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Greco C, Pares O, Pimentel N, Louro V, Morales J, Nunes B, Antunes I, Vasconcelos AL, Kociolek J, Castanheira J, Oliveira C, Silva A, Vaz S, Oliveira F, Carrasquinha E, Costa D, Fuks Z. Positron Emission Tomography-Derived Metrics Predict the Probability of Local Relapse After Oligometastasis-Directed Ablative Radiation Therapy. Adv Radiat Oncol 2022; 7:100864. [PMID: 35036636 PMCID: PMC8752878 DOI: 10.1016/j.adro.2021.100864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/05/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Early positron emission tomography-derived metrics post-oligometastasis radioablation may predict impending local relapses (LRs), providing a basis for a timely ablation. METHODS AND MATERIALS Positron emission tomography data of 623 lesions treated with either 24 Gy single-dose radiation therapy (SDRT) (n = 475) or 3 × 9 Gy stereotactic body radiation therapy (SBRT) (n = 148) were analyzed in a training data set (n = 246) to obtain optimal cutoffs for pretreatment maximum standardized uptake value (SUVmax) and its 3-month posttreatment decline (ΔSUVmax) in predicting LR risk, validated in a data set unseen to testing (n = 377). RESULTS At a median of 21.7 months, 91 lesions developed LRs: 39 of 475 (8.2%) after SDRT and 52 of 148 (35.1%) after SBRT. The optimal cutoff values were 12 for SUVmax and -75% for ΔSUVmax. Bivariate SUVmax/ΔSUVmax permutations rendered a 3-tiered LR risk stratification of dual-favorable (low risk), 1 adverse (intermediate risk) and dual-adverse (high risk). Actuarial 5-year local relapse-free survival rates were 93.9% versus 89.6% versus 57.1% (P < .0001) and 76.1% versus 48.3% versus 8.2% (P < .0001) for SDRT and SBRT, respectively. The SBRT area under the ROC curve was 0.71 (95% CI, 0.61-0.79) and the high-risk subgroup yielded a 76.5% true positive LR prediction rate. CONCLUSIONS The SBRT dual-adverse SUVmax/ΔSUVmax category LR prediction power provides a basis for prospective studies testing whether a timely ablation of impending LRs affects oligometastasis outcomes.
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Affiliation(s)
- Carlo Greco
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Oriol Pares
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Nuno Pimentel
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Vasco Louro
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Javier Morales
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Beatriz Nunes
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Inês Antunes
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Ana Luisa Vasconcelos
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Justyna Kociolek
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Joana Castanheira
- Department of Nuclear Medicine-Radiopharmacology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Carla Oliveira
- Department of Nuclear Medicine-Radiopharmacology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Angelo Silva
- Department of Nuclear Medicine-Radiopharmacology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Sofia Vaz
- Department of Nuclear Medicine-Radiopharmacology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Francisco Oliveira
- Department of Nuclear Medicine-Radiopharmacology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Eunice Carrasquinha
- Computational Clinical Imaging Group, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Durval Costa
- Department of Nuclear Medicine-Radiopharmacology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Zvi Fuks
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
- Memorial Sloan Kettering Cancer Center, New York, New York
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Benavente S, Sánchez-García A, Naches S, LLeonart ME, Lorente J. Therapy-Induced Modulation of the Tumor Microenvironment: New Opportunities for Cancer Therapies. Front Oncol 2020; 10:582884. [PMID: 33194719 PMCID: PMC7645077 DOI: 10.3389/fonc.2020.582884] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/16/2020] [Indexed: 12/15/2022] Open
Abstract
Advances in immunotherapy have achieved remarkable clinical outcomes in tumors with low curability, but their effects are limited, and increasing evidence has implicated tumoral and non-tumoral components of the tumor microenvironment as critical mediators of cancer progression. At the same time, the clinical successes achieved with minimally invasive and optically-guided surgery and image-guided and ablative radiation strategies have been successfully implemented in clinical care. More effective, localized and safer treatments have fueled strong research interest in radioimmunotherapy, which has shown the potential immunomodulatory effects of ionizing radiation. However, increasingly more observations suggest that immunosuppressive changes, metabolic remodeling, and angiogenic responses in the local tumor microenvironment play a central role in tumor recurrence. In this review, we address challenges to identify responders vs. non-responders to the immune checkpoint blockade, discuss recent developments in combinations of immunotherapy and radiotherapy for clinical evaluation, and consider the clinical impact of immunosuppressive changes in the tumor microenvironment in the context of surgery and radiation. Since the therapy-induced modulation of the tumor microenvironment presents a multiplicity of forms, we propose that overcoming microenvironment related resistance can become clinically relevant and represents a novel strategy to optimize treatment immunogenicity and improve patient outcome.
