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Busk M, Overgaard J, Horsman MR. Imaging of Tumor Hypoxia for Radiotherapy: Current Status and Future Directions. Semin Nucl Med 2020; 50:562-583. [PMID: 33059825 DOI: 10.1053/j.semnuclmed.2020.05.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Tumor regions that are transiently or chronically undersupplied with oxygen (hypoxia) and nutrients, and enriched with acidic waste products, are common due to an abnormal and inefficient tumor vasculature, and a deviant highly glycolytic energy metabolism. There is compelling evidence that tumor hypoxia is strongly linked to poor prognosis since oxygen-deprived cells are highly resistant to therapy including radio- and chemotherapy, and survival of such cells is a primary cause of disease relapse. Despite a general improvement in cancer survival rates, hypoxia remains a formidable challenge. Recent progress in radiation delivery systems with improved spatial accuracy that allows dose escalation to hypoxic tumors or even tumor subvolumes, and the development of hypoxia-selective drugs, including bioreductive prodrugs, holds great promise for overcoming this obstacle. However, apart from one notable exception, translation of promising preclinical therapies to the clinic have largely been disappointing. A major obstacle in clinical trials on hypoxia-targeting strategies has been the lack of reliable information on tumor hypoxia, which is crucial for patient stratification into groups of those that are likely to benefit from intervention and those who are not. Further, in many newer trials on hypoxia-selective drugs the choice of cancer disease and combination therapy has not always been ideal, especially not for clinical proof of principle trials. Clearly, there is a pending need for clinical applicable methodologies that may allow us to quantify, map and monitor hypoxia. Molecular imaging may provide the information required for narrowing the gap between potential and actual patient benefit of hypoxia-targeting strategies. The grand majority of preclinical and clinical work has focused on the usefulness of PET-based assessment of hypoxia-selective tracers. Since hypoxia PET has profound inherent weaknesses, the use of other methodologies, including more indirect methods that quantifies blood flow or oxygenation-dependent flux changes through ATP-generating pathways (eg, anaerobic glycolysis) is being extensively studied. In this review, we briefly discuss established and emerging hypoxia-targeting strategies, followed by a more thorough evaluation of strengths and weaknesses of clinical applicable imaging methodologies that may guide timely treatment intensification to overcome hypoxia-driven resistance. Historically, most evidence for the linkage between hypoxia and poor outcome is based on work in the field of radiotherapy. Therefore, main emphasis in this review is on targeting and imaging of hypoxia for improved radiotherapy.
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Affiliation(s)
- Morten Busk
- Experimental Clinical Oncology, Department of Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark; Danish Centre for Particle Therapy, (AUH), Aarhus, Denmark.
| | - Jens Overgaard
- Experimental Clinical Oncology, Department of Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark
| | - Michael R Horsman
- Experimental Clinical Oncology, Department of Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark
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52
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Leger S, Zwanenburg A, Leger K, Lohaus F, Linge A, Schreiber A, Kalinauskaite G, Tinhofer I, Guberina N, Guberina M, Balermpas P, von der Grün J, Ganswindt U, Belka C, Peeken JC, Combs SE, Boeke S, Zips D, Richter C, Krause M, Baumann M, Troost EG, Löck S. Comprehensive Analysis of Tumour Sub-Volumes for Radiomic Risk Modelling in Locally Advanced HNSCC. Cancers (Basel) 2020; 12:cancers12103047. [PMID: 33086761 PMCID: PMC7589463 DOI: 10.3390/cancers12103047] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 12/19/2022] Open
Abstract
Simple Summary Radiomic risk models are usually based on imaging features, which are extracted from the entire gross tumour volume (GTVentire). This approach does not explicitly consider the complex biological structure of the tumours. Therefore, in this retrospective study, we investigated the prognostic value of radiomic analyses based on different tumour sub-volumes using computed tomography imaging of patients with locally advanced head and neck squamous cell carcinoma who were treated with primary radio-chemotherapy. The GTVentire was cropped by different margins to define the rim and corresponding core sub-volumes of the tumour. Furthermore, the best performing tumour rim sub-volume was extended into surrounding tissue with different margins. As a result, the models based on the 5 mm tumour rim and on the 3 mm extended rim sub-volume showed an improved performance compared to models based on the corresponding tumour core. This indicates that the consideration of tumour sub-volumes may help to improve radiomic risk models. Abstract Imaging features for radiomic analyses are commonly calculated from the entire gross tumour volume (GTVentire). However, tumours are biologically complex and the consideration of different tumour regions in radiomic models may lead to an improved outcome prediction. Therefore, we investigated the prognostic value of radiomic analyses based on different tumour sub-volumes using computed tomography imaging of patients with locally advanced head and neck squamous cell carcinoma. The GTVentire was cropped by different margins to define the rim and the corresponding core sub-volumes of the tumour. Subsequently, the best performing tumour rim sub-volume was extended into surrounding tissue with different margins. Radiomic risk models were developed and validated using a retrospective cohort consisting of 291 patients in one of the six Partner Sites of the German Cancer Consortium Radiation Oncology Group treated between 2005 and 2013. The validation concordance index (C-index) averaged over all applied learning algorithms and feature selection methods using the GTVentire achieved a moderate prognostic performance for loco-regional tumour control (C-index: 0.61 ± 0.04 (mean ± std)). The models based on the 5 mm tumour rim and on the 3 mm extended rim sub-volume showed higher median performances (C-index: 0.65 ± 0.02 and 0.64 ± 0.05, respectively), while models based on the corresponding tumour core volumes performed less (C-index: 0.59 ± 0.01). The difference in C-index between the 5 mm tumour rim and the corresponding core volume showed a statistical trend (p = 0.10). After additional prospective validation, the consideration of tumour sub-volumes may be a promising way to improve prognostic radiomic risk models.
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Affiliation(s)
- Stefan Leger
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
- Correspondence:
| | - Alex Zwanenburg
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
| | - Karoline Leger
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Fabian Lohaus
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Annett Linge
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Andreas Schreiber
- Department of Radiotherapy, Hospital Dresden-Friedrichstadt, 01067 Dresden, Germany;
| | - Goda Kalinauskaite
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 10117 Berlin, Germany; (G.K.); (I.T.)
- Department of Radiooncology and Radiotherapy, Charité University Hospital, 10117 Berlin, Germany
| | - Inge Tinhofer
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 10117 Berlin, Germany; (G.K.); (I.T.)
- Department of Radiooncology and Radiotherapy, Charité University Hospital, 10117 Berlin, Germany
| | - Nika Guberina
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 45147 Essen, Germany; (N.G.); (M.G.)
- Department of Radiotherapy, University Hospital Essen, Medical Faculty, University of Duisburg-Essen, 45147 Essen, Germany
| | - Maja Guberina
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 45147 Essen, Germany; (N.G.); (M.G.)
- Department of Radiotherapy, University Hospital Essen, Medical Faculty, University of Duisburg-Essen, 45147 Essen, Germany
| | - Panagiotis Balermpas
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 60596 Frankfurt, Germany; (P.B.); (J.v.d.G.)
- Department of Radiotherapy and Oncology, Goethe-University Frankfurt, 60596 Frankfurt, Germany
| | - Jens von der Grün
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 60596 Frankfurt, Germany; (P.B.); (J.v.d.G.)
- Department of Radiotherapy and Oncology, Goethe-University Frankfurt, 60596 Frankfurt, Germany
| | - Ute Ganswindt
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 81377 Munich, Germany; (U.G.); (C.B.); (J.C.P.); (S.E.C.)
- Department of Radiation Oncology, Ludwig-Maximilians-Universität, 81377 Munich, Germany
- Clinical Cooperation Group, Personalized Radiotherapy in Head and Neck Cancer, Helmholtz Zentrum, 81377 Munich, Germany
- Department of Radiation Oncology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Claus Belka
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 81377 Munich, Germany; (U.G.); (C.B.); (J.C.P.); (S.E.C.)
- Department of Radiation Oncology, Ludwig-Maximilians-Universität, 81377 Munich, Germany
- Clinical Cooperation Group, Personalized Radiotherapy in Head and Neck Cancer, Helmholtz Zentrum, 81377 Munich, Germany
| | - Jan C. Peeken
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 81377 Munich, Germany; (U.G.); (C.B.); (J.C.P.); (S.E.C.)
- Department of Radiation Oncology, Technische Universität München, 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Stephanie E. Combs
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 81377 Munich, Germany; (U.G.); (C.B.); (J.C.P.); (S.E.C.)
- Department of Radiation Oncology, Technische Universität München, 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Simon Boeke
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 72076 Tübingen, Germany; (S.B.); (D.Z.)
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, 72076 Tübingen, Germany
| | - Daniel Zips
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 72076 Tübingen, Germany; (S.B.); (D.Z.)
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, 72076 Tübingen, Germany
| | - Christian Richter
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute of Radiooncology—OncoRay, Helmholtz-Zentrum Dresden—Rossendorf, 01328 Dresden, Germany
| | - Mechthild Krause
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute of Radiooncology—OncoRay, Helmholtz-Zentrum Dresden—Rossendorf, 01328 Dresden, Germany
| | - Michael Baumann
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute of Radiooncology—OncoRay, Helmholtz-Zentrum Dresden—Rossendorf, 01328 Dresden, Germany
- German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Esther G.C. Troost
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute of Radiooncology—OncoRay, Helmholtz-Zentrum Dresden—Rossendorf, 01328 Dresden, Germany
| | - Steffen Löck
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (A.Z.); (K.L.); (F.L.); (A.L.); (C.R.); (M.K.); (M.B.); (E.G.C.T.); (S.L.)
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden of the German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus and Technische Universität Dresden, 01307 Dresden, Germany
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53
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Starke S, Leger S, Zwanenburg A, Leger K, Lohaus F, Linge A, Schreiber A, Kalinauskaite G, Tinhofer I, Guberina N, Guberina M, Balermpas P, von der Grün J, Ganswindt U, Belka C, Peeken JC, Combs SE, Boeke S, Zips D, Richter C, Troost EGC, Krause M, Baumann M, Löck S. 2D and 3D convolutional neural networks for outcome modelling of locally advanced head and neck squamous cell carcinoma. Sci Rep 2020; 10:15625. [PMID: 32973220 PMCID: PMC7518264 DOI: 10.1038/s41598-020-70542-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 07/20/2020] [Indexed: 12/14/2022] Open
Abstract
For treatment individualisation of patients with locally advanced head and neck squamous cell carcinoma (HNSCC) treated with primary radiochemotherapy, we explored the capabilities of different deep learning approaches for predicting loco-regional tumour control (LRC) from treatment-planning computed tomography images. Based on multicentre cohorts for exploration (206 patients) and independent validation (85 patients), multiple deep learning strategies including training of 3D- and 2D-convolutional neural networks (CNN) from scratch, transfer learning and extraction of deep autoencoder features were assessed and compared to a clinical model. Analyses were based on Cox proportional hazards regression and model performances were assessed by the concordance index (C-index) and the model's ability to stratify patients based on predicted hazards of LRC. Among all models, an ensemble of 3D-CNNs achieved the best performance (C-index 0.31) with a significant association to LRC on the independent validation cohort. It performed better than the clinical model including the tumour volume (C-index 0.39). Significant differences in LRC were observed between patient groups at low or high risk of tumour recurrence as predicted by the model ([Formula: see text]). This 3D-CNN ensemble will be further evaluated in a currently ongoing prospective validation study once follow-up is complete.
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Affiliation(s)
- Sebastian Starke
- Helmholtz-Zentrum Dresden - Rossendorf, Department of Information Services and Computing, Dresden, Germany.
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany.
