. In a Kaplan-Meier analysis with EDIC and GTV as stratification factors, lymphopenia was not associated with OS in the EDIC>12.9 Gy group (p = .294)and EDIC ≤ 12.9 Gy group, and it was also not associated with OS in GTV>68.8 cm3 group (p = .242) and GTV ≤ 68.8 cm3 group(p = .165). GTV and EDIC had an impact on the relationship between lymphopenia and OS in patients with LAESCC undergoing definitive RT. Poorer OS, PFS, and LRFS are correlated with lymphopenia, higher EDIC, and larger GTV.
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Affiliation(s)
- Danjing Luo
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Qiulu Zhong
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Haiying Yue
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jue Wang
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qianfu Liang
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Wenqi Liu
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaodong Zhu
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
- Department of Oncology, Wuming Hospital of Guangxi Medical University, Nanning, China
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Hu Z, Mohan R, Chu Y, Wang X, van Rossum PS, Chen Y, Grayson ME, Gearhardt AG, Grassberger C, Zhi D, Hobbs BP, Lin SH, Cao W. Clinical Translation of a Deep Learning Model of Radiation-Induced Lymphopenia for Esophageal Cancer. Int J Part Ther 2024; 13:100624. [PMID: 39228692 PMCID: PMC11369390 DOI: 10.1016/j.ijpt.2024.100624] [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: 06/26/2024] [Accepted: 07/29/2024] [Indexed: 09/05/2024] Open
Abstract
Purpose Radiation-induced lymphopenia is a common immune toxicity that adversely impacts treatment outcomes. We report here our approach to translate a deep-learning (DL) model developed to predict severe lymphopenia risk among esophageal cancer into a strategy for incorporating the immune system as an organ-at-risk (iOAR) to mitigate the risk. Materials and Methods We conducted "virtual clinical trials" utilizing retrospective data for 10 intensity-modulated radiation therapy (IMRT) and 10 passively-scattered proton therapy (PSPT) esophageal cancer patients. For each patient, additional treatment plans of the modality other than the original were created employing standard-of-care (SOC) dose constraints. Predicted values of absolute lymphocyte count (ALC) nadir for all plans were estimated using a previously-developed DL model. The model also yielded the relative magnitudes of contributions of iOARs dosimetric factors to ALC nadir, which were used to compute iOARs dose-volume constraints, which were incorporated into optimization criteria to produce "IMRT-enhanced" and "intensity-modulated proton therapy (IMPT)-enhanced" plans. Results Model-predicted ALC nadir for the original IMRT (IMRT-SOC) and PSPT plans agreed well with actual values. IMPT-SOC showed greater immune sparing vs IMRT and PSPT. The average mean body doses were 13.10 Gy vs 7.62 Gy for IMRT-SOC vs IMPT-SOC for patients treated with IMRT-SOC; and 8.08 Gy vs 6.68 Gy for PSPT vs IMPT-SOC for patients treated with PSPT. For IMRT patients, the average predicted ALC nadir of IMRT-SOC, IMRT-enhanced, IMPT-SOC, and IMPT-enhanced was 281, 327, 351, and 392 cells/µL, respectively. For PSPT patients, the average predicted ALC nadir of PSPT, IMPT-SOC, and IMPT-enhanced was 258, 316, and 350 cells/µL, respectively. Enhanced plans achieved higher predicted ALC nadir, with an average improvement of 40.8 cells/µL (20.6%). Conclusion The proposed DL model-guided strategy to incorporate the immune system as iOAR in IMRT and IMPT optimization has the potential for radiation-induced lymphopenia mitigation. A prospective clinical trial is planned.
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Affiliation(s)
- Zongsheng Hu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yan Chu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Xiaochun Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Yiqing Chen
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Madison E. Grayson
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Angela G. Gearhardt
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Clemens Grassberger
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Degui Zhi
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Brian P. Hobbs
- Department of Population Health, The University of Texas at Austin, Austin, Texas, USA
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wenhua Cao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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3
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Morel D, Robert C, Paragios N, Grégoire V, Deutsch E. Translational Frontiers and Clinical Opportunities of Immunologically Fitted Radiotherapy. Clin Cancer Res 2024; 30:2317-2332. [PMID: 38477824 PMCID: PMC11145173 DOI: 10.1158/1078-0432.ccr-23-3632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/09/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
Ionizing radiation can have a wide range of impacts on tumor-immune interactions, which are being studied with the greatest interest and at an accelerating pace by the medical community. Despite its undeniable immunostimulatory potential, it clearly appears that radiotherapy as it is prescribed and delivered nowadays often alters the host's immunity toward a suboptimal state. This may impair the full recovery of a sustained and efficient antitumor immunosurveillance posttreatment. An emerging concept is arising from this awareness and consists of reconsidering the way of designing radiation treatment planning, notably by taking into account the individualized risks of deleterious radio-induced immune alteration that can be deciphered from the planned beam trajectory through lymphocyte-rich organs. In this review, we critically appraise key aspects to consider while planning immunologically fitted radiotherapy, including the challenges linked to the identification of new dose constraints to immune-rich structures. We also discuss how pharmacologic immunomodulation could be advantageously used in combination with radiotherapy to compensate for the radio-induced loss, for example, with (i) agonists of interleukin (IL)2, IL4, IL7, IL9, IL15, or IL21, similarly to G-CSF being used for the prophylaxis of severe chemo-induced neutropenia, or with (ii) myeloid-derived suppressive cell blockers.
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Affiliation(s)
- Daphné Morel
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
| | - Charlotte Robert
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
- Paris-Saclay University, School of Medicine, Le Kremlin Bicêtre, France
| | - Nikos Paragios
- Therapanacea, Paris, France
- CentraleSupélec, Gif-sur-Yvette, France
| | - Vincent Grégoire
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
- Paris-Saclay University, School of Medicine, Le Kremlin Bicêtre, France
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4
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Yu T, Jiang W, Wang Y, Zhou Y, Jiao J, Wu M. Chimeric antigen receptor T cells in the treatment of osteosarcoma (Review). Int J Oncol 2024; 64:40. [PMID: 38390935 PMCID: PMC10919759 DOI: 10.3892/ijo.2024.5628] [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: 09/12/2023] [Accepted: 01/25/2024] [Indexed: 02/24/2024] Open
Abstract
Osteosarcoma (OS) is a frequently occurring primary bone tumor, mostly affecting children, adolescents and young adults. Before 1970, surgical resection was the main treatment method for OS, but the clinical results were not promising. Subsequently, the advent of chemotherapy has improved the prognosis of patients with OS. However, there is still a high incidence of metastasis or recurrence, and chemotherapy has several side effects, thus making the 5‑year survival rate markedly low. Recently, chimeric antigen receptor T (CAR‑T) cell therapy represents an alternative immunotherapy approach with significant potential for hematologic malignancies. Nevertheless, the application of CAR‑T cells in the treatment of OS faces numerous challenges. The present review focused on the advances in the development of CAR‑T cells to improve their clinical efficacy, and discussed ways to overcome the difficulties faced by CAR T‑cell therapy for OS.
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Affiliation(s)
- Tong Yu
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Weibo Jiang
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Yang Wang
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ying Zhou
- Department of Operating Room, The Third Hospital of Qinhuangdao, Qinhuangdao, Hebei 066000, P.R. China
| | - Jianhang Jiao
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Minfei Wu
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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Wisdom AJ, Barker CA, Chang JY, Demaria S, Formenti S, Grassberger C, Gregucci F, Hoppe BS, Kirsch DG, Marciscano AE, Mayadev J, Mouw KW, Palta M, Wu CC, Jabbour SK, Schoenfeld JD. The Next Chapter in Immunotherapy and Radiation Combination Therapy: Cancer-Specific Perspectives. Int J Radiat Oncol Biol Phys 2024; 118:1404-1421. [PMID: 38184173 DOI: 10.1016/j.ijrobp.2023.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 01/08/2024]
Abstract
Immunotherapeutic agents have revolutionized cancer treatment over the past decade. However, most patients fail to respond to immunotherapy alone. A growing body of preclinical studies highlights the potential for synergy between radiation therapy and immunotherapy, but the outcomes of clinical studies have been mixed. This review summarizes the current state of immunotherapy and radiation combination therapy across cancers, highlighting existing challenges and promising areas for future investigation.
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Affiliation(s)
- Amy J Wisdom
- Harvard Radiation Oncology Program, Boston, Massachusetts
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sandra Demaria
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Silvia Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Clemens Grassberger
- Department of Radiation Oncology, University of Washington, Fred Hutch Cancer Center, Seattle, Washington
| | - Fabiana Gregucci
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - David G Kirsch
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ariel E Marciscano
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jyoti Mayadev
- Department of Radiation Oncology, UC San Diego School of Medicine, San Diego, California
| | - Kent W Mouw
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Manisha Palta
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts.
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Stepanenko AA, Sosnovtseva AO, Valikhov MP, Chernysheva AA, Abramova OV, Naumenko VA, Chekhonin VP. The need for paradigm shift: prognostic significance and implications of standard therapy-related systemic immunosuppression in glioblastoma for immunotherapy and oncolytic virotherapy. Front Immunol 2024; 15:1326757. [PMID: 38390330 PMCID: PMC10881776 DOI: 10.3389/fimmu.2024.1326757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Despite significant advances in our knowledge regarding the genetics and molecular biology of gliomas over the past two decades and hundreds of clinical trials, no effective therapeutic approach has been identified for adult patients with newly diagnosed glioblastoma, and overall survival remains dismal. Great hopes are now placed on combination immunotherapy. In clinical trials, immunotherapeutics are generally tested after standard therapy (radiation, temozolomide, and steroid dexamethasone) or concurrently with temozolomide and/or steroids. Only a minor subset of patients with progressive/recurrent glioblastoma have benefited from immunotherapies. In this review, we comprehensively discuss standard therapy-related systemic immunosuppression and lymphopenia, their prognostic significance, and the implications for immunotherapy/oncolytic virotherapy. The effectiveness of immunotherapy and oncolytic virotherapy (viro-immunotherapy) critically depends on the activity of the host immune cells. The absolute counts, ratios, and functional states of different circulating and tumor-infiltrating immune cell subsets determine the net immune fitness of patients with cancer and may have various effects on tumor progression, therapeutic response, and survival outcomes. Although different immunosuppressive mechanisms operate in patients with glioblastoma/gliomas at presentation, the immunological competence of patients may be significantly compromised by standard therapy, exacerbating tumor-related systemic immunosuppression. Standard therapy affects diverse immune cell subsets, including dendritic, CD4+, CD8+, natural killer (NK), NKT, macrophage, neutrophil, and myeloid-derived suppressor cell (MDSC). Systemic immunosuppression and lymphopenia limit the immune system's ability to target glioblastoma. Changes in the standard therapy are required to increase the success of immunotherapies. Steroid use, high neutrophil-to-lymphocyte ratio (NLR), and low post-treatment total lymphocyte count (TLC) are significant prognostic factors for shorter survival in patients with glioblastoma in retrospective studies; however, these clinically relevant variables are rarely reported and correlated with response and survival in immunotherapy studies (e.g., immune checkpoint inhibitors, vaccines, and oncolytic viruses). Our analysis should help in the development of a more rational clinical trial design and decision-making regarding the treatment to potentially improve the efficacy of immunotherapy or oncolytic virotherapy.
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Affiliation(s)
- Aleksei A. Stepanenko
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anastasiia O. Sosnovtseva
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Marat P. Valikhov
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anastasia A. Chernysheva
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Olga V. Abramova
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Victor A. Naumenko
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Vladimir P. Chekhonin
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
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7
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Lin CH, Yan JL, Yap WK, Kang CJ, Chang YC, Tsai TY, Chang KP, Liao CT, Hsu CL, Chou WC, Wang HM, Huang PW, Fan KH, Huang BS, Tung-Chieh Chang J, Tu SJ, Lin CY. Prognostic value of interim CT-based peritumoral and intratumoral radiomics in laryngeal and hypopharyngeal cancer patients undergoing definitive radiotherapy. Radiother Oncol 2023; 189:109938. [PMID: 37806562 DOI: 10.1016/j.radonc.2023.109938] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to investigate the prognostic value of peritumoral and intratumoral computed tomography (CT)-based radiomics during the course of radiotherapy (RT) in patients with laryngeal and hypopharyngeal cancer (LHC). MATERIALS AND METHODS A total of 92 eligible patients were 1:1 randomly assigned into training and validation cohorts. Pre-RT and mid-RT radiomic features were extracted from pre-treatment and interim CT. LASSO-Cox regression was used for feature selection and model construction. Time-dependent area under the receiver operating curve (AUC) analysis was applied to evaluate the models' prognostic performances. Risk stratification ability on overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method and Cox regression. The associations between radiomics and clinical parameters as well as circulating lymphocyte counts were also evaluated. RESULTS The mid-RT peritumoral (AUC: 0.77) and intratumoral (AUC: 0.79) radiomic models yielded better performance for predicting OS than the pre-RT intratumoral model (AUC: 0.62) in validation cohort. This was confirmed by Kaplan-Meier analysis, in which risk stratification depended on the mid-RT peritumoral (p = 0.009) and intratumoral (p = 0.003) radiomics could be improved for OS, in comparison to the pre-RT intratumoral radiomics (p = 0.199). Multivariate analysis identified mid-RT peritumoral and intratumoral radiomic models as independent prognostic factors for both OS and PFS. Mid-RT peritumoral and intratumoral radiomics were correlated with treatment-related lymphopenia. CONCLUSION Mid-RT peritumoral and intratumoral radiomic models are promising image biomarkers that could have clinical utility for predicting OS and PFS in patients with LHC treated with RT.
