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Chuong MD, Hallemeier CL, Li H, Zhu XR, Zhang X, Tryggestad EJ, Yu J, Yang M, Choi JI, Kang M, Liu W, Knopf A, Meijers A, Molitoris JK, Apisarnthanarax S, Giap H, Hoppe BS, Lee P, Chang JY, Simone CB, Lin SH. Executive Summary of Clinical and Technical Guidelines for Esophageal Cancer Proton Beam Therapy From the Particle Therapy Co-Operative Group Thoracic and Gastrointestinal Subcommittees. Front Oncol 2021; 11:748331. [PMID: 34737959 PMCID: PMC8560961 DOI: 10.3389/fonc.2021.748331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023] Open
Abstract
Radiation therapy (RT) is an integral component of potentially curative management of esophageal cancer (EC). However, RT can cause significant acute and late morbidity due to excess radiation exposure to nearby critical organs, especially the heart and lungs. Sparing these organs from both low and high radiation dose has been demonstrated to achieve clinically meaningful reductions in toxicity and may improve long-term survival. Accruing dosimetry and clinical evidence support the consideration of proton beam therapy (PBT) for the management of EC. There are critical treatment planning and delivery uncertainties that should be considered when treating EC with PBT, especially as there may be substantial motion-related interplay effects. The Particle Therapy Co-operative Group Thoracic and Gastrointestinal Subcommittees jointly developed guidelines regarding patient selection, treatment planning, clinical trials, and future directions of PBT for EC.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, United States
| | | | - Heng Li
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, United States
| | - Xiaorong Ronald Zhu
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Xiaodong Zhang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Erik J Tryggestad
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, United States
| | - Ming Yang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, NY, United States
| | - Minglei Kang
- Department of Radiation Oncology, New York Proton Center, New York, NY, United States
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, United States
| | - Antje Knopf
- Department of Radiation Oncology, University of Groningen, Groningen, Netherlands
| | - Arturs Meijers
- Department of Radiation Oncology, University of Groningen, Groningen, Netherlands
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland, Baltimore, Baltimore, MD, United States
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Huan Giap
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Percy Lee
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Joe Y Chang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, United States
| | - Steven H Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
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Ebrahimi S, Lim G, Liu A, Lin SH, Ellsworth SG, Grassberger C, Mohan R, Cao W. Radiation-Induced Lymphopenia Risks of Photon Versus Proton Therapy for Esophageal Cancer Patients. Int J Part Ther 2021; 8:17-27. [PMID: 34722808 PMCID: PMC8489492 DOI: 10.14338/ijpt-20-00086] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/02/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose To assess possible differences in radiation-induced lymphocyte depletion for esophageal cancer patients being treated with the following 3 treatment modalities: intensity-modulated radiation therapy (IMRT), passive scattering proton therapy (PSPT), and intensity-modulated proton therapy (IMPT). Methods and Materials We used 2 prediction models to estimate lymphocyte depletion based on dose distributions. Model I used a piecewise linear relationship between lymphocyte survival and voxel-by-voxel dose. Model II assumes that lymphocytes deplete exponentially as a function of total delivered dose. The models can be fitted using the weekly absolute lymphocyte counts measurements collected throughout treatment. We randomly selected 45 esophageal cancer patients treated with IMRT, PSPT, or IMPT at our institution (15 per modality) to demonstrate the fitness of the 2 models. A different group of 10 esophageal cancer patients who had received PSPT were included in this study of in silico simulations of multiple modalities. One IMRT and one IMPT plan were created, using our standards of practice for each modality, as competing plans to the existing PSPT plan for each patient. We fitted the models by PSPT plans used in treatment and predicted absolute lymphocyte counts for IMRT and IMPT plans. Results Model validation on each modality group of patients showed good agreement between measured and predicted absolute lymphocyte counts nadirs with mean squared errors from 0.003 to 0.023 among the modalities and models. In the simulation study of IMRT and IMPT on the 10 PSPT patients, the average predicted absolute lymphocyte count (ALC) nadirs were 0.27, 0.35, and 0.37 K/μL after IMRT, PSPT, and IMPT treatments using Model I, respectively, and 0.14, 0.22, and 0.33 K/μL using Model II. Conclusions Proton plans carried a lower predicted risk of lymphopenia after the treatment course than did photon plans. Moreover, IMPT plans outperformed PSPT in terms of predicted lymphocyte preservation.
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Affiliation(s)
- Saba Ebrahimi
- Department of Industrial Engineering, University of Houston, Houston, TX, USA
| | - Gino Lim
- Department of Industrial Engineering, University of Houston, Houston, TX, USA
| | - Amy Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Clemens Grassberger
- Departments of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wenhua Cao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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53
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Créhange G, Goudjil F, Krhili SL, Minsat M, de Marzi L, Dendale R. [The role of proton therapy in esophageal cancer]. Cancer Radiother 2021; 26:604-610. [PMID: 34688549 DOI: 10.1016/j.canrad.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022]
Abstract
Because of the physical properties of proton beam radiation therapy (PT), which allows energy to be deposited at a specific depth with a rapid energy fall-off beyond that depth, PT has several theoretical advantages over photon radiation therapy for esophageal cancer (EC). Protons have the potential to reduce the dose to healthy tissue and to more safely allow treatment of tumors near critical organs, dose escalation, trimodal treatment, and re-irradiation. In recent years, larger multicenter retrospective studies have been published showing excellent survival rates, lower than expected toxicities and even better outcomes with PT than with photon radiotherapy even using IMRT or VMAT techniques. Although PT was associated with reduced toxicities, postoperative complications, and hospital stays compared to photon radiation therapy, these studies all had inherent biases in relation with patient selection for PT. These observations were recently confirmed by a randomized phase II study in locally advanced EC that showed significantly reduced toxicities with protons compared with IMRT. Currently, two randomized phase III trials (NRG-GI006 in the US and PROTECT in Europe) are being conducted to confirm whether protons could become the standard of care in locally advanced and resectable esophageal cancers.
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Affiliation(s)
- G Créhange
- Département d'oncologie radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France; Département d'oncologie radiothérapie (Centre de Protonthérapie), institut Curie, Orsay, France; Département d'oncologie radiothérapie, institut Curie, 92, boulevard Dailly, Saint-Cloud, France.
| | - F Goudjil
- Département d'oncologie radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France; Département d'oncologie radiothérapie (Centre de Protonthérapie), institut Curie, Orsay, France
| | - S L Krhili
- Département d'oncologie radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - M Minsat
- Département d'oncologie radiothérapie, institut Curie, 92, boulevard Dailly, Saint-Cloud, France
| | - L de Marzi
- Département d'oncologie radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France; Département d'oncologie radiothérapie (Centre de Protonthérapie), institut Curie, Orsay, France; Département d'oncologie radiothérapie, institut Curie, 92, boulevard Dailly, Saint-Cloud, France; Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Campus universitaire, Orsay 91898, France
| | - R Dendale
- Département d'oncologie radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France; Département d'oncologie radiothérapie (Centre de Protonthérapie), institut Curie, Orsay, France
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Association between treatment-related lymphopenia and survival in glioblastoma patients following postoperative chemoradiotherapy. Strahlenther Onkol 2021; 198:448-457. [PMID: 34617129 PMCID: PMC9038819 DOI: 10.1007/s00066-021-01855-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 08/17/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Our study investigated the association between treatment-related lymphopenia and overall survival (OS) in a series of glioblastoma (GBM) patients. We also explored clinical and dosimetric predictors of lymphocytes depletion. METHODS Between 2015 and 2019, 64 patients were treated at the same institution with postoperative chemoradiotherapy. Peripheral lymphocyte count (PLC) data and dose-volume histogram parameters were collected. Radiotherapy (RT) schedule consisted in standard total dose of 60 Gy in 30 daily fractions, with concomitant and adjuvant temozolomide (TMZ). Posttreatment acute absolute lymphopenia (nadir AAL) was calculated as a PLC lower than 1.0 × 103/mm3. Acute relative lymphopenia (ARL) was expressed by the nadir-PLC/baseline-PLC ratio < 0.5. Nadir-PLC was the lowest PLC registered between the end of RT and the first month of follow-up. Survival rates were estimated with Kaplan-Meier curves. Clinical and dosimetric variables related to AAL/ARL and OS were identified by univariate and multivariate analyses. RESULTS A total of 57 patients were eligible and included in the analyses. The median PLC was significantly decreased following chemoradiotherapy (2180/mm3 vs 900/mm3). Median OS was 16 months (range 5-55 months), with no significant difference between patients who developed nadir AAL and those who did not (16 months vs 16.5 months; p = 0.304). When considering ARL vs non-ARL, median OS was 14 months vs 26 months (p = 0.013), respectively. In multivariate Cox regression only age, sex, extent of surgery, access to adjuvant chemotherapy and brain D98% were independently associated with OS. CONCLUSION Although iatrogenic immunosuppression could be associated with inferior clinical outcomes, our data show that treatment-related lymphopenia does not adversely affect GBM survival. Prospective studies are required to confirm these findings.
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Wang X, Hobbs B, Gandhi SJ, Muijs CT, Langendijk JA, Lin SH. Current status and application of proton therapy for esophageal cancer. Radiother Oncol 2021; 164:27-36. [PMID: 34534613 DOI: 10.1016/j.radonc.2021.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 08/11/2021] [Accepted: 09/07/2021] [Indexed: 12/25/2022]
Abstract
Esophageal cancer remains one of the leading causes of death from cancer across the world despite advances in multimodality therapy. Although early-stage disease can often be treated surgically, the current state of the art for locally advanced disease is concurrent chemoradiation, followed by surgery whenever possible. The uniform midline tumor location puts a strong importance on the need for precise delivery of radiation that would minimize dose to the heart and lungs, and the biophysical properties of proton beam makes this modality potential ideal for esophageal cancer treatment. This review covers the current state of knowledge of proton therapy for esophageal cancer, focusing on published retrospective single- and multi-institutional clinical studies, and emerging data from prospective clinical trials, that support the benefit of protons vs photon-based radiation in reducing postoperative complications, cardiac toxicity, and severe radiation induced immune suppression, which may improve survival outcomes for patients. In addition, we discuss the incorporation of immunotherapy to the curative management of esophageal cancers in the not-too-distant future. However, there is still a lack of high-level evidence to support proton therapy in the treatment of esophageal cancer, and proton therapy has its limitations in clinical application. It is expected to see the results of future large-scale randomized clinical trials and the continuous improvement of proton radiotherapy technology.
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Affiliation(s)
- Xin Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, China
| | - Brian Hobbs
- Department of Population Health, University of Texas, Austin, USA
| | - Saumil J Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christina T Muijs
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.
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Zhu C, Mohan R, Lin SH, Jun G, Yaseen A, Jiang X, Wang Q, Cao W, Hobbs BP. Identifying Individualized Risk Profiles for Radiotherapy-Induced Lymphopenia Among Patients With Esophageal Cancer Using Machine Learning. JCO Clin Cancer Inform 2021; 5:1044-1053. [PMID: 34665662 PMCID: PMC8812653 DOI: 10.1200/cci.21.00098] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/16/2021] [Accepted: 09/07/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Radiotherapy (RT)-induced lymphopenia (RIL) is commonly associated with adverse clinical outcomes in patients with cancer. Using machine learning techniques, a retrospective study was conducted for patients with esophageal cancer treated with proton and photon therapies to characterize the principal pretreatment clinical and radiation dosimetric risk factors of grade 4 RIL (G4RIL) as well as to establish G4RIL risk profiles. METHODS A single-institution retrospective data of 746 patients with esophageal cancer treated with photons (n = 500) and protons (n = 246) was reviewed. The primary end point of our study was G4RIL. Clustering techniques were applied to identify patient subpopulations with similar pretreatment clinical and radiation dosimetric characteristics. XGBoost was built on a training set (n = 499) to predict G4RIL risks. Predictive performance was assessed on the remaining n = 247 patients. SHapley Additive exPlanations were used to rank the importance of individual predictors. Counterfactual analyses compared patients' risk profiles assuming that they had switched modalities. RESULTS Baseline absolute lymphocyte count and volumes of lung and spleen receiving ≥ 15 and ≥ 5 Gy, respectively, were the most important G4RIL risk determinants. The model achieved sensitivitytesting-set 0.798 and specificitytesting-set 0.667 with an area under the receiver operating characteristics curve (AUCtesting-set) of 0.783. The G4RIL risk for an average patient receiving protons increased by 19% had the patient switched to photons. Reductions in G4RIL risk were maximized with proton therapy for patients with older age, lower baseline absolute lymphocyte count, and higher lung and heart dose. CONCLUSION G4RIL risk varies for individual patients with esophageal cancer and is modulated by radiotherapy dosimetric parameters. The framework for machine learning presented can be applied broadly to study risk determinants of other adverse events, providing the basis for adapting treatment strategies for mitigation.