| | - Stefan Leger
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Alex Zwanenburg
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Karoline Leger
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fabian Lohaus
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annett Linge
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Andreas Schreiber
- Department of Radiotherapy, Hospital Dresden-Friedrichstadt, Dresden, Germany
| | - Goda Kalinauskaite
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Berlin, Berlin, Germany
- Department of Radiooncology and Radiotherapy, Charité University Hospital, Berlin, Germany
| | - Inge Tinhofer
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Berlin, Berlin, Germany
- Department of Radiooncology and Radiotherapy, Charité University Hospital, Berlin, Germany
| | - Nika Guberina
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Essen, Essen, Germany
- Department of Radiotherapy, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Maja Guberina
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Essen, Essen, Germany
- Department of Radiotherapy, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Panagiotis Balermpas
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Frankfurt, Frankfurt, Germany
- Department of Radiotherapy and Oncology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Jens von der Grün
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Frankfurt, Frankfurt, Germany
- Department of Radiotherapy and Oncology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Ute Ganswindt
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Munich, Munich, Germany
- Department of Radiation Oncology, Ludwig-Maximilians-Universität, Munich, Germany
- Clinical Cooperation Group, Personalized Radiotherapy in Head and Neck Cancer, Helmholtz Zentrum, Munich, Germany
- Department of Radiation Oncology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Claus Belka
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Munich, Munich, Germany
- Department of Radiation Oncology, Ludwig-Maximilians-Universität, Munich, Germany
- Clinical Cooperation Group, Personalized Radiotherapy in Head and Neck Cancer, Helmholtz Zentrum, Munich, Germany
| | - Jan C Peeken
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Munich, Munich, Germany
- Department of Radiation Oncology, Technische Universität München, Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
| | - Stephanie E Combs
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Munich, Munich, Germany
- Department of Radiation Oncology, Technische Universität München, Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
| | - Simon Boeke
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Tübingen, Tübingen, Germany
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Daniel Zips
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Tübingen, Tübingen, Germany
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Michael Baumann
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Positron Emission Tomography and Molecular Imaging of Head and Neck Malignancies. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00366-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nicolay NH, Rühle A, Wiedenmann N, Niedermann G, Mix M, Weber WA, Baltas D, Werner M, Kayser G, Grosu AL. Lymphocyte Infiltration Determines the Hypoxia-Dependent Response to Definitive Chemoradiation in Head-and-Neck Cancer: Results from a Prospective Imaging Trial. J Nucl Med 2020; 62:471-478. [PMID: 32859699 DOI: 10.2967/jnumed.120.248633] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/28/2020] [Indexed: 12/24/2022] Open
Abstract
Tumor hypoxia in head-and-neck squamous cell carcinoma (HNSCC) leads to an immunosuppressive microenvironment and reduces the response to radiotherapy. In this prospective imaging trial, we investigated potential interactions between functional hypoxia imaging and infiltrating lymphocyte levels as a potential predictor for treatment response in HNSCC patients. Methods: In total, 49 patients receiving definitive chemoradiation for locally advanced HNSCCs underwent pretherapeutic biopsies and peritherapeutic hypoxia imaging using 18F-misonidazole PET at weeks 0, 2, and 5 during chemoradiation. Hematoxylin-eosin and immunohistochemical stainings for tumor-infiltrating lymphocytes, tissue-based hypoxia, and microvascular markers were analyzed and correlated with the longitudinal hypoxia dynamics and patient outcomes. Results: High levels of tumor-infiltrating total lymphocytes correlated with superior locoregional control (LRC) (hazard ratio [HR], 0.279; P = 0.011) and progression-free survival (PFS) (HR, 0.276; P = 0.006). Similarly, early resolution of 18F-misonidazole PET-detected tumor hypoxia quantified by 18F-misonidazole dynamics between weeks 0 and 2 of chemoradiation was associated with improved LRC (HR, 0.321; P = 0.015) and PFS (HR, 0.402; P = 0.043). Outcomes in the favorable early hypoxia resolution subgroup significantly depended on infiltrating lymphocyte counts, with patients who showed both an early hypoxia response and high lymphocyte infiltration levels exhibiting significantly improved LRC (HR, 0.259; P = 0.036) and PFS (HR, 0.242; P = 0.017) compared with patients with an early hypoxia response but low lymphocyte counts. These patients exhibited oncologic results comparable to those of patients with no hypoxia response within the first 2 wk of chemoradiation. Conclusion: This analysis established a clinical hypoxia-immune score that predicted treatment responses and outcomes in HNSCC patients undergoing chemoradiation and may help to devise novel concepts for biology-driven personalization of chemoradiation.
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Affiliation(s)
- Nils H Nicolay
- Department of Radiation Oncology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany .,German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
| | - Alexander Rühle
- Department of Radiation Oncology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.,German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
| | - Nicole Wiedenmann
- Department of Radiation Oncology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.,German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
| | - Gabriele Niedermann
- Department of Radiation Oncology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.,German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
| | - Michael Mix
- Department of Nuclear Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wolfgang A Weber
- Department of Nuclear Medicine, Technical University of Munich, Munich, Germany; and
| | - Dimos Baltas
- Department of Radiation Oncology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.,German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
| | - Martin Werner
- German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany.,Institute of Surgical Pathology, Department of Pathology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Gian Kayser
- German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany.,Institute of Surgical Pathology, Department of Pathology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.,German Cancer Consortium, Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
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Morand GB, Broglie MA, Schumann P, Huellner MW, Rupp NJ. Histometabolic Tumor Imaging of Hypoxia in Oral Cancer: Clinicopathological Correlation for Prediction of an Aggressive Phenotype. Front Oncol 2020; 10:1670. [PMID: 32984043 PMCID: PMC7481376 DOI: 10.3389/fonc.2020.01670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction Fluorodeoxyglucose-positron emission tomography (FDG-PET) is a widely used imaging tool for oral squamous cell carcinoma (OSCC). Preliminary studies indicate that quantification of tumor metabolic uptake may correlate with tumor hypoxia and aggressive phenotypes. Methods Retrospective review of a consecutive cohort of OSCC (n = 98) with available pretherapeutic FDG-PET/CT, treated at the University Hospital Zurich. Clinico-pathologico-radiological correlation between maximum standard uptake value (SUVmax) of the primary tumor, immunohistochemical staining for hypoxia-related proteins glucose transporter 1 (GLUT1) and hypoxia-inducible factor 1-alpha (HIF1a), depth of invasion (DOI), lymph node metastasis, and outcome was examined. Results Positive staining for GLUT1 and HIF1a on immunohistopathological analysis correlated with increased SUVmax on pretherapeutic imaging and with increased DOI (Kruskal–Wallis, P = 0.037, and P = 0.008, respectively). SUVmax and DOI showed a strong positive correlation (Spearman Rho, correlation coefficient = 0.451, P = 0.0003). An increase in SUVmax predicted nodal metastasis (Kruskal–Wallis, P = 0.017) and poor local control (log rank, P = 0.047). Conclusion In OSCC, FDG-PET-derived metabolic tumor parameter SUVmax serves as a surrogate marker for hypoxia and can be used to predict tumor aggressiveness, with more invasive phenotypes and poorer local control.
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Affiliation(s)
- Grégoire B Morand
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Martina A Broglie
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Paul Schumann
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Cranio-Maxillo-Facial and Oral Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin W Huellner
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Niels J Rupp
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
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Saksø M, Mortensen LS, Primdahl H, Johansen J, Kallehauge J, Hansen CR, Overgaard J. Influence of FAZA PET hypoxia and HPV-status for the outcome of head and neck squamous cell carcinoma (HNSCC) treated with radiotherapy: Long-term results from the DAHANCA 24 trial (NCT01017224). Radiother Oncol 2020; 151:126-133. [PMID: 32805273 DOI: 10.1016/j.radonc.2020.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/30/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Hypoxic tumor volumes can be visualized with 18F-FAZA PET/CT. In head and neck squamous cell carcinoma (HNSCC), hypoxia is important for the clinical outcome after primary radiotherapy (RT). The outcome is furthermore heavily influenced by the HPV/p16-positivity of oropharyngeal tumors (OPCp16+ tumors). The study purposes were (1) to report on locoregional failures within five years after primary RT in a prospective cohort stratified by both HPV/p16-status and PET hypoxia and (2) to characterize the failure site and the spatial association to PET hypoxia. MATERIAL AND METHODS From 2009 to 2011, 38 patients with non-metastatic SCC of the larynx, oro-, hypo- and nasopharynx completing primary RT were included in the prospective DAHANCA 24 trial (NCT01017224). Fifteen patients had OPCp16+ tumors. All were imaged with a static FAZA PET/CT prior to treatment. The hypoxia threshold was determined by a tumor-to-muscle ratio (TMR) of 1.6. Recurrences were documented histologically. Imaging of the recurrence was deformable fused with the pre-treatment FAZA PET/CT. The spatial information of recurrence- and hypoxic volumes were compared visually. RESULTS Sixteen patients had more hypoxic tumors (high tracer uptake, TMR ≥1.6) before treatment (42%). With a median follow-up of 7.8 years, nine locoregional recurrences were observed, of which seven were in patients with high-uptake tumors (44% and 9%, respectively, HR 5.8 [1.2-28.2]). The risk of locoregional recurrence was highest among patients with more hypoxic, non-OPCp16+ tumors (57% [21-94%]), with a risk difference of 45% [4-86%], when comparing to less hypoxic, non-OPCp16+ tumors. Eight patients had sufficient imaging of the recurrence for co-registration with the FAZA PET/CT. Six had hypoxic primary tumors, and in two, the recurrence was overlapping the baseline hypoxic subvolume. CONCLUSION HNSCC demonstrating a TMR ≥1.6 at baseline is significantly associated with treatment failure after primary RT. In addition to HPV/p16-status, FAZA PET/CT has potential for the selection of tumors requiring treatment intensification.
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Affiliation(s)
- Mette Saksø
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
| | | | - Hanne Primdahl
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | | | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
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Abstract
Head and neck cancers are commonly encountered malignancies in the United States, of which the majority are attributed to squamous cell carcinoma. 18F-FDG-PET/CT has been well established in the evaluation, treatment planning, prognostic implications of these tumors and is routinely applied for the management of patients with these cancers. Many alternative investigational PET radiotracers have been extensively studied in the evaluation of these tumors. Although these radiotracers have not been able to replace 18F-FDG-PET/CT in routine clinical practice currently, they may provide important additional information about the biological mechanisms of these tumors, such as foci of tumor hypoxia as seen on hypoxia specific PET radiotracers such as 18F-Fluoromisonidazole (18F-FMISO), which could be useful in targeting radioresistant hypoxic tumor foci when treatment planning. There are multiple other hypoxia-specific PET radiotracers such as 18F-Fluoroazomycinarabinoside (FAZA), 18F-Flortanidazole (HX4), which have been evaluated similarly, of which 18F-Fluoromisonidazole (18F-FMISO) has been the most investigated. Other radiotracers frequently studied in the evaluation of these tumors include radiolabeled amino acid PET radiotracers, which show increased uptake in tumor cells with limited uptake in inflammatory tissue, which can be useful especially in differentiating postradiation inflammation from residual and/or recurrent disease. 18F-Fluorothymidine (FLT) is localized intracellularly by nucleoside transport and undergoes phosphorylation thereby being retained within tumor cells and can serve as an indicator of tumor proliferation. Decrease in radiotracer activity following treatment can be an early indicator of treatment response. This review aims at synthesizing the available literature on the most studied non-FDG-PET/CT in head and neck cancer.
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Affiliation(s)
- Charles Marcus
- Department of Radiology, West Virginia University, Morgantown, WV.
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Rühle A, Grosu AL, Wiedenmann N, Mix M, Stoian R, Niedermann G, Baltas D, Werner M, Weber WA, Kayser G, Nicolay NH. Hypoxia dynamics on FMISO-PET in combination with PD-1/PD-L1 expression has an impact on the clinical outcome of patients with Head-and-neck Squamous Cell Carcinoma undergoing Chemoradiation. Am J Cancer Res 2020; 10:9395-9406. [PMID: 32802199 PMCID: PMC7415814 DOI: 10.7150/thno.48392] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 12/24/2022] Open
Abstract
Tumor-associated hypoxia influences the radiation response of head-and-neck cancer (HNSCC) patients, and a lack of early hypoxia resolution during treatment considerably deteriorates outcomes. As the detrimental effects of hypoxia are partly related to the induction of an immunosuppressive microenvironment, we investigated the interaction between tumor hypoxia dynamics and the PD-1/PD-L1 axis in HNSCC patients undergoing chemoradiation and its relevance for patient outcomes in a prospective trial. Methods: 49 patients treated with definitive chemoradiation for locally advanced HNSCC were enrolled in this trial and received longitudinal hypoxia PET imaging using fluorine-18 misonidazole ([18F]FMISO) at weeks 0, 2 and 5 during treatment. Pre-therapeutic tumor biopsies were immunohistochemically analyzed regarding the PD-1/PD-L1 expression both on immune cells and on tumor cells, and potential correlations between the PD-1/PD-L1 axis and tumor hypoxia dynamics during chemoradiation were assessed using Spearman's rank correlations. Hypoxia dynamics during treatment were quantified by subtracting the standardized uptake value (SUV) index at baseline from the SUV values at weeks 2 or 5, whereby SUV index was defined as ratio of maximum tumor [18F]FMISO SUV to mean SUV in the contralateral sternocleidomastoid muscle (i.e. tumor-to-muscle ratio). The impact of the PD-1/PD-L1 expression alone and in combination with persistent tumor hypoxia on locoregional control (LRC), progression-free survival (PFS) and overall survival (OS) was examined using log-rank tests and Cox proportional hazards models. Results: Neither PD-L1 nor PD-1 expression levels on tumor-infiltrating immune cells influenced LRC (HR = 0.734; p = 0.480 for PD-L1, HR = 0.991; p = 0.989 for PD-1), PFS (HR = 0.813; p = 0.597 for PD-L1, HR = 0.796; p = 0.713 for PD-1) or OS (HR = 0.698; p = 0.405 for PD-L1, HR = 0.315; p = 0.265 for PD-1). However, patients with no hypoxia resolution between weeks 0 and 2 and PD-L1 expression on tumor cells, quantified by a tumor proportional score (TPS) of at least 1%, showed significantly worse LRC (HR = 3.374, p = 0.022) and a trend towards reduced PFS (HR = 2.752, p = 0.052). In the multivariate Cox regression analysis, the combination of absent tumor hypoxia resolution and high tumoral PD-L1 expression remained a significant prognosticator for impaired LRC (HR = 3.374, p = 0.022). On the other side, tumoral PD-L1 expression did not compromise the outcomes of patients whose tumor-associated hypoxia declined between week 0 and 2 during chemoradiation (LRC: HR = 1.186, p = 0.772, PFS: HR = 0.846, p = 0.766). Conclusion: In this exploratory analysis, we showed for the first time that patients with both persistent tumor-associated hypoxia during treatment and PD-L1 expression on tumor cells exhibited a worse outcome, while the tumor cells' PD-L1 expression did not influence the outcomes of patients with early tumor hypoxia resolution. While the results have to be validated in an independent cohort, these findings form a foundation to investigate the combination of hypoxic modification and immune checkpoint inhibitors for the unfavorable subgroup, moving forward towards personalized radiation oncology treatment.