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Affiliation(s)
- Chia-Hsin Lin
- Proton and Radiation Therapy Center, Chang Gung Memorial Hospital-Linkou Medical Center, Department of Radiation Oncology, Chang Gung University, Taoyuan, Taiwan.
| | - Jiun-Lin Yan
- Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Wing-Keen Yap
- Proton and Radiation Therapy Center, Chang Gung Memorial Hospital-Linkou Medical Center, Department of Radiation Oncology, Chang Gung University, Taoyuan, Taiwan.
| | - Chung-Jan Kang
- Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Yun-Chen Chang
- Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Tsung-You Tsai
- Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Kai-Ping Chang
- Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Chun-Ta Liao
- Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Cheng-Lung Hsu
- Department of Hematology-Oncology, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Hung-Ming Wang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Pei-Wei Huang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan.
| | - Kang-Hsing Fan
- Department of Radiation Oncology, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan.
| | - Bing-Shen Huang
- Proton and Radiation Therapy Center, Chang Gung Memorial Hospital-Linkou Medical Center, Department of Radiation Oncology, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Science, Chang Gung University, Taoyuan, Taiwan.
| | - Joseph Tung-Chieh Chang
- Proton and Radiation Therapy Center, Chang Gung Memorial Hospital-Linkou Medical Center, Department of Radiation Oncology, Chang Gung University, Taoyuan, Taiwan; Department of Radiation Oncology, Xiamen Chang Gung Memorial Hospital, Xiamen, Fujian, China.
| | - Shu-Ju Tu
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Chien-Yu Lin
- Proton and Radiation Therapy Center, Chang Gung Memorial Hospital-Linkou Medical Center, Department of Radiation Oncology, Chang Gung University, Taoyuan, Taiwan.
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8
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Winter SF, Vaios EJ, Shih HA, Grassberger C, Parsons MW, Gardner MM, Ehret F, Kaul D, Boehmerle W, Endres M, Dietrich J. Mitigating Radiotoxicity in the Central Nervous System: Role of Proton Therapy. Curr Treat Options Oncol 2023; 24:1524-1549. [PMID: 37728819 DOI: 10.1007/s11864-023-01131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/21/2023]
Abstract
OPINION STATEMENT Central nervous system (CNS) radiotoxicity remains a challenge in neuro-oncology. Dose distribution advantages of protons over photons have prompted increased use of brain-directed proton therapy. While well-recognized among pediatric populations, the benefit of proton therapy among adults with CNS malignancies remains controversial. We herein discuss the role of protons in mitigating late CNS radiotoxicities in adult patients. Despite limited clinical trials, evidence suggests toxicity profile advantages of protons over conventional radiotherapy, including retention of neurocognitive function and brain volume. Modelling studies predict superior dose conformality of protons versus state-of-the-art photon techniques reduces late radiogenic vasculopathies, endocrinopathies, and malignancies. Conversely, potentially higher brain tissue necrosis rates following proton therapy highlight a need to resolve uncertainties surrounding the impact of variable biological effectiveness of protons on dose distribution. Clinical trials comparing best photon and particle-based therapy are underway to establish whether protons substantially improve long-term treatment-related outcomes in adults with CNS malignancies.
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Affiliation(s)
- Sebastian F Winter
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 10117, Berlin, Germany.
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael W Parsons
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melissa M Gardner
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Felix Ehret
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 10117, Berlin, Germany
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Boehmerle
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | - Matthias Endres
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Jorg Dietrich
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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9
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Tseng I, Ai D, Chen Y, Zhu H, Li F, Xu Y, Yu L, Liu Q, Deng J, Hao S, Zhu Z, Zhao W, Fan M, Li L, Su F, Zhao K. Lymphocyte recovery from radiation-induced lymphopenia in locally advanced esophageal squamous cell carcinoma: correlations with prognosis and lymphocyte-related organs. Radiat Oncol 2023; 18:172. [PMID: 37858121 PMCID: PMC10588237 DOI: 10.1186/s13014-023-02354-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Limited studies explored the relationship between lymphocyte recovery after definitive concurrent chemoradiotherapy (dCCRT) and prognosis in esophageal squamous cell carcinoma (ESCC). METHODS ESCC patients with obtainable absolute lymphocyte counts (ALCs) at 6 months after dCCRT were screened from prospective trials. Patients were divided into groups according to the grade of ALC nadir during radiotherapy (G4 or G1-3) and lymphocyte recovery status, which was assessed by lymphocyte recovery index (LRI), calculated as the ratio of post- to pre-treatment lymphocyte counts. Cox analysis was conducted to evaluate the prognostic significance of lymphocyte recovery status. Irradiated relative volumes of the bone marrow (BM) and spleen and effective dose to immune cells (EDIC) were collected to identify their impacts on lymphocyte recovery status by logistic analysis. RESULTS 232 patients were enrolled. In 69 patients with G4 ALC nadir (group A and B) and 163 patients with G1-3 ALC nadir (group C and D) during dCCRT, 27 (group A) and 67 (group C) patients showed an insufficient level of lymphocyte recovery (LRI < 60%), and 42 (group B) and 96 (group D) patients showed a satisfactory level of lymphocyte recovery (LRI ≥ 60%). Cox multivariable analysis revealed that inadequate lymphocyte recovery was significantly associated with worse overall survival (HR, 2.80 and 1.70) and local recurrence-free survival (HR, 2.82 and 1.60) both in group A vs group B and group C vs group D. Logistic analysis identified BM V5 (OR 4.24 and 2.29) as an independent predictor of inadequate lymphocyte recovery from G4 or G1-3 ALC nadir, respectively. CONCLUSIONS Insufficient lymphocyte recovery might serve as a valuable prognostic factor, regardless of whether patients experienced G4 or G1-3 ALC nadir during radiotherapy. Additionally, it was observed that a larger relative volume of BM receiving ≥ 5 Gy was correlated with a higher risk of insufficient lymphocyte recovery.
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Affiliation(s)
- Ihsuan Tseng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Dashan Ai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Yun Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Hongcheng Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Fangfang Li
- Center for Cancer Immunology, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Yang Xu
- Department of Medicine, Enhance Human Health Through Pharma Technology Innovation, Shanghai, 201800, China
| | - Lu Yu
- Shanghai Medical College of Fudan University, Shanghai, 200032, China
| | - Qi Liu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Jiaying Deng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Shengnan Hao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Weixin Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Min Fan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Ling Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Fengtao Su
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China.
- Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, 200032, China.
| | - Kuaile Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China.
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China.
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Li H, Shi ST, Wang Q, Fang Y, Zhang RR, Gu DY, Zhang Z, Guo YY, Wang T, Zhou GR, Ye JJ. Impact of hematological and radiation parameters on the clinical prognosis of esophageal cancer patients treated with definitive chemoradiotherapy. Am J Cancer Res 2023; 13:4305-4314. [PMID: 37818044 PMCID: PMC10560941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 08/06/2023] [Indexed: 10/12/2023] Open
Abstract
This study aimed to conduct a survival analysis of thoracic esophageal squamous cell carcinoma (ESCC) patients treated with radical chemoradiotherapy and identify prognostic variables from among the hematological and radiation parameters. Cases of patients with ESCC receiving definitive chemoradiotherapy at Jiangsu Cancer Hospital between January 2018 and September 2020 were screened. A Cox proportional hazards model was used to assess the effect of hematological and radiation parameters on the overall survival (OS). The neutrophil-to-lymphocyte ratio (NLR) was calculated by dividing the absolute neutrophil count (ANC) by the absolute lymphocyte count (ALC) in the week prior to radical chemoradiotherapy. Variables associated with radiation were gathered based on dose-volume histograms (DVH). X-tile software was used to determine the optimal cutoff values for pretreatment NLR and posttreatment ALC nadir. Associations between lymphopenia and dose-volume parameters were analyzed using multivariate logistic regression. The study included 104 ESCC patients. The median follow-up of surviving patients was 45.0 months (interquartile range: 40.2-52.2), with 1- and 3-year OS rates of 88.0% and 62.7%, respectively. Multivariate Cox regression analysis demonstrated a significant survival benefit in patients with low baseline NLR (≤ 2.2), high ALC nadir (> 0.24*109/L), and desirable radiation parameters for the heart and thoracic vertebrae. Increased dose-volume parameters of the heart, lungs, and thoracic vertebrae were correlated with a high probability of radiation-induced lymphopenia (RIL) risk (P < 0.05). Baseline NLR and RIL are significantly related to survival outcomes in ESCC patients. Optimization of radiation parameters of cardiopulmonary and thoracic vertebrae can be effective in the prevention of RIL.
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Affiliation(s)
- Hui Li
- Department of Oncology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical UniversityNanjing 210009, Jiangsu, China
| | - Shu-Tong Shi
- Department of Radiation Oncology, Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical UniversityNo. 42, Baiziting, Nanjing 210009, Jiangsu, China
| | - Qiang Wang
- Department of Oncology, Jiangyan Hospital Affiliated to Nanjing University of Chinese MedicineTaizhou 225500, Jiangsu, China
| | - Ying Fang
- Department of Oncology, Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical UniversityNo. 42, Baiziting, Nanjing 210009, Jiangsu, China
| | - Rong-Rong Zhang
- Department of Oncology, Jiangyan Hospital Affiliated to Nanjing University of Chinese MedicineTaizhou 225500, Jiangsu, China
| | - Da-Yong Gu
- Department of Radiation Oncology, Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical UniversityNo. 42, Baiziting, Nanjing 210009, Jiangsu, China
| | - Zhi Zhang
- Department of Thoracic Surgery, Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical UniversityNo. 42, Baiziting, Nanjing 210009, Jiangsu, China
| | - Yi-Yu Guo
- Department of Radiation Oncology, Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical UniversityNo. 42, Baiziting, Nanjing 210009, Jiangsu, China
| | - Tian Wang
- Xuzhou Medical UniversityNo. 209, Tongshanlu, Xuzhou 221004, Jiangsu, China
| | - Guo-Ren Zhou
- Department of Oncology, Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical UniversityNo. 42, Baiziting, Nanjing 210009, Jiangsu, China
| | - Jin-Jun Ye
- Department of Radiation Oncology, Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical UniversityNo. 42, Baiziting, Nanjing 210009, Jiangsu, China
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Liu J, West H, McGee HM, Williams TM, Lee P, Amini A. Challenges in synergizing radiotherapy with immunotherapy to unlock the abscopal effect in metastatic NSCLC: A systematic review. Neoplasia 2023; 43:100914. [PMID: 37348427 PMCID: PMC10314288 DOI: 10.1016/j.neo.2023.100914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/04/2022] [Accepted: 06/12/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND With the recent success of immunotherapy, there is a growing interest in combining radiation with immunotherapy to boost abscopal response rates. Several challenges exist in determining how to synergize these two modalities in the treatment of metastatic NSCLC. METHODS References for this review were identified through searches of MEDLINE/PubMed and Clinicaltrials.gov databases with the search terms "abscopal", "radiation OR radiotherapy," "NSCLC", and "lung" on the index date of July 2022 from 2000-2022. This systematic review focuses primarily on clinical papers. DISCUSSION Early work combining radiotherapy with immunotherapy show promise in unlocking the abscopal effect. Preliminary evidence suggests that radiotherapy regimens with <5 fractions and smaller fields may be superior to regimens with 15 fractions and larger fields. There does not appear to be enough evidence to draw conclusions about the optimal timing of radiotherapy in relation to immunotherapy or the optimal anatomical location of radiation to induce the abscopal effect. Several studies suggest selecting patients with a higher absolute lymphocyte count (ALC) and lower neutrophil-to-lymphocyte ratio (NLR) may help to further boost abscopal response rates. Furthermore, selecting tumors with programmed death ligand-1 (PD-L1) expression, mismatch repair deficiency, and higher tumor mutational burden may similarly achieve this goal. Lastly, additional work is needed to minimize and predict for severe toxicity associated with combination therapy.
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Affiliation(s)
- Jason Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, United States
| | - Howard West
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA 91010, United States
| | - Heather M McGee
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, United States; Department of Immuno-Oncology, City of Hope National Medical Center, Duarte, CA 91010, United States
| | - Terence M Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, United States
| | - Percy Lee
- Department of Radiation Oncology, City of Hope Orange County, Irvine, CA 92618, United States
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, United States.
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Zhang XW, Wu YS, Xu TM, Cui MH. CAR-T Cells in the Treatment of Ovarian Cancer: A Promising Cell Therapy. Biomolecules 2023; 13:biom13030465. [PMID: 36979400 PMCID: PMC10046142 DOI: 10.3390/biom13030465] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Ovarian cancer (OC) is among the most common gynecologic malignancies with a poor prognosis and a high mortality rate. Most patients are diagnosed at an advanced stage (stage III or IV), with 5-year survival rates ranging from 25% to 47% worldwide. Surgical resection and first-line chemotherapy are the main treatment modalities for OC. However, patients usually relapse within a few years of initial treatment due to resistance to chemotherapy. Cell-based therapies, particularly adoptive T-cell therapy and chimeric antigen receptor T (CAR-T) cell therapy, represent an alternative immunotherapy approach with great potential for hematologic malignancies. However, the use of CAR-T-cell therapy for the treatment of OC is still associated with several difficulties. In this review, we comprehensively discuss recent innovations in CAR-T-cell engineering to improve clinical efficacy, as well as strategies to overcome the limitations of CAR-T-cell therapy in OC.
