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Lievens Y, Janssens S, Lambrecht M, Engels H, Geets X, Jansen N, Moretti L, Remouchamps V, Roosens S, Stellamans K, Verellen D, Weltens C, Weytjens R, Van Damme N. Coverage with evidence development program on stereotactic body radiotherapy in Belgium (2013-2019): a nationwide registry-based prospective study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 44:100992. [PMID: 39045286 PMCID: PMC11265534 DOI: 10.1016/j.lanepe.2024.100992] [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: 02/29/2024] [Revised: 06/06/2024] [Accepted: 06/18/2024] [Indexed: 07/25/2024]
Abstract
Background Although stereotactic body radiotherapy (SBRT) was progressively adopted in clinical practice in Belgium, a reimbursement request in 2011 was not granted because of remaining clinical and economic uncertainty. A coverage with evidence development (CED) program on SBRT started in 2013, with the aim to assess clinical and technical patterns-of-care in Belgium and monitor survival per indication, in view of supporting inclusion in the reimbursement system. Methods The Belgian National Institute for Health and Disability Insurance (NIHDI) initiated this prospective observational registry. Participating departments, using SBRT in clinical practice, signed the 'NIHDI convention'. Eligible patients had a primary tumour (PT) or oligometastatic disease (OMD). Patient, tumour, and treatment characteristics were collected through an online module of the Belgian Cancer Registry, prerequisite for financing. Five-year overall survival (5YOS) and 30- and 90-days mortality were primary outcomes, derived from vital status information. Findings Between 10/2013 and 12/2019, 20 of the 24 accredited radiotherapy departments participated, 6 were academic. Registered cases per department ranged from 21 to 867. Of 5675 registrations analysed, the majority had good performance status and limited number of lesions. Enrolment of PTs remained stable over time, OMDs almost doubled. Peripheral lung lesions dominated in PTs as in OMDs. Other metastases were (para)spinal, 'non-standard' and hepatic. Thirty- and 90-days mortalities remained below 0.5% [95% CI 0.3%-0.8%] respectively 2.1% [95% CI 1.6%-2.7%]. 5YOS varied by indication, primary prostate patients performing best (85%, 95% CI [76%, 96%]), those with liver metastases worst (19%, 95% CI [15%, 24%]). Better OS was observed in academic departments, department size did not significantly impact survival. OMD survival was better in 2018-19. Interpretation CED can be used to define patterns-of-care and real-life outcome of innovative radiotherapy. As the observed survival for different indications was in line with outcome in emerging literature, SBRT was included in the Belgian reimbursement system as of January 2020. Funding NIHDI financed participating departments per registered case.
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Affiliation(s)
- Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Ghent, Belgium
| | | | - Maarten Lambrecht
- Radiation Oncology Department, University Hospital Leuven, Leuven, Belgium
| | - Hilde Engels
- Belgian National Institute for Health and Disability Insurance, Brussels, Belgium
| | - Xavier Geets
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Nicolas Jansen
- Radiation Oncology Department, CHU de Liège, Liège, Belgium
| | - Luigi Moretti
- Radiation Oncology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Vincent Remouchamps
- Radiation Oncology Department, CHU UCL, Namur, Site Sainte Elisabeth, Belgium
| | - Sander Roosens
- Belgian National Institute for Health and Disability Insurance, Brussels, Belgium
| | | | - Dirk Verellen
- Radiation Oncology Department Iridium Netwerk/University of Antwerp, Wilrijk, Belgium
| | - Caroline Weltens
- Radiation Oncology Department, University Hospital Leuven, Leuven, Belgium
| | - Reinhilde Weytjens
- Radiation Oncology Department Iridium Netwerk/University of Antwerp, Wilrijk, Belgium
| | | | - Belgian College for Physicians of Radiation Oncology Centres
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Ghent, Belgium
- Belgian Cancer Registry, Brussels, Belgium
- Radiation Oncology Department, University Hospital Leuven, Leuven, Belgium
- Belgian National Institute for Health and Disability Insurance, Brussels, Belgium
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Radiation Oncology Department, CHU de Liège, Liège, Belgium
- Radiation Oncology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
- Radiation Oncology Department, CHU UCL, Namur, Site Sainte Elisabeth, Belgium
- Radiation Oncology Department, AZ Groeninge, Kortrijk, Belgium
- Radiation Oncology Department Iridium Netwerk/University of Antwerp, Wilrijk, Belgium
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2
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Lynch C, Korpics MC, Katipally RR, Bestvina CM, Pitroda SP, Patel JD, Luke JJ, Chmura SJ, Juloori A. Safety of combined ablative radiotherapy and immune checkpoint inhibitors in three phase I trials. Eur J Cancer 2024; 209:114264. [PMID: 39106643 DOI: 10.1016/j.ejca.2024.114264] [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: 05/03/2024] [Revised: 07/26/2024] [Accepted: 07/30/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is safe and effective for treatment of extracranial metastatic disease, but its safety when combined with immune checkpoint inhibitors (ICI) has not yet been comprehensively reported. Here we report adverse events (AEs) associated with combined SBRT and ICI using prospectively-collected data on patients in three trials investigating multi-site SBRT combined with ICI. METHODS Patients were included from three prospective trials of ICI (pembrolizumab; nivolumab/urelumab or nivolumab/cabiralizumab; nivolumab/ipilimumab) with SBRT to 1-4 sites. AEs were recorded prospectively using the CTCAE v4.0. Survival was analyzed using Kaplan-Meier method with a 90-day landmark. Association of patient characteristics with cumulative incidence of AEs was assessed using Fine-Gray regression. RESULTS 213 patients were included, with a median follow-up of 10 months. Over the follow-up period, 50 % and 27 % of patients experienced at least one grade ≥ 2 or grade ≥ 3 AE, respectively. Cumulative incidences of grade ≥ 2 and grade ≥ 3 AEs at 6 months were 47 % and 23 %, respectively. Three grade 5 AEs rated "possibly" related to treatment occurred outside the 90-day dose-limiting toxicity window. Landmarked survival analysis of patients with or without grade ≥ 3 AEs showed no significant difference in progression-free or overall survival. Dual-agent ICI was significantly associated with grade ≥ 3 AE. CONCLUSION This analysis features the largest prospectively evaluated cohort of patients treated with combination ablative SBRT and ICI to date and provides context for future trial design. We conclude that multi-site SBRT and ICI can be safely co-administered when SBRT is delivered with prioritization of normal tissue constraints.
