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Juvkam IS, Zlygosteva O, Sitarz M, Sørensen BS, Aass HCD, Edin NJ, Galtung HK, Søland TM, Malinen E. Proton- compared to X-irradiation leads to more acinar atrophy and greater hyposalivation accompanied by a differential cytokine response. Sci Rep 2024; 14:22311. [PMID: 39333378 PMCID: PMC11437014 DOI: 10.1038/s41598-024-73110-7] [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: 03/20/2024] [Accepted: 09/13/2024] [Indexed: 09/29/2024] Open
Abstract
Proton therapy gives less dose to healthy tissue compared to conventional X-ray therapy, but systematic comparisons of normal tissue responses are lacking. The aim of this study was to investigate late tissue responses in the salivary glands following proton- or X-irradiation of the head and neck in mice. Moreover, we aimed at investigating molecular responses by monitoring the cytokine levels in serum and saliva. Female C57BL/6J mice underwent local fractionated irradiation with protons or X-rays to the maximally tolerated acute level. Saliva and serum were collected before and at different time points after irradiation to assess salivary gland function and cytokine expression. To study late responses in the major salivary glands, histological analyses were performed on tissues collected at day 105 after onset of irradiation. Saliva volume after proton and X-irradiation was significantly lower than for controls and remained reduced at all time points after irradiation. Protons caused reduced saliva production and fewer acinar cells in the submandibular glands compared to X-rays at day 105. X-rays induced a stronger inflammatory cytokine response in saliva compared to protons. This work supports previous preclinical findings and indicate that the relative biological effectiveness of protons in normal tissue might be higher than the commonly used value of 1.1.
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Affiliation(s)
- Inga Solgård Juvkam
- Institute of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
- Department of Radiation Biology, Institute of Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Olga Zlygosteva
- Department of Physics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Mateusz Sitarz
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Brita Singers Sørensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Christian D Aass
- The Blood Cell Research Group, Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Nina Jeppesen Edin
- Department of Physics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Hilde Kanli Galtung
- Institute of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
| | - Tine Merete Søland
- Institute of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Eirik Malinen
- Department of Radiation Biology, Institute of Cancer Research, Oslo University Hospital, Oslo, Norway.
- Department of Physics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.
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2
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Vasudevan SS, Deeb H, Katta A, Olinde L, Pang J, Asarkar AA, Katz S, Nathan CAO. Efficacy and safety of proton therapy versus intensity-modulated radiation therapy in the treatment of head and neck tumors: A systematic review and meta-analysis. Head Neck 2024. [PMID: 39007360 DOI: 10.1002/hed.27877] [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: 05/13/2024] [Revised: 06/19/2024] [Accepted: 07/07/2024] [Indexed: 07/16/2024] Open
Abstract
To comprehensively evaluate the therapeutic efficacy and safety when utilizing proton therapy (PT) versus intensity-modulated radiation therapy (IMRT) in head and neck cancer patients. Pubmed, ScienceDirect, Embase, Scopus, and Web of Science were systematically searched for studies on comparative PT and IMRT outcomes. We performed a random effect model meta-analysis to estimate the hazard ratio (HR) and odds ratio (OR) for efficacy and safety outcome variables between PT and IMRT. From 641 identified articles, 11 studies met the inclusion criteria, comprising 3087 patients (606 treated with PT and 2481 with IMRT). On toxicity analysis, PT is associated with decreased acute grade 1 nausea (OR = 0.34, 95% CI: 0.13-0.84, p = 0.02) compared to IMRT. In grade 2 toxicity, PT showed significant advantages over IMRT in mucositis (OR = 0.44, p < 0.0001), dysgeusia (OR = 0.35, p = 0.02), dysphagia (OR = 0.36, p < 0.0001), fatigue (OR = 0.29, p = 0.001), pain (OR = 0.34, p = 0.01), and weight loss (OR = 0.54, p = 0.02). Proton therapy also exhibited increased safety in grade 3 dysphagia incidence (OR = 0.44, p < 0.0001) compared to IMRT. PT demonstrated improved overall survival (OS) compared to IMRT across multiple time points: 1-year OS (HR = 0.43, p = 0.02), 2-year OS (HR = 0.44, p < 0.0001), and 5-year OS (HR = 0.78, p = 0.004). In terms of disease-free survival (DFS), PT also showed improved outcomes at 2-year DFS (HR = 0.65, p = 0.03) and 5-year DFS (HR = 0.81, p = 0.03). Proton therapy demonstrated superior overall survival (OS), disease-free survival (DFS), and better local control rate (LCR) compared to IMRT. The data also showed better safety outcomes in PT patients, particularly when involving grade 2 acute toxicity events.