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Affiliation(s)
- Cong Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Radhe Mohan
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Goo Jun
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Ashraf Yaseen
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Xiaoqian Jiang
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX
| | - Qianxia Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wenhua Cao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian P. Hobbs
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, TX
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The Influence of Severe Radiation-Induced Lymphopenia on Overall Survival in Solid Tumors: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2021; 111:936-948. [PMID: 34329738 DOI: 10.1016/j.ijrobp.2021.07.1695] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/10/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Emerging evidence suggests a detrimental prognostic association between radiation-induced lymphopenia (RIL) and pathologic response, progression-free survival, and overall survival (OS) in patients who undergo radiation therapy for cancer. The aim of this study was to systematically review and meta-analyze the prognostic impact of RIL on OS in patients with solid tumors. METHODS AND MATERIALS PubMed/MEDLINE and Embase were systematically searched. The analysis included intervention and prognostic studies that reported on the prognostic relationship between RIL and survival in patients with solid tumors. An overall pooled adjusted hazard ratio (aHR) was calculated using a random-effects model. Subgroup analyses for different patient-, tumor-, treatment-, and study-related characteristics were performed using meta-regression. RESULTS Pooling of 21 cohorts within 20 eligible studies demonstrated a statistically significant association between OS and grade ≥3 versus grade 0-2 RIL (n = 16; pooled aHR, 1.65; 95% confidence interval [CI], 1.43-1.90) and grade 4 RIL versus grade 0-3 (n = 5; aHR, 1.53; 95% CI, 1.24-1.90). Moderate heterogeneity among aHRs was observed, mostly attributable to overestimated aHRs in 7 studies likely subject to model-overfitting. Subgroup analysis showed significant prognostic impact of grade ≥3 RIL in 4 brain tumor (aHR, 1.63; 95% CI, 1.06-2.51), 4 lung cancer (aHR, 1.52; 95% CI, 1.01-2.29), and 3 pancreatic cancer (aHR, 1.92; 95% CI, 1.10-3.36) cohorts. CONCLUSIONS This meta-analysis demonstrates a significant detrimental prognostic association between grade ≥3 lymphopenia and OS in patients receiving radiation therapy for solid tumors. This finding appears consistent for tumors of the brain, thorax, and upper abdomen and provides an imperative to further elucidate the potential survival benefit of lymphopenia-mitigating strategies.
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Kim KS, Wu HG. Who Will Benefit from Charged-Particle Therapy? Cancer Res Treat 2021; 53:621-634. [PMID: 34176253 PMCID: PMC8291184 DOI: 10.4143/crt.2021.299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/14/2021] [Indexed: 02/07/2023] Open
Abstract
Charged-particle therapy (CPT) such as proton beam therapy (PBT) and carbon-ion radiotherapy (CIRT) exhibit substantial physical and biological advantages compared to conventional photon radiotherapy. As it can reduce the amount of radiation irradiated in the normal organ, CPT has been mainly applied to pediatric cancer and radioresistent tumors in the eloquent area. Although there is a possibility of greater benefits, high set-up cost and dearth of high level of clinical evidence hinder wide applications of CPT. This review aims to present recent clinical results of PBT and CIRT in selected diseases focusing on possible indications of CPT. We also discussed how clinical studies are conducted to increase the number of patients who can benefit from CPT despite its high cost.
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Affiliation(s)
- Kyung Su Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul,
Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University Hospital, Seoul,
Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul,
Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul,
Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul,
Korea
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Karube M, Nakayama H. Proton therapy for patients with esophageal cancer: History, characteristics, clinical outcome and future direction of proton beam therapy. Glob Health Med 2021; 3:149-156. [PMID: 34250290 DOI: 10.35772/ghm.2020.01083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/20/2021] [Accepted: 01/28/2021] [Indexed: 11/08/2022]
Abstract
After the second war, Wilson who participated in development of the atomic bomb in Los Alamos studied peaceful use of atomic energy and proposed a property of proton beam that has potential to treat cancer. According to his proposal, the first patient was treated with proton beam therapy at the University of California Berkley in 1954. The first series of proton beam therapy for patients with esophageal cancer was reported from Japan in 1993. After that many proton facilities in Japan reported the clinical outcome of patients with esophageal cancer. Many dosimetric and clinical studies showed proton beam therapy for esophageal cancer was less toxic than photon beam therapy, however there is a paucity of randomized trials and evidence that proton beam therapy has clearly superior survival compared to photon therapy. Only one randomized trial has been conducted to study less toxicity for proton beam compared with intensity modulated radiotherapy (IMRT), which was stopped early because toxicities of IMRT were higher. A phase III study comparing overall survival between proton beam therapy and IMRT is now activated. A cost reduction for proton therapy is necessary to facilitate patient care and establishment of clinical evidence.
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Affiliation(s)
- Masataka Karube
- Department of Radiation Oncology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetsugu Nakayama
- Department of Radiation Oncology, National Center for Global Health and Medicine, Tokyo, Japan
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Suh YG, Bayasgalan U, Kim HT, Lee JM, Kim MS, Lee Y, Lee DY, Lee SU, Kim TH, Moon SH. Photon Versus Proton Beam Therapy for T1-3 Squamous Cell Carcinoma of the Thoracic Esophagus Without Lymph Node Metastasis. Front Oncol 2021; 11:699172. [PMID: 34235087 PMCID: PMC8255910 DOI: 10.3389/fonc.2021.699172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 05/20/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose We compared treatment outcomes and toxicities of photon radiotherapy versus proton beam therapy (PBT) and evaluated radiation field effects for T1–3 squamous cell carcinoma of the thoracic esophagus (EC) without lymph node metastasis. Methods Medical records of 77 patients with T1–3N0M0 thoracic EC treated with radiotherapy between 2011 and 2019 were retrospectively analyzed. Among these patients, 61 (79.2%) individuals had T1 EC. The initial clinical target volume encompassed the whole esophagus with or without supraclavicular and/or abdominal lymph nodes (extended-field radiotherapy; 67 patients, 87.0%) or the area 3–5 cm craniocaudally and 1–2 cm radially from the gross tumor volume (involved-field radiotherapy; 10 patients, 13.0%). The final clinical target volume included margins of at least 1 cm from the gross tumor volume, with total radiation doses of 50–66 (median, 66) cobalt gray equivalent. Three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and PBT were used in twenty-four, five, and forty-eight patients, respectively. Concurrent chemotherapy was administered to 17 (22.0%) patients overall and only five (8.0%) T1 patients. Results PBT showed significantly lower lung and heart radiation exposure in mean dose, V5, V10, V20, and V30 than photon radiotherapy. The median follow-up for all patients was 46 (interquartile range, 22–72) months. The 5-year progression-free survival and overall survival rates were 56.5 and 64.9%, respectively, with no significant survival difference between photon radiotherapy and PBT. In patients with T1 EC, 5-year progression-free survival and overall survival rates were 62.6 and 73.5%, respectively. Conclusions Extended-field radiotherapy using modern radiotherapy techniques without chemotherapy showed satisfactory clinical outcomes for lymph node-negative T1 EC.
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Affiliation(s)
- Yang-Gun Suh
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | | | - Heung Tae Kim
- Department of Internal Medicine, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Jong Mog Lee
- Department of Thoracic Surgery, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Moon Soo Kim
- Department of Thoracic Surgery, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Youngjoo Lee
- Department of Internal Medicine, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Doo Yeul Lee
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sung Uk Lee
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Tae Hyun Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sung Ho Moon
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
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Nicholas O, Prosser S, Mortensen HR, Radhakrishna G, Hawkins MA, Gwynne SH. The Promise of Proton Beam Therapy for Oesophageal Cancer: A Systematic Review of Dosimetric and Clinical Outcomes. Clin Oncol (R Coll Radiol) 2021; 33:e339-e358. [PMID: 33931290 DOI: 10.1016/j.clon.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/08/2021] [Accepted: 04/13/2021] [Indexed: 12/25/2022]
Abstract
AIMS Due to its physical advantages over photon radiotherapy, proton beam therapy (PBT) has the potential to improve outcomes from oesophageal cancer. However, for many tumour sites, high-quality evidence supporting PBT use is limited. We carried out a systematic review of published literature of PBT in oesophageal cancer to ascertain potential benefits of this technology and to gauge the current state-of-the-art. We considered if further evaluation of this technology in oesophageal cancer is desirable. MATERIALS AND METHODS A systematic literature search of Medline, Embase, Cochrane Library and Web of Science using structured search terms was carried out. Inclusion criteria included non-metastatic cancer, full articles and English language studies only. Articles deliberating technical aspects of PBT planning or delivery were excluded to maintain a clinical focus. Studies were divided into two sections: dosimetric and clinical studies; qualitatively synthesised. RESULTS In total, 467 records were screened, with 32 included for final qualitative synthesis. This included two prospective studies with the rest based on retrospective data. There was heterogeneity in treatment protocols, including treatment intent (neoadjuvant or definitive), dose, fractionation and chemotherapy used. Compared with photon radiotherapy, PBT seemed to reduce dose to organs at risk, especially lung and heart, although not for all reported parameters. Toxicity outcomes, including postoperative complications, were reduced compared with photon radiotherapy. Survival outcomes were reported to be at least comparable with photon radiotherapy. CONCLUSION There is a paucity of high-quality evidence supporting PBT use in oesophageal cancer. Wide variation in intent and treatment protocols means that the role and 'gold-standard' treatment protocol are yet to be defined. Current literature suggests significant benefit in terms of toxicity reduction, especially in the postoperative period, with comparable survival outcomes. PBT in oesophageal cancer holds significant promise for improving patient outcomes but requires robust systematic evaluation in prospective studies.
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Affiliation(s)
- O Nicholas
- South West Wales Cancer Centre, Swansea, UK; Swansea University Medical School, Swansea, UK.
| | - S Prosser
- South West Wales Cancer Centre, Swansea, UK
| | - H R Mortensen
- The Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - M A Hawkins
- University College Hospital NHS Foundation Trust, London, UK
| | - S H Gwynne
- South West Wales Cancer Centre, Swansea, UK; Swansea University Medical School, Swansea, UK
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Khalifa J, Mazieres J, Gomez-Roca C, Ayyoub M, Moyal ECJ. Radiotherapy in the Era of Immunotherapy With a Focus on Non-Small-Cell Lung Cancer: Time to Revisit Ancient Dogmas? Front Oncol 2021; 11:662236. [PMID: 33968769 PMCID: PMC8097090 DOI: 10.3389/fonc.2021.662236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/23/2021] [Indexed: 12/15/2022] Open
Abstract
Radiation-induced immune effects have been extensively deciphered over the last few years, leading to the concept of the dual immune effect of radiotherapy with both immunostimulatory and immunosuppressive effects. This explains why radiotherapy alone is not able to drive a strong anti-tumor immune response in most cases, hence underlining the rationale for combining both radiotherapy and immunotherapy. This association has generated considerable interest and hundreds of trials are currently ongoing to assess such an association in oncology. However, while some trials have provided unprecedented results or shown much promise, many hopes have been dashed. Questions remain, therefore, as to how to optimize the combination of these treatment modalities. This narrative review aims at revisiting the old, well-established concepts of radiotherapy relating to dose, fractionation, target volumes and organs at risk in the era of immunotherapy. We then propose potential innovative approaches to be further assessed when considering a radio-immunotherapy association, especially in the field of non-small-cell lung cancer (NSCLC). We finally propose a framework to optimize the association, with pragmatic approaches depending on the stage of the disease.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
| | - Julien Mazieres
- Department of Pulmonology, Centre Hospitalo-Universitaire Larrey, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Carlos Gomez-Roca
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Department of Medical Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Maha Ayyoub
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Elizabeth Cohen-Jonathan Moyal
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
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Khin NS, Tan SH, Wang ML, Siow TR, Lim FL, Wang FQ, Ng MC, Lam JY, Yip C. Chemoradiation-induced changes in systemic inflammatory markers and their prognostic significance in oesophageal squamous cell carcinoma. Br J Radiol 2021; 94:20200314. [PMID: 33861156 DOI: 10.1259/bjr.20200314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Chemoradiation (CRT) may induce a change in systemic inflammatory state which could affect clinical outcomes in oesophageal cancer. We aimed to evaluate the changes and prognostic significance of systemic inflammatory markers following definitive CRT in oesophageal squamous cell carcinoma. METHODS A total of 53 patients treated with concurrent CRT were included in this retrospective analysis. We compared neutrophils, lymphocytes, platelets, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) before and after CRT using Wilcoxon signed-rank test. Overall survival (OS) and progression-free survival (PFS) were calculated. Univariable and multivariable survival analysis were performed using Cox regression analysis. Clinical univariable survival prognostic factors with p < 0.1 were included in a multivariable cox regression analysis for backward stepwise model selection. RESULTS Both NLR (median ∆+2.8 [IQR -0.11, 8.62], p < 001) and PLR (median ∆+227 [81.3-523.5], p < 0.001) increased significantly after CRT. Higher levels of pre-CRT, post-CRT and change (∆) in NLR and PLR were associated with inferior OS and PFS. Post-CRT NLR (HR 1.04, 95% CI 1.02-1.07, p < 0.001), post-CRT platelets (HR 1.03, 95% CI 1.01-1.05, p = 0.005), cT-stage (HR 3.83, 95% CI 1.39-10.60, p = 0.01) and RT dose (HR 0.41, 95% CI 0.21-0.81, p = 0.01) were independent prognostic factors for OS in multivariable analysis. Change in NLR (HR 1.04, 95% CI 1.01-1.06, p = 0.001), post-CRT platelets (HR 1.03, 95% CI 1.01-1.05, p = 0.002), cT-stage (HR 3.98, 95% CI 1.55-10.25, p = 0.004) and RT dose (HR 0.41, 95% CI 0.21-0.80, p = 0.009) were independent prognostic factors for PFS. CONCLUSION Both NLR and PLR increased following definitive CRT. Post-CRT NLR and ∆NLR were associated with adverse survival in oesophageal SCC. ADVANCES IN KNOWLEDGE We showed that CRT increased PLR and NLR, possibly reflecting a systemic inflammatory state which were associated with poor clinical outcomes in oesophageal SCC.