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Socarrás Fernández JA, Mönnich D, Leibfarth S, Welz S, Zwanenburg A, Leger S, Löck S, Pfannenberg C, La Fougère C, Reischl G, Baumann M, Zips D, Thorwarth D. Comparison of patient stratification by computed tomography radiomics and hypoxia positron emission tomography in head-and-neck cancer radiotherapy. Phys Imaging Radiat Oncol 2020; 15:52-59. [PMID: 33043157 PMCID: PMC7536307 DOI: 10.1016/j.phro.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Hypoxia Positron-Emission-Tomography (PET) as well as Computed Tomography (CT) radiomics have been shown to be prognostic for radiotherapy outcome. Here, we investigate the stratification potential of CT-radiomics in head and neck cancer (HNC) patients and test if CT-radiomics is a surrogate predictor for hypoxia as identified by PET. MATERIALS AND METHODS Two independent cohorts of HNC patients were used for model development and validation, HN1 (n = 149) and HN2 (n = 47). The training set HN1 consisted of native planning CT data whereas for the validation cohort HN2 also hypoxia PET/CT data was acquired using [18F]-Fluoromisonidazole (FMISO). Machine learning algorithms including feature engineering and classifier selection were trained for two-year loco-regional control (LRC) to create optimal CT-radiomics signatures.Secondly, a pre-defined [18F]FMISO-PET tumour-to-muscle-ratio (TMRpeak ≥ 1.6) was used for LRC prediction. Comparison between risk groups identified by CT-radiomics or [18F]FMISO-PET was performed using area-under-the-curve (AUC) and Kaplan-Meier analysis including log-rank test. RESULTS The best performing CT-radiomics signature included two features with nearest-neighbour classification (AUC = 0.76 ± 0.09), whereas AUC was 0.59 for external validation. In contrast, [18F]FMISO TMRpeak reached an AUC of 0.66 in HN2. Kaplan-Meier analysis of the independent validation cohort HN2 did not confirm the prognostic value of CT-radiomics (p = 0.18), whereas for [18F]FMISO-PET significant differences were observed (p = 0.02). CONCLUSIONS No direct correlation of patient stratification using [18F]FMISO-PET or CT-radiomics was found in this study. Risk groups identified by CT-radiomics or hypoxia PET showed only poor overlap. Direct assessment of tumour hypoxia using PET seems to be more powerful to stratify HNC patients.
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Affiliation(s)
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Sara Leibfarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Germany
| | - Alex Zwanenburg
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Leger
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Steffen Löck
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Christina Pfannenberg
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Germany
| | - Michael Baumann
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center DKFZ, Heidelberg, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University of Tübingen, Germany
- German Cancer Consortium (DKTK), partner Site Tübingen, Tübingen, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
- German Cancer Consortium (DKTK), partner Site Tübingen, Tübingen, Germany
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Krause M, Alsner J, Linge A, Bütof R, Löck S, Bristow R. Specific requirements for translation of biological research into clinical radiation oncology. Mol Oncol 2020; 14:1569-1576. [PMID: 32175659 PMCID: PMC7332213 DOI: 10.1002/1878-0261.12671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/23/2019] [Accepted: 03/12/2020] [Indexed: 12/15/2022] Open
Abstract
Radiotherapy has been optimized over the last decades not only through technological advances, but also through the translation of biological knowledge into clinical treatment schedules. Optimization of fractionation schedules and/or the introduction of simultaneous combined systemic treatment have significantly improved tumour cure rates in several cancer types. With modern techniques, we are currently able to measure factors of radiation resistance or radiation sensitivity in patient tumours; the definition of new biomarkers is expected to further enable personalized treatments. In this Review article, we overview important translation paths and summarize the quality requirements for preclinical and translational studies that will help to avoid bias in trial results.
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Affiliation(s)
- Mechthild Krause
- German Cancer Consortium (DKTK)Partner Site DresdenGermany
- German Cancer Research Center (DKFZ)HeidelbergGermany
- OncoRay ‐ National Center for Radiation Research in OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusHelmholtz‐Zentrum Dresden – RossendorfTU DresdenGermany
- Department of Radiotherapy and Radiation OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusTU DresdenGermany
- Helmholtz‐Zentrum Dresden ‐ RossendorfInstitute of Radiooncology – OncoRayDresdenGermany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), HeidelbergGermany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, DresdenGermany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR)DresdenGermany
| | - Jan Alsner
- Department of Experimental Clinical OncologyAarhus University HospitalDenmark
| | - Annett Linge
- German Cancer Consortium (DKTK)Partner Site DresdenGermany
- German Cancer Research Center (DKFZ)HeidelbergGermany
- OncoRay ‐ National Center for Radiation Research in OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusHelmholtz‐Zentrum Dresden – RossendorfTU DresdenGermany
- Department of Radiotherapy and Radiation OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusTU DresdenGermany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), HeidelbergGermany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, DresdenGermany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR)DresdenGermany
| | - Rebecca Bütof
- German Cancer Consortium (DKTK)Partner Site DresdenGermany
- German Cancer Research Center (DKFZ)HeidelbergGermany
- OncoRay ‐ National Center for Radiation Research in OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusHelmholtz‐Zentrum Dresden – RossendorfTU DresdenGermany
- Department of Radiotherapy and Radiation OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusTU DresdenGermany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), HeidelbergGermany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, DresdenGermany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR)DresdenGermany
| | - Steffen Löck
- German Cancer Consortium (DKTK)Partner Site DresdenGermany
- German Cancer Research Center (DKFZ)HeidelbergGermany
- OncoRay ‐ National Center for Radiation Research in OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusHelmholtz‐Zentrum Dresden – RossendorfTU DresdenGermany
- Department of Radiotherapy and Radiation OncologyFaculty of MedicineUniversity Hospital Carl Gustav CarusTU DresdenGermany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), HeidelbergGermany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, DresdenGermany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR)DresdenGermany
| | - Rob Bristow
- Translational OncogenomicsCRUK Manchester Institute and CentreDivision of Cancer SciencesUniversity of ManchesterUK
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Grégoire V, Guckenberger M, Haustermans K, Lagendijk JJW, Ménard C, Pötter R, Slotman BJ, Tanderup K, Thorwarth D, van Herk M, Zips D. Image guidance in radiation therapy for better cure of cancer. Mol Oncol 2020; 14:1470-1491. [PMID: 32536001 PMCID: PMC7332209 DOI: 10.1002/1878-0261.12751] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
The key goal and main challenge of radiation therapy is the elimination of tumors without any concurring damages of the surrounding healthy tissues and organs. Radiation doses required to achieve sufficient cancer-cell kill exceed in most clinical situations the dose that can be tolerated by the healthy tissues, especially when large parts of the affected organ are irradiated. High-precision radiation oncology aims at optimizing tumor coverage, while sparing normal tissues. Medical imaging during the preparation phase, as well as in the treatment room for localization of the tumor and directing the beam, referred to as image-guided radiotherapy (IGRT), is the cornerstone of precision radiation oncology. Sophisticated high-resolution real-time IGRT using X-rays, computer tomography, magnetic resonance imaging, or ultrasound, enables delivery of high radiation doses to tumors without significant damage of healthy organs. IGRT is the most convincing success story of radiation oncology over the last decades, and it remains a major driving force of innovation, contributing to the development of personalized oncology, for example, through the use of real-time imaging biomarkers for individualized dose delivery.
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Affiliation(s)
- Vincent Grégoire
- Department of Radiation OncologyLéon Bérard Cancer CenterLyonFrance
| | - Matthias Guckenberger
- Department for Radiation OncologyUniversity Hospital ZurichUniversity of ZurichSwitzerland
| | - Karin Haustermans
- Department of Radiation OncologyLeuven Cancer InstituteUniversity Hospital GasthuisbergLeuvenBelgium
| | | | | | - Richard Pötter
- Department of Radiation OncologyMedical UniversityGeneral Hospital of ViennaAustria
| | - Ben J. Slotman
- Department of Radiation OncologyAmsterdam University Medical CentersThe Netherlands
| | - Kari Tanderup
- Department of OncologyAarhus University HospitalDenmark
| | - Daniela Thorwarth
- Section for Biomedical PhysicsDepartment of Radiation OncologyUniversity of TübingenGermany
| | - Marcel van Herk
- Department of Biomedical Engineering and PhysicsCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamThe Netherlands
- Institute of Cancer SciencesUniversity of ManchesterUK
- Department of Radiotherapy Related ResearchThe Christie NHS Foundation TrustManchesterUK
| | - Daniel Zips
- Department of Radiation OncologyUniversity of TübingenGermany
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Wiedenmann N, Grosu AL, Büchert M, Rischke HC, Ruf J, Bielak L, Majerus L, Rühle A, Bamberg F, Baltas D, Hennig J, Mix M, Bock M, Nicolay NH. The utility of multiparametric MRI to characterize hypoxic tumor subvolumes in comparison to FMISO PET/CT. Consequences for diagnosis and chemoradiation treatment planning in head and neck cancer. Radiother Oncol 2020; 150:128-135. [PMID: 32544609 DOI: 10.1016/j.radonc.2020.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Hypoxia is an essential metabolic marker that determines chemo- and radiation resistance in head-and-neck squamous cell carcinoma (HNSCC) patients. Our exploratory analysis aimed to identify multiparametric MRI (mpMRI) parameters linked to hypoxia that might be used as surrogate for [18F]FMISO-PET in diagnosis and chemoradiation treatment (CRT) of HNSCC. MATERIALS AND METHODS 21 patients undergoing definitive CRT for HNSCC were prospectively imaged with serial [18F]FMISO-PET and 3 Tesla mpMRI for T1- and T2-weighted and dynamic contrast-enhanced perfusion and diffusion-weighted measurements (ktrans, ve, kep, ADC) in weeks 0, 2 and 5 and FDG-PET in week 0. [18F]FMISO-PET-derived hypoxic subvolumes (HSV) and complementary non-hypoxic subvolumes (nonHSV) were created for tumor and lymph nodes and projected on the mpMRI scans after PET/MRI co-registration. MpMRI and [18F]FMISO-PET parameters within HSVs and nonHSVs were statistically compared. RESULTS FMISO-PET-based HSVs of the primary tumors on MRI were characterized by lower ADC at all time points (p = 0.012 at baseline; p = 0.015 in week 2) and reduced interstitial space volume fraction ve and perfusion ktrans at baseline (p = 0.006, p = 0.047) compared to nonHSVs. Hypoxic lymph nodes were characterized by significantly lower ADC values at baseline (p = 0.039), but not at later time points and a reduction in ktrans-based perfusion at week 2 (p = 0.018). CONCLUSION MpMRI parameters differ significantly between hypoxic and non-hypoxic tumor regions, defined on FMISO-PET/CT as gold standard and might represent surrogate markers for tumor hypoxia. These findings suggest that mpMRI may be useful in the future as a surrogate modality for hypoxia imaging in order to personalize CRT.
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Affiliation(s)
- Nicole Wiedenmann
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Büchert
- Department of Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hans C Rischke
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Juri Ruf
- Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lars Bielak
- Department of Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Liette Majerus
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alexander Rühle
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Fabian Bamberg
- Department of Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Hennig
- Department of Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Mix
- Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Bock
- Department of Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Sanduleanu S, van der Wiel AM, Lieverse RI, Marcus D, Ibrahim A, Primakov S, Wu G, Theys J, Yaromina A, Dubois LJ, Lambin P. Hypoxia PET Imaging with [18F]-HX4-A Promising Next-Generation Tracer. Cancers (Basel) 2020; 12:cancers12051322. [PMID: 32455922 PMCID: PMC7280995 DOI: 10.3390/cancers12051322] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 02/04/2023] Open
Abstract
Hypoxia—a common feature of the majority of solid tumors—is a negative prognostic factor, as it is associated with invasion, metastasis and therapy resistance. To date, a variety of methods are available for the assessment of tumor hypoxia, including the use of positron emission tomography (PET). A plethora of hypoxia PET tracers, each with its own strengths and limitations, has been developed and successfully validated, thereby providing useful prognostic or predictive information. The current review focusses on [18F]-HX4, a promising next-generation hypoxia PET tracer. After a brief history of its development, we discuss and compare its characteristics with other hypoxia PET tracers and provide an update on its progression into the clinic. Lastly, we address the potential applications of assessing tumor hypoxia using [18F]-HX4, with a focus on improving patient-tailored therapies.
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Affiliation(s)
- Sebastian Sanduleanu
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
- Correspondence:
| | - Alexander M.A. van der Wiel
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Relinde I.Y. Lieverse
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Damiënne Marcus
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Abdalla Ibrahim
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
- Department of Radiology and Nuclear Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University Medical Centre+, 6229 Maastricht, The Netherlands
- Division of Nuclear Medicine and Oncological Imaging, Department of Medical Physics, Hospital Center Universitaire De Liege, 4030 Liege, Belgium
- Department of Nuclear Medicine and Comprehensive Diagnostic Center Aachen (CDCA), University Hospital RWTH Aachen University, 52074 Aachen, Germany
| | - Sergey Primakov
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Guangyao Wu
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Jan Theys
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Ala Yaromina
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Ludwig J. Dubois
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
| | - Philippe Lambin
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW—School for Oncology, Maastricht University, 6211 Maastricht, The Netherlands; (A.M.A.v.d.W.); (R.I.Y.L.); (D.M.); (A.I.); (S.P.); (G.W.); (J.T.); (A.Y.); (L.J.D.); (P.L.)