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13
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Ni W, Xiao Z, Zhou Z, Chen D, Feng Q, Liang J, Lv J. Severe radiation-induced lymphopenia during postoperative radiotherapy or chemoradiotherapy has poor prognosis in patients with stage IIB-III after radical esophagectomy: A post hoc analysis of a randomized controlled trial. Front Oncol 2022; 12:936684. [PMID: 36158699 PMCID: PMC9492938 DOI: 10.3389/fonc.2022.936684] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate whether radiation-induced lymphopenia (RIL) affects survival and identify the predictors of RIL in postoperative esophageal cancer. Materials and methods Post hoc analysis was conducted on data from 116 patients with esophageal cancer from a randomized controlled trial comparing adjuvant therapy with surgery alone. Doses of 54 Gy in 27 fractions was delivered in the postoperative radiotherapy (PORT) group and 50.4 Gy in 28 fractions combined with chemotherapy was delivered in postoperative concurrent chemoradiotherapy (POCRT) group. Blood counts were obtained before, during, and at first follow-up after treatment. Lymphopenia was graded per version 4.03 of the Common Terminology Criteria for Adverse Events. Disease-free survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method, and compared between groups using the log-rank test. Receiver operating characteristic curves identified thresholds for preventing grade 4 (G4) lymphopenia. Results Median follow-up duration was 56.0 months. During treatment, 16 patients (13.8%) had G4 lymphopenia. All cases of G4 lymphopenia occurred in group PORT (30.2% vs 0.0%, p<0.001). Baseline absolute lymphocyte count was comparable between G1-3 and G4 patients (2.0 ± 0.8 *109/L vs 1.7 ± 0.5 *109/L; p=0.101). The 3-year DFS was significantly lower in group G4 lymphopenia than that in group G1-3 (31.3% vs 57.6%, p=0.036). The 3-year OS was comparable between both groups (50.0% vs 66.5%, p=0.095). Logistic regression analysis revealed that exposed more thoracic marrow (TM V20 ≥75%; TVB V20 ≥71%), heart (V15 ≥40%) and PTV (volume ≥507 ml) were associated with G4 lymphopenia (p<0.05). Conclusions G4 RIL had poor disease-free survival, which may be related to more dose exposure of thoracic marrow and heart due to larger PTV. Reasonably reducing the radiation field combined with concurrent chemotherapy, or radiation dose constraints for these normal tissues may be sufficient to decrease the incidence of G4 lymphopenia, but further prospective trials are needed to verify the results. Clinical Trial Registration clinicaltrials.gov, identifier NCT02279134
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Affiliation(s)
- Wenjie Ni
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Radiation Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zefen Xiao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Zefen Xiao,
| | - Zongmei Zhou
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dongfu Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qinfu Feng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Liang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jima Lv
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Cao W, Rocha H, Mohan R, Lim G, Goudarzi HM, Ferreira BC, Dias JM. Reflections on beam configuration optimization for intensity-modulated proton therapy. Phys Med Biol 2022; 67. [PMID: 35561700 DOI: 10.1088/1361-6560/ac6fac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Abstract
Abstract
Presumably, intensity-modulated proton radiotherapy (IMPT) is the most powerful form of proton radiotherapy. In the current state of the art, IMPT beam configurations (i.e. the number of beams and their directions) are, in general, chosen subjectively based on prior experience and practicality. Beam configuration optimization (BCO) for IMPT could, in theory, significantly enhance IMPT’s therapeutic potential. However, BCO is complex and highly computer resource-intensive. Some algorithms for BCO have been developed for intensity-modulated photon therapy (IMRT). They are rarely used clinically mainly because the large number of beams typically employed in IMRT renders BCO essentially unnecessary. Moreover, in the newer form of IMRT, volumetric modulated arc therapy, there are no individual static beams. BCO is of greater importance for IMPT because it typically employs a very small number of beams (2-4) and, when the number of beams is small, BCO is critical for improving plan quality. However, the unique properties and requirements of protons, particularly in IMPT, make BCO challenging. Protons are more sensitive than photons to anatomic changes, exhibit variable relative biological effectiveness along their paths, and, as recently discovered, may spare the immune system. Such factors must be considered in IMPT BCO, though doing so would make BCO more resource intensive and make it more challenging to extend BCO algorithms developed for IMRT to IMPT. A limited amount of research in IMPT BCO has been conducted; however, considerable additional work is needed for its further development to make it truly effective and computationally practical. This article aims to provide a review of existing BCO algorithms, most of which were developed for IMRT, and addresses important requirements specific to BCO for IMPT optimization that necessitate the modification of existing approaches or the development of new effective and efficient ones.
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Pre-Treatment and Preoperative Neutrophil-to-Lymphocyte Ratio Predicts Prognostic Value of Glioblastoma: A Meta-Analysis. Brain Sci 2022; 12:brainsci12050675. [PMID: 35625061 PMCID: PMC9139478 DOI: 10.3390/brainsci12050675] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 02/01/2023] Open
Abstract
Objective: Although some meta-analyses have shown a correlation between a high neutrophil-to-lymphocyte ratio (NLR) and low survival in patients with gliomas, their conclusions are controversial, and no study has specifically explored the relationship between a high pre-treatment and pre-operative NLR and low survival in patients with glioblastoma (GBM). Therefore, we further investigated this correlation through meta-analysis. Methods: We searched the PubMed, Metstr, and Cochrane databases in March 2022 for published literature related to high pre-treatment and pre-operative NLR and low survival in patients with GBM. The literature was rigorously searched according to inclusion and exclusion criteria to calculate the overall hazard ratio (HR) and 95% confidence interval (CI) corresponding to a high NLR using a random effects model. Results: The total HR for the pre-treatment and pre-operative NLR was 1.46 (95% CI: 1.17–1.75, p = 0.000, I2 = 76.5%), indicating a significant association between a high pre-treatment and pre-operative NLR, and low overall survival in patients with GBM. Sub-group analysis was performed because of the high heterogeneity. The results for the sub-group with a cut-off value of 4 showed an HR of 1.39 (95% CI: 1.12–1.65, p = 0.000, I2 = 22.2%), with significantly low heterogeneity, whereas those for the sub-group without a cut-off value of 4 showed an HR of 1.45 (95% CI: 1.01–1.89, p = 0.000, I2 = 83.3%). Conclusions: The results of this study demonstrate that a high pre-treatment and pre-operative NLR suggests low survival in patients with GBM based on data from a large sample. Furthermore, the meta-regression analysis results indicate that underlying data, such as age and extent of surgical resection, lead to a high degree of heterogeneity, providing a theoretical basis for further research.
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Yin T, Wang P, Yu J, Teng F. Treatment-related lymphopenia impairs the treatment response of anti-PD-1 therapy in esophageal squamous cell carcinoma. Int Immunopharmacol 2022; 106:108623. [PMID: 35203044 DOI: 10.1016/j.intimp.2022.108623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/28/2021] [Accepted: 02/10/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Great interest has been focused on radiotherapy (RT) with immunotherapy. We sought to investigate the significance of treatment-related lymphopenia (TRL) in esophageal squamous cell carcinoma (ESCC) patients receiving anti-PD-1 therapy and the factors associated with TRL, especially RT. METHODS 167 patients with ESCC that received anti-PD-1 therapy wereidentified, 72 of them received RT. TRL was defined as absolute lymphocyte count (ALC) < 0.50 × 109 cells/L at the start of immunotherapy and/or during immunotherapy. Depending on the presence of TRL, patients were divided into two groups. RESULTS At median follow-up of 6.5 months, the ORR of patients without TRL (n = 65; 38.9%) reached 29.4% while patients (n = 102; 61.1%) with TRL was 23.1%, DCR was 81.4% and 75.4% respectively. Patients with TRL showed shorter progression-free survival (PFS) compared with patients without TRL (median PFS: 4.8 vs. 7.0 months, P = 0.009). Multivariate analyses confirmed TRL is an independent prognostic factor for poorer PFS (HR, 1.855; P = 0.008). RT significantly increased the occurrence of TRL (OR = 0.502, P = 0.035). Patients receiving ICIs < 33.5 days after RT showed a poorer PFS compared to that ≥ 33.5 days (median PFS: 4.1 vs 7.3 months, P = 0.008). The explanation is that patients with shorter time interval had a higher incidence of TRL (P = 0.028). CONCLUSION TRL was an independent predictor of poor outcomes in ESCC patients receiving anti-PD-1 therapy. RT was a key factor affecting TRL. A shorter time interval of < 33.5 days between RT and anti-PD-1 therapy can lead to a poor prognosis by increasing the occurrence of TRL.
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Affiliation(s)
- Tianwen Yin
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Peiliang Wang
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Feifei Teng
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, People's Republic of China.
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Moitra P, Chatterjee A, Kota PK, Epari S, Patil V, Dasgupta A, Kowtal P, Sarin R, Gupta T. Temozolomide-induced myelotoxicity and single nucleotide polymorphisms in the MGMT gene in patients with adult diffuse glioma: a single-institutional pharmacogenetic study. J Neurooncol 2022; 156:625-634. [PMID: 35037156 DOI: 10.1007/s11060-022-03944-6] [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: 12/03/2021] [Accepted: 01/03/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Nearly 10% of patients with adult diffuse glioma develop clinically significant myelotoxicity while on temozolomide (TMZ) leading to treatment interruptions. This study aimed to assess single nucleotide polymorphisms (SNPs) in the O6-methylguanine-DNA methyltransferase (MGMT) gene in adults with biopsy-proven diffuse glioma who develop TMZ-induced myelotoxicity and correlate their presence with severity and duration of such toxicity. METHODS This study assessed 33 adults treated with TMZ for diffuse glioma who developed ≥ grade 2 thrombocytopenia and/or ≥ grade 3 neutropenia. Genomic DNA was extracted from peripheral blood cells for MGMT SNP analysis after written informed consent. TMZ-induced severe myelotoxicity (≥ grade 3) was correlated with three specified SNPs commonly seen in the MGMT gene (L84F, I143V/K178R) using chi-square test or Fischer's exact test as appropriate. RESULTS Of the 33 adults, 24 (72.7%) experienced ≥ grade 3 thrombocytopenia and/or neutropenia, while 9 (27.3%) developed grade 2 thrombocytopenia only. The variant T allele of L84F was expressed in 28.7% (19/66) of analyzed alleles, which was substantially higher than previously reported for South Asian ancestry. The variant G allele of I143V/K178R was expressed in 9.3% (6/64) of analyzed alleles. Of which 3 patients showed statistically significant association with prolonged myelosuppression for > 2 months (p = 0.03). No significant correlation was established between the mentioned SNPs and severe myelotoxicity. CONCLUSIONS There is substantially higher frequency of variant T allele (L84F) in Indian patients than previously reported for South Asians. The presence of specific SNPs in the MGMT gene correlates with prolonged duration but not severity of TMZ-induced myelotoxicity.
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Affiliation(s)
- Prithwijit Moitra
- Departments of Radiation Oncology, Tata Memorial Hospital (TMH)/Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 410210, India
| | - Abhishek Chatterjee
- Departments of Radiation Oncology, Tata Memorial Hospital (TMH)/Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 410210, India
| | - Priti Khatri Kota
- Sarin Lab, Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Sridhar Epari
- Department of Pathology, Tata Memorial Hospital (TMH)/Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Hospital (TMH)/Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Archya Dasgupta
- Departments of Radiation Oncology, Tata Memorial Hospital (TMH)/Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 410210, India
| | - Pradnya Kowtal
- Sarin Lab, Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Rajiv Sarin
- Departments of Radiation Oncology, Tata Memorial Hospital (TMH)/Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 410210, India
- Sarin Lab, Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Tejpal Gupta
- Departments of Radiation Oncology, Tata Memorial Hospital (TMH)/Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 410210, India.
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Aiyappa-Maudsley R, Chalmers AJ, Parsons JL. Factors affecting the radiation response in glioblastoma. Neurooncol Adv 2022; 4:vdac156. [PMID: 36325371 PMCID: PMC9617255 DOI: 10.1093/noajnl/vdac156] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Glioblastoma (GBM) is a highly invasive primary brain tumor in adults with a 5-year survival rate of less than 10%. Conventional radiotherapy with photons, along with concurrent and adjuvant temozolomide, is the mainstay for treatment of GBM although no significant improvement in survival rates has been observed over the last 20 years. Inherent factors such as tumor hypoxia, radioresistant GBM stem cells, and upregulated DNA damage response mechanisms are well established as contributing to treatment resistance and tumor recurrence. While it is understandable that efforts have focused on targeting these factors to overcome this phenotype, there have also been striking advances in precision radiotherapy techniques, including proton beam therapy and carbon ion radiotherapy (CIRT). These enable higher doses of radiation to be delivered precisely to the tumor, while minimizing doses to surrounding normal tissues and organs at risk. These alternative radiotherapy techniques also benefit from increased biological effectiveness, particularly in the case of CIRT. Although not researched extensively to date, combining these new radiation modalities with radio-enhancing agents may be particularly effective in improving outcomes for patients with GBM.