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Affiliation(s)
- Srivatsa Surya Vasudevan
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Haya Deeb
- Department of Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Anuhya Katta
- Department of Academics, Jonelta Foundation School of Medicine, University of Perpetual Help System Dalta, Las Piñas, Philippines
| | - Lindsay Olinde
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - John Pang
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Ameya A Asarkar
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Sanford Katz
- Department of Radiation Oncology, Willis-Knighton Cancer Center, Shreveport, Louisiana, USA
| | - Cherie-Ann O Nathan
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Surgery, Overton Brooks Veterans Administration Medical Center, Shreveport, Louisiana, USA
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3
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Lillo S, Mirandola A, Vai A, Camarda AM, Ronchi S, Bonora M, Ingargiola R, Vischioni B, Orlandi E. Current Status and Future Directions of Proton Therapy for Head and Neck Carcinoma. Cancers (Basel) 2024; 16:2085. [PMID: 38893203 PMCID: PMC11171191 DOI: 10.3390/cancers16112085] [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: 05/13/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
The growing interest in proton therapy (PT) in recent decades is justified by the evidence that protons dose distribution allows maximal dose release at the tumor depth followed by sharp distal dose fall-off. But, in the holistic management of head and neck cancer (HNC), limiting the potential of PT to a mere dosimetric advantage appears reductive. Indeed, the precise targeting of PT may help evaluate the effectiveness of de-escalation strategies, especially for patients with human papillomavirus associated-oropharyngeal cancer (OPC) and nasopharyngeal cancer (NPC). Furthermore, PT could have potentially greater immunogenic effects than conventional photon therapy, possibly enhancing both the radiotherapy (RT) capability to activate anti-tumor immune response and the effectiveness of immunotherapy drugs. Based on these premises, the aim of the present paper is to conduct a narrative review reporting the safety and efficacy of PT compared to photon RT focusing on NPC and OPC. We also provide a snapshot of ongoing clinical trials comparing PT with photon RT for these two clinical scenarios. Finally, we discuss new insights that may further develop clinical research on PT for HNC.
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Affiliation(s)
- Sara Lillo
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Alfredo Mirandola
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.); (A.V.)
| | - Alessandro Vai
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.); (A.V.)
| | - Anna Maria Camarda
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Sara Ronchi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Maria Bonora
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Rossana Ingargiola
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Barbara Vischioni
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
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4
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Dok R, Vanderwaeren L, Verstrepen KJ, Nuyts S. Radiobiology of Proton Therapy in Human Papillomavirus-Negative and Human Papillomavirus-Positive Head and Neck Cancer Cells. Cancers (Basel) 2024; 16:1959. [PMID: 38893080 PMCID: PMC11171379 DOI: 10.3390/cancers16111959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Photon-based radiotherapy (XRT) is one of the most frequently used treatment modalities for HPV-negative and HPV-positive locally advanced head and neck squamous cell carcinoma (HNSCC). However, locoregional recurrences and normal RT-associated toxicity remain major problems for these patients. Proton therapy (PT), with its dosimetric advantages, can present a solution to the normal toxicity problem. However, issues concerning physical delivery and the lack of insights into the underlying biology of PT hamper the full exploitation of PT. Here, we assessed the radiobiological processes involved in PT in HPV-negative and HPV-positive HNSCC cells. We show that PT and XRT activate the DNA damage-repair and stress response in both HPV-negative and HPV-positive cells to a similar extent. The activation of these major radiobiological mechanisms resulted in equal levels of clonogenic survival and mitotic cell death. Altogether, PT resulted in similar biological effectiveness when compared to XRT. These results emphasize the importance of dosimetric parameters when exploiting the potential of increased clinical effectiveness and reduced normal tissue toxicity in PT treatment.