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Affiliation(s)
- Ni Sann Khin
- Department of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Sze Huey Tan
- Division of Clinical Trials and Epidemiological Sciences, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Michael Lc Wang
- Department of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Tian Rui Siow
- Department of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Faye Lwt Lim
- Department of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Fu Qiang Wang
- Department of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Matthew Ch Ng
- Department of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Justina Yc Lam
- Department of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Connie Yip
- Department of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
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Prognosis of severe lymphopenia after postoperative radiotherapy in non-small cell lung cancer: Results of a long-term follow up study. Clin Transl Radiat Oncol 2021; 28:54-61. [PMID: 33778173 PMCID: PMC7985216 DOI: 10.1016/j.ctro.2021.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/19/2021] [Accepted: 02/27/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose To investigate the incidence and prognosis of severe radiation-induced lymphopenia (sRIL) after postoperative radiotherapy (PORT) for resected NSCLC. Patients and methods Between 1998 and 2017, 170 patients treated with PORT for NSCLC were retrospectively reviewed. Lymphopenia was divided into tertiles with severe lymphopenia defined as absolute lymphocyte counts (ALC) < 0.37 × 103/ul. Results sRIL was observed in 32.3% of patients. Multivariable logistic regression analysis indicated sRIL was associated with planning target volume radiation fraction numbers (OR 1.09, p = 0.005) and total lung mean dose (OR 1.12, p = 0.006). With a median follow-up time of 12.2 years, the median progression-free survival and overall survival were 14.8 months and 28.4 months respectively in patients with sRIL, vs. 21.7 months (p = 0.008) and 48.3 months (p = 0.01) respectively in patients without sRIL. Multivariable analyses indicated sRIL significantly decreased OS (HR 1.95, p < 0.01). Since PORT for stage I-II NSCLC was done largely for positive margins, which may confound the contribution of severe RIL, we analyzed stage III separately and found that sRIL also significantly decreased OS (HR 1.88, p = 0.004) in multivariable analysis. Conclusion For this long-term outcome study, severe RIL correlated with total lung mean dose and radiation fractionation numbers, and was a strong prognostic factor for poor survival in PORT patients, particularly in patients with stage III NSCLC, highlighting the importance of an intact immune system for post-radiation immunologic disease surveillance.
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Ho YC, Lai YC, Lin HY, Ko MH, Wang SH, Yang SJ, Lin PJ, Chou TW, Hung LC, Huang CC, Chang TH, Lin JB, Lin JC. Low cardiac dose and neutrophil-to-lymphocyte ratio predict overall survival in inoperable esophageal squamous cell cancer patients after chemoradiotherapy. Sci Rep 2021; 11:6644. [PMID: 33758232 PMCID: PMC7988072 DOI: 10.1038/s41598-021-86019-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/09/2021] [Indexed: 12/25/2022] Open
Abstract
We aimed to determine the prognostic significance of cardiac dose and hematological immunity parameters in esophageal cancer patients after concurrent chemoradiotherapy (CCRT). During 2010-2015, we identified 101 newly diagnosed esophageal squamous cell cancer patients who had completed definitive CCRT. Patients' clinical, dosimetric, and hematological data, including absolute neutrophil count, absolute lymphocyte count, and neutrophil-to-lymphocyte ratio (NLR), at baseline, during, and post-CCRT were analyzed. Cox proportional hazards were calculated to identify potential risk factors for overall survival (OS). Median OS was 13 months (95% confidence interval [CI]: 10.38-15.63). Univariate analysis revealed that male sex, poor performance status, advanced nodal stage, higher percentage of heart receiving 10 Gy (heart V10), and higher NLR (baseline and follow-up) were significantly associated with worse OS. In multivariate analysis, performance status (ECOG 0 & 1 vs. 2; hazard ratio [HR] 3.12, 95% CI 1.30-7.48), heart V10 (> 84% vs. ≤ 84%; HR 2.24, 95% CI 1.26-3.95), baseline NLR (> 3.56 vs. ≤ 3.56; HR 2.36, 95% CI 1.39-4.00), and follow-up NLR (> 7.4 vs. ≤ 7.4; HR 1.95, 95% CI 1.12-3.41) correlated with worse OS. Volume of low cardiac dose and NLR (baseline and follow-up) were associated with worse patient survival.
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Affiliation(s)
- Yu-Chieh Ho
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Yuan-Chun Lai
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.,Department of Medical Imaging Radiological Science, Central Taiwan University of Science and Technology, Taichung, 406, Taiwan
| | - Hsuan-Yu Lin
- Division of Hematology/Oncology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Ming-Hui Ko
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Sheng-Hung Wang
- Department of Radiation Oncology, Lukang Christian Hospital, Changhua Christian Medical Foundation, Lukang, 505, Taiwan
| | - Shan-Jun Yang
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Po-Ju Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Tsai-Wei Chou
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Li-Chung Hung
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Chia-Chun Huang
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Tung-Hao Chang
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.,Department of Medical Imaging Radiological Science, Central Taiwan University of Science and Technology, Taichung, 406, Taiwan.,Department of Medical Imaging and Radiological Technology, Yuanpei University of Science and Technology, Hsinchu, 300, Taiwan
| | - Jhen-Bin Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.
| | - Jin-Ching Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.,Division of Translation Research, Research Department, Changhua Christian Hospital, Changhua, 500, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, 112, Taiwan
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Friedrich T, Henthorn N, Durante M. Modeling Radioimmune Response-Current Status and Perspectives. Front Oncol 2021; 11:647272. [PMID: 33796470 PMCID: PMC8008061 DOI: 10.3389/fonc.2021.647272] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/25/2021] [Indexed: 12/13/2022] Open
Abstract
The combination of immune therapy with radiation offers an exciting and promising treatment modality in cancer therapy. It has been hypothesized that radiation induces damage signals within the tumor, making it more detectable for the immune system. In combination with inhibiting immune checkpoints an effective anti-tumor immune response may be established. This inversion from tumor immune evasion raises numerous questions to be solved to support an effective clinical implementation: These include the optimum immune drug and radiation dose time courses, the amount of damage and associated doses required to stimulate an immune response, and the impact of lymphocyte status and dynamics. Biophysical modeling can offer unique insights, providing quantitative information addressing these factors and highlighting mechanisms of action. In this work we review the existing modeling approaches of combined ‘radioimmune’ response, as well as associated fields of study. We propose modeling attempts that appear relevant for an effective and predictive model. We emphasize the importance of the time course of drug and dose delivery in view to the time course of the triggered biological processes. Special attention is also paid to the dose distribution to circulating blood lymphocytes and the effect this has on immune competence.
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Affiliation(s)
- Thomas Friedrich
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany
| | - Nicholas Henthorn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Marco Durante
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany.,Institute for Solid State Physics, Technical University Darmstadt, Darmstadt, Germany
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Wang JL, Ma R, Kong W, Zhao R, Wang YY. Lymphopenia in Esophageal Cancer: What Have We Learned? Front Oncol 2021; 11:625963. [PMID: 33791213 PMCID: PMC8006429 DOI: 10.3389/fonc.2021.625963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/01/2021] [Indexed: 02/03/2023] Open
Abstract
Lymphopenia caused by disease or treatment is frequent in patients with cancer, which seriously affects the prognosis of these patients. Immune checkpoint inhibitors (ICIs) have garnered attention as one of the most promising strategies for the treatment of esophageal cancer (EC). The status of the immune system, such as, the lymphocyte count, is now considered to be an important biomarker for ICI treatments. Recognition of the significant impact of the lymphocyte count on the survival of patients with EC in the era of immunotherapy has revived interest in understanding the causes of lymphopenia and in developing strategies to predict, prevent and eliminate the adverse effect of lymphopenia. Here, we review what we have learned about lymphopenia in EC, including the prognostic and predictive value of lymphopenia in patients with EC, the predictors of lymphopenia, and the strategies to ameliorate the effect of lymphopenia in patients with EC.
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Affiliation(s)
- Jia-Lin Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Rong Ma
- Graduate School, Ningxia Medical University, Yinchuan, China
| | - Wei Kong
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Ren Zhao
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Yan-Yang Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
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Patient-Specific Lymphocyte Loss Kinetics as Biomarker of Spleen Dose in Patients Undergoing Radiation Therapy for Upper Abdominal Malignancies. Adv Radiat Oncol 2021; 6:100545. [PMID: 33665481 PMCID: PMC7897770 DOI: 10.1016/j.adro.2020.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/26/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose Radiation therapy (RT)-induced lymphopenia (RIL) is linked with inferior survival in esophageal and pancreatic cancers. Previous work has demonstrated a correlation between spleen dose and RIL risk. The present study correlates spleen dose-volume parameters with fractional lymphocyte loss rate (FLL) and total percent change in absolute lymphocyte count (%ΔALC) and suggests spleen dose constraints to reduce RIL risk. Methods and Materials This registry-based study included 140 patients who underwent RT for pancreatic (n = 67), gastroesophageal (n = 61), or biliary tract (n = 12) adenocarcinoma. Patient-specific parameters of lymphocyte loss kinetics, including FLL and %ΔALC, were calculated based on serial ALCs obtained during RT. Spearman's rho was used to correlate spleen dose-volume parameters with %ΔALC, end-treatment ALC, and FLL. Multivariable logistic regression was used to identify predictors of ≥grade 3 and grade 4 RIL. Results Spleen dose-volume parameters, including mean spleen dose (MSD), all correlated with %ΔALC, end-treatment ALC, and FLL. Controlling for baseline ALC and planning target volume (PTV), an increase in any spleen dose-volume parameter increased the odds of developing ≥grade 3 lymphopenia. Each 1-Gy increase in MSD increased the odds of ≥grade 3 RIL by 18.6%, and each 100-cm3 increase in PTV increased the odds of ≥grade 3 lymphopenia by 20%. Patients with baseline ALC < 1500 cells/μL had a high risk of ≥grade 3 RIL regardless of MSD or PTV. FLL was an equally good predictor of ≥grade 3 lymphopenia as any spleen dose-volume parameter. Conclusions In patients undergoing RT for upper abdominal malignancies, higher spleen dose is associated with higher per-fraction lymphocyte loss rates, higher total %ΔALC, and increased odds of severe lymphopenia. Spleen dose constraints should be individualized based on baseline ALC and PTV size to minimize RIL risk, although our findings require validation in larger, ideally prospective data sets.
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De B, Ng SP, Liu AY, Avila S, Tao R, Holliday EB, Brownlee Z, Kaseb A, Lee S, Raghav K, Vauthey JN, Minsky BD, Herman JM, Das P, Smith GL, Taniguchi CM, Krishnan S, Crane CH, Grassberger C, Hong TS, Lin SH, Koong AC, Mohan R, Koay EJ. Radiation-Associated Lymphopenia and Outcomes of Patients with Unresectable Hepatocellular Carcinoma Treated with Radiotherapy. J Hepatocell Carcinoma 2021; 8:57-69. [PMID: 33688489 PMCID: PMC7937383 DOI: 10.2147/jhc.s282062] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/11/2021] [Indexed: 12/14/2022] Open
Abstract
Background The immune system plays a crucial role in cancer surveillance. Previous studies have shown that lymphopenia associated with radiotherapy (RT) portends a poor prognosis. We sought to differentiate the effects of proton and photon RT on changes in absolute lymphocyte count (ALC) for patients with hepatocellular carcinoma (HCC). Patients and Methods Patients with HCC treated with definitive RT from 2006 to 2016 were studied. Serial ALCs were graded according to CTCAE v4.0. Overall survival (OS), disease-free survival, and distant metastasis-free survival were analyzed using the Kaplan-Meier method. Univariable and multivariable Cox-proportional hazards analyses were used to identify predictors of OS. A cohort analysis matched for treatment volume was performed to investigate differences in ALC dynamics between photon and proton therapy. Results Of 143 patients identified, the median age was 66 (range, 19-90) years. The treatment modality was photon in 103 (72%) and proton in 40 (28%). Median follow-up was 17 months (95% confidence interval, 13-25 months). The median time to ALC nadir after initiation of RT was 17 days with a median relative decrease of 67%. Those who received proton RT had a higher median ALC nadir (0.41 vs 0.32 k/µL, p=0.002) and longer median OS (33 vs 13 months, p=0.002) than those who received photon RT. Matched cohort analyses revealed a larger low-dose liver volume in the photon group, which correlated with lower ALC. On multivariable Cox analysis, Grade 3 or higher lymphopenia prior to or after RT, portal venous tumor thrombus, larger planning target volumes, Child-Pugh (CP) Class B, and increased CP score after RT were associated with a higher risk of death, whereas the use of proton therapy was associated with lower risk. Conclusion Grade 3 or higher lymphopenia may be associated with poorer outcomes in patients receiving RT for HCC. Protons may mitigate lymphopenia compared with photons, potentially due to reduced dose exposure of sites of lymphopoiesis.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Radiation Oncology, Austin Health, Melbourne, Victoria, Australia
| | - Amy Y Liu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Santiago Avila
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randa Tao
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zachary Brownlee
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA, USA
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung Lee
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Kanwal Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph M Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Radhe Mohan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Terrones-Campos C, Ledergerber B, Vogelius IR, Helleberg M, Specht L, Lundgren J. Hematological toxicity in patients with solid malignant tumors treated with radiation - Temporal analysis, dose response and impact on survival. Radiother Oncol 2021; 158:175-183. [PMID: 33662438 DOI: 10.1016/j.radonc.2021.02.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To describe the kinetics of the peripheral blood components after radiotherapy, to examine radiation exposure vs. End-of-Radiation-Therapy (EoRT) counts and to associate the EoRT lymphocyte count with death and cancer treatment failure. MATERIALS AND METHODS Cohort study of patients who received curative intent radiotherapy for solid tumor diagnoses from 2009-2016 at Rigshospitalet, Copenhagen and had available 3D radiation exposure data. We illustrated peripheral blood count kinetics within 12 months before and after radiotherapy start and analyzed the impact of the irradiated body volume. We investigated overall survival and cancer treatment failure according to EoRT lymphopenia using Cox regression analyses. RESULTS We analyzed 4055 patients with both pre-treatment and EoRT platelet counts and 2318 patients who also had neutrophil and lymphocyte counts. Only the lymphocyte decline after radiotherapy start was clinically relevant and remained low one year after radiotherapy. The higher the volume of the body exposed to radiation, the lower the EoRT blood counts. Female gender (p < 0.001), number of fractions (p = 0.010), dose-volume (p < 0.001) and concomitant use of chemotherapy, particularly the platinum compounds (p < 0.001) were independently associated with a lower EoRT lymphocyte count. Patients with head and neck cancer had the lowest EoRT lymphocyte count. Patients with lymphopenia had a higher risk of death in the year after radiotherapy, compared with patients with no lymphopenia. CONCLUSION Radiation schemes with fewer fractions and radiation techniques allowing reduction of the volume of the body exposed to radiation could be expected to better preserve patients' immune function.