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Affiliation(s)
- Radhika Aiyappa-Maudsley
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, William Henry Duncan Building, Liverpool, L7 8TX, UK
| | - Anthony J Chalmers
- Institute of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Jason L Parsons
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, William Henry Duncan Building, Liverpool, L7 8TX, UK
- Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, CH63 4JY, UK
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19
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Song AJ, Ding K, Alnahhas I, Laperriere NJ, Perry J, Mason WP, Winch C, O'Callaghan CJ, Menten JJ, Brandes AA, Phillips C, Fay MF, Nishikawa R, Osoba D, Cairncross JG, Roa W, Wick W, Shi W. Impact of lymphopenia on survival for elderly patients with glioblastoma: A secondary analysis of the CCTG CE.6 (EORTC 26062-22061, TROG03.01) randomized clinical trial. Neurooncol Adv 2021; 3:vdab153. [PMID: 34765975 PMCID: PMC8577525 DOI: 10.1093/noajnl/vdab153] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Lymphopenia may lead to worse outcomes for glioblastoma patients. This study is a secondary analysis of the CCTG CE.6 trial evaluating the impact of chemotherapy and radiation on lymphopenia, and effects of lymphopenia on overall survival (OS). Methods CCTG CE.6 randomized elderly glioblastoma patients (≥ 65 years) to short-course radiation alone (RT) or short-course radiation with temozolomide (RT + TMZ). Lymphopenia (mild-moderate: grade 1–2; severe: grade 3–4) was defined per CTCAE v3.0, and measured at baseline, 1 week and 4 weeks post-RT. Preselected key factors for analysis included age, sex, ECOG, resection extent, MGMT methylation, Mini-Mental State Examination, and steroid use. Multinomial logistic regression and multivariable Cox regression models were used to identify lymphopenia-associated factors and association with survival. Results Five hundred and sixty-two patients were analyzed (281 RT vs 281 RT+TMZ). At baseline, both arms had similar rates of mild-moderate (21.4% vs 21.4%) and severe (3.2% vs 2.9%) lymphopenia. However, at 4 weeks post-RT, RT+TMZ was more likely to develop lymphopenia (mild-moderate: 27.9% vs 18.2%; severe: 9.3% vs 1.8%; p<0.001). Developing any lymphopenia post-RT was associated with baseline lymphopenia (P < .001). Baseline lymphopenia (hazard ratio [HR] 1.3) was associated with worse OS (HR: 1.30, 95% confidence interval [CI] 1.05–1.62; P = .02), regardless of MGMT status. Conclusions Development of post-RT lymphopenia is associated with addition of TMZ and baseline lymphopenia and not with RT alone in patients treated with short-course radiation. However, regardless of MGMT status, only baseline lymphopenia is associated with worse OS, which may be considered as a prognostic biomarker for elderly glioblastoma patients.
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Affiliation(s)
- Andrew J Song
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Keyue Ding
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Iyad Alnahhas
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Normand J Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - James Perry
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Warren P Mason
- Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chad Winch
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Chris J O'Callaghan
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Johan J Menten
- Department of Experimental Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Alba A Brandes
- Department of Medical oncology, IRCCS Istituto Scienze Neurologiche - Bologna, Italy
| | - Claire Phillips
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - David Osoba
- QOL Consulting, West Vancouver, British Columbia, Canada
| | - J Gregory Cairncross
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Wilson Roa
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Wolfgang Wick
- Division of Neurology, Heidelberg University Medical Center, Clinical Cooperation Unit Neurooncology, German Cancer Research Center, Heidelberg, Germany
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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20
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Kroese TE, Jairam J, Ruurda JP, Lin SH, Mohan R, Mook S, Haitjema S, Hoefer I, Haj Mohammad N, Peters M, van Hillegersberg R, van Rossum PSN. Severe lymphopenia acquired during chemoradiotherapy for esophageal cancer: Incidence and external validation of a prediction model. Radiother Oncol 2021; 163:192-198. [PMID: 34453954 DOI: 10.1016/j.radonc.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The incidence of grade 4 lymphopenia in patients treated with chemoradiotherapy (CRT) according to Chemoradiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) regimen is unclear. The primary aim was to determine the incidence of grade 4 lymphopenia during CROSS for esophageal cancer. Secondary aims were to externally validate a prediction model for grade 4 lymphopenia and compare overall survival between patients with and without grade 4 lymphopenia. METHODS Patients who underwent CRT for esophageal cancer between 2014 and 2019 were eligible for inclusion. Patients with a planned radiation dose of 41.4 Gy (CROSS) or 50.4 Gy ("extended-CROSS") and concurrent carboplatin and paclitaxel were included. The primary outcome was the incidence of grade 4 lymphopenia during CRT defined according to Common Terminology Criteria for Adverse Events version 5.0 (i.e. lymphocyte count nadir < 0.2 µL). The secondary outcome measures were the prediction model's external performance (i.e. discrimination and calibration). Overall survival for patients with versus without grade 4 lymphopenia was compared using Kaplan-Meier analysis. RESULTS A total of 219 patients were included of whom 176 patients (80%) underwent CROSS and 43 patients (20%) extended-CROSS. The incidence of grade 4 lymphopenia was 11% in CROSS and 33% in extended-CROSS (p < 0.001). External discrimination yielded a c-statistic of 0.80 (95% confidence interval: 0.70-0.89). External calibration of the model was poor in CROSS but fair in extended-CROSS. Adjusted calibration using intercept correction (adjusted for the lower a-priori risk for grade 4 lymphopenia in CROSS) showed fair agreement between the observed and predicted risk for grade 4 lymphopenia. Median overall survival in patients with versus without grade 4 lymphopenia was 12.7 versus 42.5 months (p = 0.045). CONCLUSION The incidence of grade 4 lymphopenia is significantly higher in esophageal cancer patients receiving extended-CROSS compared to those receiving CROSS. The prediction model demonstrated good external performance in the setting of the CROSS-regimen and could be used to identify patients at high-risk for grade 4 lymphopenia who might be eligible for lymphopenia-mitigating strategies.
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Affiliation(s)
- Tiuri E Kroese
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Jasvir Jairam
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Saskia Haitjema
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Imo Hoefer
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Peter S N van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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21
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The Influence of Severe Radiation-Induced Lymphopenia on Overall Survival in Solid Tumors: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2021; 111:936-948. [PMID: 34329738 DOI: 10.1016/j.ijrobp.2021.07.1695] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/10/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Emerging evidence suggests a detrimental prognostic association between radiation-induced lymphopenia (RIL) and pathologic response, progression-free survival, and overall survival (OS) in patients who undergo radiation therapy for cancer. The aim of this study was to systematically review and meta-analyze the prognostic impact of RIL on OS in patients with solid tumors. METHODS AND MATERIALS PubMed/MEDLINE and Embase were systematically searched. The analysis included intervention and prognostic studies that reported on the prognostic relationship between RIL and survival in patients with solid tumors. An overall pooled adjusted hazard ratio (aHR) was calculated using a random-effects model. Subgroup analyses for different patient-, tumor-, treatment-, and study-related characteristics were performed using meta-regression. RESULTS Pooling of 21 cohorts within 20 eligible studies demonstrated a statistically significant association between OS and grade ≥3 versus grade 0-2 RIL (n = 16; pooled aHR, 1.65; 95% confidence interval [CI], 1.43-1.90) and grade 4 RIL versus grade 0-3 (n = 5; aHR, 1.53; 95% CI, 1.24-1.90). Moderate heterogeneity among aHRs was observed, mostly attributable to overestimated aHRs in 7 studies likely subject to model-overfitting. Subgroup analysis showed significant prognostic impact of grade ≥3 RIL in 4 brain tumor (aHR, 1.63; 95% CI, 1.06-2.51), 4 lung cancer (aHR, 1.52; 95% CI, 1.01-2.29), and 3 pancreatic cancer (aHR, 1.92; 95% CI, 1.10-3.36) cohorts. CONCLUSIONS This meta-analysis demonstrates a significant detrimental prognostic association between grade ≥3 lymphopenia and OS in patients receiving radiation therapy for solid tumors. This finding appears consistent for tumors of the brain, thorax, and upper abdomen and provides an imperative to further elucidate the potential survival benefit of lymphopenia-mitigating strategies.
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22
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The predictive value of absolute lymphocyte counts on tumor progression and pseudoprogression in patients with glioblastoma. BMC Cancer 2021; 21:285. [PMID: 33726710 PMCID: PMC7968315 DOI: 10.1186/s12885-021-08004-2] [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: 09/09/2020] [Accepted: 03/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background Differentiating true glioblastoma multiforme (GBM) from pseudoprogression (PsP) remains a challenge with current standard magnetic resonance imaging (MRI). The objective of this study was to explore whether patients’ absolute lymphocyte count (ALC) levels can be utilized to predict true tumor progression and PsP. Methods Patients were considered eligible for the study if they had 1) GBM diagnosis, 2) a series of blood cell counts and clinical follow-ups, and 3) tumor progression documented by both MRI and pathology. Data analysis results include descriptive statistics, median (IQR) for continuous variables and count (%) for categorical variables, p values from Wilcoxon rank sum test or Fisher’s exact test for comparison, respectively, and Kaplan-Meier analysis for overall survival (OS). OS was defined as the time from patients’ second surgery to their time of death or last follow up if patients were still alive. Results 78 patients were included in this study. The median age was 56 years. Median ALC dropped 34.5% from baseline 1400 cells/mm3 to 917 cells/mm3 after completion of radiation therapy (RT) and temozolomide (TMZ). All study patients had undergone surgical biopsy upon MRI-documented progression. 37 had true tumor progression (47.44%) and 41 had pseudoprogression (52.56%). ALC before RT/TMZ, post RT/TMZ and at the time of MRI-documented progression did not show significant difference between patients with true progression and PsP. Although not statistically significant, this study found that patients with true progression had worse OS compared to those with PsP (Hazard Ratio [HR] 1.44, 95% CI 0.86–2.43, P = 0.178). This study also found that patients with high ALC (dichotomized by median) post-radiation had longer OS. Conclusion Our results indicate that ALC level in GBM patients before or after treatment does not have predictive value for true disease progression or pseudoprogression. Patients with true progression had worse OS compared to those who had pseudoprogression. A larger sample size that includes CD4 cell counts may be needed to evaluate the PsP predictive value of peripheral blood biomarkers.
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23
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Wang JL, Ma R, Kong W, Zhao R, Wang YY. Lymphopenia in Esophageal Cancer: What Have We Learned? Front Oncol 2021; 11:625963. [PMID: 33791213 PMCID: PMC8006429 DOI: 10.3389/fonc.2021.625963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/01/2021] [Indexed: 02/03/2023] Open
Abstract
Lymphopenia caused by disease or treatment is frequent in patients with cancer, which seriously affects the prognosis of these patients. Immune checkpoint inhibitors (ICIs) have garnered attention as one of the most promising strategies for the treatment of esophageal cancer (EC). The status of the immune system, such as, the lymphocyte count, is now considered to be an important biomarker for ICI treatments. Recognition of the significant impact of the lymphocyte count on the survival of patients with EC in the era of immunotherapy has revived interest in understanding the causes of lymphopenia and in developing strategies to predict, prevent and eliminate the adverse effect of lymphopenia. Here, we review what we have learned about lymphopenia in EC, including the prognostic and predictive value of lymphopenia in patients with EC, the predictors of lymphopenia, and the strategies to ameliorate the effect of lymphopenia in patients with EC.
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Affiliation(s)
- Jia-Lin Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Rong Ma
- Graduate School, Ningxia Medical University, Yinchuan, China
| | - Wei Kong
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Ren Zhao
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Yan-Yang Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
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24
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Mohan R, Liu AY, Brown PD, Mahajan A, Dinh J, Chung C, McAvoy S, McAleer MF, Lin SH, Li J, Ghia AJ, Zhu C, Sulman EP, de Groot JF, Heimberger AB, McGovern SL, Grassberger C, Shih H, Ellsworth S, Grosshans DR. Proton therapy reduces the likelihood of high-grade radiation-induced lymphopenia in glioblastoma patients: phase II randomized study of protons vs photons. Neuro Oncol 2021; 23:284-294. [PMID: 32750703 PMCID: PMC7906048 DOI: 10.1093/neuonc/noaa182] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We investigated differences in radiation-induced grade 3+ lymphopenia (G3+L), defined as an absolute lymphocyte count (ALC) nadir of <500 cells/µL, after proton therapy (PT) or X-ray (photon) therapy (XRT) for patients with glioblastoma (GBM). METHODS Patients enrolled in a randomized phase II trial received PT (n = 28) or XRT (n = 56) concomitantly with temozolomide. ALC was measured before, weekly during, and within 1 month after radiotherapy. Whole-brain mean dose (WBMD) and brain dose-volume indices were extracted from planned dose distributions. Univariate and multivariate logistic regression analyses were used to identify independent predictive variables. The resulting model was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS Rates of G3+L were lower in men (7/47 [15%]) versus women (19/37 [51%]) (P < 0.001), and for PT (4/28 [14%]) versus XRT (22/56 [39%]) (P = 0.024). G3+L was significantly associated with baseline ALC, WBMD, and brain volumes receiving 5‒40 Gy(relative biological effectiveness [RBE]) or higher (ie, V5 through V40). Stepwise multivariate logistic regression analysis identified being female (odds ratio [OR] 6.2, 95% confidence interval [CI]: 1.95‒22.4, P = 0.003), baseline ALC (OR 0.18, 95% CI: 0.05‒0.51, P = 0.003), and whole-brain V20 (OR 1.07, 95% CI: 1.03‒1.13, P = 0.002) as the strongest predictors. ROC analysis yielded an area under the curve of 0.86 (95% CI: 0.79-0.94) for the final G3+L prediction model. CONCLUSIONS Sex, baseline ALC, and whole-brain V20 were the strongest predictors of G3+L for patients with GBM treated with radiation and temozolomide. PT reduced brain volumes receiving low and intermediate doses and, consequently, reduced G3+L.