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Affiliation(s)
- Rüveyda Dok
- Laboratory of Experimental Radiotherapy, Department of Oncology, KU Leuven, University of Leuven, 3000 Leuven, Belgium
| | - Laura Vanderwaeren
- Laboratory of Experimental Radiotherapy, Department of Oncology, KU Leuven, University of Leuven, 3000 Leuven, Belgium
| | - Kevin J. Verstrepen
- Laboratory for Systems Biology, VIB-KU Leuven Center for Microbiology, 3000 Leuven, Belgium
- Laboratory of Genetics and Genomics, Centre for Microbial and Plant Genetics, KU Leuven, 3000 Leuven, Belgium
| | - Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, KU Leuven, University of Leuven, 3000 Leuven, Belgium
- Department of Radiation Oncology, Leuven Cancer Institute, UZ Leuven, 3000 Leuven, Belgium
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5
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Orlandi E, Fontana G, Licitra L, Tinelli C, Camarda AM, Grau C, Frank SJ. Comprehensive insights on the underlying potential and advantage of proton therapy over intensity-modulated photon radiation therapy as highlighted in a wide real world data analysis. Radiother Oncol 2024; 193:110122. [PMID: 38309585 DOI: 10.1016/j.radonc.2024.110122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/30/2024] [Indexed: 02/05/2024]
Affiliation(s)
- Ester Orlandi
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy; Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Giulia Fontana
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy
| | - Lisa Licitra
- Scientific Directorate, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy; Department of Head & Neck Medical Oncology 3, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; Department of Oncology & Haemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Carmine Tinelli
- CNAO National Center for Oncological Hadrontherapy, Scientific Direction Office, Pavia, Italy
| | - Anna Maria Camarda
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy
| | - Cai Grau
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Steven Jay Frank
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX 77030, USA
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6
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Helm A, Fournier C. High-LET charged particles: radiobiology and application for new approaches in radiotherapy. Strahlenther Onkol 2023; 199:1225-1241. [PMID: 37872399 PMCID: PMC10674019 DOI: 10.1007/s00066-023-02158-7] [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: 03/02/2023] [Accepted: 09/17/2023] [Indexed: 10/25/2023]
Abstract
The number of patients treated with charged-particle radiotherapy as well as the number of treatment centers is increasing worldwide, particularly regarding protons. However, high-linear energy transfer (LET) particles, mainly carbon ions, are of special interest for application in radiotherapy, as their special physical features result in high precision and hence lower toxicity, and at the same time in increased efficiency in cell inactivation in the target region, i.e., the tumor. The radiobiology of high-LET particles differs with respect to DNA damage repair, cytogenetic damage, and cell death type, and their increased LET can tackle cells' resistance to hypoxia. Recent developments and perspectives, e.g., the return of high-LET particle therapy to the US with a center planned at Mayo clinics, the application of carbon ion radiotherapy using cost-reducing cyclotrons and the application of helium is foreseen to increase the interest in this type of radiotherapy. However, further preclinical research is needed to better understand the differential radiobiological mechanisms as opposed to photon radiotherapy, which will help to guide future clinical studies for optimal exploitation of high-LET particle therapy, in particular related to new concepts and innovative approaches. Herein, we summarize the basics and recent progress in high-LET particle radiobiology with a focus on carbon ions and discuss the implications of current knowledge for charged-particle radiotherapy. We emphasize the potential of high-LET particles with respect to immunogenicity and especially their combination with immunotherapy.
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Affiliation(s)
- Alexander Helm
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany
| | - Claudia Fournier
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany.