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Affiliation(s)
- Cynthia Terrones-Campos
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Bruno Ledergerber
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marie Helleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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71
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Mohan R, Liu AY, Brown PD, Mahajan A, Dinh J, Chung C, McAvoy S, McAleer MF, Lin SH, Li J, Ghia AJ, Zhu C, Sulman EP, de Groot JF, Heimberger AB, McGovern SL, Grassberger C, Shih H, Ellsworth S, Grosshans DR. Proton therapy reduces the likelihood of high-grade radiation-induced lymphopenia in glioblastoma patients: phase II randomized study of protons vs photons. Neuro Oncol 2021; 23:284-294. [PMID: 32750703 PMCID: PMC7906048 DOI: 10.1093/neuonc/noaa182] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We investigated differences in radiation-induced grade 3+ lymphopenia (G3+L), defined as an absolute lymphocyte count (ALC) nadir of <500 cells/µL, after proton therapy (PT) or X-ray (photon) therapy (XRT) for patients with glioblastoma (GBM). METHODS Patients enrolled in a randomized phase II trial received PT (n = 28) or XRT (n = 56) concomitantly with temozolomide. ALC was measured before, weekly during, and within 1 month after radiotherapy. Whole-brain mean dose (WBMD) and brain dose-volume indices were extracted from planned dose distributions. Univariate and multivariate logistic regression analyses were used to identify independent predictive variables. The resulting model was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS Rates of G3+L were lower in men (7/47 [15%]) versus women (19/37 [51%]) (P < 0.001), and for PT (4/28 [14%]) versus XRT (22/56 [39%]) (P = 0.024). G3+L was significantly associated with baseline ALC, WBMD, and brain volumes receiving 5‒40 Gy(relative biological effectiveness [RBE]) or higher (ie, V5 through V40). Stepwise multivariate logistic regression analysis identified being female (odds ratio [OR] 6.2, 95% confidence interval [CI]: 1.95‒22.4, P = 0.003), baseline ALC (OR 0.18, 95% CI: 0.05‒0.51, P = 0.003), and whole-brain V20 (OR 1.07, 95% CI: 1.03‒1.13, P = 0.002) as the strongest predictors. ROC analysis yielded an area under the curve of 0.86 (95% CI: 0.79-0.94) for the final G3+L prediction model. CONCLUSIONS Sex, baseline ALC, and whole-brain V20 were the strongest predictors of G3+L for patients with GBM treated with radiation and temozolomide. PT reduced brain volumes receiving low and intermediate doses and, consequently, reduced G3+L.
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Affiliation(s)
- Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy Y Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic Hospital, Rochester, Minnesota
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic Hospital, Rochester, Minnesota
| | - Jeffrey Dinh
- Millennium Physicians Radiation Oncology, The Woodlands, Texas
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah McAvoy
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cong Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center, Houston, Texas
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, New York
| | - John F de Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy B Heimberger
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Susannah Ellsworth
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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72
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Byun HK, Chung SY, Kim KJ, Seong J. Role of Interleukin-7 in the Development of and Recovery from Radiation-Induced Lymphopenia: A Post-hoc Analysis of a Prospective Cohort. Cancer Res Treat 2021; 53:962-972. [PMID: 33540496 PMCID: PMC8524008 DOI: 10.4143/crt.2020.1053] [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: 10/14/2020] [Accepted: 01/25/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose Radiation-induced lymphopenia is associated with worse outcomes in solid tumors. We assessed the impact of interleukin-7 (IL-7), a key cytokine in lymphocyte homeostasis, on radiation-induced lymphopenia. Materials and Methods A post-hoc analysis was performed in a prospective cohort of 98 patients with hepatocellular carcinoma who were treated with radiotherapy in 2016–2018. Blood IL-7 levels were assayed before and at the end of radiotherapy. Acute severe lymphopenia (ASL) was defined as a total lymphocyte count of < 200/μL during radiotherapy. Cox and logistic regression analyses were performed to identify predictors of survival and ASL development, respectively. Results Patients with ASL (n=41) had significantly poorer overall survival than those without (12.0 months vs. 25.3 months, p=0.001). Patients with lymphocyte recovery showed significantly longer overall survival than those without (21.8 months vs. 10.3 months, p=0.042). ASL was an independent predictor of poor survival (hazard ratio, 2.07; p=0.015). Patients with ASL had significantly lower pre-radiotherapy IL-7 levels (2.07 pg/mL vs. 3.01 pg/mL, p=0.010). A high pre-radiotherapy IL-7 level was an independent predictor of a reduced risk of ASL development (hazard ratio, 0.40; p=0.004). IL-7 levels reflected a feedback response to ASL, with a higher ΔIL-7 in patients with ASL and a lower ΔIL-7 in those without ASL (0.48 pg/mL vs. −0.66 pg/mL, p < 0.001). Post-radiotherapy IL-7 levels were significantly positively correlated with the total lymphocyte counts at 2 months. Conclusion IL-7 is associated with the development of and recovery from ASL, which may impact survival. To overcome radiation-induced lymphopenia, a novel strategy using IL-7 may be considered.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yeun Chung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.,Department of Radiation Oncology, Ajou University Medical Center, Suwon, Korea
| | - Kyoung-Jin Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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73
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Koukourakis MI, Giatromanolaki A. Lymphopenia and intratumoral lymphocytic balance in the era of cancer immuno-radiotherapy. Crit Rev Oncol Hematol 2021; 159:103226. [PMID: 33482348 DOI: 10.1016/j.critrevonc.2021.103226] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/15/2020] [Accepted: 01/16/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The immune response has been recognized as a major tumor-eradication component of radiotherapy. OBJECTIVE This review studies, under a clinical perspective, two contrasting effects of radiotherapy, namely immunosuppression and radiovaccination. MATERIALS AND METHODS We critically reviewed the available clinical and experimental experience on radiotherapy-induced lymphopenia. RESULTS Radiation-induced tumor damage promotes radio-vaccination, enhances cytotoxic immune responses, and potentiates immunotherapy. Nevertheless, radiotherapy induces systemic and intratumoral lymphopenia. The above effects are directly related to radiotherapy fractionation and field size/location, and tumor characteristics. DISCUSSION Hypofractionated stereotactic and accelerated irradiation better promotes radio-vaccination and produces less severe lymphopenia. Adopting cytoprotective policies and combining lympho-stimulatory agents or agents blocking regulatory lymphocyte activity are awaited to unmask the radio-vaccination effect, enhancing the efficacy immuno-radiotherapy. CONCLUSION Radiation-induced lymphopenia and immunosuppression are important issues that should be considered in the design of immuno-radiotherapy clinical trials.
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Affiliation(s)
- Michael I Koukourakis
- Department of Radiotherapy/Oncology, Medical School, Democritus University of Thrace, Alexandroupolis 68100, Greece.
| | - Alexandra Giatromanolaki
- Department of Pathology, Medical School, Democritus University of Thrace, Alexandroupolis 68100, Greece
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74
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Review of clinical results of charged-particle therapy for esophageal cancer. Esophagus 2021; 18:33-40. [PMID: 32654019 DOI: 10.1007/s10388-020-00759-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/24/2020] [Indexed: 02/03/2023]
Abstract
Esophageal cancer is one of the common causes of cancer-related death. The treatment for esophageal cancer, particularly unresectable cases, is a difficult problem. Reports about charged-particle therapy including proton beam therapy and carbon-ion radiotherapy for esophageal cancer have increased. The objective of this study was to review the clinical results of charged-particle therapy for esophageal cancer. Charged-particle therapy was used with an expectation of increasing overall survival with reducing toxicities because charged-particle therapy can reduce the irradiated dose for normal tissues around the target tumor due to its characteristics, hence the name Bragg peak. Proton beam therapy showed a superior distribution of irradiation dose over X-ray therapy including intensity-modulated radiotherapy in silico, but clinical results were not the same. Some reports suggested that proton beam therapy may reduce acute and late toxicities, particularly in the heart and lung, during and after treatment, although it cannot lead to a higher overall survival than that in X-ray therapy. On the other hand, there are a few reports about carbon-ion radiotherapy for esophageal cancer. The special feature of carbon-ion radiotherapy is that hypofractionated radiotherapy is possible as compared to that in X-ray therapy or proton beam therapy. However, the true clinical impact of proton beam therapy or carbon-ion radiotherapy remains unclear because there are no prospective clinical trials comparing charged-particle therapy to X-ray therapy. In view of charged-particle therapy may become one of the treatment choices for esophageal cancer, further studies are needed.
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75
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Kim N, Myoung Noh J, Lee W, Park B, Park H, Young Park J, Pyo H. Proton beam therapy reduces the risk of severe radiation-induced lymphopenia during chemoradiotherapy for locally advanced non-small cell lung cancer: A comparative analysis of proton versus photon therapy. Radiother Oncol 2020; 156:166-173. [PMID: 33359267 DOI: 10.1016/j.radonc.2020.12.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 12/23/2022]
Abstract
HYPOTHESIS We investigated differences in severe radiation-induced lymphopenia (SRL) after pencil beam scanning proton therapy (PBSPT) or intensity-modulated (photon) radiotherapy (IMRT) for patients with locally advanced non-small cell lung cancer. METHODS We retrospectively reviewed 223 patients who received definitive concurrent chemoradiotherapy with PBSPT (n = 29) or IMRT (n = 194). SRL was defined when ≥2 events of absolute lymphocyte counts (ALCs) of <200 cells/μL were observed in weekly laboratory tests conducted during treatment. Stepwise multivariate logistic regression with 10-fold cross-validation was performed to identify predictive values of SRL. Furthermore, 1:2 propensity score matching (PSM) analysis was performed between the PBSPT and IMRT groups. RESULTS Baseline ALC was comparable between the PBSPT and IMRT groups (median, 2130 vs. 2040 cells/μL; p = 0.983). Lung volumes receiving ≥ 5-20 GyE and the mean dose were significantly lower in patients receiving PBSPT than those receiving IMRT (p < 0.001). Among 72 (32.3%) patients with SRL; 69 (95.8%) and 3 (4.2%) patients were treated with IMRT and PBSPT, respectively. After multivariable analysis, PBSPT reduced SRL compared to IMRT (odds ratio [OR] 0.13, p = 0.003). Specifically, lung V5Gy were identified as the strongest predictor of SRL before (OR 1.11) and after PSM (OR, 1.07) (p < 0.05). With a median follow-up of 23.0 months, the 2-year overall survival in patients with SRL was worse than that those without SRL (63.4% vs. 79.9%; p = 0.003). CONCLUSIONS Reduced irradiated lung volumes of PBSPT consequently reduced SRL. In addition, lung V5Gy contributed to the SRL. Reduction of SRL through the optimized RT might be essential to improve the outcomes.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Woojin Lee
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byoungsuk Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Heejoo Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Young Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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76
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Gergelis KR, Jethwa KR, Tryggestad EJ, Ashman JB, Haddock MG, Hallemeier CL. Proton beam radiotherapy for esophagus cancer: state of the art. J Thorac Dis 2020; 12:7002-7010. [PMID: 33282405 PMCID: PMC7711403 DOI: 10.21037/jtd-2019-cptn-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The majority of esophageal cancer patients are diagnosed with locoregionally confined disease, which is often amenable to curative intent therapy. Chemoradiotherapy (CRT) improves overall survival (OS) in stage II and III esophagus cancer in the neoadjuvant and definitive settings. Due to the close proximity of organs at risk (OARs), including lungs, heart, stomach, bowel, kidneys, and spinal cord, esophageal CRT can result in profound acute and late toxicities. Acute toxicities can include esophagitis, nausea, vomiting, fatigue, and cytopenias. Late complications may also occur months or years after completion of thoracic radiotherapy, including significant cardiac, pulmonary, liver, kidney, or bowel toxicities, which can be life-threatening or fatal. Photon-based radiotherapy exposes OARs to significant doses of radiation, whereas proton beam therapy (PBT) has unique physical properties, as it lacks an exit dose. This allows PBT to deliver, a more conformal dose to the target and minimize the volume of OARs exposed to radiation. This dosimetric advantage may portend an increased therapeutic ratio of CRT for esophagus cancer. The objective of this review is to discuss the evolution of photon and proton-based radiotherapy techniques, rationale, dosimetric and clinical studies comparing outcomes of photon- and proton-based techniques, ongoing prospective trials, and future directions of PBT as a means of reducing toxicity and improving oncologic outcomes for patients with esophagus cancer.