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Affiliation(s)
- Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy Y Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic Hospital, Rochester, Minnesota
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic Hospital, Rochester, Minnesota
| | - Jeffrey Dinh
- Millennium Physicians Radiation Oncology, The Woodlands, Texas
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah McAvoy
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cong Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center, Houston, Texas
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, New York
| | - John F de Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy B Heimberger
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Susannah Ellsworth
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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The Association of Human Herpesviruses with Malignant Brain Tumor Pathology and Therapy: Two Sides of a Coin. Int J Mol Sci 2021; 22:ijms22052250. [PMID: 33668202 PMCID: PMC7956256 DOI: 10.3390/ijms22052250] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/13/2021] [Accepted: 02/17/2021] [Indexed: 02/06/2023] Open
Abstract
The role of certain viruses in malignant brain tumor development remains controversial. Experimental data demonstrate that human herpesviruses (HHVs), particularly cytomegalovirus (CMV), Epstein–Barr virus (EBV) and human herpes virus 6 (HHV-6), are implicated in brain tumor pathology, although their direct role has not yet been proven. CMV is present in most gliomas and medulloblastomas and is known to facilitate oncomodulation and/or immunomodulation, thus promoting cancer cell proliferation, invasion, apoptosis, angiogenesis, and immunosuppression. EBV and HHV-6 have also been detected in brain tumors and high-grade gliomas, showing high rates of expression and an inflammatory potential. On the other hand, due to the neurotropic nature of HHVs, novel studies have highlighted the engagement of such viruses in the development of new immunotherapeutic approaches in the context of oncolytic viral treatment and vaccine-based strategies against brain tumors. This review provides a comprehensive evaluation of recent scientific data concerning the emerging dual role of HHVs in malignant brain pathology, either as potential causative agents or as immunotherapeutic tools in the fight against these devastating diseases.
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26
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Evaluation of interim MRI changes during limited-field radiation therapy for glioblastoma and implications for treatment planning. Radiother Oncol 2021; 158:237-243. [PMID: 33587967 DOI: 10.1016/j.radonc.2021.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/10/2021] [Accepted: 01/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Consensus for defining gross tumor volume (GTV) and clinical target volume (CTV) for limited-field radiation therapy (LFRT) of GBM are not well established. We leveraged a department MRI simulator to image patients before and during LFRT to address these questions. MATERIALS AND METHODS Supratentorial GBM patients receiving LFRT (46 Gy + boost to 60 Gy) underwent baseline MRI (MRI1) and interim MRI during RT (MRI2). GTV1 was defined as T1 enhancement + surgical cavity on MRI1 without routine inclusion of T2 abnormality (unless tumor did not enhance). The initial CTV margin was 15 mm from GTV1, and the boost CTV margin was 5-7 mm. The GTV1 characteristics were categorized into three groups: identical T1 and T2 abnormality (Group A), T1 only with larger T2 abnormality not included (Group B), and T2 abnormality when tumor lacked enhancement (Group C). GTV2 was contoured on MRI2 and compared with GTV1 plus 5-15 mm expansions. RESULTS Among 120 patients treated from 2014-2019, 29 patients (24%) underwent replanning based on MRI2. On MRI2, 84% of GTV2 were covered by GTV1 + 5 mm, 93% by GTV1 + 7 mm, and 98% by GTV1 + 15 mm. On MRI1, 43% of GTV1 could be categorized into Group A, 39% Group B, and 18% Group C. Group B's patterns of failure, local control, or progression-free survival were similar to Group A/C. CONCLUSIONS Initial CTV margin of 15 mm followed by a boost CTV margin of 7 mm is a reasonable approach for LFRT of GBM. Omitting routine inclusion of T2 abnormality from GTV delineation may not jeopardize disease control.
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Xu H, Lin M, Hu Y, Zhang L, Li Q, Zhu J, Wang S, Xi M. Lymphopenia During Definitive Chemoradiotherapy in Esophageal Squamous Cell Carcinoma: Association with Dosimetric Parameters and Patient Outcomes. Oncologist 2020; 26:e425-e434. [PMID: 32960471 DOI: 10.1002/onco.13533] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 08/26/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The objective of this study was to investigate the relationship between clinical characteristics, as well as dosimetric parameters, and the risk of treatment-related lymphopenia in esophageal squamous cell carcinoma (ESCC) treated with definitive chemoradiotherapy (CRT). MATERIALS AND METHODS Clinical characteristics and dosimetric parameters were collected from 436 patients with ESCC who received definitive CRT from 2010 through 2017. Absolute lymphocyte counts (ALCs) were obtained before, during, and 1 month after CRT. Grade 4 (G4) lymphopenia was defined as ALC <0.2 × 109 /L during CRT. Logistic regression analysis was used to evaluate the effect of each factor on predicting G4 lymphopenia. The relationship between lymphopenia and overall survival (OS) was examined, and a nomogram was developed to predict OS. RESULTS G4 lymphopenia was observed in 103 patients (23.6%) during CRT. Multivariate analysis indicated that planning target volume (PTV), lung V10 , heart V10 , performance status, and pretreatment lymphopenia were significant risk factors for G4 lymphopenia. Patients with G4 lymphopenia had significantly worse survival than those without. Based on multivariate analysis, clinical TNM stage, radiotherapy modality, pretreatment ALC, and G4 lymphopenia were predictive of OS and were incorporated into the nomogram, yielding a concordance index of 0.71. CONCLUSIONS G4 lymphopenia during definitive CRT was associated with larger PTVs, higher lung V10 and heart V10 , and worse survival. IMPLICATIONS FOR PRACTICE The purpose of this study was to investigate the relationship between clinical characteristics, as well as dosimetric parameters, and the risk of treatment-related lymphopenia in 436 patients with esophageal squamous cell carcinoma who received definitive chemoradiotherapy. Grade 4 (G4) lymphopenia was observed in 23.6% of patients during radiotherapy. G4 lymphopenia was associated with larger planning target volumes, higher lung V10 and heart V10 , and worse survival. Then, a nomogram was built based on multivariate analysis, yielding excellent performance to predict overall survival. Prospective studies are needed to investigate potential approaches for mitigating severe lymphopenia, which may ultimately convert into survival benefits.
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Affiliation(s)
- Hui Xu
- Department of Head and Neck Oncology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, People's Republic of China
| | - Maosheng Lin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yingying Hu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Department of Nuclear Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Li Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Qiaoqiao Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jinhan Zhu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Shi Wang
- Department of Engineering Physics, Tsinghua University, Beijing, People's Republic of China
| | - Mian Xi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
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Abravan A, Faivre-Finn C, Kennedy J, McWilliam A, van Herk M. Radiotherapy-Related Lymphopenia Affects Overall Survival in Patients With Lung Cancer. J Thorac Oncol 2020; 15:1624-1635. [PMID: 32553694 DOI: 10.1016/j.jtho.2020.06.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Lymphopenia after radiotherapy has an adverse effect on the patient's outcome. However, the relationship between radiotherapy dose delivery and lymphopenia is not fully understood. This work used image-based data mining to identify anatomical regions where the received dose is correlated with severe lymphopenia. METHODS A total of 901 patients with lung cancer were analyzed. A Cox model was used to assess prognostic factors of overall survival (OS). Two matched groups were defined-patients with lymphopenia of grade 3 or higher and patients without lymphopenia of grade 3-based on tumor volume, baseline lymphocytes, and prescribed dose. Then, data mining was used to identify regions where dose correlates significantly with lymphopenia of grade 3 or higher. For this, dose matrices were aligned using registration of the computed tomography images to one reference patient. Mean dose distributions were obtained for the two groups, and organs of significance were detected. Dosimetric parameters from the identified organs that had the highest correlation with lymphocytes at nadir were selected. Multivariable analysis was conducted for lymphopenia of grade 3 or higher on the full lung cohort, and the model was tested on 305 patients with esophageal cancer. RESULTS Adjusted Cox regression revealed that lymphopenia of grade 3 or higher is an independent factor of OS. The anatomical regions identified were the heart, lung, and thoracic vertebrae. Dosimetric parameters for lymphopenia included thoracic vertebrae V20, mean lung dose, and mean heart dose, which were further validated in the esophageal cancer cohort. CONCLUSIONS We report that severe lymphopenia during radiotherapy is a poor prognostic factor for OS in patients with lung cancer and could be mitigated by minimizing thoracic vertebrae V20, mean lung dose, and mean heart dose to limit the irradiation of stem cells and blood pool.
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Affiliation(s)
- Azadeh Abravan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jason Kennedy
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Alan McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Marcel van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
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29
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Xia WY, Zhu XR, Feng W, Liu J, Wang JM, Lv CX, Zhang Q, Yu W, Cai XW, Fu XL. Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio associations with heart and body dose and their effects on patient outcomes in locally advanced non-small cell lung cancer treated with definitive radiotherapy. Transl Lung Cancer Res 2020; 9:1996-2007. [PMID: 33209619 PMCID: PMC7653146 DOI: 10.21037/tlcr-20-831] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Inflammation plays a vital role in tumor growth and progression and can be affected by radiotherapy (RT) and chemotherapy. We sought to investigate the prognostic significance of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), and their associations with dosimetric factors in locally advanced non-small cell lung cancer (LA-NSCLC). Methods In this retrospective study, subjects consisted of 244 patients who had received definitive RT ± chemotherapy for LA-NSCLC between 2012 and 2016. Absolute lymphocyte count (ALC), NLR and PLR recorded at pretreatment, during RT and post-RT were analyzed. Multivariable analysis (MVA) was performed to correlate clinical factors and inflammatory biomarkers with progression-free survival (PFS) and overall survival (OS) using a Cox regression model. Relationships between NLR or PLR with OS and PFS were evaluated with Kaplan-Meier analysis and compared with log-rank test results. Multiple stepwise linear regression was used to assess the associations between dosimetric factors and NLR or PLR. Results The median PFS and OS for all patients were 8.6 and 15.8 months, respectively. On MVA for PFS and OS, higher 1-month post-RT start NLR [hazard ratio (HR) 1.049; 95% CI: 1.018–1.080; P=0.001] or higher 1-month post-RT start PLR (HR 1.001; 95% CI: 1.000–1.002; P<0.001) was associated with inferior PFS. Higher 1-month post-RT start NLR (HR 1.040; 95% CI: 1.013–1.069; P=0.004) or PLR (HR 1.001; 95% CI: 1.001–1.002; P<0.001) was also an independent predictor of OS. ALCmin, baseline NLR and PLR were not associated with treatment outcomes. Multiple stepwise linear regression analysis confirmed that baseline NLR (P<0.001), heart V20 (P<0.001), heart V40 (P<0.001), and mean body dose (MBD) were significantly associated with 1-month post-RT start NLR. Also, baseline PLR (P<0.001) and MBD (P<0.001) were significantly associated with 1-month post-RT start PLR. Conclusions Higher NLR and PLR during treatment were associated with worse patient outcomes, and heart dose or body dose was correlated with NLR or PLR in advanced NSCLC patients treated with definitive RT.
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Affiliation(s)
- Wu-Yan Xia
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xue-Ru Zhu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Feng
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Liu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jia-Ming Wang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chang-Xing Lv
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Zhang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Yu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xu-Wei Cai
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Long Fu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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30
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Xia WY, Feng W, Zhang CC, Shen YJ, Zhang Q, Yu W, Cai XW, Fu XL. Radiotherapy for non-small cell lung cancer in the immunotherapy era: the opportunity and challenge-a narrative review. Transl Lung Cancer Res 2020; 9:2120-2136. [PMID: 33209631 PMCID: PMC7653139 DOI: 10.21037/tlcr-20-827] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
Immunotherapy has radically changed the clinical management of patients with cancer in recent years. Immune checkpoint inhibitors (ICIs) reversing the immunosuppressive effects of the tumor microenvironment are one type of immunotherapy, several of which are approved by the US Food and Drug Administration (FDA) as first-line treatments for patients with non-small cell lung cancer (NSCLC). However, response rates to ICIs are around 19-47% among patients with advanced NSCLC. As a result, the development of combined ICI and radiotherapy has begun with the aim of strengthening patients' antitumor immunity. Radiotherapy with substantial technological improvements not only achieves local tumor control through the induction of deoxyribonucleic acid (DNA) damage in irradiated regions, but also has the potential to mediate immunostimulatory effects that could result in tumor regression beyond irradiated regions. At present, numerous preclinical and clinical research are investigating the efficiency and safety of combining ICI with radiotherapy. The PACIFIC trial showed that combining chemoradiotherapy with ICI could improve clinical outcomes. In this review, we summarize the rationale for combining radiotherapy with immunotherapy. We also discuss the opportunities and challenges of combination therapy, including the timing of radiotherapy, optimal dose and fractionations, radiotherapy target and target volume, acquired resistance, patient selection, and radioimmunotherapy toxicity.
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Affiliation(s)
- Wu-Yan Xia
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Wen Feng
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Chen-Chen Zhang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Yu-Jia Shen
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Qin Zhang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Wen Yu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Xu-Wei Cai
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
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31
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Li CC, Lin CB, Chu SC, Huang WH, Lee JJ, Yang GG, Wang TF, Wu YF. Lymphocyte percentage and platelet count correlate with the treatment outcome to tyrosine kinase inhibitors in epidermal growth factor receptor-mutated lung adenocarcinoma. Medicine (Baltimore) 2020; 99:e21275. [PMID: 32702917 PMCID: PMC7373628 DOI: 10.1097/md.0000000000021275] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This observational study evaluated the treatment outcomes of clinical factors on the patients with lung adenocarcinoma with epidermal growth factor receptor mutations who received tyrosine kinase inhibitors as first-line treatment.Patients with stage IIIb or IV lung adenocarcinoma with mutated epidermal growth factor receptor were enrolled retrospectively between March 2010 and December 2017. The hematologic markers on progression-free survival (PFS) and overall survival (OS) were analyzed.Totally 190 patients were enrolled. In univariate analysis by hematologic markers, lower lymphocyte percentage and higher platelet count were associated with significantly poor PFS and OS. Multivariate analysis showed lower lymphocyte percentage was independent poor prognostic factors for PFS and OS. Higher platelet count was an independent poor prognostic factor for OS only.Patients with lung adenocarcinoma receiving tyrosine kinase inhibitors with lower lymphocyte percentage and higher platelet count had poorer prognoses compared with other patients.