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7
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Xia X, Pi W, Chen M, Wang W, Cai D, Wang X, Lan Y, Yang H. Emerging roles of PHLPP phosphatases in lung cancer. Front Oncol 2023; 13:1216131. [PMID: 37576883 PMCID: PMC10414793 DOI: 10.3389/fonc.2023.1216131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Pleckstrin homologous domain leucine-rich repeating protein phosphatases (PHLPPs) were originally identified as protein kinase B (Akt) kinase hydrophobic motif specific phosphatases to maintain the cellular homeostasis. With the continuous expansion of PHLPPs research, imbalanced-PHLPPs were mainly found as a tumor suppressor gene of a variety of solid tumors. In this review, we simply described the history and structures of PHLPPs and summarized the recent achievements in emerging roles of PHLPPs in lung cancer by 1) the signaling pathways affected by PHLPPs including Phosphoinositide 3-kinase (PI3K)/AKT, RAS/RAF/mitogen-activated protein kinase (MEK)/extracellular signal-regulated kinase (ERK) and Protein kinase C (PKC) signaling cascades. 2) function of PHLPPs regulatory factor USP46 and miR-190/miR-215, 3) the potential roles of PHLPPs in disease prognosis, Epidermal growth factor receptors (EGFR)- tyrosine kinase inhibitor (TKI) resistance and DNA damage, 4) and the possible function of PHLPPs in radiotherapy, ferroptosis and inflammation response. Therefore, PHLPPs can be considered as either biomarker or prognostic marker for lung cancer treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Haihua Yang
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Department of Radiation Oncology, Taizhou Hospital Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
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8
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Zhou Z, Guan B, Xia H, Zheng R, Xu B. Particle radiotherapy in the era of radioimmunotherapy. Cancer Lett 2023:216268. [PMID: 37331583 DOI: 10.1016/j.canlet.2023.216268] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/24/2023] [Accepted: 06/11/2023] [Indexed: 06/20/2023]
Abstract
Radiotherapy (RT) is one of the key modalities for cancer treatment, and more than 70% of tumor patients will receive RT during the course of their disease. Particle radiotherapy, such as proton radiotherapy, carbon-ion radiotherapy (CIRT) and boron neutron capture therapy (BNCT), is currently available for the treatment of patients Immunotherapy combined with photon RT has been successfully used in the clinic. The effect of immunotherapy combined with particle RT is an area of interest. However, the molecular mechanisms underlying the effects of combined immunotherapy and particle RT remain largely unknown. In this review, we summarize the properties of different types of particle RT and the mechanisms underlying their radiobiological effects. Additionally, we compared the main molecular players in photon RT and particle RT and the mechanisms involved the RT-mediated immune response.
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Affiliation(s)
- Zihan Zhou
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350000, Fuzhou, China.
| | - Bingjie Guan
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350000, Fuzhou, China.
| | - Huang Xia
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350000, Fuzhou, China.
| | - Rong Zheng
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350000, Fuzhou, China; Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Fuzhou, Xinquan Road 29, Fuzhou, 350000, Fujian, China; Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, Xinquan Road 29, Fuzhou, 350000, Fujian, China.
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350000, Fuzhou, China; Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Fuzhou, Xinquan Road 29, Fuzhou, 350000, Fujian, China; Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, Xinquan Road 29, Fuzhou, 350000, Fujian, China.
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9
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Helm A, Totis C, Durante M, Fournier C. Are charged particles a good match for combination with immunotherapy? Current knowledge and perspectives. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2023; 376:1-36. [PMID: 36997266 DOI: 10.1016/bs.ircmb.2023.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Charged particle radiotherapy, mainly using protons and carbon ions, provides physical characteristics allowing for a volume conformal irradiation and a reduction of the integral dose to normal tissue. Carbon ion therapy additionally features an increased biological effectiveness resulting in peculiar molecular effects. Immunotherapy, mostly performed with immune checkpoint inhibitors, is nowadays considered a pillar in cancer therapy. Based on the advantageous features of charged particle radiotherapy, we review pre-clinical evidence revealing a strong potential of its combination with immunotherapy. We argue that the combination therapy deserves further investigation with the aim of translation in clinics, where a few studies have been set up already.
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Affiliation(s)
- A Helm
- Biophysics Department, GSI, Darmstadt, Germany
| | - C Totis
- Biophysics Department, GSI, Darmstadt, Germany
| | - M Durante
- Biophysics Department, GSI, Darmstadt, Germany.