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Affiliation(s)
| | - Krishan R Jethwa
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix/Scottsdale, AZ, USA
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Guo T, Zou L, Ni J, Chu X, Zhu Z. Radiotherapy for unresectable locally advanced non-small cell lung cancer: a narrative review of the current landscape and future prospects in the era of immunotherapy. Transl Lung Cancer Res 2020; 9:2097-2112. [PMID: 33209629 PMCID: PMC7653144 DOI: 10.21037/tlcr-20-511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Significant recent advances have occurred in the use of radiation therapy for locally advanced non-small cell lung cancer (LA-NSCLC). In fact, the past few decades have seen both therapeutic gains and setbacks in the evolution of radiotherapy for LA-NSCLC. The PACIFIC trial has heralded a new era of immunotherapy and has raised important questions for future study, such as the future directions of radiation therapy for LA-NSCLC in the era of immunotherapy. Modern radiotherapy techniques such as three-dimensional (3D) conformal radiotherapy and intensity-modulated radiotherapy (IMRT) provide opportunities for improved target conformity and reduced normal-tissue exposure. However, the low-dose radiation volume brought by IMRT and its effects on the immune system deserve particular attention when combing radiotherapy and immunotherapy. Particle radiotherapy offers dosimetric advantages and exhibits great immunoregulatory potential. With the ongoing improvement in particle radiotherapy techniques and knowledge, the combination of immunotherapy and particle radiotherapy has tremendous potential to improve treatment outcomes. Of particular importance are questions on the optimal radiation schedule in the settings of radio-immunotherapy. Strategies for the reduction of the irradiated field such as involved-field irradiation (IFI) and omission of clinical target volume (CTV) hold promise for better preservation of immune function while not compromising locoregional and distant control. In addition, different dose-fractionation regimens can have diverse effects on the immune system. Thus, prospective trials are urgently needed to establish the optimal dose fractionation regimen. Moreover, personalized radiotherapy which allows the tailoring of radiation dose to each individual's genetic background and immune state is of critical importance in maximizing the benefit of radiation to patients with LA-NSCLC.
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Affiliation(s)
- Tiantian Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Liqing Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College.,Institute of Thoracic Oncology, Fudan University, Shanghai, China
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78
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Xu H, Lin M, Hu Y, Zhang L, Li Q, Zhu J, Wang S, Xi M. Lymphopenia During Definitive Chemoradiotherapy in Esophageal Squamous Cell Carcinoma: Association with Dosimetric Parameters and Patient Outcomes. Oncologist 2020; 26:e425-e434. [PMID: 32960471 DOI: 10.1002/onco.13533] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 08/26/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The objective of this study was to investigate the relationship between clinical characteristics, as well as dosimetric parameters, and the risk of treatment-related lymphopenia in esophageal squamous cell carcinoma (ESCC) treated with definitive chemoradiotherapy (CRT). MATERIALS AND METHODS Clinical characteristics and dosimetric parameters were collected from 436 patients with ESCC who received definitive CRT from 2010 through 2017. Absolute lymphocyte counts (ALCs) were obtained before, during, and 1 month after CRT. Grade 4 (G4) lymphopenia was defined as ALC <0.2 × 109 /L during CRT. Logistic regression analysis was used to evaluate the effect of each factor on predicting G4 lymphopenia. The relationship between lymphopenia and overall survival (OS) was examined, and a nomogram was developed to predict OS. RESULTS G4 lymphopenia was observed in 103 patients (23.6%) during CRT. Multivariate analysis indicated that planning target volume (PTV), lung V10 , heart V10 , performance status, and pretreatment lymphopenia were significant risk factors for G4 lymphopenia. Patients with G4 lymphopenia had significantly worse survival than those without. Based on multivariate analysis, clinical TNM stage, radiotherapy modality, pretreatment ALC, and G4 lymphopenia were predictive of OS and were incorporated into the nomogram, yielding a concordance index of 0.71. CONCLUSIONS G4 lymphopenia during definitive CRT was associated with larger PTVs, higher lung V10 and heart V10 , and worse survival. IMPLICATIONS FOR PRACTICE The purpose of this study was to investigate the relationship between clinical characteristics, as well as dosimetric parameters, and the risk of treatment-related lymphopenia in 436 patients with esophageal squamous cell carcinoma who received definitive chemoradiotherapy. Grade 4 (G4) lymphopenia was observed in 23.6% of patients during radiotherapy. G4 lymphopenia was associated with larger planning target volumes, higher lung V10 and heart V10 , and worse survival. Then, a nomogram was built based on multivariate analysis, yielding excellent performance to predict overall survival. Prospective studies are needed to investigate potential approaches for mitigating severe lymphopenia, which may ultimately convert into survival benefits.
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Affiliation(s)
- Hui Xu
- Department of Head and Neck Oncology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, People's Republic of China
| | - Maosheng Lin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yingying Hu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Department of Nuclear Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Li Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Qiaoqiao Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jinhan Zhu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Shi Wang
- Department of Engineering Physics, Tsinghua University, Beijing, People's Republic of China
| | - Mian Xi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
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Wu Y, Chen J, Zhao L, Li Q, Zhu J, Yang H, Guo S, Xi M. Prediction of Pathologic Response to Neoadjuvant Chemoradiotherapy in Patients with Esophageal Squamous Cell Carcinoma Incorporating Hematological Biomarkers. Cancer Res Treat 2020; 53:172-183. [PMID: 32898941 PMCID: PMC7812014 DOI: 10.4143/crt.2020.594] [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: 06/19/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to develop a nomogram for predicting pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) in patients with esophageal squamous cell carcinoma (ESCC) by integrating hematological biomarkers and clinicopathological characteristics. Materials and Methods Between 2003 and 2017, 306 ESCC patients who underwent neoadjuvant CRT followed by esophagectomy were analyzed. Besides clinicopathological factors, hematological parameters before, during, and after CRT were collected. Univariate and multivariate logistic regression analyses were performed to identify predictive factors for pCR. A nomogram model was built and internally validated. RESULTS Absolute lymphocyte count (ALC), lymphocyte to monocyte ratio, albumin, hemoglobin, white blood cell, neutrophil, and platelet count generally declined, whereas neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) increased significantly following neoadjuvant CRT. After surgery, 124 patients (40.5%) achieved a pCR. The pCR group demonstrated significantly more favorable survival than the non-pCR group. On multivariate analysis, significant factors associated with pCR included sex, chemotherapy regimen, post-CRT endoscopic finding, pre-CRT NLR, ALC nadir during CRT, and post-CRT PLR, which were incorporated into the prediction model. The nomogram indicated good accuracy in predicting pCR, with a C-index of 0.75 (95% confidence interval, 0.71 to 0.78). CONCLUSION Female, chemotherapy regimen of cisplatin/vinorelbine, negative post-CRT endoscopic finding, pre-CRT NLR (≤ 2.1), ALC nadir during CRT (> 0.35 ×109/L), and post-CRT PLR (≤ 83.0) were significantly associated with pCR in ESCC patients treated with neoadjuvant CRT. A nomogram incorporating hematological biomarkers to predict pCR was developed and internally validated, showing good predictive performance.
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Affiliation(s)
- Yingjia Wu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jinbin Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lei Zhao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qiaoqiao Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jinhan Zhu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hong Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Suping Guo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Mian Xi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
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80
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Moon SH, Suh YG. The Role of Modern Radiotherapy Technology in the Treatment of Esophageal Cancer. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:184-190. [PMID: 32793450 PMCID: PMC7409878 DOI: 10.5090/kjtcs.2020.53.4.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/06/2020] [Accepted: 07/11/2020] [Indexed: 11/16/2022]
Abstract
Radiation therapy (RT) has improved patient outcomes, but treatment-related complication rates remain high. In the conventional 2-dimensional and 3-dimensional conformal RT (3D-CRT) era, there was little room for toxicity reduction because of the need to balance the estimated toxicity to organs at risk (OARs), derived from dose-volume histogram data for organs including the lung, heart, spinal cord, and liver, with the planning target volume (PTV) dose. Intensity-modulated RT (IMRT) is an advanced form of conformal RT that utilizes computer-controlled linear accelerators to deliver precise radiation doses to the PTV. The dosimetric advantages of IMRT enable better sparing of normal tissues and OARs than is possible with 3D-CRT. A major breakthrough in the treatment of esophageal cancer (EC), whether early or locally advanced, is the use of proton beam therapy (PBT). Protons deposit their highest dose of radiation at the tumor, while leaving none behind; the resulting effective dose reduction to healthy tissues and OARs considerably reduces acute and delayed RT-related toxicity. In recent studies, PBT has been found to alleviate severe lymphopenia resulting from combined chemo-radiation, opening up the possibility of reducing immune suppression, which might be associated with a poor prognosis in cases of locally advanced EC.
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Affiliation(s)
- Sung Ho Moon
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Yang-Gun Suh
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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81
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DeCesaris CM, Berger M, Choi JI, Carr SR, Burrows WM, Regine WF, Simone CB, Molitoris JK. Pathologic complete response (pCR) rates and outcomes after neoadjuvant chemoradiotherapy with proton or photon radiation for adenocarcinomas of the esophagus and gastroesophageal junction. J Gastrointest Oncol 2020; 11:663-673. [PMID: 32953150 DOI: 10.21037/jgo-20-205] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) is associated with improved survival in patients treated for esophageal cancer. While proton beam therapy (PBT) has been demonstrated to reduce toxicities with nCRT, no data comparing pCR rates between modalities exist to date. We investigated pCR rates in patients with distal esophageal/GEJ adenocarcinomas undergoing trimodality therapy with nCRT-PBT or photon-based nCRT with the hypothesis that pathologic responses with PBT would be at least as high as with photon therapy. Methods A single-institutional review of patients with distal esophageal adenocarcinoma treated with trimodality therapy from 2015-2018 using PBT was completed. PBT patients were matched 1:2 to patients treated with photons. Chi square and two-sample t-tests were utilized to compare characteristics, and the Kaplan Meier method was used to estimate oncologic endpoints. Results Eighteen consecutive PBT patients were identified and compared to 36 photon patients. All patients received concurrent chemotherapy; 98% with carboplatin/paclitaxel. Most patients were male (91%) and White (89%); median age was 62 years (range, 31-76 years). Median radiation dose in both cohorts was 50.4 Gy (range, 41.4-50.4 Gy); all courses were delivered in 1.8Gy fractions. Age, gender and race were well balanced. Patients treated with PBT had a significantly higher pre-treatment nodal stage (N) and AJCC 7th edition stage grouping (P=0.02, P=0.03). Despite this, tumoral and nodal clearance and pCR rates were equivalent between cohorts (P=0.66, P=0.11, P=0.63, respectively). Overall pCR and individual primary and nodal clearance rates, overall survival (OS), locoregional control (LRC), and distant metastatic control did not significantly differ between modalities (all P>0.05). Major perioperative events were balanced; however, there were 5 (14%) perioperative deaths in the photon cohort compared to 0 (0%) in the proton cohort (P=0.06). Conclusions The use of PBT in trimodality therapy for distal esophageal adenocarcinoma yields pCR rates comparable to photon radiation and historical controls. Pathologic responses and oncologic outcomes in this study did not differ significantly between modalities despite PBT patients having higher AJCC stages and nodal disease burdens.