- Department of Radiology and Nuclear Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University Medical Centre+, 6229 Maastricht, The Netherlands
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Müller J, Schürer M, Neubert C, Tillner F, Beyreuther E, Suckert T, Peters N, von Neubeck C, Lühr A, Krause M, Bütof R, Dietrich A. Multi-modality bedding platform for combined imaging and irradiation of mice. Biomed Phys Eng Express 2020; 6:037003. [PMID: 33438682 DOI: 10.1088/2057-1976/ab79f1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Preclinical imaging and irradiation yields valuable insights into clinically relevant research topics. While complementary imaging methods such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) can be combined within single devices, this is technically demanding and cost-intensive. Similarly, bedding and setup solutions are often specific to certain devices and research questions. We present a bedding platform for mice that is compatible with various preclinical imaging modalities (combined PET/MRI, cone beam CT) and irradiation with photons and protons. It consists of a 3D-printed bedding unit (acrylonitrile butadiene styrene, ABS) holding the animal and features an inhalation anesthesia mask, jaw fixation, ear pins, and immobilization for the hind leg. It can be embedded on mounting adaptors for multi-modal imaging and into a transport box (polymethyl methacrylate, PMMA) for experiments outside dedicated animal facilities while maintaining the animal's hygiene status. A vital support unit provides heating, inhalation anesthesia, and a respiration monitor. We dosimetrically evaluated used materials in order to assess their interaction with incident irradiation. Proof-of-concept multi-modal imaging protocols were used on phantoms and mice. The measured attenuation of the bedding unit for 40/60/80/200 kV X-rays was less than 3%. The measured stopping-power-ratio of ABS was 0.951, the combined water-equivalent thickness of bedding unit and transport box was 4.2 mm for proton energies of 150 MeV and 200 MeV. Proof-of-concept imaging showed no loss of image quality. Imaging data of individual mice from different imaging modalities could be aligned rigidly. The presented bed aims to provide a platform for experiments related to both multi-modal imaging and irradiation, thus offering the possibility for image-guided irradiation which relies on precise imaging and positioning. The usage as a self-contained, stand-alone unit outside dedicated animal facilities represents an advantage over setups designed for specific devices.
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Affiliation(s)
- Johannes Müller
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany. Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Institute of Radiooncology-OncoRay, Germany
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66
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[ 18F]-HX4 PET/CT hypoxia in patients with squamous cell carcinoma of the head and neck treated with chemoradiotherapy: Prognostic results from two prospective trials. Clin Transl Radiat Oncol 2020; 23:9-15. [PMID: 32368624 PMCID: PMC7184102 DOI: 10.1016/j.ctro.2020.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/06/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction The presence of hypoxia in head-and-neck squamous cell carcinoma is a negative prognostic factor. PET imaging with [18F] HX4 can be used to visualize hypoxia, but it is currently unknown how this correlates with prognosis. We investigated the prognostic value of [18F] HX4 PET imaging in patients treated with definitive radio(chemo)therapy (RTx). Materials and methods We analyzed 34 patients included in two prospective clinical trials (NCT01347281, NCT01504815). Static [18F] HX4 PET-CT images were collected, both pre-treatment (median 4 days before start RTx, range 1-16), as well as during RTx (median 13 days after start RTx, range 3-17 days). Static uptake at both time points (n = 33 pretreatment, n = 28 during RTx) and measured changes in hypoxic fraction (HF) and hypoxic volume (HV) (n = 27 with 2 time points) were analyzed. Univariate cox analyses were done for local progression free survival (PFS) and overall survival (OS) at both timepoints. Change in uptake was analyzed by comparing outcome with Kaplan-Meier curves and log-rank test between patients with increased and decreased/stable hypoxia, similarly between patients with and without residual hypoxia (rHV = ratio week 2/baseline HV with cutoff 0.2). Voxelwise Spearman correlation coefficients were calculated between normalized [18F] HX4 PET uptake at baseline and week 2. Results Analyses of static images showed no prognostic value for [18F] HX4 uptake. Analysis of dynamic changes showed that both OS and local PFS were significantly shorter (log-rank P < 0.05) in patients with an increase in HV during RTx and OS was significantly shorter in patients with rHV, with no correlation to HPV-status. The voxel-based correlation to evaluate spatial distribution yielded a median Spearman correlation coefficient of 0.45 (range 0.11-0.65). Conclusion The change of [18F] HX4 uptake measured on [18F] HX4 PET early during treatment can be considered for implementation in predictive models. With these models patients with a worse prognosis can be selected for treatment intensification.
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67
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Cao X, Rao Allu S, Jiang S, Jia M, Gunn JR, Yao C, LaRochelle EP, Shell JR, Bruza P, Gladstone DJ, Jarvis LA, Tian J, Vinogradov SA, Pogue BW. Tissue pO 2 distributions in xenograft tumors dynamically imaged by Cherenkov-excited phosphorescence during fractionated radiation therapy. Nat Commun 2020; 11:573. [PMID: 31996677 PMCID: PMC6989492 DOI: 10.1038/s41467-020-14415-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/04/2020] [Indexed: 12/24/2022] Open
Abstract
Hypoxia in solid tumors is thought to be an important factor in resistance to therapy, but the extreme microscopic heterogeneity of the partial pressures of oxygen (pO2) between the capillaries makes it difficult to characterize the scope of this phenomenon without invasive sampling of oxygen distributions throughout the tissue. Here we develop a non-invasive method to track spatial oxygen distributions in tumors during fractionated radiotherapy, using oxygen-dependent quenching of phosphorescence, oxygen probe Oxyphor PtG4 and the radiotherapy-induced Cherenkov light to excite and image the phosphorescence lifetimes within the tissue. Mice bearing MDA-MB-231 breast cancer and FaDu head neck cancer xenografts show different pO2 responses during each of the 5 fractions (5 Gy per fraction), delivered from a clinical linear accelerator. This study demonstrates subsurface in vivo mapping of tumor pO2 distributions with submillimeter spatial resolution, thus providing a methodology to track response of tumors to fractionated radiotherapy.
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Affiliation(s)
- Xu Cao
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA.,Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, Shaanxi, China
| | - Srinivasa Rao Allu
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Chemistry, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Shudong Jiang
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mengyu Jia
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Jason R Gunn
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Cuiping Yao
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA.,Key Laboratory of Biomedical Information Engineering of Ministry of Education, Institute of Biomedical Analytical Technology and Instrumentation, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | | | - Jennifer R Shell
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Petr Bruza
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - David J Gladstone
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Lesley A Jarvis
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Jie Tian
- Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, Shaanxi, China.,CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Sergei A Vinogradov
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Chemistry, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian W Pogue
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA. .,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
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Nicolay NH, Wiedenmann N, Mix M, Weber WA, Werner M, Grosu AL, Kayser G. Correlative analyses between tissue-based hypoxia biomarkers and hypoxia PET imaging in head and neck cancer patients during radiochemotherapy-results from a prospective trial. Eur J Nucl Med Mol Imaging 2019; 47:1046-1055. [PMID: 31811344 DOI: 10.1007/s00259-019-04598-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/04/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Tumor hypoxia impairs the response of head-and-neck cancer (HNSCC) patients to radiotherapy and can be detected both by tissue biomarkers and PET imaging. However, the value of hypoxia biomarkers and imaging for predicting HNSCC patient outcomes are incompletely understood, and potential correlations between tissue and PET data remain to be elucidated. Here, we performed exploratory analyses of potential correlations between tissue-based hypoxia biomarkers and longitudinal hypoxia imaging in a prospective trial of HNSCC patients. METHODS Forty-nine patients undergoing chemoradiation for locally advanced HNSCCs were enrolled in this prospective trial. They underwent baseline biopsies and [18F]FDG PET imaging and [18F]FMISO PET at weeks 0, 2, and 5 during treatment. Immunohistochemical analyses for p16, Ki67, CD34, HIF1α, CAIX, Ku80, and CD44 were performed, and HPV status was assessed. Biomarker expression was correlated with biological imaging information and patient outcome data. RESULTS High HIF1α tumor levels significantly correlated with increased tumor hypoxia at week 2 as assessed by the difference in the [18F]FMISO tumor-to-background ratios, and high HIF1α and CAIX expressions were both associated with a deferred decrease in hypoxia between weeks 2 and 5. Loco-regional recurrence rates after radiotherapy were significantly higher in patients with high CAIX expression and also increased for high levels of the DNA repair factor Ku80. HPV status did not correlate with any of the tested hypoxia biomarkers, and HPV-positive patients showed higher loco-regional control rates and progression-free survival independent of their hypoxia dynamics. CONCLUSION In this exploratory trial, high expression of the tissue-based hypoxia biomarkers HIF1α and CAIX correlated with adverse hypoxia dynamics in HNSCCs during chemoradiation as assessed by PET imaging, and high CAIX levels were associated with increased loco-regional recurrence rates. Hence, hypoxia biomarkers warrant further investigations as potential predictors of hypoxia dynamics and hypoxia-associated radiation resistance.
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Affiliation(s)
- Nils H Nicolay
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany. .,German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Nicole Wiedenmann
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Mix
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang A Weber
- Department of Nuclear Medicine, Technical University of Munich, Munich, Germany
| | - Martin Werner
- German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Surgical Pathology, Department of Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Gian Kayser
- German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Surgical Pathology, Department of Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Textural features of hypoxia PET predict survival in head and neck cancer during chemoradiotherapy. Eur J Nucl Med Mol Imaging 2019; 47:1056-1064. [PMID: 31773233 DOI: 10.1007/s00259-019-04609-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/07/2019] [Indexed: 01/24/2023]
Abstract
PURPOSE The aim of this study was to investigate whether textural features of tumour hypoxia, assessed with serial [18F]fluoromisonidazole (FMISO)-PET, were able to predict clinical outcome in patients with head and neck squamous cell carcinoma (HNSCC, T1-4, N+, M0) during chemoradiotherapy (CRT). METHODS In a preliminary evaluation of a prospective trial, tumour hypoxia was evaluated in 29 patients via serial FMISO-PET before and during CRT. All patients received an initial [18F]fluorodeoxyglucose (FDG)-PET before CRT, and tumour regions were defined on this FDG-PET. The first-order metrics tumour-to-background ratio (TBRmean, TBRmax, TBRpeak), coefficient of variation, total lesion uptake and integral non-uniformity were calculated for all scans. Further, 3 second-order (textural) features from two grey-level matrices were calculated, as well as differential non-uniformity (udiff). Prognostic value was examined by median split for group separation (GS) in Kaplan-Meier estimates and correlated with overall survival (OS), quantified via log-rank tests (p ≤ 0.05) and group-relative hazard ratios (HR). RESULTS Within a median follow-up of 29.6 months (95% CI: 16.8-48.0 months), no first-order metrics predicted OS with a significant GS (all p > 0.05) on any FMISO-PET scan. Only udiff before and in week 2 during CRT (p = 0.03, HR = 10.8 and p = 0.05, HR = 5.2) and non-uniformity from grey-level run length matrix in week 2 separated prognostic groups (p = 0.05, HR = 5.3); lower values were correlated with better OS. Further, the decrease in udiff from before CRT to week 2 was correlated with better OS (p = 0.04, HR = 9.4). FDG-PET before CRT did not predict outcome in any measure. CONCLUSIONS Textural features on FMISO-PET scans before CRT, in week 2 and, to a limited degree, the change of features during CRT, were able to identify head and neck squamous cell carcinoma patients with better OS, suggesting that a higher homogeneity of the degree of hypoxia in tumours could correlate with a better outcome after CRT.
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Broglie MA, Dulguerov P, Henke G, Siano M, Putora PM, Simon C, Zwahlen D, Huber GF, Ballerini G, Beffa L, Giger R, Rothschild S, Negri SV, Elicin O. A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 4 (Biomarkers). Front Oncol 2019; 9:1128. [PMID: 31709188 PMCID: PMC6822019 DOI: 10.3389/fonc.2019.01128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer. Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51-74%), moderate (75-84%), and high (≥85%). Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate, and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively. Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.
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Affiliation(s)
- Martina A Broglie
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pavel Dulguerov
- Department of Otorhinolaryngology, Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Guido Henke
- Department of Radiation Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marco Siano
- Department of Medical Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Medical Oncology, Hôpital Riviera-Chablais, Vevey, Switzerland
| | - Paul Martin Putora
- Department of Radiation Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Simon
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Daniel Zwahlen
- Department of Radiation Oncology, Cantonal Hospital Graubünden, Chur, Switzerland.,Department of Radiation Oncology, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Gerhard F Huber
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Giorgio Ballerini
- Department of Radiation Oncology, Clinica Luganese SA, Lugano, Switzerland
| | - Lorenza Beffa
- Department of Radiation Oncology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Roland Giger
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Sacha Rothschild
- Department of Medical Oncology, University Hospital of Basel, Basel, Switzerland
| | - Sandro V Negri
- Department of Otorhinolaryngology, Lindenhofspital, Bern, Switzerland
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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71
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Abstract
The progressive integration of positron emission tomography/computed tomography (PET/CT) imaging in radiation therapy has its rationale in the biological intertumoral and intratumoral heterogeneity of malignant lesions that require the individual adjustment of radiation dose to obtain an effective local tumor control in cancer patients. PET/CT provides information on the biological features of tumor lesions such as metabolism, hypoxia, and proliferation that can identify radioresistant regions and be exploited to optimize treatment plans. Here, we provide an overview of the basic principles of PET-based target volume selection and definition using 18F-fluorodeoxyglucose (18F-FDG) and then we focus on the emerging strategies of dose painting and adaptive radiotherapy using different tracers. Previous studies provided consistent evidence that integration of 18F-FDG PET/CT in radiotherapy planning improves delineation of target volumes and reduces the uncertainties and variabilities of anatomical delineation of tumor sites. PET-based dose painting and adaptive radiotherapy are feasible strategies although their clinical implementation is highly demanding and requires strong technical, computational, and logistic efforts. Further prospective clinical trials evaluating local tumor control, survival, and toxicity of these emerging strategies will promote the full integration of PET/CT in radiation oncology.
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Affiliation(s)
- Rosa Fonti
- Institute of Biostructures and Bioimages, National Research Council, Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Silvana Del Vecchio
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy.