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Affiliation(s)
- Connor Lynch
- The University of Chicago Medical Center, Department of Radiation and Cellular Oncology, United States
| | - Mark C Korpics
- The University of Chicago Medical Center, Department of Radiation and Cellular Oncology, United States
| | - Rohan R Katipally
- The University of Chicago Medical Center, Department of Radiation and Cellular Oncology, United States
| | - Christine M Bestvina
- The University of Chicago Medical Center, Department of Medical Oncology, United States
| | - Sean P Pitroda
- The University of Chicago Medical Center, Department of Radiation and Cellular Oncology, United States
| | - Jyoti D Patel
- Northwestern University, Division of Hematology and Oncology, United States
| | - Jason J Luke
- UPMC Hillman Cancer Center and University of Pittsburgh, United States
| | - Steven J Chmura
- The University of Chicago Medical Center, Department of Radiation and Cellular Oncology, United States
| | - Aditya Juloori
- The University of Chicago Medical Center, Department of Radiation and Cellular Oncology, United States.
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3
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Lynch C, Pitroda SP, Weichselbaum RR. Radiotherapy, immunity, and immune checkpoint inhibitors. Lancet Oncol 2024; 25:e352-e362. [PMID: 39089313 DOI: 10.1016/s1470-2045(24)00075-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 08/03/2024]
Abstract
Radiotherapy exerts immunostimulatory and immunosuppressive effects, both locally, within the irradiated tumour microenvironment, and systemically, outside the radiation field. Inspired by preclinical data that showed synergy between radiotherapy and immune checkpoint inhibitors, multiple clinical trials were initiated with the hypothesis that combined treatment with radiotherapy and immune checkpoint inhibitors could stimulate a robust systemic immune response and improve clinical outcomes. However, despite early optimism, radioimmunotherapy trials in the curative and metastatic settings have met with little success. In this Review, we summarise the immunostimulatory effects of radiotherapy that provided the theoretical basis for trials of combination radiotherapy and immune checkpoint inhibitors. We also discuss findings from clinical trials incorporating radiotherapy and immune checkpoint inhibitors and examine the success of these trials in the context of the immunosuppressive effects of radiotherapy. We conclude by highlighting targets for relieving radiotherapy-induced immunosuppression with the goal of enhancing the combined effects of radiotherapy and immune checkpoint inhibitors.
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Affiliation(s)
- Connor Lynch
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Sean P Pitroda
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA; Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
| | - Ralph R Weichselbaum
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA; Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA.