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Affiliation(s)
- Cristina M DeCesaris
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Melanie Berger
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Shamus R Carr
- Department of Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Whitney M Burrows
- Department of Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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82
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Wang X, Zhao Z, Wang P, Geng X, Zhu L, Li M. Low Lymphocyte Count Is Associated With Radiotherapy Parameters and Affects the Outcomes of Esophageal Squamous Cell Carcinoma Patients. Front Oncol 2020; 10:997. [PMID: 32656085 PMCID: PMC7324641 DOI: 10.3389/fonc.2020.00997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/20/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose: Lymphocytes are central players in systemic anti-tumor immune responses. In this study, we aimed to identify the relationship between absolute lymphocyte count (ALC) nadir during definitive radiotherapy (RT) and survival outcomes in patients with esophageal squamous cell carcinoma (ESCC), as well as evaluate the effect of RT parameters on ALC during RT. Materials and methods: We retrospectively reviewed 189 patients with stage I-IVA ESCC, who were treated with definitive RT at a single institution between 2012 and 2015. ALC values were assessed before, weekly during RT, and 1 month after the end of RT. Kaplan–Meier and Cox regression analyses were used to evaluate the relationship between ALC nadir during RT and patient outcomes. Predictors of low ALC nadir were assessed using univariate and multivariate logistic regression analyses. Results: The median ALC before treatment was 1.73 × 103 cells/μL. Fifty-eight (58.2) percent of the patients exhibited low ALC nadir (≤ 0.38 × 103 cells/μL) during RT. A low ALC nadir during RT was significantly associated with poor OS, PFS, and LRFS. The planning target volume (PTV) was larger in patients with low ALC nadir compared with patients with high ALC nadir (418.5 vs. 347.7 cm3, P = 0.023). Multivariate logistic regression analysis revealed that tumor stage III-IVA (P = 0.002), low ALC before treatment (P = 0.028), large Log10(PTV) (P = 0.01), high heart V10 (P = 0.003), and high heart V20 (P = 0.028) were associated with low ALC nadir during RT. Conclusions: In ESCC patients who received definitive RT, a low ALC nadir during RT was associated with large PTVs, and it was an independent prognostic factor of outcomes.
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Affiliation(s)
- Xin Wang
- Department of Clinical Medicine, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Zongxing Zhao
- Department of Radiation Oncology, Liaocheng People's Hospital, Liaocheng, China
| | - Peiliang Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,School of Medicine, Shandong University, Jinan, China
| | - Xiaotao Geng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,School of Medicine, Shandong University, Jinan, China
| | - Liqiong Zhu
- Department of Clinical Medicine, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Minghuan Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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83
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Wang X, Wang P, Zhao Z, Mao Q, Yu J, Li M. A review of radiation-induced lymphopenia in patients with esophageal cancer: an immunological perspective for radiotherapy. Ther Adv Med Oncol 2020; 12:1758835920926822. [PMID: 32518598 PMCID: PMC7252357 DOI: 10.1177/1758835920926822] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/24/2020] [Indexed: 12/16/2022] Open
Abstract
Radiotherapy is a frequently utilized therapeutic modality in the treatment of esophageal cancer (EC). Even though extensive studies are carried out in radiotherapy for EC, the design of the clinical target volume and the radiation dose is not satisfactorily uniform. Radiotherapy acts as a double-edged sword on the immune system; it has both an immunostimulatory effect and an immunosuppressive effect. Radiation-induced lymphopenia and its potential association with tumor control and survival outcomes remain to be understood. The advent of immunotherapy has renewed the focus on preserving a pool of functioning lymphocytes in the circulation. In this review, we summarize the potential impact mechanisms of radiotherapy on peripheral blood lymphocytes and the prognostic role of radiation-induced lymphopenia in patients with EC. We also propose the concept of organs-at-risk of lymphopenia and discuss potential strategies to mitigate its effects on patients with EC. From an immunological perspective, we put forward the hypothesis that optimizing radiation modalities, radiation target volume schemes, and radiation doses could help to reduce radiation-induced lymphopenia risks and maximize the immunomodulatory role of radiotherapy. An optimized radiotherapy plan may further enhance the feasibility and effectiveness of combining immunotherapy with radiotherapy for EC.
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Affiliation(s)
- Xin Wang
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Peiliang Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Zongxing Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Qingfeng Mao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Minghuan Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong province 250117, China
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84
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Cesaire M, Le Mauff B, Rambeau A, Toutirais O, Thariat J. [Mechanisms of radiation-induced lymphopenia and therapeutic impact]. Bull Cancer 2020; 107:813-822. [PMID: 32451070 DOI: 10.1016/j.bulcan.2020.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 01/29/2023]
Abstract
Radiation induced lymphopenia is frequent and can be severe and durable. Although lymphocytes have long been known as highly radiosensitive cells, it is poorly characterized. Radiation-induced lymphopenia seems to affect lymphocyte subpopulations differently and seems to be influenced by radiation modalities. The depth and duration of lymphopenia depend on the location of the irradiation and the volumes of treatment. Importantly, radiation-induced lymphopenia has been associated with poorer prognosis in several tumor types. The knowledge about radiation-induced lymphopenia might lead to a rethinking of the modalities of radiotherapy and new approaches to restore lymphocytes counts.
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Affiliation(s)
- Mathieu Cesaire
- Centre François-Baclesse/ARCHADE, département de radiothérapie, 3, avenue General Harris, 14000 Caen, France
| | - Brigitte Le Mauff
- Normandie University, UNICAEN, sérine protéases et physiopathologie de l'unité neurovasculaire, Inserm U919, Caen, France; University Hospital of Caen, Department of Immunology, Caen, France
| | - Audrey Rambeau
- Centre François-Baclesse/ARCHADE, département de radiothérapie, 3, avenue General Harris, 14000 Caen, France
| | - Olivier Toutirais
- Normandie University, UNICAEN, sérine protéases et physiopathologie de l'unité neurovasculaire, Inserm U919, Caen, France; University Hospital of Caen, Department of Immunology, Caen, France
| | - Juliette Thariat
- Centre François-Baclesse/ARCHADE, département de radiothérapie, 3, avenue General Harris, 14000 Caen, France; Laboratoire de physique corpusculaire IN2P3/ENSICAEN - UMR6534, Caen, France; Normandie University, UNICAEN, Caen, France.
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85
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Vogelius IR, Petersen J, Bentzen SM. Harnessing data science to advance radiation oncology. Mol Oncol 2020; 14:1514-1528. [PMID: 32255249 PMCID: PMC7332210 DOI: 10.1002/1878-0261.12685] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/27/2020] [Accepted: 04/01/2020] [Indexed: 12/20/2022] Open
Abstract
Radiation oncology, a major treatment modality in the care of patients with malignant disease, is a technology‐ and computer‐intensive medical specialty. As such, it should lend itself ideally to data science methods, where computer science, statistics, and clinical knowledge are combined to advance state‐of‐the‐art care. Nevertheless, data science methods in radiation oncology research are still in their infancy and successful applications leading to improved patient care remain scarce. Here, we discuss data interoperability issues within and across organizational boundaries that hamper the introduction of big data and data science techniques in radiation oncology. At the semantic level, creating common underlying models and codification of the data, including the use of data elements with standardized definitions, an ontology, remains a work in progress. Methodological issues in data science and in the use of large population‐based health data registries are identified. We show that data science methods and big data cannot replace randomized clinical trials in comparative effectiveness research by reviewing a series of instances where the outcomes of big data analyses and randomized trials are at odds. We also discuss the modern wave of machine learning and artificial intelligence as represented by deep learning and convolutional neural networks. Finally, we identify promising research avenues and remain optimistic that the data sources in radiation oncology can be linked to yield important insights in the near future. We argue that data science will be a valuable complement to, but not a replacement of, the traditional hypothesis‐driven translational research chain and the randomized clinical trials that form the backbone of evidence‐based medicine.
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Affiliation(s)
- Ivan R. Vogelius
- Deptartment of OncologyRigshospitaletCopenhagenDenmark
- Faculty of Health and Medical SciencesUniversity of CopenhagenDenmark
| | - Jens Petersen
- Deptartment of Computer ScienceUniversity of CopenhagenDenmark
| | - Søren M. Bentzen
- Department of Epidemiology & Public HealthGreenebaum Cancer CenterUniversity of Maryland BaltimoreMDUSA
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86
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So TH, Chan SK, Chan WL, Choi H, Chiang CL, Lee V, Lam TC, Wong I, Law S, Kwong D, Ming Spring Kong F, Jin JY, Lam KO. Lymphopenia and Radiation Dose to Circulating Lymphocytes With Neoadjuvant Chemoradiation in Esophageal Squamous Cell Carcinoma. Adv Radiat Oncol 2020; 5:880-888. [PMID: 33089018 PMCID: PMC7560564 DOI: 10.1016/j.adro.2020.03.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose We hypothesized that radiation-induced lymphopenia could be predicted by the effective dose to the circulating immune cells (EDIC) in advanced esophageal squamous cell carcinoma treated with trimodality therapy according to the Dutch ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) trial regimen. To test this hypothesis, we examined the effect of EDIC on the degree of lymphocyte drop (lymphocyte nadir). Methods and Materials Patients with advanced nonmetastatic esophageal squamous cell carcinoma treated in a single tertiary cancer center from 2012 to 2018 were eligible for this study. All patients had to have a radiation therapy plan available for EDIC computation and received neoadjuvant chemoradiation according to the Dutch CROSS trial regimen before radical esophagectomy. The EDIC was calculated as a function of integral doses to the lung, heart, and total body with a verified mathematical model. The association between EDIC and lymphocyte nadir was studied, and the relationships of overall survival (OS) with lymphocyte nadir and EDIC were assessed using multivariable Cox regression model. Results This analysis included 92 eligible consecutive patients (77 men and 15 women). The mean EDIC was 2.8 Gy (range, 0.6-4.4). EDIC was significantly correlated with lymphocyte nadir (Spearman coefficient = –0.505; P < .01), and lymphocyte nadir was a significant independent factor for shorter OS (hazard ratio = 0.63; P < .001). Lymphocyte nadir was also the most significant factor in determining OS among other clinical parameters. Exploratory analysis showed significant OS differences between EDIC groups (<2, 2-4, and >4 Gy). The 2–year OS rates were 66.7%, 42.7%, and 16.7% for EDIC <2, 2 to 4, and >4 Gy, respectively. Conclusions There was a significant correlation between radiation dose to circulating immune cells and lymphocyte nadir, which in turn affected OS in patients with advanced nonmetastatic esophageal squamous cell carcinoma treated by trimodality therapy.
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Affiliation(s)
- Tsz Him So
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Sik Kwan Chan
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Wing Lok Chan
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Horace Choi
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Chi Leung Chiang
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Victor Lee
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Tai Chung Lam
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Ian Wong
- Department of Surgery, the University of Hong Kong, Hong Kong
| | - Simon Law
- Department of Surgery, the University of Hong Kong, Hong Kong
| | - Dora Kwong
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | | | - Jian Yue Jin
- Department of Radiation Oncology, University Hospitals/Seidman Cancer Center and Case Comprehensive Cancer Center, Mentor, Ohio
| | - Ka On Lam
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
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87
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Lambin P, Lieverse RIY, Eckert F, Marcus D, Oberije C, van der Wiel AMA, Guha C, Dubois LJ, Deasy JO. Lymphocyte-Sparing Radiotherapy: The Rationale for Protecting Lymphocyte-rich Organs When Combining Radiotherapy With Immunotherapy. Semin Radiat Oncol 2020; 30:187-193. [PMID: 32381298 PMCID: PMC8412054 DOI: 10.1016/j.semradonc.2019.12.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There is now strong clinical and preclinical evidence that lymphocytes, for example, CD8+ T cells, are key effectors of immunotherapy and that irradiation of large blood vessels, the heart, and lymphoid organs (including nodes, spleen, bones containing bone marrow, and thymus in children) causes transient or persistent lymphopenia. Furthermore, there is extensive clinical evidence, across multiple cancer sites and treatment modalities, that lymphopenia correlates strongly with decreased overall survival. At the moment, we lack quantitative evidence to establish the relationship between dose-volume and dose-rate to critical normal structures and lymphopenia. Therefore, we propose that data should be systematically recorded to characterise a possible quantitative relationship. This might enable us to improve the efficacy of radiotherapy and develop strategies to predict and prevent treatment-related lymphopenia. In anticipation of more quantitative data, we recommend the application of the principle of As Low As Reasonably Achievable to lymphocyte-rich regions for radiotherapy treatment planning to reduce the radiation doses to these structures, thus moving toward "Lymphocyte-Sparing Radiotherapy."