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72
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Alterio D, Marvaso G, Ferrari A, Volpe S, Orecchia R, Jereczek-Fossa BA. Modern radiotherapy for head and neck cancer. Semin Oncol 2019; 46:233-245. [PMID: 31378376 DOI: 10.1053/j.seminoncol.2019.07.002] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/15/2019] [Indexed: 02/07/2023]
Abstract
Radiation therapy (RT) plays a key role in curative-intent treatments for head and neck cancers. Its use is indicated as a sole therapy in early stage tumors or in combination with surgery or concurrent chemotherapy in advanced stages. Recent technologic advances have resulted in both improved oncologic results and expansion of the indications for RT in clinical practice. Despite this, RT administered to the head and neck region is still burdened by a high rate of acute and late side effects. Moreover, about 50% of patients with high-risk disease experience loco-regional recurrence within 3 years of follow-up. Therefore, in recent decades, efforts have been dedicated to optimize the cost/benefit ratio of RT in this subset of patients. The aim of the present review was to highlight modern concepts of RT for head and neck cancers considering both the technological advances that have been achieved and recent knowledge that has informed the biological interaction between radiation and both tumor and healthy tissues.
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Affiliation(s)
- Daniela Alterio
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Giulia Marvaso
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy.
| | - Annamaria Ferrari
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Stefania Volpe
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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73
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Integrating molecular nuclear imaging in clinical research to improve anticancer therapy. Nat Rev Clin Oncol 2019; 16:241-255. [PMID: 30479378 DOI: 10.1038/s41571-018-0123-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Effective patient selection before or early during treatment is important to increasing the therapeutic benefits of anticancer treatments. This selection process is often predicated on biomarkers, predominantly biospecimen biomarkers derived from blood or tumour tissue; however, such biomarkers provide limited information about the true extent of disease or about the characteristics of different, potentially heterogeneous tumours present in an individual patient. Molecular imaging can also produce quantitative outputs; such imaging biomarkers can help to fill these knowledge gaps by providing complementary information on tumour characteristics, including heterogeneity and the microenvironment, as well as on pharmacokinetic parameters, drug-target engagement and responses to treatment. This integrative approach could therefore streamline biomarker and drug development, although a range of issues need to be overcome in order to enable a broader use of molecular imaging in clinical trials. In this Perspective article, we outline the multistage process of developing novel molecular imaging biomarkers. We discuss the challenges that have restricted the use of molecular imaging in clinical oncology research to date and outline future opportunities in this area.
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74
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Salem A, Little RA, Latif A, Featherstone AK, Babur M, Peset I, Cheung S, Watson Y, Tessyman V, Mistry H, Ashton G, Behan C, Matthews JC, Asselin MC, Bristow RG, Jackson A, Parker GJM, Faivre-Finn C, Williams KJ, O'Connor JPB. Oxygen-enhanced MRI Is Feasible, Repeatable, and Detects Radiotherapy-induced Change in Hypoxia in Xenograft Models and in Patients with Non-small Cell Lung Cancer. Clin Cancer Res 2019; 25:3818-3829. [PMID: 31053599 DOI: 10.1158/1078-0432.ccr-18-3932] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/04/2019] [Accepted: 03/14/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Hypoxia is associated with poor prognosis and is predictive of poor response to cancer treatments, including radiotherapy. Developing noninvasive biomarkers that both detect hypoxia prior to treatment and track change in tumor hypoxia following treatment is required urgently. EXPERIMENTAL DESIGN We evaluated the ability of oxygen-enhanced MRI (OE-MRI) to map and quantify therapy-induced changes in tumor hypoxia by measuring oxygen-refractory signals in perfused tissue (perfused Oxy-R). Clinical first-in-human study in patients with non-small cell lung cancer (NSCLC) was performed alongside preclinical experiments in two xenograft tumors (Calu6 NSCLC model and U87 glioma model). RESULTS MRI perfused Oxy-R tumor fraction measurement of hypoxia was validated with ex vivo tissue pathology in both xenograft models. Calu6 and U87 experiments showed that MRI perfused Oxy-R tumor volume was reduced relative to control following single fraction 10-Gy radiation and fractionated chemoradiotherapy (P < 0.001) due to both improved perfusion and reduced oxygen consumption rate. Next, evaluation of 23 patients with NSCLC showed that OE-MRI was clinically feasible and that tumor perfused Oxy-R volume is repeatable [interclass correlation coefficient: 0.961 (95% CI, 0.858-0.990); coefficient of variation: 25.880%]. Group-wise perfused Oxy-R volume was reduced at 14 days following start of radiotherapy (P = 0.015). OE-MRI detected between-subject variation in hypoxia modification in both xenograft and patient tumors. CONCLUSIONS These findings support applying OE-MRI biomarkers to monitor hypoxia modification, to stratify patients in clinical trials of hypoxia-modifying therapies, to identify patients with hypoxic tumors that may fail treatment with immunotherapy, and to guide adaptive radiotherapy by mapping regional hypoxia.
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Affiliation(s)
- Ahmed Salem
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
- Department of Clinical Oncology, The Christie Hospital NHS Trust, Manchester, United Kingdom
| | - Ross A Little
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Ayşe Latif
- Division of Pharmacy, University of Manchester, Manchester, United Kingdom
| | - Adam K Featherstone
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Muhammad Babur
- Division of Pharmacy, University of Manchester, Manchester, United Kingdom
| | - Isabel Peset
- Imaging and Flow Cytometry, Cancer Research UK Manchester Institute, Manchester, United Kingdom
| | - Susan Cheung
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Yvonne Watson
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Victoria Tessyman
- Division of Pharmacy, University of Manchester, Manchester, United Kingdom
| | - Hitesh Mistry
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Division of Pharmacy, University of Manchester, Manchester, United Kingdom
| | - Garry Ashton
- Histology, Cancer Research UK Manchester Institute, Manchester, United Kingdom
| | - Caron Behan
- Histology, Cancer Research UK Manchester Institute, Manchester, United Kingdom
| | - Julian C Matthews
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
| | - Marie-Claude Asselin
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Robert G Bristow
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Clinical Oncology, The Christie Hospital NHS Trust, Manchester, United Kingdom
| | - Alan Jackson
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Geoff J M Parker
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
- Bioxydyn Limited, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Clinical Oncology, The Christie Hospital NHS Trust, Manchester, United Kingdom
| | - Kaye J Williams
- Division of Pharmacy, University of Manchester, Manchester, United Kingdom
| | - James P B O'Connor
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom. James.O'
- Department of Radiology, The Christie Hospital NHS Trust, Manchester, United Kingdom
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75
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Gérard M, Corroyer-Dulmont A, Lesueur P, Collet S, Chérel M, Bourgeois M, Stefan D, Limkin EJ, Perrio C, Guillamo JS, Dubray B, Bernaudin M, Thariat J, Valable S. Hypoxia Imaging and Adaptive Radiotherapy: A State-of-the-Art Approach in the Management of Glioma. Front Med (Lausanne) 2019; 6:117. [PMID: 31249831 PMCID: PMC6582242 DOI: 10.3389/fmed.2019.00117] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/13/2019] [Indexed: 01/31/2023] Open
Abstract
Severe hypoxia [oxygen partial pressure (pO2) below 5–10 mmHg] is more frequent in glioblastoma multiforme (GBM) compared to lower-grade gliomas. Seminal studies in the 1950s demonstrated that hypoxia was associated with increased resistance to low–linear energy transfer (LET) ionizing radiation. In experimental conditions, the total radiation dose has to be multiplied by a factor of 3 to achieve the same cell lethality in anoxic situations. The presence of hypoxia in human tumors is assumed to contribute to treatment failures after radiotherapy (RT) in cancer patients. Therefore, a logical way to overcome hypoxia-induced radioresistance would be to deliver substantially higher doses of RT in hypoxic volumes delineated on pre-treatment imaging as biological target volumes (BTVs). Such an approach faces various fundamental, technical, and clinical challenges. The present review addresses several technical points related to the delineation of hypoxic zones, which include: spatial accuracy, quantitative vs. relative threshold, variations of hypoxia levels during RT, and availability of hypoxia tracers. The feasibility of hypoxia imaging as an assessment tool for early tumor response to RT and for predicting long-term outcomes is discussed. Hypoxia imaging for RT dose painting is likewise examined. As for the radiation oncologist's point of view, hypoxia maps should be converted into dose-distribution objectives for RT planning. Taking into account the physics and the radiobiology of various irradiation beams, preliminary in silico studies are required to investigate the feasibility of dose escalation in terms of normal tissue tolerance before clinical trials are undertaken.
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Affiliation(s)
- Michael Gérard
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen, France.,Department of Radiation Oncology, Centre Lutte Contre le Cancer François Baclesse, Caen, France
| | | | - Paul Lesueur
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen, France.,Department of Radiation Oncology, Centre Lutte Contre le Cancer François Baclesse, Caen, France
| | - Solène Collet
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen, France.,Department of Radiophysics, Centre Lutte Contre le Cancer François Baclesse, Caen, France
| | - Michel Chérel
- Team 13-Nuclear Oncology, INSERM U1232 Centre de Recherche en Cancérologie et Immunologie Nantes Angers (CRCINA), Nantes, France
| | - Mickael Bourgeois
- Team 13-Nuclear Oncology, INSERM U1232 Centre de Recherche en Cancérologie et Immunologie Nantes Angers (CRCINA), Nantes, France
| | - Dinu Stefan
- Department of Radiation Oncology, Centre Lutte Contre le Cancer François Baclesse, Caen, France
| | - Elaine Johanna Limkin
- Department of Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Cécile Perrio
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/LDM-TEP Group, GIP Cyceron, Caen, France
| | - Jean-Sébastien Guillamo
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen, France.,Department of Neurology, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Bernard Dubray
- Département de Radiothérapie et de Physique Médicale, Laboratoire QuantIF-LITIS [EA 4108], Centre de Lutte Contre le Cancer Henri Becquerel, Université de Normandie, Rouen, France
| | - Myriam Bernaudin
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen, France
| | - Juliette Thariat
- Department of Radiation Oncology, Centre Lutte Contre le Cancer François Baclesse, Caen, France
| | - Samuel Valable
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen, France
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76
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Zhao S, Yu W, Ukon N, Tan C, Nishijima KI, Shimizu Y, Higashikawa K, Shiga T, Yamashita H, Tamaki N, Kuge Y. Elimination of tumor hypoxia by eribulin demonstrated by 18F-FMISO hypoxia imaging in human tumor xenograft models. EJNMMI Res 2019; 9:51. [PMID: 31161539 PMCID: PMC6546772 DOI: 10.1186/s13550-019-0521-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/27/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Eribulin, an inhibitor of microtubule dynamics, shows antitumor potency against a variety of solid cancers through its antivascular activity and remodeling of tumor vasculature. 18F-Fluoromisonidazole (18F-FMISO) is the most widely used PET probe for imaging tumor hypoxia. In this study, we utilized 18F-FMISO to clarify the effects of eribulin on the tumor hypoxic condition in comparison with histological findings. MATERIAL AND METHODS Mice bearing a human cancer cell xenograft were intraperitoneally administered a single dose of eribulin (0.3 or 1.0 mg/kg) or saline. Three days after the treatment, mice were injected with 18F-FMISO and pimonidazole (hypoxia marker for immunohistochemistry), and intertumoral 18F-FMISO accumulation levels and histological characteristics were determined. PET/CT was performed pre- and post-treatment with eribulin (0.3 mg/kg, i.p.). RESULTS The 18F-FMISO accumulation levels and percent pimonidazole-positive hypoxic area were significantly lower, whereas the number of microvessels was higher in the tumors treated with eribulin. The PET/CT confirmed that 18F-FMISO distribution in the tumor was decreased after the eribulin treatment. CONCLUSIONS Using 18F-FMISO, we demonstrated the elimination of the tumor hypoxic condition by eribulin treatment, concomitantly with the increase in microvessel density. These findings indicate that PET imaging using 18F-FMISO may provide the possibility to detect the early treatment response in clinical patients undergoing eribulin treatment.