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Affiliation(s)
- Chi-Cheng Li
- Department of Hematology and Oncology
- Center of Stem Cell & Precision Medicine
| | - Chih-Bin Lin
- Division of Chest Medicine, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Department of Medicine, College of Medicine, Tzu Chi University
| | - Sung-Chao Chu
- Department of Hematology and Oncology
- Department of Medicine, College of Medicine, Tzu Chi University
| | - Wei-Han Huang
- Department of Hematology and Oncology
- Department of Clinical Pathology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan, ROC
| | - Jen-Jyh Lee
- Division of Chest Medicine, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Department of Medicine, College of Medicine, Tzu Chi University
| | - Gee-Gwo Yang
- Division of Chest Medicine, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Department of Medicine, College of Medicine, Tzu Chi University
| | - Tso-Fu Wang
- Department of Hematology and Oncology
- Department of Medicine, College of Medicine, Tzu Chi University
| | - Yi-Feng Wu
- Department of Hematology and Oncology
- Department of Medicine, College of Medicine, Tzu Chi University
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32
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Zou Z, Bowen SR, Thomas HMT, Sasidharan BK, Rengan R, Zeng J. Scanning Beam Proton Therapy versus Photon IMRT for Stage III Lung Cancer: Comparison of Dosimetry, Toxicity, and Outcomes. Adv Radiat Oncol 2020; 5:434-443. [PMID: 32529138 PMCID: PMC7276696 DOI: 10.1016/j.adro.2020.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 02/03/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose There are limited clinical data on scanning-beam proton therapy (SPT) in treating locally advanced lung cancer, as most published studies have used passive-scatter technology. There is increasing interest in whether the dosimetric advantages of SPT compared with photon therapy can translate into superior clinical outcomes. We present our experience of SPT and photon intensity modulated radiation therapy (IMRT) with clinical dosimetry and outcomes in patients with stage III lung cancer. Methods and Materials Patients with stage III lung cancer treated at our center between 2013 and May 2018 were identified in compliance with our institutional review board (64 patients = 34 SPT + 30 IMRT). Most proton patients were treated with pencil beam scanning (28 of 34), and 6 of 34 were treated with uniform scanning. Fisher exact test, χ2 test, and Mann-Whitney test were used to compare groups. All tests were 2-sided. Results Patient characteristics were similar between the IMRT and SPT patients, except for worse lung function in the IMRT group. Mean dose to lung, heart, and esophagus was lower in the SPT group, with most benefit in the low-dose region (lungs, 9.7 Gy vs 15.7 Gy for SPT vs IMRT, respectively [P = .004]; heart, 7 Gy vs 14 Gy [P = .001]; esophagus, 28.2 Gy vs 30.9 Gy [P = .023]). Esophagitis and dermatitis grades were not different between the 2 groups. Grade 2+ pneumonitis was 21% in the SPT group and 40% in the IMRT group (P = .107). Changes in blood counts were not different between the 2 groups. Overall survival and progression-free survival were not different between SPT and IMRT (median overall survival, 41.6 vs 30.7 months, respectively [P = .52]; median progression-free survival, 19.5 vs 14.6 months [P = .50]). Conclusions We report our experience with SPT and IMRT in stage III lung cancer. Our cohort of patients treated with SPT had lower doses to normal organs (lungs, heart, esophagus) than our IMRT cohort. There was no statistically significant difference in toxicity rates or survival, although there may have been a trend toward lower rates of pneumonitis.
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Affiliation(s)
- Zhenwei Zou
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Stephen R Bowen
- Departments of Radiation Oncology, Seattle, Washington.,Radiology, University of Washington, Seattle, Washington
| | | | | | - Ramesh Rengan
- Departments of Radiation Oncology, Seattle, Washington
| | - Jing Zeng
- Departments of Radiation Oncology, Seattle, Washington
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33
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Xu C, Jin JY, Zhang M, Liu A, Wang J, Mohan R, Kong FS, Lin SH. The impact of the effective dose to immune cells on lymphopenia and survival of esophageal cancer after chemoradiotherapy. Radiother Oncol 2020; 146:180-186. [PMID: 32182504 DOI: 10.1016/j.radonc.2020.02.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To test the hypothesis that effective dose to circulating immune cells (EDIC) impacts the severity of radiation-induced lymphopenia and clinical outcomes of esophageal cancer patients treated with concurrent chemoradiotherapy (CCRT). MATERIAL AND METHODS 488 esophageal cancer patients treated with CCRT with and without surgery were analyzed. The EDIC model considers the exposure of circulating immune cells as the proportion of blood flow to lung, heart, liver, and the volume of the exposed area of the body, with the basis of mean lung dose (MLD), mean heart dose (MHD), mean liver dose (MlD), and integral dose (ITD) of the body region scanned, calculated as: EDIC=0.12∗MLD+0.08∗MHD+0.15∗0.85∗MlD∗n451/2+0.45+0.35∗0.85∗nk1/2∗ITD62∗103 Where n is the fraction number. Correlations of EDIC with overall survival (OS), progression free survival (PFS), distant metastasis free survival (DMFS), and locoregional control (LRC) rates were analyzed using both univariable and multivariable Cox models. Lymphopenia during CCRT was graded according to Common Terminology Criteria for Adverse Events version 4.0. RESULTS Grade 4 lymphopenia resulted in inferior clinical outcomes, including OS, PFS, and DMFS. The median EDIC was 3.6 Gy (range, 0.8-6.0 Gy). Higher EDIC was strongly associated with severe lymphopenia, particularly when EDIC was above 4 Gy. Patients with EDIC > 4.0 Gy had more G4 lymphopenia than those with EDIC ≤ 4.0 Gy (67.3% vs. 40.8%; P < 0.001). On multivariate analysis, increasing EDIC was independently and inversely associated with worse OS, PFS, and DMFS. CONCLUSION EDIC can be recommended as a useful tool to predict lymphopenia and inferior clinical outcomes, and it should be minimized below 4 Gy.
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Affiliation(s)
- Cai Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jian-Yue Jin
- Department of Radiation Oncology, University Hospitals/Seidman Cancer Center and Case Comprehensive Cancer Center of Case Western Reserve University, USA
| | - Ming Zhang
- Department of Radiation Oncology, Hebei General Hospital, Shijiazhuang, China
| | - Amy Liu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jun Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Radhe Mohan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.
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Abravan A, Eide HA, Helland Å, Malinen E. Radiotherapy-related lymphopenia in patients with advanced non-small cell lung cancer receiving palliative radiotherapy. Clin Transl Radiat Oncol 2020; 22:15-21. [PMID: 32181373 PMCID: PMC7063172 DOI: 10.1016/j.ctro.2020.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
Abstract
Risk of grade 3 lymphopenia increased with RT dose to the soft tissue and trabecular bone. High baseline CRP/Albumin was negatively associated with overall survival. Risk of lymphopenia may decrease by limiting irradiation field in palliative RT.
Background Lymphopenia during radiotherapy (RT) may have an adverse effect on treatment outcome. The aim of this study is to investigate associations between lymphopenia and RT parameters in patients with advanced lung cancer. Moreover, to investigate the prognostic role of lymphopenia, blood protein levels, and treatment and patient-related factors. Material and Methods Sixty-two advanced stage non-small cell lung cancer (NSCLC) patients were retrospectively analyzed. Blood counts were available prior to, during, and after RT (3Gyx10). For each patient, a thoracic volume of interest (VOI) –including thoracic soft tissue and trabecular bone– was obtained by applying a CT window of −500 to 1200 HU in the planning CT. Dose parameters from thoracic VOI and other regions including lungs and vertebrae were calculated. Association between risk of lymphopenia ≥ G3 (lymphocytes at nadir according to CTCAE v4.0) and therapeutic parameters was investigated using Logistic regression. Relationships between overall survival (OS) and RT dose parameters, baseline blood counts and protein levels, and clinical factors were evaluated using Log-rank and Cox models. Result Mean thoracic RT dose (odds ratio [OR] 1.67; p = 0.04), baseline lymphocytes (OR 0.65; p = 0.01), and corticosteroids use (OR 6.07; p = 0.02) were significantly associated with increased risk of lymphopenia ≥ G3 in multivariable analysis. Worse OS was associated with high mean thoracic RT dose, high CRP/Albumin, large tumor volume and corticosteroids use (p < 0.05, univariate analysis), but not with lymphopenia ≥ G3. CRP/Albumin ratio > 0.12 (hazard ratio [HR] 2.28, p = 0.03) and corticosteroid use (HR 2.52, p = 0.01) were independently associated with worse OS. Conclusion High thoracic RT dose gave a higher risk of lymphopenia ≥ G3; hence limiting dose volume to the thorax may be valuable in preventing severe lymphopenia for patients receiving palliative fractionated RT. Still, lymphopenia ≥ G3 was not associated with worse OS. however, high baseline CRP/Albumin was associated with poorer OS and may carry important information as a prognostic factor of OS in advanced NSCLC receiving palliative RT.
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Key Words
- C-reactive protein/Albumin
- CRP, C-Reactive Protein
- CRT, Chemo-radiotherapy
- CT, Computed Tomography
- CTCAE, Common Terminology Criteria for Adverse Events
- Corticosteroid
- ECOG, Eastern Cooperative Oncology Group
- GTV, Gross Tumor Volume
- HR, Hazard Ratio
- Hematologic toxicity
- Lung cancer
- Lymphopenia
- NSCLC, Non-Small Cell Lung Cancer
- OR, Odds Ratio
- OS, Overall Survival
- Overall survival
- RT, Radiotherapy
- Radiotherapy
- VOI, Volume of Interest
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Affiliation(s)
- Azadeh Abravan
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
- Corresponding author at: Department of Medical Physics, Oslo University Hospital, PO Box 4953 Nydalen, N-0424 Oslo, Norway.
| | - Hanne Astrid Eide
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Åslaug Helland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Eirik Malinen
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
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Dutoit V, Philippin G, Widmer V, Marinari E, Vuilleumier A, Migliorini D, Schaller K, Dietrich PY. Impact of Radiochemotherapy on Immune Cell Subtypes in High-Grade Glioma Patients. Front Oncol 2020; 10:89. [PMID: 32117743 PMCID: PMC7034105 DOI: 10.3389/fonc.2020.00089] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 01/17/2020] [Indexed: 11/23/2022] Open
Abstract
Glioblastoma is a dreadful disease with very poor prognosis, median overall survival being <2 years despite standard-of-care treatment. This has led to the development of alternative strategies, among which immunotherapy is being actively tested. In particular, many clinical trials of therapeutic vaccination using peptides or tumor cells are ongoing. A major issue in implementing therapeutic vaccines in patients with high-grade glioma is that immune responses have to be elicited in the context of immunosuppressive treatments. Indeed, radiotherapy, chemotherapy, and steroids, which are part of the standard of care for patients with glioblastoma, are known to deplete leukocytes. Whether lymphopenia is beneficial or detrimental to elicitation of efficient immune responses is still debated. Here, in order to determine the impact of standard radiochemotherapy on immune cell subsets, we analyzed the phenotype and function of immune populations in 25 patients with high-grade glioma along concomitant radiochemotherapy and adjuvant chemotherapy with temozolomide. Thirteen healthy individuals were studied along the same period. We show that absolute T and B cell counts are reduced upon concomitant radiochemotherapy. Importantly, T cell counts were not restored long-term after discontinuation of treatment. In addition, the percentage of T regulatory cells among CD4 T cells was increased during the same period and was not decreased upon treatment discontinuation. Finally, we show that the ability of T cells to proliferate is transiently reduced after concomitant radiochemotherapy but is restored at the time of adjuvant TMZ cycles. Although not experimentally validated, transient reduction in proliferation associated with strong lymphopenia during radiochemotherapy may suggest that vaccine-induced T cell stimulation would be suboptimal in that period and that therapeutic vaccination should be performed outside radiochemotherapy administration. In addition, strategies aiming at depleting Treg cells should be implemented in future trials.