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Affiliation(s)
- Philippe Lambin
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.
| | - Relinde I Y Lieverse
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Franziska Eckert
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Damiënne Marcus
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Cary Oberije
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Alexander M A van der Wiel
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Chandan Guha
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY
| | - Ludwig J Dubois
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
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88
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Zou Z, Bowen SR, Thomas HMT, Sasidharan BK, Rengan R, Zeng J. Scanning Beam Proton Therapy versus Photon IMRT for Stage III Lung Cancer: Comparison of Dosimetry, Toxicity, and Outcomes. Adv Radiat Oncol 2020; 5:434-443. [PMID: 32529138 PMCID: PMC7276696 DOI: 10.1016/j.adro.2020.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 02/03/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose There are limited clinical data on scanning-beam proton therapy (SPT) in treating locally advanced lung cancer, as most published studies have used passive-scatter technology. There is increasing interest in whether the dosimetric advantages of SPT compared with photon therapy can translate into superior clinical outcomes. We present our experience of SPT and photon intensity modulated radiation therapy (IMRT) with clinical dosimetry and outcomes in patients with stage III lung cancer. Methods and Materials Patients with stage III lung cancer treated at our center between 2013 and May 2018 were identified in compliance with our institutional review board (64 patients = 34 SPT + 30 IMRT). Most proton patients were treated with pencil beam scanning (28 of 34), and 6 of 34 were treated with uniform scanning. Fisher exact test, χ2 test, and Mann-Whitney test were used to compare groups. All tests were 2-sided. Results Patient characteristics were similar between the IMRT and SPT patients, except for worse lung function in the IMRT group. Mean dose to lung, heart, and esophagus was lower in the SPT group, with most benefit in the low-dose region (lungs, 9.7 Gy vs 15.7 Gy for SPT vs IMRT, respectively [P = .004]; heart, 7 Gy vs 14 Gy [P = .001]; esophagus, 28.2 Gy vs 30.9 Gy [P = .023]). Esophagitis and dermatitis grades were not different between the 2 groups. Grade 2+ pneumonitis was 21% in the SPT group and 40% in the IMRT group (P = .107). Changes in blood counts were not different between the 2 groups. Overall survival and progression-free survival were not different between SPT and IMRT (median overall survival, 41.6 vs 30.7 months, respectively [P = .52]; median progression-free survival, 19.5 vs 14.6 months [P = .50]). Conclusions We report our experience with SPT and IMRT in stage III lung cancer. Our cohort of patients treated with SPT had lower doses to normal organs (lungs, heart, esophagus) than our IMRT cohort. There was no statistically significant difference in toxicity rates or survival, although there may have been a trend toward lower rates of pneumonitis.
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Affiliation(s)
- Zhenwei Zou
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Stephen R Bowen
- Departments of Radiation Oncology, Seattle, Washington.,Radiology, University of Washington, Seattle, Washington
| | | | | | - Ramesh Rengan
- Departments of Radiation Oncology, Seattle, Washington
| | - Jing Zeng
- Departments of Radiation Oncology, Seattle, Washington
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89
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Lin SH, Hobbs BP, Verma V, Tidwell RS, Smith GL, Lei X, Corsini EM, Mok I, Wei X, Yao L, Wang X, Komaki RU, Chang JY, Chun SG, Jeter MD, Swisher SG, Ajani JA, Blum-Murphy M, Vaporciyan AA, Mehran RJ, Koong AC, Gandhi SJ, Hofstetter WL, Hong TS, Delaney TF, Liao Z, Mohan R. Randomized Phase IIB Trial of Proton Beam Therapy Versus Intensity-Modulated Radiation Therapy for Locally Advanced Esophageal Cancer. J Clin Oncol 2020; 38:1569-1579. [PMID: 32160096 DOI: 10.1200/jco.19.02503] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Whether dosimetric advantages of proton beam therapy (PBT) translate to improved clinical outcomes compared with intensity-modulated radiation therapy (IMRT) remains unclear. This randomized trial compared total toxicity burden (TTB) and progression-free survival (PFS) between these modalities for esophageal cancer. METHODS This phase IIB trial randomly assigned patients to PBT or IMRT (50.4 Gy), stratified for histology, resectability, induction chemotherapy, and stage. The prespecified coprimary end points were TTB and PFS. TTB, a composite score of 11 distinct adverse events (AEs), including common toxicities as well as postoperative complications (POCs) in operated patients, quantified the extent of AE severity experienced over the duration of 1 year following treatment. The trial was conducted using Bayesian group sequential design with three planned interim analyses at 33%, 50%, and 67% of expected accrual (adjusted for follow-up). RESULTS This trial (commenced April 2012) was approved for closure and analysis upon activation of NRG-GI006 in March 2019, which occurred immediately prior to the planned 67% interim analysis. Altogether, 145 patients were randomly assigned (72 IMRT, 73 PBT), and 107 patients (61 IMRT, 46 PBT) were evaluable. Median follow-up was 44.1 months. Fifty-one patients (30 IMRT, 21 PBT) underwent esophagectomy; 80% of PBT was passive scattering. The posterior mean TTB was 2.3 times higher for IMRT (39.9; 95% highest posterior density interval, 26.2-54.9) than PBT (17.4; 10.5-25.0). The mean POC score was 7.6 times higher for IMRT (19.1; 7.3-32.3) versus PBT (2.5; 0.3-5.2). The posterior probability that mean TTB was lower for PBT compared with IMRT was 0.9989, which exceeded the trial's stopping boundary of 0.9942 at the 67% interim analysis. The 3-year PFS rate (50.8% v 51.2%) and 3-year overall survival rates (44.5% v 44.5%) were similar. CONCLUSION For locally advanced esophageal cancer, PBT reduced the risk and severity of AEs compared with IMRT while maintaining similar PFS.
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Affiliation(s)
- Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian P Hobbs
- Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
| | - Rebecca S Tidwell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erin M Corsini
- Department of Cardiovascular and Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Isabel Mok
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiong Wei
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Luyang Yao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xin Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, People's Republic of China
| | - Ritsuko U Komaki
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen G Chun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melenda D Jeter
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen G Swisher
- Department of Cardiovascular and Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mariela Blum-Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ara A Vaporciyan
- Department of Cardiovascular and Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Reza J Mehran
- Department of Cardiovascular and Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Saumil J Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wayne L Hofstetter
- Department of Cardiovascular and Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Thomas F Delaney
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Radhe Mohan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Sun GY, Wang SL, Song YW, Jin J, Wang WH, Liu YP, Ren H, Fang H, Tang Y, Zhao XR, Song YC, Yu ZH, Liu XF, Li YX. Radiation-Induced Lymphopenia Predicts Poorer Prognosis in Patients With Breast Cancer: A Post Hoc Analysis of a Randomized Controlled Trial of Postmastectomy Hypofractionated Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 108:277-285. [PMID: 32147519 DOI: 10.1016/j.ijrobp.2020.02.633] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE The aim of this study was to determine whether radiation-induced lymphopenia affects the survival of patients with breast cancer. METHODS AND MATERIALS Post hoc analysis was conducted on data from 598 patients with breast cancer from a randomized controlled trial comparing postmastectomy hypofractionated radiation therapy (HFRT; 43.5 Gy in 15 fractions over 3 weeks) with conventional fractionated radiation therapy (CFRT; 50 Gy in 25 fractions over 5 weeks). Mean peripheral lymphocyte count (PLC) at different time points in the 2 groups was compared by the t test. Disease-free survival and overall survival were analyzed by the Kaplan-Meier method and compared between groups by the log-rank test. RESULTS Baseline PLC (pre-PLC) was comparable between HFRT and CFRT patients (1.60 ± 0.57 × 109/L vs 1.56 ± 0.52 × 109/L; P = .33). In both groups, the PLC declined steadily during the course of radiation therapy but started to recover at 1 month after radiation therapy. Incidence of lymphopenia was significantly lower in HFRT patients (45.4% vs 55.7%; P = .01). Nadir-PLC was significantly higher in HFRT patients (1.08 ± 0.37 × 109/L vs 0.97 ± 0.31× 109/L; P < .001), as was the nadir-PLC/pre-PLC ratio (0.72 ± 0.28 vs 0.67 ± 0.28; P = .02). Median follow-up was 57.6 months (interquartile range, 38.5-81.4). The 5-year disease-free survival was significantly lower in patients with a nadir-PLC/pre-PLC ratio <0.8 than in those with a ratio ≥0.8 (71.8% vs 82.6%; P = .01); however, overall survival was comparable between the groups (85.8% vs 90.6%; P = .24). CONCLUSIONS The risk of radiation-induced lymphopenia in patients with breast cancer is lower with HFRT than with CFRT. A low nadir-PLC/pre-PLC ratio may predict poor prognosis.
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Affiliation(s)
- Guang-Yi Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Hu Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Ren
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu-Ran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Chun Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Hao Yu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Fan Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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91
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Ng SP, Bahig H, Jethanandani A, Pollard C, Berends J, Sturgis EM, Johnson FM, Elgohari B, Elhalawani H, Rosenthal DI, Skinner HD, Gunn GB, Phan J, Frank SJ, Mohamed ASR, Fuller CD, Garden AS. Lymphopenia during radiotherapy in patients with oropharyngeal cancer. Radiother Oncol 2020; 145:95-100. [PMID: 31931292 DOI: 10.1016/j.radonc.2019.12.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 12/20/2019] [Accepted: 12/22/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE/OBJECTIVE Radiation-induced lymphopenia has been associated with poor survival outcomes in certain solid tumors such as esophageal, lung, cervical and pancreatic cancers. We aim to determine the effect of treatment-related lymphopenia during radiotherapy on outcomes of patients with oropharyngeal cancer. MATERIALS/METHODS A retrospective analysis of all patients who completed definitive radiotherapy for oropharyngeal cancer at The University of Texas MD Anderson Cancer Center and had blood counts taken during radiotherapy from 2002 to 2013 were included. Patient, tumor and treatment characteristics, clinical outcomes and lymphocyte counts during radiotherapy were recorded. Lymphopenia was graded according to the CTCAE v4.0. Survival rates were estimated using the Kaplan-Meier method and compared with log-rank tests. RESULTS 850 patients were evaluated. The median age was 57 years. The majority of the cohort had p16/HPV-positive disease (71%), 8% had HPV-negative disease and 21% were unknown. The median radiation total dose was 70 Gy. 45% of patients had induction chemotherapy, and 87% had concurrent chemotherapy. 703 (83%) patients developed ≥grade 3 (G3) lymphopenia and 209 (25%) had grade 4 (G4) lymphopenia during radiotherapy. The median follow-up was 59 months; the 5-year overall survival rate was 81%. There were no significant differences in overall survival rates nor in disease control rates, in those who developed G3/G4 lymphopenia compared with those who did not. No significant effect of lymphopenia on survival was observed when analyzed according to p16/HPV status. CONCLUSION In this large cohort of patients with oropharyngeal cancer, the development of lymphopenia during radiotherapy did not impact outcomes.
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Affiliation(s)
- Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Houda Bahig
- Department of Radiation Oncology, Centre Hospitalier de l'Universite de Montreal, Canada
| | - Amit Jethanandani
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Courtney Pollard
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Joel Berends
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Faye M Johnson
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Baher Elgohari
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Heath D Skinner
- Department of Radiation Oncology, UPMC Hillman Cancer Centers, Pittsburgh, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.
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Goossens ME, Van den Bulcke M, Gevaert T, Meheus L, Verellen D, Cosset JM, Storme G. Is there any benefit to particles over photon radiotherapy? Ecancermedicalscience 2019; 13:982. [PMID: 32010206 PMCID: PMC6974365 DOI: 10.3332/ecancer.2019.982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Indexed: 12/18/2022] Open
Abstract
Particle, essentially, proton radiotherapy (RT) could provide some benefits over photon RT, especially in reducing the side effects of RT. We performed a systematic review to identify the performed randomised clinical trials (RCTs) and ongoing RCTs comparing particle RT with photon therapy. So far, there are no results available from phase 3 RCTs comparing particle RT with photon therapy. Furthermore, the results on side effects comparing proton and carbon ion beam RT with photon RT do vary. The introduction of new techniques in photon RT, such as image-guided RT (IGRT), intensity-modulated RT (IMRT), volumetric arc therapy (VMAT) and stereotactic body RT (SBRT) was already effective in reducing side effects. At present, the lack of evidence limits the indications for proton and carbon ion beam RTs and makes the particle RT still experimental.
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Affiliation(s)
- Maria E Goossens
- Cancer Centre, Sciensano (Scientific Institute of Public Health), 1050 Brussels, Belgium
| | - Marc Van den Bulcke
- Cancer Centre, Sciensano (Scientific Institute of Public Health), 1050 Brussels, Belgium
| | - Thierry Gevaert
- Department of Radiotherapy, University Hospital Brussels, Vrije Universiteit Brussel, 1050 Brussel, Belgium
| | - Lydie Meheus
- The Anticancer Fund, Reliable Cancer Therapies, Strombeek-Bever, 1853, Belgium
| | - Dirk Verellen
- Department of Radiotherapy, University Hospital Brussels, Vrije Universiteit Brussel, 1050 Brussel, Belgium
- Iridium Kankernetwerk Antwerp, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, 1050 Brussel, Belgium
| | - Jean-Marc Cosset
- Centre de Radiothérapie Charlebourg, Groupe Amethyst, 65, Avenue Foch, 92250 La Garenne-Colombes, France
| | - Guy Storme
- Department of Radiotherapy, University Hospital Brussels, Vrije Universiteit Brussel, 1050 Brussel, Belgium
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93
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Ultra high dose rate (35 Gy/sec) radiation does not spare the normal tissue in cardiac and splenic models of lymphopenia and gastrointestinal syndrome. Sci Rep 2019; 9:17180. [PMID: 31748640 PMCID: PMC6868225 DOI: 10.1038/s41598-019-53562-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022] Open
Abstract
Recent reports have shown that very high dose rate radiation (35–100 Gy/second) referred to as FLASH tends to spare the normal tissues while retaining the therapeutic effect on tumor. We undertook a series of experiments to assess if ultra-high dose rate of 35 Gy/second can spare the immune system in models of radiation induced lymphopenia. We compared the tumoricidal potency of ultra-high dose rate and conventional dose rate radiation using a classical clonogenic assay in murine pancreatic cancer cell lines. We also assessed the lymphocyte sparing potential in cardiac and splenic irradiation models of lymphopenia and assessed the severity of radiation-induced gastrointestinal toxicity triggered by the two dose rate regimes in vivo. Ultra-high dose rate irradiation more potently induces clonogenic cell death than conventional dose rate irradiation with a dose enhancement factor at 10% survival (DEF10) of 1.310 and 1.365 for KPC and Panc02 cell lines, respectively. Ultra-high dose rate was equally potent in depleting CD3, CD4, CD8, and CD19 lymphocyte populations in both cardiac and splenic irradiation models of lymphopenia. Radiation-induced gastrointestinal toxicity was more pronounced and mouse survival (7 days vs. 15 days, p = 0.0001) was inferior in the ultra-high dose rate arm compared to conventional dose rate arm. These results suggest that, contrary to published data in other models of radiation-induced acute and chronic toxicity, dose rates of 35 Gy/s do not protect mice from the detrimental side effects of irradiation in our models of cardiac and splenic radiation-induced lymphopenia or gastrointestinal mucosal injury.