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Vounckx M, Tijtgat J, Stevens L, Dirven I, Ilsen B, Vandenbroucke F, Raeymaeckers S, Vekens K, Forsyth R, Geeraerts X, Van Riet I, Schwarze JK, Tuyaerts S, Decoster L, De Ridder M, Dufait I, Neyns B. A randomized phase II clinical trial of stereotactic body radiation therapy (SBRT) and systemic pembrolizumab with or without intratumoral avelumab/ipilimumab plus CD1c (BDCA-1) +/CD141 (BDCA-3) + myeloid dendritic cells in solid tumors. Cancer Immunol Immunother 2024; 73:167. [PMID: 38954010 PMCID: PMC11219623 DOI: 10.1007/s00262-024-03751-0] [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: 03/15/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Radiotherapy (RT) synergizes with immune checkpoint blockade (ICB). CD1c(BDCA-1)+/CD141(BDCA-3)+ myeloid dendritic cells (myDC) in the tumor microenvironment are indispensable at initiating effector T-cell responses and response to ICB. METHODS In this phase II clinical trial, anti-PD-1 ICB pretreated oligometastatic patients (tumor agnostic) underwent a leukapheresis followed by isolation of CD1c(BDCA-1)+/CD141(BDCA-3)+ myDC. Following hypofractionated stereotactic body RT (3 × 8 Gy), patients were randomized (3:1). Respectively, in arm A (immediate treatment), intratumoral (IT) ipilimumab (10 mg) and avelumab (40 mg) combined with intravenous (IV) pembrolizumab (200 mg) were administered followed by IT injection of myDC; subsequently, IV pembrolizumab and IT ipilimumab/avelumab were continued (q3W). In arm B (contemporary control arm), patients received IV pembrolizumab, with possibility to cross-over at progression. Primary endpoint was 1-year progression-free survival rate (PFS). Secondary endpoints were safety, feasibility, objective response rate, PFS, and overall survival (OS). RESULTS Thirteen patients (10 in arm A, eight non-small cell lung cancer, and five melanoma) were enrolled. Two patients crossed over. One-year PFS rate was 10% in arm A and 0% in arm B. Two patients in arm A obtained a partial response, and one patient obtained a stable disease as best response. In arm B, one patient obtained a SD. Median PFS and OS were 21.8 weeks (arm A) versus 24.9 (arm B), and 62.7 versus 57.9 weeks, respectively. An iatrogenic pneumothorax was the only grade 3 treatment-related adverse event. CONCLUSION SBRT and pembrolizumab with or without IT avelumab/ipilimumab and IT myDC in oligometastatic patients are safe and feasible with a clinically meaningful tumor response rate. However, the study failed to reach its primary endpoint. TRIAL REGISTRATION NUMBER Clinicaltrials.gov: NCT04571632 (09 AUG 2020). EUDRACT 2019-003668-32. Date of registration: 17 DEC 2019, amendment 1: 6 MAR 2021, amendment 2: 4 FEB 2022.
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Affiliation(s)
- Manon Vounckx
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Jens Tijtgat
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Latoya Stevens
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Iris Dirven
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Bart Ilsen
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Frederik Vandenbroucke
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Steven Raeymaeckers
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Karolien Vekens
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Ramses Forsyth
- Department of Pathology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Xenia Geeraerts
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Ivan Van Riet
- Department of Hematology, Stem Cell Laboratory, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Julia Katharina Schwarze
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Sandra Tuyaerts
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Lore Decoster
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Ines Dufait
- Department of Radiotherapy, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Bart Neyns
- Department of Medical Oncology, Laboratory for Medical and Molecular Oncology (LMMO), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
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5
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Wang L, Lynch C, Pitroda SP, Piffkó A, Yang K, Huser AK, Liang HL, Weichselbaum RR. Radiotherapy and immunology. J Exp Med 2024; 221:e20232101. [PMID: 38771260 PMCID: PMC11110906 DOI: 10.1084/jem.20232101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/29/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024] Open
Abstract
The majority of cancer patients receive radiotherapy during the course of treatment, delivered with curative intent for local tumor control or as part of a multimodality regimen aimed at eliminating distant metastasis. A major focus of research has been DNA damage; however, in the past two decades, emphasis has shifted to the important role the immune system plays in radiotherapy-induced anti-tumor effects. Radiotherapy reprograms the tumor microenvironment, triggering DNA and RNA sensing cascades that activate innate immunity and ultimately enhance adaptive immunity. In opposition, radiotherapy also induces suppression of anti-tumor immunity, including recruitment of regulatory T cells, myeloid-derived suppressor cells, and suppressive macrophages. The balance of pro- and anti-tumor immunity is regulated in part by radiotherapy-induced chemokines and cytokines. Microbiota can also influence radiotherapy outcomes and is under clinical investigation. Blockade of the PD-1/PD-L1 axis and CTLA-4 has been extensively investigated in combination with radiotherapy; we include a review of clinical trials involving inhibition of these immune checkpoints and radiotherapy.
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Affiliation(s)
- Liangliang Wang
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
| | - Connor Lynch
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
| | - Sean P. Pitroda
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
| | - András Piffkó
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kaiting Yang
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
| | - Amy K. Huser
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Hua Laura Liang
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
| | - Ralph R. Weichselbaum
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL, USA
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Verma V, Barsoumian HB, Welsh JW. Is Single-Site Radiation Therapy Enough to Augment the Immune System and Enhance Immunotherapy for Metastatic Disease? Semin Radiat Oncol 2024; 34:272-275. [PMID: 38880535 DOI: 10.1016/j.semradonc.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Despite the promise of combining immunotherapy and radiotherapy (RT) for metastatic cancers, existing randomized data have not been consistent on whether RT to a single irradiated site improves clinical outcomes. Mechanistically, this could result from a low quantity/diversity of tumor antigens released for immune detection, immunosuppressive molecules released by tumor masses, and the lack of immune infiltration into tumor bulk. Herein, multi-site RT is discussed as a potential solution, given that it can directly improve upon each of the mechanistic issues. Just as it is illogical to use systemic therapy alone in place of a dedicated local therapeutic option (e.g., RT) for most stage II-III malignancies, so too is illogical to irradiate one site only in case of metastatic neoplasms instead of implementing systemic therapy and/or multi-site RT. Although it may theoretically be possible to address all systemic disease with systemic therapy, that notion assumes that all areas of systemic disease will be responsive to systemic therapy in the first place. However, in reality, certain sites may develop innate or acquired resistance to systemic therapy, hence opening the door to multi-site localized treatment strategies. Further investigation is required to address whether multi-site RT would be effective in the setting of suboptimal immune function and/or resistance/refractoriness to multiple prior systemic therapies. Methods to improve the effectiveness of multi-site RT are also discussed, such as ablatively-/definitively-dosed RT, along with staggered timing of RT administration (pulsed RT).