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Affiliation(s)
- Songji Zhao
- Department of Tracer Kinetics and Bioanalysis, Graduate School of Medicine, Hokkaido University, Sapporo, Japan. .,Advanced Clinical Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan.
| | - Wenwen Yu
- Department of Tracer Kinetics and Bioanalysis, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoyuki Ukon
- Advanced Clinical Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan.,Central Institute of Isotope Science, Hokkaido University, Sapporo, Japan
| | - Chengbo Tan
- Advanced Clinical Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan
| | - Ken-Ichi Nishijima
- Central Institute of Isotope Science, Hokkaido University, Sapporo, Japan.,Department of Integrated Molecular Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoichi Shimizu
- Faculty of Pharmaceutical Science, Hokkaido University, Sapporo, Japan
| | - Kei Higashikawa
- Central Institute of Isotope Science, Hokkaido University, Sapporo, Japan.,Department of Integrated Molecular Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tohru Shiga
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroko Yamashita
- Department of Breast Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Nagara Tamaki
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuji Kuge
- Central Institute of Isotope Science, Hokkaido University, Sapporo, Japan.,Department of Integrated Molecular Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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77
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Thorwarth D, Welz S, Mönnich D, Pfannenberg C, Nikolaou K, Reimold M, La Fougère C, Reischl G, Mauz PS, Paulsen F, Alber M, Belka C, Zips D. Prospective Evaluation of a Tumor Control Probability Model Based on Dynamic 18F-FMISO PET for Head and Neck Cancer Radiotherapy. J Nucl Med 2019; 60:1698-1704. [PMID: 31076504 DOI: 10.2967/jnumed.119.227744] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022] Open
Abstract
Our purpose was to evaluate an imaging parameter-response relationship between the extent of tumor hypoxia quantified by dynamic 18F-fluoromisonidazole (18F-FMISO) PET/CT and the risk of relapse after radiotherapy in patients with head and neck cancer. Methods: Before a prospective cohort of 25 head and neck cancer patients started radiotherapy, they were examined with dynamic 18F-FMISO PET/CT 0-240 min after tracer injection. 18F-FMISO image parameters, including a hypoxia metric, M FMISO , derived from pharmacokinetic modeling of dynamic 18F-FMISO and maximum tumor-to-muscle ratio (TMRmax) at 4 h after injection, gross tumor volume (GTV), relative hypoxic volume based on M FMISO , and a logistic regression model combining GTV and TMRmax, were assessed and compared with a previous training cohort (n = 15). Dynamic 18F-FMISO was used to validate a tumor control probability model based on M FMISO The prognostic potential with respect to local control of all potential parameters was validated using the concordance index for univariate Cox regression models determined from the training cohort, in addition to Kaplan-Meier analysis including the log-rank test. Results: The tumor control probability model was confirmed, indicating that dynamic 18F-FMISO allows stratification of patients into different risk groups according to radiotherapy outcome. In this study, M FMISO was the only parameter that was confirmed as prognostic in the independent validation cohort (concordance index, 0.71; P = 0.004). All other investigated parameters, such as TMRmax, GTV, relative hypoxic volume, and the combination of GTV and TMRmax, were not able to stratify patient groups according to outcome in this validation cohort (P = not statistically significant). Conclusion: In this study, the relationship between M FMISO and the risk of relapse was prospectively validated. The data support further evaluation and external validation of dynamic 18F-FMISO PET/CT as a promising method for patient stratification and hypoxia-based radiotherapy personalization, including dose painting.
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Affiliation(s)
- Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany .,German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Christina Pfannenberg
- Diagnostic and Interventional Radiology, Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Diagnostic and Interventional Radiology, Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Matthias Reimold
- Department of Nuclear Medicine, University of Tübingen, Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, University of Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Markus Alber
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany.,Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany; and
| | - Claus Belka
- German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, LMU Munich, München, Germany
| | - Daniel Zips
- German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
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78
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Peitzsch C, Kurth I, Ebert N, Dubrovska A, Baumann M. Cancer stem cells in radiation response: current views and future perspectives in radiation oncology. Int J Radiat Biol 2019; 95:900-911. [PMID: 30897014 DOI: 10.1080/09553002.2019.1589023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose: Despite technological improvement and advances in biology-driven patient stratification, many patients still fail radiotherapy resulting in loco-regional and distant recurrence. Tumor heterogeneity remains a key challenge to effective cancer treatment, and reliable stratification of cancer patients for prediction of outcomes is highly important. Intratumoral heterogeneity is manifested at the different levels, including different tumorigenic properties of cancer cells. Since John Dick et al. isolated leukemia initiating cells in 1990, the populations of tumor initiating or cancer stem cells (CSCs) were identified and characterized also for a broad spectrum of solid tumor types. The properties of CSCs are of considerable clinical relevance: CSCs have self-renewal and tumor initiating potential, and the metastases are initiated by the CSC clones with the ability to disseminate from the primary tumor site. Conclusion: Evidence from both, experimental and clinical studies demonstrates that the probability of achieving local tumor control by radiation therapy depends on the complete eradication of CSC populations. The number, properties and molecular signature of CSCs are highly predictive for clinical outcome of radiotherapy, whereas targeted therapies against CSCs combined with conventional treatment are expected to provide an improved clinical response and prevent tumor relapse. In this review, we discuss the modern methods to study CSCs in radiation biology, the role of CSCs in personalized cancer therapy as well as future directions for CSC research in translational radiooncology.
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Affiliation(s)
- Claudia Peitzsch
- a OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany.,b National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz-Zentrum Dresden - Rossendorf (HZDR) , Dresden , Germany.,c German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ) , Heidelberg , Germany
| | - Ina Kurth
- d German Cancer Research Center (DKFZ) , Heidelberg , Germany
| | - Nadja Ebert
- d German Cancer Research Center (DKFZ) , Heidelberg , Germany.,f Department of Radiotherapy and Radiation Oncology , Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Anna Dubrovska
- a OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany.,c German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ) , Heidelberg , Germany.,e Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay , Dresden , Germany
| | - Michael Baumann
- d German Cancer Research Center (DKFZ) , Heidelberg , Germany.,f Department of Radiotherapy and Radiation Oncology , Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
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Linge A, Schmidt S, Lohaus F, Krenn C, Bandurska-Luque A, Platzek I, von Neubeck C, Appold S, Nowak A, Gudziol V, Buchholz F, Baretton GB, Baumann M, Löck S, Krause M. Independent validation of tumour volume, cancer stem cell markers and hypoxia-associated gene expressions for HNSCC after primary radiochemotherapy. Clin Transl Radiat Oncol 2019; 16:40-47. [PMID: 30993218 PMCID: PMC6449705 DOI: 10.1016/j.ctro.2019.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 03/13/2019] [Accepted: 03/17/2019] [Indexed: 12/21/2022] Open
Abstract
Tumour volume, p16 status and N stage could be validated regarding LRC and OS. Addition of cancer stem cell markers can further improve the baseline model. Prognostic value of tumour hypoxia warrants analysis in a larger cohort.
Objective To independently validate the impact of tumour volume, p16 status, cancer stem cell (CSC) marker expression and hypoxia-associated gene signatures as potential prognostic biomarkers for patients with locally advanced head and neck squamous cell carcinoma (HNSCC), who underwent primary radiotherapy or radiochemotherapy (RCTx). These markers have previously been reported in a study of the German Cancer Consortium Radiation Oncology Group (DKTK-ROG) (Linge et al., 2016). Materials and methods In this retrospective monocentric study, 92 patients with locally advanced HNSCC were included. Univariable and multivariable logistic regressions and Cox models presented in the study of the DKTK-ROG were validated using the area under the curve (AUC) and the concordance index (ci), respectively. The primary endpoint of this study was loco-regional tumour control (LRC) after primary RCTx. Results Although both cohorts significantly differed in the proportion of the tumour subsites, the parameters tumour volume, p16 status and N stage could be validated regarding LRC and overall survival (OS) using multivariable Cox regression (LRC ci: 0.59, OS ci: 0.63). These models were slightly improved by combination with the putative CSC marker CD44 (LRC ci: 0.61, OS ci: 0.69). The logistic regression model for 2-year LRC based on tumour volume, p16 status and CD44 protein was validated with an AUC of 0.64. The patient stratification based on hypoxia-associated gene signatures status was similar to the original study but without significant differences in LRC and OS. Conclusions In this validation study, the inclusion of the putative CSC marker CD44 slightly improved the prognostic performance of the baseline parameters tumour volume, p16 status and N stage. No improvement was observed when including expressions of the hypoxia-associated gene signatures. Prospective validation on a larger cohort is warranted to assess the clinical relevance of these markers.
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Affiliation(s)
- Annett Linge
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Stefan Schmidt
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Germany
| | - Fabian Lohaus
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Constanze Krenn
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Anna Bandurska-Luque
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Ivan Platzek
- Department of Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Cläre von Neubeck
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Steffen Appold
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Alexander Nowak
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Department of Oral and Maxillofacial Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Volker Gudziol
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Department of Otorhinolaryngology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universiät Dresden, Germany
| | - Frank Buchholz
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,University Cancer Centre (UCC), Medical Systems Biology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Gustavo B Baretton
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Institute of Pathology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.,Tumour- and Normal Tissue Bank, University Cancer Centre (UCC), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Michael Baumann
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Steffen Löck
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Mechthild Krause
- German Cancer Consortium (DKTK) Partner Site Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Germany
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Repeat FMISO-PET imaging weakly correlates with hypoxia-associated gene expressions for locally advanced HNSCC treated by primary radiochemotherapy. Radiother Oncol 2019; 135:43-50. [PMID: 31015169 DOI: 10.1016/j.radonc.2019.02.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/07/2019] [Accepted: 02/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hypoxia is an important factor of tumour resistance to radiotherapy, chemotherapy and potentially immunotherapy. It can be measured e.g. by positron emission tomography (PET) imaging or hypoxia-associated gene expressions from tumour biopsies. Here we correlate [18F]fluoromisonidazole (FMISO)-PET/CT imaging with hypoxia-associated gene expressions on a cohort of 50 head and neck squamous cell carcinoma (HNSCC) patients and compare their prognostic value for response to radiochemotherapy (RCTx). METHODS FMISO-PET/CT images of 50 HNSCC patients were acquired at four time-points before and during RCTx. For 42 of these patients, hypoxia-associated gene expressions were evaluated by nanoString technology based on a biopsy obtained before any treatment. The FMISO-PET parameters tumour-to-background ratio and hypoxic volume were correlated to the expressions of 58 hypoxia-associated genes using the Spearman correlation coefficient ρ. Three hypoxia-associated gene signatures were compared regarding their correlation with the FMISO-PET parameters using their median expression. In addition, the correlation with tumour volume was analysed. The impact of both hypoxia measurement methods on loco-regional tumour control (LRC) and overall survival (OS) was assessed by Cox regression. RESULTS The median expression of hypoxia-associated genes was weakly correlated to hypoxia measured by FMISO-PET imaging (ρ ≤ 0.43), with higher correlations to imaging after weeks 1 and 2 of treatment (p < 0.001). Moderate correlations were obtained between FMISO-PET imaging and tumour volume (ρ ≤ 0.69). Prognostic models for LRC and OS based on the FMISO-PET parameters could not be improved by including hypoxia classifiers. CONCLUSION We observed low correlations between hypoxia FMISO-PET parameters and expressions of hypoxia-associated genes. Since FMISO-PET showed a superior patient stratification, it may be the preferred biomarker over hypoxia-associated genes for stratifying patients with locally advanced HNSCC treated by primary RCTx.
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Bandurska-Luque A, Löck S, Haase R, Richter C, Zöphel K, Perrin R, Appold S, Krause M, Steinbach J, Kotzerke J, Hofheinz F, Zips D, Baumann M, Troost EG. Correlation between FMISO-PET based hypoxia in the primary tumour and in lymph node metastases in locally advanced HNSCC patients. Clin Transl Radiat Oncol 2019; 15:108-112. [PMID: 30834349 PMCID: PMC6384311 DOI: 10.1016/j.ctro.2019.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 02/07/2023] Open
Abstract
We investigated correlation between hypoxia in the primary tumour and LN before and during RCTx. The Correlation between primary tumour and LN hypoxia is stronger in patients with large LN compared to the entire cohort. We advise to perform a comprehensive evaluation of hypoxia in the primary tumour and LN.
Purpose This secondary analysis of the prospective study on repeat [18F]fluoromisonidazole (FMISO)-PET in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) assessed the correlation of hypoxia in the primary tumour and lymph node metastases (LN) prior to and during primary radiochemotherapy. Methods This analysis included forty-five LN-positive HNSCC patients having undergone FMISO-PET/CTs at baseline, and at week 1, 2 and 5 of radiochemotherapy. The quantitative FMISO-PET/CT parameters maximum standardised uptake value (SUVmax, corrected for partial volume effect) and peak tumour-to-background ratio (TBRpeak) were estimated in the primary tumour as well as in index and large LN, respectively. Statistical analysis was performed using the Spearman correlation coefficient ρ. Results In 15 patients with large LN (FDG-PET positive volume >5 ml), there was a significant correlation between the hypoxia measured in the primary tumour and the large LN at three out of four time-points using the TBRpeak (baseline: ρ = 0.57, p = 0.006; week 2: ρ = 0.64, p = 0.003 and week 5: ρ = 0.68, p = 0.001). For the entire cohort (N = 45) only assessed prior to the treatment, there was a statistically significant, though weak correlation between FMISO-SUVmax of the primary tumour and the index LN (ρ = 0.36, p = 0.015). Conclusions We observed a significant correlation between FMISO-based hypoxia in the primary tumour and large lymph node(s) in advanced stage HNSCC patients. However, since most patients only had relatively small hypoxic lymph node metastases, a comprehensive assessment of the primary tumour and lymph node hypoxia is essential.
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Affiliation(s)
- Anna Bandurska-Luque
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Corresponding author at: Department of Radiotherapy and Radiation Oncology, University Hospital Carl Gustav Carus Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
| | - Steffen Löck
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Robert Haase
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Christian Richter
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Klaus Zöphel
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Rosalind Perrin
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Steffen Appold
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mechthild Krause
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
- Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Jörg Steinbach
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Rossendorf, Germany
- Faculty of Chemistry and Food Chemistry, Technische Universität Dresden, Dresden, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Frank Hofheinz
- Helmholtz-Zentrum Dresden-Rossendorf, PET Center, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Germany
| | - Michael Baumann
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
- Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Esther G.C. Troost
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
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82
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Zwanenburg A, Leger S, Agolli L, Pilz K, Troost EGC, Richter C, Löck S. Assessing robustness of radiomic features by image perturbation. Sci Rep 2019; 9:614. [PMID: 30679599 PMCID: PMC6345842 DOI: 10.1038/s41598-018-36938-4] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/19/2018] [Indexed: 12/22/2022] Open
Abstract
Image features need to be robust against differences in positioning, acquisition and segmentation to ensure reproducibility. Radiomic models that only include robust features can be used to analyse new images, whereas models with non-robust features may fail to predict the outcome of interest accurately. Test-retest imaging is recommended to assess robustness, but may not be available for the phenotype of interest. We therefore investigated 18 combinations of image perturbations to determine feature robustness, based on noise addition (N), translation (T), rotation (R), volume growth/shrinkage (V) and supervoxel-based contour randomisation (C). Test-retest and perturbation robustness were compared for combined total of 4032 morphological, statistical and texture features that were computed from the gross tumour volume in two cohorts with computed tomography imaging: I) 31 non-small-cell lung cancer (NSCLC) patients; II): 19 head-and-neck squamous cell carcinoma (HNSCC) patients. Robustness was determined using the 95% confidence interval (CI) of the intraclass correlation coefficient (1, 1). Features with CI ≥ 0:90 were considered robust. The NTCV, TCV, RNCV and RCV perturbation chain produced similar results and identified the fewest false positive robust features (NSCLC: 0.2–0.9%; HNSCC: 1.7–1.9%). Thus, these perturbation chains may be used as an alternative to test-retest imaging to assess feature robustness.