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Affiliation(s)
- Valérie Dutoit
- Laboratory of Tumor Immunology and Center of Oncology, Geneva University Hospital, Geneva, Switzerland.,Translational Research Center for Oncohematology, Department of Internal Medicine Specialties, University of Geneva, Geneva, Switzerland
| | - Géraldine Philippin
- Laboratory of Tumor Immunology and Center of Oncology, Geneva University Hospital, Geneva, Switzerland.,Translational Research Center for Oncohematology, Department of Internal Medicine Specialties, University of Geneva, Geneva, Switzerland
| | - Valérie Widmer
- Laboratory of Tumor Immunology and Center of Oncology, Geneva University Hospital, Geneva, Switzerland.,Translational Research Center for Oncohematology, Department of Internal Medicine Specialties, University of Geneva, Geneva, Switzerland
| | - Eliana Marinari
- Laboratory of Tumor Immunology and Center of Oncology, Geneva University Hospital, Geneva, Switzerland.,Translational Research Center for Oncohematology, Department of Internal Medicine Specialties, University of Geneva, Geneva, Switzerland
| | | | - Denis Migliorini
- Laboratory of Tumor Immunology and Center of Oncology, Geneva University Hospital, Geneva, Switzerland.,Translational Research Center for Oncohematology, Department of Internal Medicine Specialties, University of Geneva, Geneva, Switzerland
| | - Karl Schaller
- Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospital, Geneva, Switzerland
| | - Pierre-Yves Dietrich
- Laboratory of Tumor Immunology and Center of Oncology, Geneva University Hospital, Geneva, Switzerland.,Translational Research Center for Oncohematology, Department of Internal Medicine Specialties, University of Geneva, Geneva, Switzerland.,Department of Oncology, Geneva University Hospital, Geneva, Switzerland
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Liao XY, Liu CY, He JF, Wang LS, Zhang T. Combination of checkpoint inhibitors with radiotherapy in esophageal squamous cell carcinoma treatment: A novel strategy. Oncol Lett 2019; 18:5011-5021. [PMID: 31612012 PMCID: PMC6781725 DOI: 10.3892/ol.2019.10893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 08/13/2019] [Indexed: 02/07/2023] Open
Abstract
Despite the rapid development of numerous types of treatment, including radiotherapy (RT) as the main strategy, esophageal squamous cell carcinoma (ESCC) has a poor prognosis. Recent studies demonstrated that immunotherapy can improve the survival of patients with locally advanced and metastatic ESCC. Furthermore, previous studies reported that the expression of programmed death-ligand 1 is significantly associated with esophageal cancer prognosis. At present, several ongoing clinical trials have extended the use of immunotherapy from palliative and salvage treatments to neoadjuvant treatment with concurrent chemoradiation. The first- or second-line treatments were used to explore antitumor efficacy with reduced adverse events. The combination of RT and immunotherapy can exert a local therapeutic effect and improve the function of the immune system, enhancing antitumor efficacy. This review investigated the role of immunotherapy and radiotherapy in ESCC and described the potential efficacy of combining immunotherapy with radiotherapy in ESCC.
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Affiliation(s)
- Xiu-Yong Liao
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
- Department of Oncology, Chongqing Qianjiang Central Hospital, Chongqing 409000, P.R. China
| | - Chao-Yuan Liu
- Department of Neurosurgery, Chongqing Qianjiang Central Hospital, Chongqing 409000, P.R. China
| | - Jian-Feng He
- Department of General Surgery, Chongqing Qianjiang Central Hospital, Chongqing 409000, P.R. China
| | - Li-Shu Wang
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tao Zhang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
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Wu G, Baine MJ, Zhao N, Li S, Li X, Lin C. Lymphocyte-sparing effect of stereotactic body radiation therapy compared to conventional fractionated radiation therapy in patients with locally advanced pancreatic cancer. BMC Cancer 2019; 19:977. [PMID: 31640607 PMCID: PMC6805585 DOI: 10.1186/s12885-019-6220-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 09/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conventionally fractionated (CF) radiation therapy (RT) has been associated with lymphopenia, leading to compromised overall survival (OS) in cancer patients. It currently remains unknown if stereotactic body (SB) RT induces lymphopenia to the same degree. The aim of this study is to determine if SBRT with either chemotherapy (CMT) (Fluorouracil (5FU) or capecitabine) or Nelfinavir (NFV) to pancreatic adenocarcinoma induces lymphopenia to the same degree as CFRT with 5FU or capecitabine and how any associated difference affects patient survival outcomes. METHODS Medical records of pancreatic adenocarcinoma patients treated with induction CMT followed by RT with concurrent CMT or NFV were reviewed. Patients with total lymphocyte counts (TLCs) available both prior to and following initiation of RT were included. Three groups were identified: CFRT/CMT, SBRT/CMT, and SBRT/NFV. Median delivered RT doses for CFRT and SBRT were 50.4 Gy in 1.8 Gy fractions and 35 Gy in 7 Gy fractions, respectively. TLCs from day 0 (the first day of RT) to 40 were recorded and analyzed using the Kruskal-Wallis test with p-values adjusted with Bonferroni's method. Linear regressions were utilized to estimate the slope of TLCs as it changes with time and survival analysis was performed via Kaplan-Meier plots. RESULTS One hundred patients were identified (28 CFRT/CMT, 27 SBRT/CMT, 45 SBRT/NFV). Median pre-RT TLCs were not different among groups. Median lowest TLCs were significantly lower (p < 0.0001) and median TLCs reduction over time were significantly greater (p < 0.0001) in the CFRT group than SBRT groups. There was no difference in lowest TLCs or TLCs reduction over time between SBRT groups. Across all groups, the median time to lowest TLCs was similar. Survival analysis revealed no significant difference in median OS between SBRT and CFRT groups. However, in patients with surgery, Median OS for patients with SBRT/CMT was significantly higher than in those with SBRT/NFV (p = 0.03). CONCLUSIONS Compared to CFRT, SBRT is associated with less lymphopenia. Further study of the effect of radiation technique on immune status is warranted.
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Affiliation(s)
- Guangyin Wu
- Department of Radiation Oncology, Henan Provincial People's Hospital; People's Hospital of Zhengzhou University, Henan, China.,Department of Radiation Oncology, University of Nebraska Medical Center, 986861 Nebraska Medical Center, Omaha, NE, 68198-68618, USA
| | - Michael J Baine
- Department of Radiation Oncology, University of Nebraska Medical Center, 986861 Nebraska Medical Center, Omaha, NE, 68198-68618, USA
| | - Nan Zhao
- Department of Radiation Oncology, University of Nebraska Medical Center, 986861 Nebraska Medical Center, Omaha, NE, 68198-68618, USA
| | - Sicong Li
- Department of Radiation Oncology, University of Nebraska Medical Center, 986861 Nebraska Medical Center, Omaha, NE, 68198-68618, USA
| | - Xiaobo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China. .,College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, Fujian, China.
| | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, 986861 Nebraska Medical Center, Omaha, NE, 68198-68618, USA.
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Wang X, Lu J, Teng F, Yu J. Lymphopenia association with accelerated hyperfractionation and its effects on limited-stage small cell lung cancer patients' clinical outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:385. [PMID: 31555699 DOI: 10.21037/atm.2019.07.58] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background An assessment of trends in lung cancer patient survival is very important to determine the outcomes and to modulate where advancements should be made. This study investigated whether the absolute lymphocyte count just after chemoradiation (after-ALC) and 3 months after chemoradiation initiation (post-ALC) could predict limited-stage small cell lung cancer (LS-SCLC) patients' clinical outcomes. Methods We retrospectively reviewed 304 patients who were newly diagnosed with LS-SCLC and received treatment with chemoradiation (CRT). Finally we collected data at the time of pretreatment, after-ALC and post-ALC from 226 patients. Kaplan-Meier survival curves and log-rank statistics were used to assess the prognostic significance of after-ALC and post-ALC for survival rates. Cox proportional hazards models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs). Results Two hundred and twenty-six patients had a documented ALC pretreatment, just after CRT and 3 months after CRT. Relative lymphopenia of pre-treatment ALC was in 47.8% of patients, whereas the lymphopenia (<655 cells/mm3) proportion was increased to 61.1% just after CRT, and the lymphopenia (<1,430 cells/mm3) proportion continued to rise to 70.4% at the time of 3 months after initiating CRT. After-ALC lymphopenia patients showed inferior median OS (18.1 vs. 36.0 months, P<0.001) and similar PFS (9.7 vs. 26.2 months, P<0.001) compared to patients without lymphopenia. Multivariate analysis demonstrated after-ALC <655 cells/mm3 and post-ALC <1,430 cells/mm3 (HR: 1.339; P=0.038) had a 105% and 33% (HR: 2.056; P<0.001) increase in hazards of death respectively. Similarly, after-ALC <655 cells/mm3 and post-ALC <1,430 cells/mm3 had a 160% (HR: 2.606; P=0.002) and 40% (HR: 1.409; P=0.015) increase in hazards of progression respectively. Furthermore, hyperfractionated RT showed more likely to cause lymphopenia in patients than conventional fractionated RT. Conclusions Nearly half of LS-SCLC patients treatment with CRT experienced severe lymphopenia and more than half patients exhibited prolonged lymphopenia. Statistical significance that lymphopenia after treatment was associated with decreased survival was obviously observed. Further study is warranted, given that explanation lymphopenia is a mechanism for shorter survival or just a predictor.
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Affiliation(s)
- Xin Wang
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430060, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, China
| | - Jie Lu
- Department of Neurosurgery, Shandong Province Qianfoshan Hospital of Shandong University, Jinan 250014, 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
| | - Jinming Yu
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430060, China.,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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Kent MS, Emami S, Rebhun R, Theon A, Hansen K, Sparger E. The effects of local irradiation on circulating lymphocytes in dogs receiving fractionated radiotherapy. Vet Comp Oncol 2019; 18:191-198. [PMID: 31424596 DOI: 10.1111/vco.12531] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/25/2019] [Accepted: 08/13/2019] [Indexed: 01/26/2023]
Abstract
Localized radiation therapy can be an effective treatment for cancer but is associated with localized and systemic side effects. Several studies have noted changes in complete blood count (CBC) parameters including decreases in the absolute lymphocyte count (ALC) and increases in the neutrophil:lymphocyte ratio (NLR). These changes could reflect immunosuppression and may contribute to decreased efficacy of immunotherapies used to treat cancer. We hypothesized that dogs would demonstrate decreased ALCs during a course of radiotherapy. A retrospective study was conducted on 203 dogs receiving definitive-intent radiotherapy. Demographic information, CBC values and details of the radiotherapy protocol were collected. The mean lymphocyte count pre-treatment was 1630.68 cells/μL (SD ± 667.56) with a mean NLR of 3.66 (SD ± 4.53). The mean lymphocyte count mid-treatment was 1251.07 cells/μL (SD ± 585.96) and the mean NLR was 6.23 (SD ± 4.99). There was a significant decrease in the mean lymphocyte count by 351.41 lymphocytes/μL (SD ± 592.32) between pre-treatment and mid-treatment (P < .0001), and a corresponding significant increase in the mean NLR of 0.93 (P = .02). Lymphopenia grade increased in 33.5% of dogs and was significant (P = .03). The ALC decrease was not correlated with the volume irradiated (P = .27), but correlated with the irradiated volume:body weight ratio (P = .03). A subset of patients (n = 35) with additional CBCs available beyond the mid-treatment time point demonstrated significant and sustained downward trends in the ALC compared with baseline. Although severe lymphopenia was rare, these decreases, especially if sustained, could impact adjuvant therapy for their cancer.
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Affiliation(s)
- Michael S Kent
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California
| | - Shaheen Emami
- College of Agricultural and Environmental Sciences, University of California Davis, Davis, California
| | - Rob Rebhun
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California
| | - Alain Theon
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California
| | - Katherine Hansen
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California
| | - Ellen Sparger
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, Davis, California
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van Rossum PSN, Deng W, Routman DM, Liu AY, Xu C, Shiraishi Y, Peters M, Merrell KW, Hallemeier CL, Mohan R, Lin SH. Prediction of Severe Lymphopenia During Chemoradiation Therapy for Esophageal Cancer: Development and Validation of a Pretreatment Nomogram. Pract Radiat Oncol 2019; 10:e16-e26. [PMID: 31369887 DOI: 10.1016/j.prro.2019.07.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/10/2019] [Accepted: 07/21/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In patients with esophageal cancer, occurrence of severe radiation-induced lymphopenia during chemoradiation therapy has been associated with worse progression-free and overall survival. The aim of this study was to develop and validate a pretreatment clinical nomogram for the prediction of grade 4 lymphopenia. METHODS AND MATERIALS A development set of consecutive patients who underwent chemoradiation therapy for esophageal cancer and an independent validation set of patients from another institution were identified. Grade 4 lymphopenia was defined as an absolute lymphocyte count nadir during chemoradiation therapy of <0.2 × 103/μL. Multivariable logistic regression analysis was used to create a prediction model for grade 4 lymphopenia in the development set, which was internally validated using bootstrapping and externally validated by applying the model to the validation set. The model was presented as a nomogram yielding 4 risk groups. RESULTS Among 860 included patients, 322 (37%) experienced grade 4 lymphopenia. Higher age, larger planning target volume in interaction with lower body mass index, photon- rather than proton-based therapy, and lower baseline absolute lymphocyte count were predictive in the final model (corrected c-statistic, 0.76). External validation in 144 patients, among whom 58 (40%) had grade 4 lymphopenia, yielded a c-statistic of 0.71. Four nomogram-based risk groups yielded predicted risk rates of 10%, 24%, 43%, and 70%, respectively. CONCLUSIONS A pretreatment clinical nomogram was developed and validated for the prediction of grade 4 radiation-induced lymphopenia during chemoradiation therapy for esophageal cancer. The nomogram can risk stratify individual patients suitable for lymphopenia-mitigating strategies or potential future therapeutic approaches to ultimately improve survival.