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - James W Welsh
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX..
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7
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Deutsch E, Levy A. Eradicating gross tumor disease: a prerequisite for efficient radioimmunotherapy? J Natl Cancer Inst 2024; 116:1008-1011. [PMID: 38539049 DOI: 10.1093/jnci/djae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/22/2023] [Accepted: 03/18/2024] [Indexed: 07/06/2024] Open
Abstract
Radiation therapy may induce off-target antitumor "abscopal" immunostimulatory and immunosuppressive effects. Several preclinical and early clinical studies revealed promising results when combining radiation therapy with immunostimulatory agents. Most radioimmunotherapy randomized trials showed disappointing results in patients with advanced tumors. In contrast, outcomes were encouraging when immunotherapy was delivered on top of gross disease elimination with curative-intent radiation therapy. In this review, we highlight available results from randomized trials and discuss the potential impact of overall tumor burden on the observed efficacy of radioimmunotherapy.
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Affiliation(s)
- Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- Université Paris-Saclay, INSERM U1030, Molecular Radiotherapy and Therapeutic Innovation, Villejuif, France
- Université Paris-Saclay, Faculté de Médecine, Kremlin-Bicêtre, France
| | - Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- Université Paris-Saclay, INSERM U1030, Molecular Radiotherapy and Therapeutic Innovation, Villejuif, France
- Université Paris-Saclay, Faculté de Médecine, Kremlin-Bicêtre, France
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8
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Morel D, Robert C, Paragios N, Grégoire V, Deutsch E. Translational Frontiers and Clinical Opportunities of Immunologically Fitted Radiotherapy. Clin Cancer Res 2024; 30:2317-2332. [PMID: 38477824 PMCID: PMC11145173 DOI: 10.1158/1078-0432.ccr-23-3632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/09/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
Ionizing radiation can have a wide range of impacts on tumor-immune interactions, which are being studied with the greatest interest and at an accelerating pace by the medical community. Despite its undeniable immunostimulatory potential, it clearly appears that radiotherapy as it is prescribed and delivered nowadays often alters the host's immunity toward a suboptimal state. This may impair the full recovery of a sustained and efficient antitumor immunosurveillance posttreatment. An emerging concept is arising from this awareness and consists of reconsidering the way of designing radiation treatment planning, notably by taking into account the individualized risks of deleterious radio-induced immune alteration that can be deciphered from the planned beam trajectory through lymphocyte-rich organs. In this review, we critically appraise key aspects to consider while planning immunologically fitted radiotherapy, including the challenges linked to the identification of new dose constraints to immune-rich structures. We also discuss how pharmacologic immunomodulation could be advantageously used in combination with radiotherapy to compensate for the radio-induced loss, for example, with (i) agonists of interleukin (IL)2, IL4, IL7, IL9, IL15, or IL21, similarly to G-CSF being used for the prophylaxis of severe chemo-induced neutropenia, or with (ii) myeloid-derived suppressive cell blockers.
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Affiliation(s)
- Daphné Morel
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
| | - Charlotte Robert
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
- Paris-Saclay University, School of Medicine, Le Kremlin Bicêtre, France
| | - Nikos Paragios
- Therapanacea, Paris, France
- CentraleSupélec, Gif-sur-Yvette, France
| | - Vincent Grégoire
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
- Paris-Saclay University, School of Medicine, Le Kremlin Bicêtre, France
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9
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Chang JY, Verma V, Weichselbaum RR. Reconciling the discrepancies in randomized data of combining immunotherapy and radiation therapy: Not all radiotherapy is created equal. Eur J Cancer 2024; 201:113972. [PMID: 38430868 DOI: 10.1016/j.ejca.2024.113972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/05/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
It remains highly unclear and debatable whether combining radiotherapy (RT) and immune checkpoint blocker (ICB) therapy yields improved outcomes compared to either modality alone. Whereas some randomized data have shown improved outcomes, others have not. As a result of these conflicting data, it is essential to reconcile differences in the data and postulate reasons thereof. This work seeks to address these discrepancies, and uses the lessons learned from both positive and negative trials, including the most cutting-edge data available, in order to guide future clinical trial design and clarify the ideal/expected role of combinatorial therapy going forward. Because RT offers two distinct contributions (cytoreductive (local) effects & immune-stimulating (systemic) effects), RT should complement immunotherapy by addressing immunotherapy-resistant clones, and immunotherapy should complement RT by addressing RT-resistant or out-of-field clones. RT is not merely a single "drug", but rather a constellation of diverse "drugs" that can be varied based on dose regimens, previous systemic therapy regimens, number of irradiated sites, treatment intent/location/timing, tumor biology, and individual patient immunological circumstances. These factors are discussed as an important explanation for the discrepancies in results of various randomized trials in heterogeneous populations and clinical settings, and these discrepancies may continue until trials of more uniform circumstances are designed to use particular RT paradigms that meaningfully add value to systemic therapy.