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94
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Tustumi F, Takeda FR, Brandão AAGS, Sallum RAA, Ribeiro Junior U, Cecconello I. LYMPHOCYTE COUNT AND PLATELET VOLUME PREDICTS POSTOPERATIVE COMPLICATIONS IN ESOPHAGECTOMY FOR CANCER: A COHORT STUDY. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:377-385. [PMID: 31618397 DOI: 10.1590/s0004-2803.201900000-70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/15/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Biomarkers from routine complete blood count are known predictive factors of long-term outcomes in cancer patients. The value of these biomarkers in the setting of trimodal therapy for esophageal cancer in predicting early postoperative outcomes is not studied. OBJECTIVE The present study evaluated the value of cellular blood components changes during neoadjuvant chemoradiotherapy followed by curative intent esophagectomy for cancer in predicting postoperative mortality and morbidity. METHODS A cohort of 149 consecutive patients that underwent chemoradiotherapy using platinum- and taxane-based regimens followed by esophagectomy was analyzed. Cellular components of blood collected before neoadjuvant therapy (period A) and before surgery (period B) were assessed for postoperative mortality and complications. Univariate and multivariate Cox regression models were applied to evaluate the independent prognostic significance of blood count variables. RESULTS Postoperative morbidity was present in 46% of the patients. On multiple regression analysis platelet volume (B) (OR: 1.53; 95% CI: 1.2-2.33) was an independent predictor of general complications. Severe postoperative surgical complications were present in 17% of the patients. On multiple regression analysis, lymphocyte decrease between B-A periods (OR: 0.992; 95% CI: 0.990-0.997) was related to higher risk for severe complications. Cervical anastomotic leakage was present in 25.6% of the patients. On univariate analysis eosinophil count in A and B periods was related to cervical anastomotic leakage. For this outcome, multivariate joint model could not identify independent risk variables of cellular components of blood. The 30-day mortality rate was 7.4%. On univariate analysis, platelet count in period B was associated to higher risk for mortality. The multivariate joint model could not accurately predict mortality due to the few number of patients in the mortality group. CONCLUSION This is the first study to assess the relationship between peripheral blood count variables changes during neoadjuvant chemoradiotherapy using a platinum- and taxane-based regimen followed by curative intent esophagectomy for cancer in predicting postoperative complications. The platelet volume prior to surgery is related to postoperative complications and the lymphocyte count change prior to surgery predicts severe postoperative complications in the setting of trimodal therapy for esophageal cancer.
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Affiliation(s)
- Francisco Tustumi
- Universidade de São Paulo, Divisão de Cirurgia Digestiva, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Flávio Roberto Takeda
- Universidade de São Paulo, Divisão de Cirurgia Digestiva, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | | | - Rubens Antonio Aissar Sallum
- Universidade de São Paulo, Divisão de Cirurgia Digestiva, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Ulysses Ribeiro Junior
- Universidade de São Paulo, Divisão de Cirurgia Digestiva, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Ivan Cecconello
- Universidade de São Paulo, Divisão de Cirurgia Digestiva, Departamento de Gastroenterologia, São Paulo, SP, Brasil
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Spiegelberg L, van Hoof SJ, Biemans R, Lieuwes NG, Marcus D, Niemans R, Theys J, Yaromina A, Lambin P, Verhaegen F, Dubois LJ. Evofosfamide sensitizes esophageal carcinomas to radiation without increasing normal tissue toxicity. Radiother Oncol 2019; 141:247-255. [PMID: 31431383 PMCID: PMC6913516 DOI: 10.1016/j.radonc.2019.06.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Esophageal cancer incidence is increasing and is rarely curable. Hypoxic tumor areas cause resistance to conventional therapies, making them susceptible for treatment with hypoxia-activated prodrugs (HAPs). We investigated in vivo whether the HAP evofosfamide (TH-302) could increase the therapeutic ratio by sensitizing esophageal carcinomas to radiotherapy without increasing normal tissue toxicity. MATERIALS AND METHODS To assess therapeutic efficacy, growth of xenografted esophageal squamous cell (OE21) or adeno (OE19) carcinomas was monitored after treatment with TH-302 (50 mg/kg, QD5) and irradiation (sham or 10 Gy). Short- and long-term toxicity was assessed in a gut mucosa and lung fibrosis irradiation model, sensitive to acute and late radiation injury respectively. Mice were injected with TH-302 (50 mg/kg, QD5) and the abdominal area (sham, 8 or 10 Gy) or the upper part of the right lung (sham, 20 Gy) was irradiated. Damage to normal tissues was assessed 84 hours later by histology and blood plasma citrulline levels (gut) and for up to 1 year by non-invasive micro CT imaging (lung). RESULTS The combination treatment of TH-302 with radiotherapy resulted in significant tumor growth delay in OE19 (P = 0.02) and OE21 (P = 0.03) carcinomas, compared to radiotherapy only. Irradiation resulted in a dose-dependent decrease of crypt survival (P < 0.001), mucosal surface area (P < 0.01) and citrulline levels (P < 0.001) in both tumor and non-tumor bearing animals. On the long-term, irradiation increased CT density in the lung, indicating fibrosis, over time. TH-302 did not influence the radiation-induced short-term and long-term toxicity, confirmed by histological evaluation. CONCLUSION The combination of TH-302 and radiotherapy might be a promising approach to improve the therapeutic index for esophageal cancer patients.
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Affiliation(s)
- Linda Spiegelberg
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Stefan J van Hoof
- Department of Radiation Oncology (Maastro), GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Rianne Biemans
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Natasja G Lieuwes
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Damiënne Marcus
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Raymon Niemans
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Jan Theys
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Ala Yaromina
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Philippe Lambin
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Frank Verhaegen
- Department of Radiation Oncology (Maastro), GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ludwig J Dubois
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands.
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Badiyan SN, Robinson CG, Bradley JD. Radiation Toxicity in Lung Cancer Patients: The Heart of the Problem? Int J Radiat Oncol Biol Phys 2019; 104:590-592. [DOI: 10.1016/j.ijrobp.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 12/25/2022]
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Zhou XL, Zhu WG, Zhu ZJ, Wang WW, Deng X, Tao WJ, Ji FZ, Tong YS. Lymphopenia in Esophageal Squamous Cell Carcinoma: Relationship to Malnutrition, Various Disease Parameters, and Response to Concurrent Chemoradiotherapy. Oncologist 2019; 24:e677-e686. [PMID: 31040254 PMCID: PMC6693723 DOI: 10.1634/theoncologist.2018-0723] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/18/2019] [Accepted: 04/02/2019] [Indexed: 12/16/2022] Open
Abstract
Management of esophageal squamous cell carcinoma remains challenging, because detection often occurs at advanced stages and because of the high incidence of lymph node metastasis. This article focuses on whether lymphopenia is associated with response and tumor progression in patients with advanced esophageal squamous cell carcinoma who received concurrent chemotherapy. Background. Lymphopenia occurs commonly in esophageal squamous cell carcinoma (ESCC) and may influence treatment outcomes. We aimed to examine its association with treatment response and tumor progression in patients with locally advanced ESCC treated with concurrent chemoradiotherapy (CCRT). Materials and Methods. A total of 286 patients with stage II–IVa ESCC treated with CCRT between 2015 and 2017 were analyzed. Total lymphocyte counts were assessed at baseline, weekly, and 4 weeks after CCRT. Pretreatment lymphopenia was defined as total lymphocyte count <1,000 cells per mm3 at diagnosis, and treatment‐related lymphopenia was defined as total lymphocyte count <200 cells per mm3 with 6 weeks after starting CCRT. Univariate and multivariate logistic regression methods were used to analyze factors associated treatment‐related lymphopenia and treatment response. Results. Lymphopenia was observed in 44 patients (15.4%) at initial diagnosis. Pretreatment lymphopenia was significantly associated with greater tumor length, worse T status, body mass index ≤18.5 kg/m2, and weight loss ≥3 kg in the previous 3 months. Six weeks after starting CCRT, 89 patients (31%) developed treatment‐related lymphopenia. Tumor progression and cancer‐related death were more frequently observed in treatment‐related lymphopenia group than those without (76.4% vs. 52.8% and 58.4% vs. 39.6%). A complete response (CR) was achieved in 62 patients (21.7%). In multivariate analysis, treatment‐related lymphopenia was significantly associated with lack of clinical CR, and older age, lower tumor location, greater tumor length, and larger planning target volume were independent predictors of treatment‐related lymphopenia. Conclusion. Treatment‐related lymphopenia during CCRT is an independent predictor for poor treatment response in ESCC. Implications for Practice. A total of 286 patients with locally advanced esophageal squamous cell carcinoma were treated with concurrent chemoradiotherapy (CCRT), and treatment‐related lymphopenia occurred in 31% of patients within 6 weeks from the start of CCRT. Treatment‐related lymphopenia was significantly associated with lack of treatment response, and older age, lower tumor location, greater tumor length, and larger planning target volume were independent predictors of treatment‐related lymphopenia. Lymphocyte count is an inexpensive biomarker that may be easily used by clinicians to identify patients who are most likely to benefit from CCRT.
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Affiliation(s)
- Xi-Lei Zhou
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
| | - Wei-Guo Zhu
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
| | - Zhi-Jian Zhu
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
| | - Wan-Wei Wang
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
| | - Xue Deng
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
| | - Wei-Jing Tao
- Department of Radiology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
| | - Fu-Zhi Ji
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
| | - Yu-Suo Tong
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, People's Republic of China
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Li Q, Zhou S, Liu S, Liu S, Yang H, Zhao L, Liu M, Hu Y, Xi M. Treatment-Related Lymphopenia Predicts Pathologic Complete Response and Recurrence in Esophageal Squamous Cell Carcinoma Undergoing Neoadjuvant Chemoradiotherapy. Ann Surg Oncol 2019; 26:2882-2889. [DOI: 10.1245/s10434-019-07334-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Indexed: 02/07/2023]
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Jiang DM, Fyles A, Nguyen LT, Neel BG, Sacher A, Rottapel R, Wang BX, Ohashi PS, Sridhar SS. Phase I study of local radiation and tremelimumab in patients with inoperable locally recurrent or metastatic breast cancer. Oncotarget 2019; 10:2947-2958. [PMID: 31105877 PMCID: PMC6508206 DOI: 10.18632/oncotarget.26893] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/14/2019] [Indexed: 12/31/2022] Open
Abstract
Immunotherapy has shown modest activity in metastatic breast cancer (MBC). In this phase I dose escalation study, we assessed safety of tremelimumab, a humanized anti-CTLA4 monoclonal antibody, at starting dose 3 mg/kg, on the third day of palliative radiotherapy (2000cGy in 5 daily fractions) in patients with MBC. Primary objective was to determine the maximum tolerated dose (MTD) of tremelimumab combined with RT. Secondary objective was to assess response. Among 6 patients enrolled between July 2010 and October 2011, 5 had hormone receptor-positive MBC, 1 had triple negative MBC. Median age was 45 years. Common toxicities included lymphopenia (83%), fatigue (50%) and rash (33%). One dose-limiting toxicity occurred at 6 mg/kg, however the trial closed before MTD could be determined. One patient discontinued treatment due to a pathological fracture. Best response was stable disease (SD), 1 patient had SD for >6 months. Median follow up was 27.0 months. Median OS was 50.8 months, with 1 patient surviving >8 years. Peripheral blood mononuclear cell (PBMC) profiles showed increasing proliferating (Ki67+) Treg cells 1 week post treatment in 5 patients. Overall, tremelimumab at 3 mg/kg combined with RT appears to be a tolerable treatment strategy. Further studies are needed to optimize this combination approach.
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Affiliation(s)
- Di Maria Jiang
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Linh T Nguyen
- Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Benjamin G Neel
- Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Adrian Sacher
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Robert Rottapel
- Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Ben X Wang
- Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Pamela S Ohashi
- Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Immunology, Faculty University of Toronto, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Srikala S Sridhar
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
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Deng W, Xu C, Liu A, van Rossum PS, Deng W, Liao Z, Koong AC, Mohan R, Lin SH. The relationship of lymphocyte recovery and prognosis of esophageal cancer patients with severe radiation-induced lymphopenia after chemoradiation therapy. Radiother Oncol 2019; 133:9-15. [DOI: 10.1016/j.radonc.2018.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/29/2018] [Accepted: 12/02/2018] [Indexed: 12/24/2022]
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