| | - C Fournier
- Biophysics Department, GSI, Darmstadt, Germany
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10
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Tiwari DK, Hannen R, Unger K, Kohl S, Heß J, Lauber K, Subtil FSB, Dikomey E, Engenhart-Cabillic R, Schötz U. IL1 Pathway in HPV-Negative HNSCC Cells Is an Indicator of Radioresistance After Photon and Carbon Ion Irradiation Without Functional Involvement. Front Oncol 2022; 12:878675. [PMID: 35530351 PMCID: PMC9072779 DOI: 10.3389/fonc.2022.878675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Treatment of locally advanced HPV-negative head and neck squamous cell carcinoma (HNSCC) with photon radiation is the standard of care but shows only moderate success. Alterations in response toward DNA DSB repair, apoptosis, and senescence are underlying determinants of radioresistance in the tumor cells. Recently, senescence and the associated secretory phenotype (SASP) came into the focus of research and raised the need to identify the tumor-promoting molecular mechanisms of the SASP. The aim of this project was to unravel more of this process and to understand the impact of the IL1 pathway, which plays a major role in SASP. The studies were performed for photon and 12C-ion irradiation, which strongly vary in their effect on radioresistance. Materials and Methods A panel of five HPV-negative HNSCC cell lines was treated with photon and 12C-ion irradiation and examined for clonogenic survival, DNA DSB repair, and senescence. SASP and IL1 gene expressions were determined by RNA sequencing and activation of the IL1 pathway by ELISA. A functional impact of IL1A and IL1B was examined by specific siRNA knockdown. Results Cell killing and residual DSBs were higher after 12C-ion than after photon irradiation. 12C-ion induced more senescence with a significant correlation with cell survival. The impact on radioresistance appears to be less than after photon irradiation. The expression of SASP-related genes and the IL1 pathway are strongly induced by both types of irradiation and correlate with radioresistance and senescence, especially IL1A and IL1B which exhibit excellent associations. Surprisingly, knockdown of IL1A and IL1B revealed that the IL1 pathway is functionally not involved in radioresistance, DSB repair, or induction of senescence. Conclusions IL1A and IL1B are excellent indicators of cellular radioresistance and senescence in HNSCC cells without functional involvement in these processes. Clearly more research is needed to understand the molecular mechanisms of senescence and SASP and its impact on radioresistance.
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Affiliation(s)
- Dinesh Kumar Tiwari
- Department of Radiotherapy and Radiooncology, Philipps-University Marburg, Marburg, Germany
| | - Ricarda Hannen
- Department of Radiotherapy and Radiooncology, Philipps-University Marburg, Marburg, Germany
| | - Kristian Unger
- Research Unit Radiation Cytogenetics, Helmholtz Center Munich, German Research Center for Environmental Health GmbH, Neuherberg, Germany
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU) München, Munich, Germany
- Clinical Cooperation Group “Personalized Radiotherapy in Head and Neck Cancer”, Helmholtz Zentrum München, Neuherberg, Germany
| | - Sibylla Kohl
- Department of Radiotherapy and Radiooncology, Philipps-University Marburg, Marburg, Germany
| | - Julia Heß
- Research Unit Radiation Cytogenetics, Helmholtz Center Munich, German Research Center for Environmental Health GmbH, Neuherberg, Germany
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU) München, Munich, Germany
- Clinical Cooperation Group “Personalized Radiotherapy in Head and Neck Cancer”, Helmholtz Zentrum München, Neuherberg, Germany
| | - Kirsten Lauber
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU) München, Munich, Germany
| | | | - Ekkehard Dikomey
- Department of Radiotherapy and Radiooncology, Philipps-University Marburg, Marburg, Germany
| | | | - Ulrike Schötz
- Department of Radiotherapy and Radiooncology, Philipps-University Marburg, Marburg, Germany
- *Correspondence: Ulrike Schötz,
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11
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Key biological mechanisms involved in high-LET radiation therapies with a focus on DNA damage and repair. Expert Rev Mol Med 2022; 24:e15. [PMID: 35357290 DOI: 10.1017/erm.2022.6] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
DNA damage and repair studies are at the core of the radiation biology field and represent also the fundamental principles informing radiation therapy (RT). DNA damage levels are a function of radiation dose, whereas the type of damage and biological effects such as DNA damage complexity, depend on radiation quality that is linear energy transfer (LET). Both levels and types of DNA damage determine cell fate, which can include necrosis, apoptosis, senescence or autophagy. Herein, we present an overview of current RT modalities in the light of DNA damage and repair with emphasis on medium to high-LET radiation. Proton radiation is discussed along with its new adaptation of FLASH RT. RT based on α-particles includes brachytherapy and nuclear-RT, that is proton-boron capture therapy (PBCT) and boron-neutron capture therapy (BNCT). We also discuss carbon ion therapy along with combinatorial immune-based therapies and high-LET RT. For each RT modality, we summarise relevant DNA damage studies. Finally, we provide an update of the role of DNA repair in high-LET RT and we explore the biological responses triggered by differential LET and dose.