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Affiliation(s)
- Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Vivek Verma
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ralph R Weichselbaum
- Department of Radiation and Cellular Oncology and The Ludwig Center for Metastasis Research, The University of Chicago, Chicago, IL, United States
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10
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Kim BH, Park HC, Kim TH, Koh YH, Hong JY, Cho Y, Sinn DH, Park B, Park JW. Concurrent nivolumab and external beam radiation therapy for hepatocellular carcinoma with macrovascular invasion: A phase II study. JHEP Rep 2024; 6:100991. [PMID: 38463541 PMCID: PMC10920711 DOI: 10.1016/j.jhepr.2023.100991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 03/12/2024] Open
Abstract
Background and Aims Nivolumab was the first immune checkpoint inhibitor approved for hepatocellular carcinoma (HCC). External beam radiation therapy (EBRT) is locally effective and may enhance the effectiveness of immunotherapy. This study investigated the efficacy and safety of concurrent nivolumab and EBRT in HCC with macrovascular invasion. Methods In this phase II multicenter trial, patients with HCC and macrovascular invasion were concurrently treated with intravenous nivolumab (3 mg/kg every 2 weeks) and EBRT, followed by maintenance nivolumab until progression or unacceptable toxicity. Primary endpoints were progression-free survival (PFS) and safety, and secondary endpoints were overall survival, time-to-progression, objective response rate, and disease control rate. Results Between January 2020 and June 2021, 50 patients (male 84%, median age 62.5) were enrolled; 47 (94.0%) and 13 (26.0%) with portal (Vp1/2, n = 21; Vp3, n = 23; Vp4, n = 3) and hepatic vein invasion, respectively. Patients received EBRT (median dose: 50 [IQR 43-50] Gy) after the first nivolumab dose. The median number of nivolumab doses was 8.5. Median PFS was 5.6 (90% CI 3.6-9.9) months. Median overall survival and time-to-progression were 15.2 (90% CI 10.8-19.6) and 5.6 (90% CI 3.6-9.9) months, respectively. The objective response rate and disease control rate were 36.0% and 74.0%, respectively. The median duration of response was 9.9 months. Of 35 patients with follow-up data, 23 received subsequent systemic treatment, including atezolizumab-bevacizumab, sorafenib, lenvatinib, and regorafenib. Treatment-related any grade adverse events (AEs) and grade 3/4 AEs occurred in 40 (80.0%) and 6 (12.0%) patients, respectively. Common treatment-related AEs included pruritus (38.0%) and rash (16.0%), with no treatment-related deaths. Conclusion Concurrent nivolumab therapy and EBRT showed encouraging PFS with acceptable safety in patients with advanced HCC and macrovascular invasion. Impact and implications Immune checkpoint inhibitors, the standard care for advanced hepatocellular carcinoma (HCC), show relatively poor therapeutic effects in patients with advanced HCC and macrovascular invasion. In this investigator-initiated phase II study, we, for the first time, show that concurrent external beam radiation therapy with nivolumab, an immune checkpoint inhibitor, led to encouraging progression-free survival in patients with HCC and macrovascular invasion. The concurrent treatment was tolerable without significant safety concerns. Further randomized studies investigating the combination of immunotherapy and external beam radiation therapy are required. ClinicalTrialsgov identifier NCT04611165.
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Affiliation(s)
- Bo Hyun Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea
- Center for Proton Therapy, National Cancer Center, Goyang, Republic of Korea
| | - Young-Hwan Koh
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea
- Department of Radiology, National Cancer Center, Goyang, Republic of Korea
| | - Jung Yong Hong
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Dong Hyun Sinn
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Boram Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Joong-Won Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea
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11
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Wisdom AJ, Barker CA, Chang JY, Demaria S, Formenti S, Grassberger C, Gregucci F, Hoppe BS, Kirsch DG, Marciscano AE, Mayadev J, Mouw KW, Palta M, Wu CC, Jabbour SK, Schoenfeld JD. The Next Chapter in Immunotherapy and Radiation Combination Therapy: Cancer-Specific Perspectives. Int J Radiat Oncol Biol Phys 2024; 118:1404-1421. [PMID: 38184173 DOI: 10.1016/j.ijrobp.2023.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 01/08/2024]
Abstract
Immunotherapeutic agents have revolutionized cancer treatment over the past decade. However, most patients fail to respond to immunotherapy alone. A growing body of preclinical studies highlights the potential for synergy between radiation therapy and immunotherapy, but the outcomes of clinical studies have been mixed. This review summarizes the current state of immunotherapy and radiation combination therapy across cancers, highlighting existing challenges and promising areas for future investigation.