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Affiliation(s)
- Alex Zwanenburg
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany. .,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany. .,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Stefan Leger
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Linda Agolli
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Karoline Pilz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Emerging Functional Imaging Biomarkers of Tumour Responses to Radiotherapy. Cancers (Basel) 2019; 11:cancers11020131. [PMID: 30678055 PMCID: PMC6407112 DOI: 10.3390/cancers11020131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/11/2019] [Accepted: 01/13/2019] [Indexed: 12/11/2022] Open
Abstract
Tumour responses to radiotherapy are currently primarily assessed by changes in size. Imaging permits non-invasive, whole-body assessment of tumour burden and guides treatment options for most tumours. However, in most tumours, changes in size are slow to manifest and can sometimes be difficult to interpret or misleading, potentially leading to prolonged durations of ineffective treatment and delays in changing therapy. Functional imaging techniques that monitor biological processes have the potential to detect tumour responses to treatment earlier and refine treatment options based on tumour biology rather than solely on size and staging. By considering the biological effects of radiotherapy, this review focusses on emerging functional imaging techniques with the potential to augment morphological imaging and serve as biomarkers of early response to radiotherapy.
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84
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Göttgens EL, Ostheimer C, Span PN, Bussink J, Hammond EM. HPV, hypoxia and radiation response in head and neck cancer. Br J Radiol 2019; 92:20180047. [PMID: 29493265 PMCID: PMC6435089 DOI: 10.1259/bjr.20180047] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 12/21/2022] Open
Abstract
Over the last decades, the incidence of human papilloma virus (HPV) positive head and neck squamous-cell carcinoma (HNSCC) has significantly increased. Infection with high-risk HPV types drives tumourigenesis through expression of the oncoproteins E6 and E7. Currently, the primary treatment of HNSCC consists of radiotherapy, often combined with platinum-based chemotherapeutics. One of the common features of HNSCC is the occurrence of tumour hypoxia, which impairs the efficacy of radiotherapy and is a negative prognostic factor. Therefore, it is important to detect and quantify the severity of hypoxia, as well as develop strategies to specifically target hypoxic tumours. HPV-positive tumours are remarkably radiosensitive compared to HPV-negative tumours and consequently the HPV-positive patients have a better prognosis. This provides an opportunity to elucidate mechanisms of radiation sensitivity, which may reveal targets for improved therapy for HPV-negative head and neck cancers. In this review, we will discuss the differences between HPV-positive and HPV-negative head and neck tumours and methods of hypoxia detection and targeting in these disease types. Particular emphasis will be placed on the mechanisms by which HPV infection impacts radiosensitivity.
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Affiliation(s)
- Eva-Leonne Göttgens
- Department of Radiation Oncology, Radiotherapy & OncoImmunology laboratory, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Paul N Span
- Department of Radiation Oncology, Radiotherapy & OncoImmunology laboratory, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jan Bussink
- Department of Radiation Oncology, Radiotherapy & OncoImmunology laboratory, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ester M Hammond
- Department of Oncology, CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
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85
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Martens RM, Noij DP, Ali M, Koopman T, Marcus JT, Vergeer MR, de Vet H, de Jong MC, Leemans CR, Hoekstra OS, de Bree R, de Graaf P, Boellaard R, Castelijns JA. Functional imaging early during (chemo)radiotherapy for response prediction in head and neck squamous cell carcinoma; a systematic review. Oral Oncol 2018; 88:75-83. [PMID: 30616800 DOI: 10.1016/j.oraloncology.2018.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
Abstract
This systematic review gives an extensive overview of the current state of functional imaging during (chemo)radiotherapy to predict locoregional control (LRC) and overall survival (OS) for head and neck squamous cell carcinoma. MEDLINE and EMBASE were searched for literature until April 2018 assessing the predictive performance of functional imaging (computed tomography perfusion (CTp), MRI and positron-emission tomography (PET)) within 4 weeks after (chemo)radiotherapy initiation. Fifty-two studies (CTp: n = 4, MRI: n = 19, PET: n = 26, MRI/PET: n = 3) were included involving 1623 patients. Prognostic information was extracted according the PRISMA protocol. Pooled estimation and subgroup analyses were performed for comparable parameters and outcome. However, the heterogeneity of included studies limited the possibility for comparison. Early tumoral changes from (chemo)radiotherapy can be captured by functional MRI and 18F-FDG-PET and could allow for personalized treatment adaptation. Lesions showed potentially prognostic intratreatment changes in perfusion, diffusion and metabolic activity. Intratreatment ADCmean increase (decrease of diffusion restriction) and low SUVmax (persistent low or decrease of 18F-FDG uptake) were most predictive of LRC. Intratreatment persistent high or increase of perfusion on CT/MRI (i.e. blood flow, volume, permeability) also predicted LRC. Low SUVmax and total lesion glycolysis (TLG) predicted favorable OS. The optimal timing to perform functional imaging to predict LRC or OS was 2-3 weeks after treatment initiation.
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Affiliation(s)
- Roland M Martens
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands.
| | - Daniel P Noij
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Meedie Ali
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Thomas Koopman
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - J Tim Marcus
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Marije R Vergeer
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Henrica de Vet
- Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Marcus C de Jong
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - C René Leemans
- Department of Otolaryngology - Head and Neck Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Otto S Hoekstra
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pim de Graaf
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Ronald Boellaard
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Jonas A Castelijns
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
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86
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Yin X, Wei Z, Song C, Tang C, Xu W, Wang Y, Xie J, Lin Z, Han W. Metformin sensitizes hypoxia-induced gefitinib treatment resistance of HNSCC via cell cycle regulation and EMT reversal. Cancer Manag Res 2018; 10:5785-5798. [PMID: 30510448 PMCID: PMC6250113 DOI: 10.2147/cmar.s177473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives The objectives of this study were to explore the mechanisms of metformin sensitization to hypoxia-induced gefitinib treatment in resistant head and neck squamous cell carcinoma (HNSCC) and evaluate the effects of this combined treatment strategy. Methods The effects of gefitinib treatment on HNSCC were measured under normoxic and hypoxic conditions. The relationship between hypoxia and cell cycle and epithelial-mesenchymal transition (EMT) in tumor cells were analyzed. Palbociclib and LY294002 were used in combination with gefitinib to evaluate the effects on HNSCC cell cytotoxicity during hypoxia. Finally, metformin was used to evaluate the sensitizing effects of gefitinib treatment on HNSCC in vivo and in vitro. Results Cell viability and apoptosis assays demonstrated a significant difference in HNSCC cells treated with gefitinib between the normoxia and hypoxia groups. Hypoxia induced the expression of cyclin D1, decreased the percentage of cells in G1, and promoted the EMT of tumor cells. Both palbociclib and LY294002 enhanced gefitinib-induced cytotoxicity of HNSCC cells under hypoxic conditions. Encouragingly, metformin sensitized HNSCC to gefitinib treatment in vivo and in vitro. Conclusion Hypoxia promotes G1-S cell cycle progression and EMT in HNSCC, resulting in gefitinib treatment resistance. Metformin sensitizes HNSCC to gefitinib treatment, which might serve as a novel combined treatment strategy.
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Affiliation(s)
- Xiteng Yin
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
| | - Zheng Wei
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
| | - Chuanhui Song
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
| | - Chuanchao Tang
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
| | - Wenguang Xu
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
| | - Yufeng Wang
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
| | - Junqi Xie
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
| | - Zitong Lin
- Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, , .,Department of Dentomaxillofacial Radiology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China,
| | - Wei Han
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, .,Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China, ,
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Andreassen C, Eriksen J, Jensen K, Hansen C, Sørensen B, Lassen P, Alsner J, Schack L, Overgaard J, Grau C. IMRT – Biomarkers for dose escalation, dose de-escalation and personalized medicine in radiotherapy for head and neck cancer. Oral Oncol 2018; 86:91-99. [DOI: 10.1016/j.oraloncology.2018.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/03/2018] [Indexed: 12/13/2022]
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88
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Hamming-Vrieze O, Navran A, Al-Mamgani A, Vogel WV. Biological PET-guided adaptive radiotherapy for dose escalation in head and neck cancer: a systematic review. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2018; 62:349-368. [DOI: 10.23736/s1824-4785.18.03087-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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89
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Gensheimer MF, Le QT. Adaptive radiotherapy for head and neck cancer: Are we ready to put it into routine clinical practice? Oral Oncol 2018; 86:19-24. [DOI: 10.1016/j.oraloncology.2018.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/17/2018] [Indexed: 12/27/2022]
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FMISO-PET-based lymph node hypoxia adds to the prognostic value of tumor only hypoxia in HNSCC patients. Radiother Oncol 2018; 130:97-103. [PMID: 30293643 DOI: 10.1016/j.radonc.2018.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE This secondary analysis of the prospective study on repeat [18F]fluoromisonidazole (FMISO)-PET in patients with locally advanced head and neck squamous cell carcinomas (HNSCC) assessed the prognostic value of synchronous hypoxia in primary tumor (Tu) and lymph node metastases (LN), and evaluated whether the combined reading was of higher prognostic value than that of primary tumor hypoxia only. METHODS This analysis included forty-five LN-positive HNSCC patients. FMISO-PET/CTs were performed at baseline, weeks 1, 2 and 5 of radiochemotherapy. Based on a binary scale, Tu and LN were categorized as hypoxic or normoxic, and two prognostic parameters were defined: Tu-hypoxia (independent of the LN oxygenation status) and synchronous Tu-and-LN-hypoxia. In fifteen patients with large LN (N = 21), additional quantitative analyses of FMISO-PET/CTs were performed. Imaging parameters at different time-points were correlated to the endpoints, i.e., locoregional control (LRC), local control (LC), regional control (RC) and time to progression (TTP). Survival curves were estimated using the cumulative incidence function. Univariable and multivariable Cox regression was used to evaluate the prognostic impact of hypoxia on the endpoints. RESULTS Synchronous Tu-and-LN-hypoxia was a strong adverse prognostic factor for LC, LRC and TTP at any of the four time-points (p ≤ 0.004), whereas Tu-hypoxia only was significantly associated with poor LC and LRC in weeks 2 and 5 (p ≤ 0.047), and with TTP in week 1 (p = 0.046). The multivariable analysis confirmed the prognostic value of synchronous Tu-and-LN-hypoxia regarding LRC (HR = 14.8, p = 0.017). The quantitative FMISO-PET/CT parameters correlated with qualitative hypoxia scale and RC (p < 0.001, p ≤ 0.033 at week 2, respectively). CONCLUSIONS This secondary analysis suggests that combined reading of primary tumor and LN hypoxia adds to the prognostic information of FMSIO-PET in comparison to primary tumor assessment alone in particular prior and early during radiochemotherapy. Confirmation in ongoing trials is needed before using this marker for personalized radiation oncology.
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91
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Bonnitcha P, Grieve S, Figtree G. Clinical imaging of hypoxia: Current status and future directions. Free Radic Biol Med 2018; 126:296-312. [PMID: 30130569 DOI: 10.1016/j.freeradbiomed.2018.08.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/30/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022]
Abstract
Tissue hypoxia is a key feature of many important causes of morbidity and mortality. In pathologies such as stroke, peripheral vascular disease and ischaemic heart disease, hypoxia is largely a consequence of low blood flow induced ischaemia, hence perfusion imaging is often used as a surrogate for hypoxia to guide clinical diagnosis and treatment. Importantly, ischaemia and hypoxia are not synonymous conditions as it is not universally true that well perfused tissues are normoxic or that poorly perfused tissues are hypoxic. In pathologies such as cancer, for instance, perfusion imaging and oxygen concentration are less well correlated, and oxygen concentration is independently correlated to radiotherapy response and overall treatment outcomes. In addition, the progression of many diseases is intricately related to maladaptive responses to the hypoxia itself. Thus there is potentially great clinical and scientific utility in direct measurements of tissue oxygenation. Despite this, imaging assessment of hypoxia in patients is rarely performed in clinical settings. This review summarises some of the current methods used to clinically evaluate hypoxia, the barriers to the routine use of these methods and the newer agents and techniques being explored for the assessment of hypoxia in pathological processes.