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12
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Cell death mechanisms in head and neck cancer cells in response to low and high-LET radiation. Expert Rev Mol Med 2022. [DOI: 10.1017/erm.2021.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AbstractHead and neck squamous cell carcinoma (HNSCC) is a common malignancy that develops in or around the throat, larynx, nose, sinuses and mouth, and is mostly treated with a combination of chemo- and radiotherapy (RT). The main goal of RT is to kill enough of the cancer cell population, whilst preserving the surrounding normal and healthy tissue. The mechanisms by which conventional photon RT achieves this have been extensively studied over several decades, but little is known about the cell death pathways that are activated in response to RT of increasing linear energy transfer (LET), including proton beam therapy and heavy ions. Here, we provide an up-to-date review on the observed radiobiological effects of low- versus high-LET RT in HNSCC cell models, particularly in the context of specific cell death mechanisms, including apoptosis, necrosis, autophagy, senescence and mitotic death. We also detail some of the current therapeutic strategies targeting cell death pathways that have been investigated to enhance the radiosensitivity of HNSCC cells in response to RT, including those that may present with clinical opportunities for eventual patient benefit.
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High-Throughput 3D Tumor Spheroid Array Platform for Evaluating Sensitivity of Proton-Drug Combinations. Int J Mol Sci 2022; 23:ijms23020587. [PMID: 35054773 PMCID: PMC8775525 DOI: 10.3390/ijms23020587] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/25/2021] [Accepted: 01/04/2022] [Indexed: 12/18/2022] Open
Abstract
Proton beam therapy (PBT) is a critical treatment modality for head and neck squamous cell carcinoma (HNSCC). However, not much is known about drug combinations that may improve the efficacy of PBT. This study aimed to test the feasibility of a three-dimensional (3D) tumor-spheroid-based high-throughput screening platform that could assess cellular sensitivity against PBT. Spheroids of two HNSCC cell lines—Fadu and Cal27—cultured with a mixture of Matrigel were arrayed on a 384-pillar/well plate, followed by exposure to graded doses of protons or targeted drugs including olaparib at various concentrations. Calcein staining of HNSCC spheroids revealed a dose-dependent decrease in cell viability for proton irradiation or multiple targeted drugs, and provided quantitative data that discriminated the sensitivity between the two HNSCC cell lines. The combined effect of protons and olaparib was assessed by calculating the combination index from the survival rates of 4 × 4 matrices, showing that Cal27 spheroids had greater synergy with olaparib than Fadu spheroids. In contrast, adavosertib did not synergize with protons in both spheroids. Taken together, we demonstrated that the 3D pillar/well array platform was a useful tool that provided rapid, quantitative data for evaluating sensitivity to PBT and drug combinations. Our results further supported that administration of the combination of PBT and olaparib may be an effective treatment strategy for HNSCC patients.
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Novello L, Agarwal N, Vennarini S, Lorentini S, Zacà D, Mussano A, Pasternak O, Jovicich J. Longitudinal Changes in Brain Diffusion MRI Indices during and after Proton Beam Therapy in a Child with Pilocytic Astrocytoma: A Case Report. Diagnostics (Basel) 2021; 12:diagnostics12010026. [PMID: 35054192 PMCID: PMC8775026 DOI: 10.3390/diagnostics12010026] [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: 11/25/2021] [Revised: 12/17/2021] [Accepted: 12/19/2021] [Indexed: 11/16/2022] Open
Abstract
Proton beam therapy (PBT) is an effective pediatric brain tumor treatment. However, the resulting microstructural changes within and around irradiated tumors are unknown. We retrospectively applied diffusion tensor imaging (DTI) and free-water imaging (FWI) on diffusion-weighted magnetic resonance imaging (dMRI) data to monitor microstructural changes during the PBT and after 8 months in a pilocytic astrocytoma (PA) and normal-appearing white matter (NAWM). We evaluated the conventional MRI- and dMRI-derived indices from six MRI sessions (t0–t5) in a Caucasian child with a hypothalamic PA: at baseline (t0), during the PBT (t1–t4) and after 8 months (t5). The tumor voxels were classified as “solid” or “fluid” based on the FWI. While the tumor volume remained stable during the PBT, the dMRI analyses identified two different response patterns: (i) an increase in fluid content and diffusivity with anisotropy reductions in the solid voxels at t1, followed by (ii) smaller variations in fluid content but higher anisotropy in the solid voxels at t2–t4. At follow-up (t5), the tumor volume, fluid content, and diffusivity in the solid voxels increased. The NAWM showed dose-dependent microstructural changes. The use of the dMRI and FWI showed complex dynamic microstructural changes in the irradiated mass during the PBT and at follow-up, opening new avenues in our understanding of radiation-induced pathophysiologic mechanisms in tumors and the surrounding tissues.