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Affiliation(s)
- Amy J Wisdom
- Harvard Radiation Oncology Program, Boston, Massachusetts
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sandra Demaria
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Silvia Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Clemens Grassberger
- Department of Radiation Oncology, University of Washington, Fred Hutch Cancer Center, Seattle, Washington
| | - Fabiana Gregucci
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - David G Kirsch
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ariel E Marciscano
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jyoti Mayadev
- Department of Radiation Oncology, UC San Diego School of Medicine, San Diego, California
| | - Kent W Mouw
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Manisha Palta
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts.
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12
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Lynch C, Korpics MC, Katipally RR, Wu T, Bestvina CM, Pitroda S, Chmura SJ, Juloori A. Combined Stereotactic Body Radiation Therapy and Immune Checkpoint Inhibition for Liver Metastases: Safety and Outcomes in a Pooled Analysis of 3 Phase 1 Trials. Int J Radiat Oncol Biol Phys 2024; 118:1519-1530. [PMID: 38199382 DOI: 10.1016/j.ijrobp.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/02/2024] [Accepted: 01/02/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) safely and effectively controls liver metastases (LMs), but its safety and efficacy when combined with immune checkpoint inhibitors (ICIs) are not well characterized. This analysis of 3 phase 1 trials of combination SBRT and ICI evaluates whether LM-SBRT increases the risk for hepatotoxicity when combined with ICI and explores efficacy endpoints. METHODS AND MATERIALS Data were analyzed from 3 phase 1 trials of combination SBRT and ICI for patients with metastatic solid tumors conducted between 2016 and 2020. ICI was administered per trial protocol with LM-SBRT delivered to 45 Gy in 3 fractions with mean liver dose <16 Gy and ≥700 cc of normal liver spared 17.1 Gy. Hepatic adverse events (HAEs) were defined as hepatic failure, autoimmune hepatitis, or elevation of aspartate transaminase, alanine transaminase, bilirubin, or alkaline phosphatase using Common Terminology Criteria for Adverse Events version 4.0. Cumulative incidence of HAEs and local failure were modeled with death as a competing risk. Competing risk regression was performed using Fine-Gray modeling. Survival was estimated via the Kaplan-Meier method. RESULTS Two hundred patients were analyzed, including 81 patients with LM, 57 of whom received LM-SBRT. The 12-month rate of any grade ≥2 HAE was 11% and 10% in LM-SBRT and non-LM-SBRT patients, respectively non-significant (NS). Radiographic evidence for liver disease and dual-agent ICI was significantly associated with HAEs on univariable and multivariable analysis, but liver dose metrics were not. Patients with LM had significantly worse progression-free and overall survival compared with those without, and local failure of treated LM was significantly higher than for treated extrahepatic metastases (28% vs 4% at 12 months, P < .001). CONCLUSIONS Combination LM-SBRT and ICI did not significantly increase the risk for HAEs compared with ICI without LM-SBRT, suggesting hepatotoxicity is largely driven by factors other than liver radiation therapy, such as choice of ICI. LM is associated with worse overall survival and local control outcomes.
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Affiliation(s)
- Connor Lynch
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Mark C Korpics
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Rohan R Katipally
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Tianming Wu
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | | | - Sean Pitroda
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Steven J Chmura
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Aditya Juloori
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois.
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13
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Sakai A, Ebisumoto K, Iijima H, Yamauchi M, Maki D, Fukuzawa T, Okami K. Abscopal effect in maxillary sinus cancer: Insights from two case reports and a literature review. Cancer Rep (Hoboken) 2024; 7:e1994. [PMID: 38351554 PMCID: PMC10864721 DOI: 10.1002/cnr2.1994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/07/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The abscopal effect is a rare phenomenon in which localized radiation therapy triggers tumor reduction in nontargeted areas. Although this phenomenon has been observed in various cancer types, it remains infrequent and not fully understood. CASE Two patients with maxillary sinus cancer with distant metastases were treated with radiotherapy after immune checkpoint inhibitor (ICI) therapy. The patients demonstrated abscopal effects following ICI therapy and radiotherapy, showing shrinkage in metastatic areas not directly targeted by radiation. CONCLUSION This report was reviewed to examine the synergistic effects of ICI and radiotherapy and to identify optimal strategies to enhance the abscopal effect in clinical practice. It has also touched on various ongoing debates and clinical trials aimed at understanding and exploiting this effect to improve cancer treatment. The exact mechanisms and optimal treatment protocols remain areas for future research.