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Affiliation(s)
- Paul Bonnitcha
- Northern and Central Clinical Schools, Faculty of Medicine, Sydney University, Sydney, NSW 2006, Australia; Chemical Pathology Department, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia; Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales 2065, Australia.
| | - Stuart Grieve
- Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre and Sydney Medical School, University of Sydney, NSW 2050, Australia
| | - Gemma Figtree
- Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales 2065, Australia; Cardiology Department, Royal North Shore Hospital, St Leonards, New South Wales 2065, Australia
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92
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Wiedenmann N, Bunea H, Rischke HC, Bunea A, Majerus L, Bielak L, Protopopov A, Ludwig U, Büchert M, Stoykow C, Nicolay NH, Weber WA, Mix M, Meyer PT, Hennig J, Bock M, Grosu AL. Effect of radiochemotherapy on T2* MRI in HNSCC and its relation to FMISO PET derived hypoxia and FDG PET. Radiat Oncol 2018; 13:159. [PMID: 30157883 PMCID: PMC6114038 DOI: 10.1186/s13014-018-1103-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/17/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To assess the effect of radiochemotherapy (RCT) on proposed tumour hypoxia marker transverse relaxation time (T2*) and to analyse the relation between T2* and 18F-misonidazole PET/CT (FMISO-PET) and 18F-fluorodeoxyglucose PET/CT (FDG-PET). METHODS Ten patients undergoing definitive RCT for squamous cell head-and-neck cancer (HNSCC) received repeat FMISO- and 3 Tesla T2*-weighted MRI at weeks 0, 2 and 5 during treatment and FDG-PET at baseline. Gross tumour volumes (GTV) of tumour (T), lymph nodes (LN) and hypoxic subvolumes (HSV, based on FMISO-PET) and complementary non-hypoxic subvolumes (nonHSV) were generated. Mean values for T2* and SUVmean FDG were determined. RESULTS During RCT, marked reduction of tumour hypoxia on FMISO-PET was observed (T, LN), while mean T2* did not change significantly. At baseline, mean T2* values within HSV-T (15 ± 5 ms) were smaller compared to nonHSV-T (18 ± 3 ms; p = 0.051), whereas FDG SUVmean (12 ± 6) was significantly higher for HSV-T (12 ± 6) than for nonHSV-T (6 ± 3; p = 0.026) and higher for HSV-LN (10 ± 4) than for nonHSV-LN (5 ± 2; p ≤ 0.011). Correlation between FMISO PET and FDG PET was higher than between FMSIO PET and T2* (R2 for GTV-T (FMISO/FDG) = 0.81, R2 for GTV-T (FMISO/T2*) = 0.32). CONCLUSIONS Marked reduction of tumour hypoxia between week 0, 2 and 5 found on FMISO PET was not accompanied by a significant T2*change within GTVs over time. These results suggest a relation between tumour oxygenation status and T2* at baseline, but no simple correlation over time. Therefore, caution is warranted when using T2* as a substitute for FMISO-PET to monitor tumour hypoxia during RCT in HNSCC patients. TRIAL REGISTRATION DRKS, DRKS00003830 . Registered 23.04.2012.
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Affiliation(s)
- Nicole Wiedenmann
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Hatice Bunea
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hans C Rischke
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andrei Bunea
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Liette Majerus
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lars Bielak
- Department of Radiology, Medical Physics, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexey Protopopov
- Department of Radiology, Medical Physics, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ute Ludwig
- Department of Radiology, Medical Physics, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Büchert
- Department of Radiology, Medical Physics, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Stoykow
- Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang A Weber
- Clinic for Nuclear Medicine, Technische Universität München, Munich, Germany
| | - Michael Mix
- Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Philipp T Meyer
- Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Hennig
- Department of Radiology, Medical Physics, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Bock
- Department of Radiology, Medical Physics, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
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Marcu LG, Reid P, Bezak E. The Promise of Novel Biomarkers for Head and Neck Cancer from an Imaging Perspective. Int J Mol Sci 2018; 19:E2511. [PMID: 30149561 PMCID: PMC6165113 DOI: 10.3390/ijms19092511] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/18/2018] [Accepted: 08/23/2018] [Indexed: 01/25/2023] Open
Abstract
It is an agreed fact that overall survival among head and neck cancer patients has increased over the last decade. Several factors however, are still held responsible for treatment failure requiring more in-depth evaluation. Among these, hypoxia and proliferation-specific parameters are the main culprits, along with the more recently researched cancer stem cells. This paper aims to present the latest developments in the field of biomarkers for hypoxia, stemness and tumour proliferation, from an imaging perspective that includes both Positron Emission Tomography (PET) and Single Photon Emission Computed Tomography (SPECT) as well as functional magnetic resonance imaging (MRI). Quantitative imaging of biomarkers is a prerequisite for accurate treatment response assessment, bringing us closer to the highly needed personalised therapy.
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Affiliation(s)
- Loredana G Marcu
- Faculty of Science, University of Oradea, 410087 Oradea, Romania.
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.
| | - Paul Reid
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.
- Department of Physics, University of Adelaide, Adelaide, SA 5005, Australia.
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Stieb S, Eleftheriou A, Warnock G, Guckenberger M, Riesterer O. Longitudinal PET imaging of tumor hypoxia during the course of radiotherapy. Eur J Nucl Med Mol Imaging 2018; 45:2201-2217. [PMID: 30128659 DOI: 10.1007/s00259-018-4116-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022]
Abstract
Hypoxia results from an imbalance between oxygen supply and consumption. It is a common phenomenon in solid malignant tumors such as head and neck cancer. As hypoxic cells are more resistant to therapy, tumor hypoxia is an indicator for poor prognosis. Several techniques have been developed to measure tissue oxygenation. These are the Eppendorf O2 polarographic needle electrode, immunohistochemical analysis of endogenous (e.g., hypoxia-inducible factor-1α (HIF-1a)) and exogenous markers (e.g., pimonidazole) as well as imaging methods such as functional magnetic resonance imaging (e.g., blood oxygen level dependent (BOLD) imaging, T1-weighted imaging) and hypoxia positron emission tomography (PET). Among the imaging modalities, only PET is sufficiently validated to detect hypoxia for clinical use. Hypoxia PET tracers include 18F-fluoromisonidazole (FMISO), the most commonly used hypoxic marker, 18F-flouroazomycin arabinoside (FAZA), 18Ffluoroerythronitroimidazole (FETNIM), 18F-2-nitroimidazolpentafluoropropylacetamide (EF5) and 18F-flortanidazole (HX4). As technical development provides the opportunity to increase the radiation dose to subregions of the tumor, such as hypoxic areas, it has to be ensured that these regions are stable not only from imaging to treatment but also through the course of radiotherapy. The aim of this review is therefore to characterize the behavior of tumor hypoxia during radiotherapy for the whole tumor and for subregions by using hypoxia PET tracers, with focus on head and neck cancer patients.
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Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,Institute of Diagnostic and Interventional Radiology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Afroditi Eleftheriou
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Geoffrey Warnock
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Department of Nuclear Medicine, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Leger S, Zwanenburg A, Pilz K, Zschaeck S, Zöphel K, Kotzerke J, Schreiber A, Zips D, Krause M, Baumann M, Troost EGC, Richter C, Löck S. CT imaging during treatment improves radiomic models for patients with locally advanced head and neck cancer. Radiother Oncol 2018; 130:10-17. [PMID: 30087056 DOI: 10.1016/j.radonc.2018.07.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 06/27/2018] [Accepted: 07/24/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE The development of radiomic risk models to predict clinical outcome is usually based on pre-treatment imaging, such as computed tomography (CT) scans used for radiation treatment planning. Imaging data acquired during the course of treatment may improve their prognostic performance. We compared the performance of radiomic risk models based on the pre-treatment CT and CT scans acquired in the second week of therapy. MATERIAL AND METHODS Treatment planning and second week CT scans of 78 head and neck squamous cell carcinoma patients treated with primary radiochemotherapy were collected. 1538 image features were extracted from each image. Prognostic models for loco-regional tumour control (LRC) and overall survival (OS) were built using 6 feature selection methods and 6 machine learning algorithms. Prognostic performance was assessed using the concordance index (C-Index). Furthermore, patients were stratified into risk groups and differences in LRC and OS were evaluated by log-rank tests. RESULTS The performance of radiomic risk model in predicting LRC was improved using the second week CT scans (C-Index: 0.79), in comparison to the pre-treatment CT scans (C-Index: 0.65). This was confirmed by Kaplan-Meier analyses, in which risk stratification based on the second week CT could be improved for LRC (p = 0.002) compared to pre-treatment CT (p = 0.063). CONCLUSION Incorporation of imaging during treatment may be a promising way to improve radiomic risk models for clinical treatment adaption, i.e., to select patients that may benefit from dose modification.
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Affiliation(s)
- Stefan Leger
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - Alex Zwanenburg
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Karoline Pilz
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Department of Radiotherapy, Hospital Dresden-Friedrichstadt, Germany
| | - Sebastian Zschaeck
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Charité Universitätsmedizin Berlin, Department of Radiation Oncology, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, PET Center, Institute of Radiopharmaceutical Cancer Research, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, PET Center, Institute of Radiopharmaceutical Cancer Research, Germany
| | - Andreas Schreiber
- Department of Radiotherapy, Hospital Dresden-Friedrichstadt, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, Germany
| | - Mechthild Krause
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology OncoRay, Germany
| | - Michael Baumann
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology OncoRay, Germany
| | - Esther G C Troost
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology OncoRay, Germany
| | - Christian Richter
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology OncoRay, Germany
| | - Steffen Löck
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
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Abstract
The concept of tumour hypoxia as a cause of radiation resistance has been prevalent for over 100 years. During this time, our understanding of tumour hypoxia has matured with the recognition that oxygen tension within a tumour is influenced by both diffusion and perfusion mechanisms. In parallel, clinical strategies to modify tumour hypoxia with the expectation that this will improve response to radiation have been developed and tested in clinical trials. Despite many disappointments, meta-analysis of the data on hypoxia modification confirms a significant impact on both tumour control and survival. Early trials evaluated hyperbaric oxygen followed by a generation of studies testing oxygen mimetics such as misonidazole, pimonidazole and etanidazole. One highly significant result stands out from the use of nimorazole in advanced laryngeal cancer with a significant advantage seen for locoregional control using this radiosensitiser. More recent studies have evaluated carbogen and nicotinamide targeting both diffusion related and perfusion related hypoxia. A significant survival advantage is seen in muscle invasive bladder cancer and also for locoregional control in hypopharygeal cancer associated with a low haemoglobin. New developments include the recognition that mitochondrial complex inhibitors reducing tumour oxygen consumption are potential radiosensitising agents and atovaquone is currently in clinical trials. One shortcoming of past hypoxia modifying trials is the failure to identify oxygenation status and select those patient with significant hypoxia. A range of biomarkers are now available including histological necrosis, immunohistochemical intrinsic markers such as CAIX and Glut 1 and hypoxia gene signatures which have been shown to predict outcome and will inform the next generation of hypoxia modifying clinical trials.
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Affiliation(s)
- Hannah Tharmalingham
- Mount Vernon Cancer Centre, Northwood, UK.,University of Manchester, Manchester, UK.,Christie Hospital, Manchester, UK
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, UK.,University of Manchester, Manchester, UK.,Christie Hospital, Manchester, UK.,Manchester Cancer Research Centre, Manchester, UK
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Pötter R, Balosso J, Baumann M, Bert C, Davies J, Enghardt W, Fossati P, Harris S, Jones B, Krämer M, Mayer R, Mock U, Pullia M, Schreiner T, Dosanjh M, Debus J, Orecchia R, Georg D. Union of light ion therapy centers in Europe (ULICE EC FP7) – Objectives and achievements of joint research activities. Radiother Oncol 2018; 128:83-100. [DOI: 10.1016/j.radonc.2018.04.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 04/21/2018] [Indexed: 12/25/2022]
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Increased evidence for the prognostic value of FDG uptake on late-treatment PET in non-tumour-affected oesophagus in irradiated patients with oesophageal carcinoma. Eur J Nucl Med Mol Imaging 2018; 45:1752-1761. [PMID: 29679113 DOI: 10.1007/s00259-018-3996-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/16/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE 18F-FDG uptake in irradiated non-tumour-affected oesophagus (NTO) on restaging PET is a potential surrogate for the measurement of radiation-induced inflammation. Radiation-induced inflammation itself has been shown to be of high prognostic relevance in patients undergoing preoperative radiochemotherapy (RCT) for locally advanced oesophageal cancer. We assessed the prognostic relevance of FDG uptake in the NTO in an independent cohort of patients treated with definitive RCT. METHODS This retrospective evaluation included 72 patients with oesophageal squamous cell carcinoma treated with definitive RCT with curative intent. All patients underwent pretreatment and restaging FDG PET after receiving a radiation dose of 40-50 Gy. Standardized uptake values (SUVmax/SUVmean), metabolic tumour volume (MTV) and relative changes from pretreatment to restaging PET (∆SUVmax/∆SUVmean) were determined within the tumour and NTO. Univariate Cox regression with respect to overall survival (OS), local control (LC), distant metastases (DM) and treatment failure (TF) was performed. Independence of parameters was tested by multivariate Cox regression. RESULTS ∆SUVmax NTO and MTV were prognostic factors for all investigated clinical endpoints (OS, LC, DM, TF). Inclusion of clinical and PET tumour parameters in multivariate analysis showed that ∆SUVmax NTO was an independent prognostic factor. Furthermore, multivariate analysis of ∆SUVmax NTO using previously published cut-off values from preoperatively treated patients revealed that ∆SUVmax NTO was independent prognostic factor for OS (HR = 1.88, p = 0.038), TF (HR = 2.11, p = 0.048) and DM (HR = 3.02, p = 0.047). CONCLUSION NTO-related tracer uptake during the course of treatment in patients with oesophageal carcinoma was shown to be of high prognostic relevance. Thus, metabolically activity of NTO measured in terms of ∆SUVmax NTO is a potential candidate for future treatment individualization (i.e. organ preservation).
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Local recurrences after curative IMRT for HNSCC: Effect of different GTV to high-dose CTV margins. Radiother Oncol 2018; 126:48-55. [DOI: 10.1016/j.radonc.2017.11.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 01/29/2023]
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