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Affiliation(s)
- Peter S N van Rossum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wei Deng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Amy Y Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cai Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yutaka Shiraishi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Lymphocyte Count Kinetics, Factors Associated with the End-of-Radiation-Therapy Lymphocyte Count, and Risk of Infection in Patients with Solid Malignant Tumors Treated with Curative-Intent Radiation Therapy. Int J Radiat Oncol Biol Phys 2019; 105:812-823. [PMID: 31344435 DOI: 10.1016/j.ijrobp.2019.07.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/12/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Lymphopenia has been associated with poor outcomes in patients with cancer. We sought to describe the lymphocyte kinetics in patients who received radiation therapy; to identify factors associated with the end-of-radiation-therapy (EoRT) lymphocyte count; and to determine the association of radiation therapy-induced lymphopenia with subsequent infection. METHODS AND MATERIALS Patients with solid malignant tumors treated at the Department of Oncology at Rigshospitalet, University of Copenhagen, Denmark, were included if they had received their first external beam radiation therapy with curative intent from January 2005 to December 2016 and had pretreatment and EoRT lymphocyte counts measured. Factors associated with the EoRT lymphocyte count were identified using regression analyses. The risk of subsequent infection was estimated using Cox proportional hazards regression. RESULTS We included 3920 patients. More patients had lymphopenia (<1000 cells/μL) at EoRT than at pretreatment (67.1% vs 14.9%; P < .001). Patients who received schemes with higher intensities (equivalent dose in 2-Gy fractions [EQD2] >65 Gy) in shorter time (<25 days) had a higher predicted EoRT lymphocyte count than patients who received schemes delivering EQD2 of 50 to 65 Gy in 25 to 45 days (1439 cells/μL, 95% confidence interval [1293-1585] vs 784 [754-814]). Radiation to multiple sites and concomitant chemotherapy use, particularly platinum compounds versus none, were associated with a lower EoRT lymphocyte count (698 [655-742] vs 852 [833-870]; and 612 [565-659] vs 937 [909-964], respectively). Patients with EoRT lymphopenia grade ≥3 (<500 cells/μL) had a higher risk of infection in the 3 months after radiation therapy (hazard ratio, 2.15 [95% confidence interval, 1.53-3.02]; P < .001), compared with patients with an EoRT lymphocyte count >1000 cells/μL. CONCLUSIONS The lymphocyte count declined during radiation therapy. Short duration schemes (<25 days), despite high total radiation dose (EQD2 >65 Gy), were associated with a higher EoRT lymphocyte count, whereas radiation to multiple sites and concomitant chemotherapy were associated with a lower count. EoRT lymphopenia was associated with an increased risk of infection.
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Li Q, Zhou S, Liu S, Liu S, Yang H, Zhao L, Liu M, Hu Y, Xi M. Treatment-Related Lymphopenia Predicts Pathologic Complete Response and Recurrence in Esophageal Squamous Cell Carcinoma Undergoing Neoadjuvant Chemoradiotherapy. Ann Surg Oncol 2019; 26:2882-2889. [DOI: 10.1245/s10434-019-07334-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Indexed: 02/07/2023]
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Clinical observation of lymphopenia in patients with newly diagnosed glioblastoma. J Neurooncol 2019; 143:321-328. [DOI: 10.1007/s11060-019-03167-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 04/08/2019] [Indexed: 12/26/2022]
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44
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Deng W, Xu C, Liu A, van Rossum PS, Deng W, Liao Z, Koong AC, Mohan R, Lin SH. The relationship of lymphocyte recovery and prognosis of esophageal cancer patients with severe radiation-induced lymphopenia after chemoradiation therapy. Radiother Oncol 2019; 133:9-15. [DOI: 10.1016/j.radonc.2018.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/29/2018] [Accepted: 12/02/2018] [Indexed: 12/24/2022]
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Rajani KR, Carlstrom LP, Parney IF, Johnson AJ, Warrington AE, Burns TC. Harnessing Radiation Biology to Augment Immunotherapy for Glioblastoma. Front Oncol 2019; 8:656. [PMID: 30854331 PMCID: PMC6395389 DOI: 10.3389/fonc.2018.00656] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/12/2018] [Indexed: 12/22/2022] Open
Abstract
Glioblastoma is the most common adult primary brain tumor and carries a dismal prognosis. Radiation is a standard first-line therapy, typically deployed following maximal safe surgical debulking, when possible, in combination with cytotoxic chemotherapy. For other systemic cancers, standard of care is being transformed by immunotherapies, including checkpoint-blocking antibodies targeting CTLA-4 and PD-1/PD-L1, with potential for long-term remission. Ongoing studies are evaluating the role of immunotherapies for GBM. Despite dramatic responses in some cases, randomized trials to date have not met primary outcomes. Challenges have been attributed in part to the immunologically "cold" nature of glioblastoma relative to other malignancies successfully treated with immunotherapy. Radiation may serve as a mechanism to improve tumor immunogenicity. In this review, we critically evaluate current evidence regarding radiation as a synergistic facilitator of immunotherapies through modulation of both the innate and adaptive immune milieu. Although current preclinical data encourage efforts to harness synergistic biology between radiation and immunotherapy, several practical and scientific challenges remain. Moreover, insights from radiation biology may unveil additional novel opportunities to help mobilize immunity against GBM.
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Affiliation(s)
- Karishma R. Rajani
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Lucas P. Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Ian F. Parney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Aaron J. Johnson
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
| | | | - Terry C. Burns
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
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Abstract
High-grade glioma is the most common primary brain tumor, with glioblastoma multiforme (GBM) accounting for 52% of all brain tumors. The current standard of care (SOC) of GBM involves surgery followed by adjuvant fractionated radiotherapy and chemotherapy. However, little progress has been made in extending overall survival, progression-free survival, and quality of life. Attempts to characterize and customize treatment of GBM have led to mitigating the deleterious effects of radiotherapy using hypofractionated radiotherapy, as well as various immunotherapies as a promising strategy for the incurable disease. A combination of radiotherapy and immunotherapy may prove to be even more effective than either alone, and preclinical evidence suggests that hypofractionated radiotherapy can actually prime the immune system to make immunotherapy more effective. This review addresses the complications of the current radiotherapy regimen, various methods of immunotherapy, and preclinical and clinical data from combined radioimmunotherapy trials.
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Hematologic Markers as Prognostic Factors in Nonmetastatic Esophageal Cancer Patients under Concurrent Chemoradiotherapy. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1263050. [PMID: 30834254 PMCID: PMC6374875 DOI: 10.1155/2019/1263050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/14/2019] [Indexed: 12/17/2022]
Abstract
Nonmetastatic esophageal cancer can demonstrate a high local recurrence rate even under the standard treatment. We evaluated platelet counts before and after concurrent chemoradiotherapy (CCRT), neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio for predicting esophageal cancer prognosis under CCRT. Newly diagnosed patients with esophageal cancer (stages IA–IIIC) who underwent CCRT during January 2013–December 2017 were enrolled. The data were collected retrospectively. Overall survival (OS), time to progressive disease (TPD), and time to metastasis (TM) were recorded for indicating prognosis. Kaplan–Meier curves were plotted and univariate and multivariate analyses were performed. In total, 105 patients were enrolled. The stages of esophageal cancer and surgery were associated with prognosis (i.e., OS, TPD, and TM). Based on TPD and TM, women had better prognosis than men. In the univariate analysis, high pre- and post-CCRT platelet counts (>300,000/μL), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR) as well as low lymphocyte percentage were significantly associated with poor prognosis. However, in the multivariate analysis, only post-CCRT high platelet count (>300,000/μL) remained significantly associated with poor prognosis (P = .041, .045, and .023 for OS, TPD, and TM, respectively). Poor prognosis was observed in patients with high platelet counts, PLR, NLR, and low lymphocyte percentage. Surgery was an independent factor predicting better prognosis. Our findings may have clinical significance with regard to therapeutic decision-making.
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The Utility of Pretreatment and Posttreatment Lymphopenia in Cervical Squamous Cell Carcinoma Patients Treated With Definitive Chemoradiotherapy. Int J Gynecol Cancer 2018; 28:1553-1559. [DOI: 10.1097/igc.0000000000001345] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
ObjectiveThe aim of this study was to investigate the prognostic significance of pretreatment and posttreatment lymphopenia in locally advanced squamous cell carcinoma (SCC) cervical cancer patients treated with definitive chemoradiotherapy (ChRT).MethodsData from 95 patients with SCC were retrospectively analyzed. Relationships between pretreatment or posttreatment lymphopenia and patient or tumor characteristics, and overall survival (OS) and disease-free survival (DFS) were evaluated.ResultsMedian follow-ups for the entire cohort and survivors were 68 months (range, 3–133 months) and 88 months (range, 22–133 months), respectively. Ten patients (11%) exhibited pretreatment lymphopenia, whereas 58 patients (61%) exhibited posttreatment lymphopenia. Median pretreatment total lymphocyte counts decreased from 2029 cells/μL to 506 cells/μL 2 months after ChRT (P< 0.001). The 5-year OS and DFS rates were significantly higher in patients without pretreatment lymphopenia compared with patients with pre-retreatment lymphopenia (61% vs 20% [P< 0.001], 55% vs 20% [P< 0.001]). Patients without posttreatment lymphopenia had significantly higher 5-year OS and DFS rates than their counterparts (70% vs 46% [P= 0.02], 70% vs 39% [P= 0.004]). Complete response (CR) was observed in significantly fewer patients with pretreatment lymphopenia than in those without, after ChRT. Patients with posttreatment lymphopenia had higher rates of lymph node metastasis (P= 0.001) and lower posttreatment CR rates (P= 0.01) versus patients without posttreatment lymphopenia. In univariate analysis, International Federation of Gynecology and Obstetrics stage, tumor size, lymph node metastasis, and treatment response were prognostic for OS and DFS. In multivariate analysis, pretreatment lymphopenia, lymph node metastasis, and treatment response were independent predictors of OS and DFS. Age was predictive of OS. Tumor size was prognostic for DFS.ConclusionsPretreatment lymphopenia and posttreatment lymphopenia are associated with worse treatment response in patients given ChRT for cervical SCC. Pretreatment lymphopenia is predictive for OS and DFS. Therapeutic strategies including pretreatment or posttreatment immune preservation or modulation may improve response rates and survival in women with cervical SCC.
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Xu J, Wang Y, Shi J, Liu J, Li Q, Chen L. Combination therapy: A feasibility strategy for CAR-T cell therapy in the treatment of solid tumors. Oncol Lett 2018; 16:2063-2070. [PMID: 30008901 PMCID: PMC6036511 DOI: 10.3892/ol.2018.8946] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 03/07/2018] [Indexed: 12/16/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapies have been demonstrated to have durable and potentially curative therapeutic efficacies in patients with hematological malignancies. Currently, multiple clinical trials in CAR-T cell therapy have been evaluated for the treatment of patients with solid malignancies, but have had less marked therapeutic effects when the agents are used as monotherapies. When summarizing relevant studies, the present study found that combination therapy strategies for solid tumors based on CAR-T cell therapies might be more effective. This review will focus on various aspects of treating solid tumors with CAR-T cell therapy: i) The therapeutic efficacy of CAR-T cell monotherapy, ii) the feasibility of the CAR-T cell therapy in conjunction with chemotherapy, iii) the feasibility of CAR-T cell therapy with radiotherapy, iv) the feasibility of CAR-T cell therapy with chemoradiotherapy, and v) the feasibility of the combination of CAR-T cell therapy with other strategies.
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Affiliation(s)
- Jinjing Xu
- Galactophore Department, Jiangsu Huai'an Maternity and Children Hospital, Huai'an, Jiangsu 223001, P.R. China
| | - Yali Wang
- Galactophore Department, Jiangsu Huai'an Maternity and Children Hospital, Huai'an, Jiangsu 223001, P.R. China
| | - Jing Shi
- Galactophore Department, Jiangsu Huai'an Maternity and Children Hospital, Huai'an, Jiangsu 223001, P.R. China
| | - Juan Liu
- Galactophore Department, Jiangsu Huai'an Maternity and Children Hospital, Huai'an, Jiangsu 223001, P.R. China
| | - Qingguo Li
- Galactophore Department, Jiangsu Huai'an Maternity and Children Hospital, Huai'an, Jiangsu 223001, P.R. China
| | - Longzhou Chen
- Galactophore Department, Jiangsu Huai'an Maternity and Children Hospital, Huai'an, Jiangsu 223001, P.R. China
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Using Smaller-Than-Standard Radiation Treatment Margins Does Not Change Survival Outcomes in Patients with High-Grade Gliomas. Pract Radiat Oncol 2018; 9:16-23. [PMID: 30195927 DOI: 10.1016/j.prro.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/10/2018] [Accepted: 06/04/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE The number of studies that evaluate treatment margins for high grade gliomas (HGG) are limited. We hypothesize that patients with HGG who are treated with a gross tumor volume (GTV) to planning tumor volume (PTV) expansion of ≤1 cm will have progression-free survival (PFS) and overall survival (OS) rates similar to those treated in accordance with standard protocols by the Radiation Therapy Oncology Group or European Organisation for Research and Treatment of Cancer. Furthermore, the PFS and OS of subgroups within the study population will have equivalent survival outcomes with GTV1-to-PTV1 margins of 1.0 cm and 0.4 cm. METHODS AND MATERIALS Treatment plans and outcomes for patients with pathologically confirmed HGG were analyzed (n = 267). Survival (PFS and OS) was calculated from the time of the first radiation treatment and a χ2 test or Fisher exact test was used to calculate the associations between margin size and patient characteristics. Survival was estimated using Kaplan-Meier and compared using the log-rank test. All analyses were performed on the univariate level. RESULTS The median PFS and OS times were 10.6 and 19.1 months, respectively. By disease, the median PFS and OS times were 8.6 and 16.1 months for glioblastoma and 26.7 and 52.5 months for anaplastic glioma. The median follow-up time was 18.3 months. The treatment margin had no effect on outcome and the 1.0 cm GTV1-PTV1 margin subgroup (n = 212) showed median PFS and OS times of 10.7 and 19.1 months, respectively, and the 0.4 cm margin subgroup (n = 55) 10.2 and 19.3 months, respectively. In comparison with the standard treatment with 2 cm to 3 cm margins, there was not a significant difference in outcomes. CONCLUSIONS There is no apparent difference in survival when utilizing smaller versus larger margins as defined by the guidelines of the Radiation Therapy Oncology Group and European Organisation for Research and Treatment of Cancer. Although there remains no class I evidence that outcomes after treatment with smaller margins are identical to those after treatment with larger margins, this large series with long-term follow up suggests that a reduction of the margins is safe and further investigation is warranted.
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