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Affiliation(s)
- Akihiro Sakai
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Koji Ebisumoto
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Hiroaki Iijima
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Mayu Yamauchi
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Daisuke Maki
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
| | - Tsuyoshi Fukuzawa
- Department of Radiation OncologyTokai University, School of MedicineIseharaJapan
| | - Kenji Okami
- Department of Otolaryngology, Head and Neck SurgeryTokai University, School of MedicineIseharaJapan
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14
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Harris JP, Park J, Ku E, Seyedin S, Stitzlein R, Goldin A, Chen WP, McLaren C, Chen AM, Chow W. A Pilot Study of Pembrolizumab Combined With Stereotactic Ablative Radiotherapy for Patients With Advanced or Metastatic Sarcoma. Cancer Control 2024; 31:10732748241237331. [PMID: 38449377 PMCID: PMC10919132 DOI: 10.1177/10732748241237331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES Immunotherapy with immune checkpoint inhibitors has shown only limited success in the management of metastatic soft tissue sarcoma. Overall response rates (ORR) with single agent pembrolizumab were 18% and median PFS was 18 weeks on the clinical trial SARC028. One strategy to improve the responses to immunotherapy is with stereotactic body radiation therapy (SBRT), which can enhance the antitumor CD8 T cell response through the release of tumor-specific antigens, potentially priming a more diverse class of T cell receptors. METHODS This is a phase 0, pilot prospective study taking place at a single center with 2 arms. In Arm A, patients are treated with pembrolizumab 400 mg IV infusion on day 1 of a 42-day cycle. Stereotactic body radiation therapy (SBRT) is delivered in 1-5 fractions starting on C1D15-28 and given every other day. In Arm B, patients who have started an immune checkpoint inhibitor within 60 days are treated with SBRT in addition to the current therapy. RESULTS In this study we outline testing the feasibility of adding SBRT to pembrolizumab. CONCLUSION The ultimate goal of combination therapy is improved overall response, including tumors not treated with SBRT. This trial can be found registered online: NCT05488366.
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Affiliation(s)
- Jeremy P. Harris
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Jino Park
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Eric Ku
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Steven Seyedin
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Russell Stitzlein
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Amanda Goldin
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Wen-Pin Chen
- Biostatistics Shared Resource, University of California Irvine, Chao Family Comprehensive Cancer Center, Orange, CA, USA
| | - Christine McLaren
- Biostatistics Shared Resource, University of California Irvine, Chao Family Comprehensive Cancer Center, Orange, CA, USA
| | - Allen M. Chen
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Warren Chow
- Department of Medicine, Division of Hematology/Oncology, University of California Irvine, Orange, CA, USA
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15
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Popp I, Vaes RDW, Wieten L, Adebahr S, Hendriks L, Bavafaye Haghighi E, Degens J, Schäfer H, Greil C, Peeters S, Waller CF, Houben R, Niedermann G, Rawluk J, Gkika E, Duyster J, Grosu AL, De Ruysscher D. Radiotherapy to reinvigorate immunotherapy activity after acquired resistance in metastatic non-small-cell lung cancer: A pooled analysis of two institutions prospective phase II single arm trials. Radiother Oncol 2024; 190:110048. [PMID: 38070686 DOI: 10.1016/j.radonc.2023.110048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/20/2024]
Abstract
AIM The current work aimed to investigate the clinical benefit of radiotherapy in patients with metastatic non-small cell lung cancer (NSCLC) developing acquired resistance to immune checkpoint inhibitors. METHOD We report on a pooled, two-institution, phase II single-arm prospective cohort study. The study included patients with stage IV NSCLC who showed progression of one or more measurable lesions under anti-PD-(L)1 inhibition alone, after initially having achieved at least stable disease. Hypofractionated radiotherapy (hRT) of one to four metastases was performed, while one or more lesions were kept untreated. Following hRT, treatment with immune checkpoint inhibitors was continued unchanged until further evidence of tumor progression or unacceptable toxicity. Primary endpoint of the pooled analysis was progression-free survival (PFS), secondary endpoints included overall survival (OS) and toxicity. RESULTS A total of 48 patients were enrolled: mean age was 67.1 ± 9.3 years, 50 % were male and 72.9 % were PD-L1 positive. Immunotherapy was in 95.8 % of patients the first or second line therapy at time of enrollment. hRT was performed to one (93.8 % of cases) or more lesions (median total dose: 27.5 Gy, median 6.5 Gy/fraction). Forty-five patients (93.8 %) were able to continue immunotherapy for a median of 6.2 months following hRT. Median PFS was 4.4 months, with 62.5 % disease control at three months and 37.5 % at six months. Median OS was 14.9 months. Severe adverse events (grade ≥ 2) were reported in 12 cases (25 %), of which none were radiotherapy-related and four were immunotherapy-related. Salvage therapy consisted of chemotherapy (48.8 %) or repeated irradiation (21.9 %). No further tumor treatment was performed in 29.3 % of patients. CONCLUSIONS The current pooled analysis is a prospective evaluation of the role of radiation therapy for metastatic NSCLC in the setting of newly acquired immunotherapy resistance. Hypofractionated radiotherapy can support the outcome of immune checkpoint inhibitors and thus allow continuation of treatment for a relevant amount of time despite initial tumor progression.