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Affiliation(s)
- Sergi Benavente
- Radiation Oncology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Almudena Sánchez-García
- Biomedical Research in Cancer Stem Cells Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvia Naches
- Otorhinolaryngology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matilde Esther LLeonart
- Biomedical Research in Cancer Stem Cells Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.,Spanish Biomedical Research Network Centre in Oncology, CIBERONC, Barcelona, Spain
| | - Juan Lorente
- Otorhinolaryngology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
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Conformal Avoidance of Normal Organs at Risk by Perfusion-Modulated Dose Sculpting in Tumor Single-Dose Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 109:288-297. [PMID: 32777335 DOI: 10.1016/j.ijrobp.2020.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/02/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Although 24 Gy single-dose radiation therapy (SDRT) renders >90% 5-year local relapse-free survival in human solid tumor lesions, SDRT delivery is not feasible in ∼50% of oligometastatic lesions owing to interference by dose/volume constraints of a serial organ at risk (OAR). Conformal OAR avoidance is based on a hypothetical model positing that the recently described SDRT biology specifically permits volumetric subdivision of the SDRT dose, such that high-intensity vascular drivers of SDRT lethality, generated within a major tumor subvolume exposed to a high 24 Gy dose (high-dose planning target volume [PTVHD]), would equilibrate SDRT signaling intensity throughout the tumor interstitial space, rendering bystander radiosensitization of a minor subvolume (perfusion-modulated dose sculpting PTV [PTVPMDS]), dose-sculpted to meet a serial OAR dose/volume constraint. An engineered PTVPMDS may thus yield tumor ablation despite PMDS dose reduction and conformally avoiding OAR exposure to a toxic dose. METHODS AND MATERIALS Dose fall-off within the PTVPMDS penumbra of oligometastatic lesions was planned and delivered by intensity modulated inverse dose painting. SDRT- and SDRT-PMDS-treated lesions were followed with periodic positron emission tomography/computed tomography imaging to assess local tumor control. RESULTS Cumulative baseline 5-year local relapse rates of oligometastases treated with 24 Gy SDRT alone (8% relapses, n = 292) were similar in moderate PTVPMDS dose-sculpted (23-18 Gy, n = 76, 11% relapses, P = .36) and extreme dose-sculpted (<18 Gy, n = 61, 14% relapses, P = .29) lesions, provided the major 24 Gy PTVHD constituted ≥60% of the total PTV. In contrast, 28% of local relapses occurred in 26 extreme dose-sculpted PTVPMDS lesions when PTVHD constituted <60% of the total PTV (P = .004), suggesting a threshold for the PTVPMDS bystander effect. CONCLUSION The study provides compelling clinical support for the bystander radiosensitization hypothesis, rendering local cure of tumor lesions despite a ≥25% PTVPMDS dose reduction of the 24 Gy PTVHD dose, adapted to conformally meet OAR dose/volume constraints. The SDRT-PMDS approach thus provides a therapeutic resolution to otherwise radioablation-intractable oligometastatic disease.
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