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Affiliation(s)
- Lisa Novello
- Center for Mind/Brain Sciences (CIMeC), University of Trento, 38068 Rovereto, Italy; (N.A.); (D.Z.); (J.J.)
- Correspondence:
| | - Nivedita Agarwal
- Center for Mind/Brain Sciences (CIMeC), University of Trento, 38068 Rovereto, Italy; (N.A.); (D.Z.); (J.J.)
- Proton Therapy Center, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (S.V.); (S.L.)
- Radiology Unit, Santa Maria del Carmine Hospital, 38068 Rovereto, Italy
- Neuroradiology & Radiology Services, Scientific Institute, IRCCS “Eugenio Medea”, 23842 Bosisio Parini, Italy
| | - Sabina Vennarini
- Proton Therapy Center, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (S.V.); (S.L.)
| | - Stefano Lorentini
- Proton Therapy Center, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (S.V.); (S.L.)
| | - Domenico Zacà
- Center for Mind/Brain Sciences (CIMeC), University of Trento, 38068 Rovereto, Italy; (N.A.); (D.Z.); (J.J.)
| | - Anna Mussano
- Pediatric Radiotherapy Service, S. Anna Hospital, A.O. Città della Salute e della Scienza, 10121 Torino, Italy;
| | - Ofer Pasternak
- Departments of Psychiatry and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Jorge Jovicich
- Center for Mind/Brain Sciences (CIMeC), University of Trento, 38068 Rovereto, Italy; (N.A.); (D.Z.); (J.J.)
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Hanania AN, Zhang X, Gunn GB, Rosenthal DI, Garden AS, Fuller CD, Phan J, Reddy JP, Moreno A, Chronowski G, Shah S, Ausat N, Hanna E, Ferrarotto R, Frank SJ. Proton Therapy for Major Salivary Gland Cancer: Clinical Outcomes. Int J Part Ther 2021; 8:261-272. [PMID: 34285952 PMCID: PMC8270094 DOI: 10.14338/ijpt-20-00044.1] [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: 08/24/2020] [Accepted: 11/23/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose To report clinical outcomes in terms of disease control and toxicity in patients with major salivary gland cancers (SGCs) treated with proton beam therapy. Materials and Methods Clinical and dosimetric characteristics of patients with SGCs treated from August 2011 to February 2020 on an observational, prospective, single-institution protocol were abstracted. Local control and overall survival were calculated by the Kaplan-Meier method. During radiation, weekly assessments of toxicity were obtained, and for patients with ≥ 90 days of follow-up, late toxicity was assessed. Results Seventy-two patients were identified. Median age was 54 years (range, 23-87 years). Sixty-three patients (88%) received postoperative therapy, and nine patients (12%) were treated definitively. Twenty-six patients (36%) received concurrent chemotherapy. Nine patients (12%) had received prior radiation. All (99%) but one patient received unilateral treatment with a median dose of 64 GyRBE (relative biological effectiveness) (interquartile range [IQR], 60-66), and 53 patients (74%) received intensity-modulated proton therapy with either single-field or multifield optimization. The median follow-up time was 30 months. Two-year local control and overall survival rates were 96% (95% confidence interval [CI] 85%-99%) and 89% (95% CI 76%-95%], respectively. Radiation dermatitis was the predominant grade-3 toxicity (seen in 21% [n = 15] of the patients), and grade ≥ 2 mucositis was rare (14%; n = 10 patients). No late-grade ≥ 3 toxicities were reported. Conclusion Proton beam therapy for treatment of major SGCs manifests in low rates of acute mucosal toxicity. In addition, the current data suggest a high rate of local control and minimal late toxicity.
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Affiliation(s)
- Alexander N Hanania
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalin Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Noveen Ausat
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ehab Hanna
- Department of Head and Neck Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Sherry AD, Pasalic D, Gunn GB, Fuller CD, Phan J, Rosenthal DI, Morrison WH, Sturgis EM, Gross ND, Gillison ML, Ferrarotto R, El-Naggar AK, Garden AS, Frank SJ. Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life. Int J Part Ther 2021; 8:234-247. [PMID: 34285950 PMCID: PMC8270080 DOI: 10.14338/ijpt-20-00034.1] [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: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT. Patients and Methods Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns. Results Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively. Conclusion Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.