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Affiliation(s)
- Ilinca Popp
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Rianne D W Vaes
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Lotte Wieten
- Department of Transplantation Immunology, GROW School for Oncology and Reproduction. Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lizza Hendriks
- Department of Respiratory Diseases, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Juliette Degens
- Department of Respiratory Diseases, Zuyderland Hospital, Sittard-Geleen, the Netherlands
| | - Henning Schäfer
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christine Greil
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stéphanie Peeters
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Cornelius F Waller
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ruud Houben
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Gabriele Niedermann
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg, Freiburg, Germany
| | - Justyna Rawluk
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Justus Duyster
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg, Freiburg, Germany
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
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16
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Pezzicoli G, Salonne F, Musci V, Ciciriello F, Tommasi S, Lacalamita R, Zito A, Allegretta SA, Solimando AG, Rizzo M. Concomitant Immunotherapy and Metastasis-Directed Radiotherapy in Upper Tract Urothelial Carcinoma: A Biomarker-Driven, Original, Case-Based Proof-of-Concept Study. J Clin Med 2023; 12:7761. [PMID: 38137830 PMCID: PMC10744017 DOI: 10.3390/jcm12247761] [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: 10/31/2023] [Revised: 12/03/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
Metastatic upper tract urothelial carcinoma (mUTUC) has a poor prognosis. Immune checkpoint inhibitors (ICIs) have demonstrated efficacy in patients with metastatic urothelial carcinoma. However, data supporting the use of ICIs in patients with mUTUC are limited. A promising synergy between ICI and concomitant radiotherapy (RT) has been reported in patients with mUTUC. Our research involved a case-based investigation and emphasized the successful integration of different specialists' skills. Observed after partial urethrectomy procedures for muscle-invasive upper tract urothelial carcinoma (UTUC), the radiological detection of lung metastases prompted us to implement cisplatin-based first-line chemotherapy and molecular characterization in the treatment process. We uncovered alterations in the ERBB2 and FGFR3 genes and mismatch repair deficiency at a molecular level. First-line chemotherapy treatment led to a stable disease, and the patient was started on maintenance immunotherapy with Avelumab. Subsequently, an increase in the size of the lung nodules was described, and the patient received radiotherapy for three lung lesions in combination with immunotherapy. After 3 months, a restaging CT scan reported a complete response, which is still ongoing. We discuss the mechanisms driving RT/ICI synergy and the molecular profile of mUTUC as factors that should be considered in therapeutic strategy planning. Molecular insight enhances the originality of our study, providing a nuanced understanding of the genetic landscape of mUTUC and paving the way for targeted therapeutic strategies. The therapeutic armamentarium expansion encourages the design of a multimodal and personalized approach for each mUTUC patient, taking into account tumor heterogeneity and molecular profiling.
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Affiliation(s)
- Gaetano Pezzicoli
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.P.); (F.S.); (V.M.); (F.C.)
| | - Francesco Salonne
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.P.); (F.S.); (V.M.); (F.C.)
| | - Vittoria Musci
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.P.); (F.S.); (V.M.); (F.C.)
| | - Federica Ciciriello
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.P.); (F.S.); (V.M.); (F.C.)
| | - Stefania Tommasi
- Molecular Diagnostics and Pharmacogenetics Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy; (S.T.); (R.L.)
| | - Rosanna Lacalamita
- Molecular Diagnostics and Pharmacogenetics Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy; (S.T.); (R.L.)
| | - Alfredo Zito
- Pathology Department, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
| | | | - Antonio Giovanni Solimando
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area-(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, Italy;
| | - Mimma Rizzo
- Medical Oncology Unit, Azienda Ospedaliera Universitaria Consorziale—Policlinico di Bari, 70124 Bari, Italy
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Mertens LS, Psutka SP, Mir MC. Bladder cancer oligometastases - definition and treatment. Nat Rev Urol 2023; 20:701-702. [PMID: 37591959 DOI: 10.1038/s41585-023-00815-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Affiliation(s)
- Laura S Mertens
- Department of Urology, Netherlands Cancer Institute, Amsterdam, Netherlands.
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Maria Carmen Mir
- Department of Urology, Hospital Universitario La Ribera, Valencia, Spain
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18
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Mohr T. [The combination of stereotactic radiotherapy with checkpoint inhibitors: results of the CHEERS phase II trial]. Strahlenther Onkol 2023; 199:1262-1264. [PMID: 37855930 PMCID: PMC10673722 DOI: 10.1007/s00066-023-02160-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Tobias Mohr
- Klinik für Strahlentherapie, Universitätsklinikum des Saarlandes, Kirrberger Str. Gebäude 6.5, 66421, Homburg/Saar, Deutschland.
- Arbeitsgruppe junge DEGRO, Deutsche Gesellschaft für Radioonkologie e. V. (DEGRO), Berlin, Deutschland.
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