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Affiliation(s)
| | - Dario Pasalic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura L Gillison
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Proton Therapy for HPV-Associated Oropharyngeal Cancers of the Head and Neck: a De-Intensification Strategy. Curr Treat Options Oncol 2021; 22:54. [PMID: 34086150 PMCID: PMC8178129 DOI: 10.1007/s11864-021-00847-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 12/02/2022]
Abstract
The rise in the incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPC), the relatively young age at which it is diagnosed, and its favorable prognosis necessitate the use of treatment techniques that reduce the likelihood of side effects during and after curative treatment. Intensity-modulated proton therapy (IMPT) is a form of radiotherapy that de-intensifies treatment through dose de-escalation to normal tissues without compromising dose to the primary tumor and involved, regional lymph nodes. Preclinical studies have demonstrated that HPV-positive squamous cell carcinoma is more sensitive to proton radiation than is HPV-negative squamous cell carcinoma. Retrospective studies comparing intensity-modulated photon (X-ray) radiotherapy to IMPT for OPC suggest comparable rates of disease control and lower rates of pain, xerostomia, dysphagia, dysgeusia, gastrostomy tube dependence, and osteoradionecrosis with IMPT—all of which meaningfully affect the quality of life of patients treated for HPV-associated OPC. Two phase III trials currently underway—the “Randomized Trial of IMPT versus IMRT for the Treatment of Oropharyngeal Cancer of the Head and Neck” and the “TOxicity Reduction using Proton bEam therapy for Oropharyngeal cancer (TORPEdO)” trial—are expected to provide prospective, level I evidence regarding the effectiveness of IMPT for such patients.
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18
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Yang G, Lu C, Mei Z, Sun X, Han J, Qian J, Liang Y, Pan Z, Kong D, Xu S, Liu Z, Gao Y, Qi G, Shou Y, Chen S, Cao Z, Zhao Y, Lin C, Zhao Y, Geng Y, Ma W, Yan X. Association of Cancer Stem Cell Radio-Resistance Under Ultra-High Dose Rate FLASH Irradiation With Lysosome-Mediated Autophagy. Front Cell Dev Biol 2021; 9:672693. [PMID: 33996830 PMCID: PMC8116574 DOI: 10.3389/fcell.2021.672693] [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: 02/26/2021] [Accepted: 04/06/2021] [Indexed: 12/03/2022] Open
Abstract
Cancer stem cell (CSC) is thought to be the major cause of radio-resistance and relapse post radiotherapy (RT). Recently ultra-high dose rate “FLASH-RT” evokes great interest for its decreasing normal tissue damages while maintaining tumor responses compared with conventional dose rate RT. However, the killing effect and mechanism of FLASH irradiation (FLASH-IR) on CSC and normal cancer cell are still unclear. Presently the radiation induced death profile of CSC and normal cancer cell were studied. Cells were irradiated with FLASH-IR (∼109 Gy/s) at the dose of 6–9 Gy via laser-accelerated nanosecond particles. Then the ratio of apoptosis, pyroptosis and necrosis were determined. The results showed that FLASH-IR can induce apoptosis, pyroptosis and necrosis in both CSC and normal cancer cell with different ratios. And CSC was more resistant to radiation than normal cancer cell under FLASH-IR. Further experiments tracing lysosome and autophagy showed that CSCs had higher levels of lysosome and autophagy. Taken together, our results suggested that the radio-resistance of CSC may associate with the increase of lysosome-mediated autophagy, and the decrease of apoptosis, necrosis and pyroptosis. To our limited knowledge, this is the first report shedding light on the killing effects and death pathways of CSC and normal cancer cell under FLASH-IR. By clarifying the death pathways of CSC and normal cancer cell under FLASH-IR, it may help us improve the understanding of the radio-resistance of CSC and thus help to optimize the future clinical FLASH treatment plan.
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Affiliation(s)
- Gen Yang
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Chunyang Lu
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Zhusong Mei
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Xiaoyi Sun
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Jintao Han
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Jing Qian
- Teaching and Research Section of Nuclear Medicine, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Yulan Liang
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Zhuo Pan
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Defeng Kong
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Shirui Xu
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Zhipeng Liu
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Ying Gao
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Guijun Qi
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Yinren Shou
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Shiyou Chen
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Zhengxuan Cao
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Ye Zhao
- Teaching and Research Section of Nuclear Medicine, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Chen Lin
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Yanying Zhao
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Yixing Geng
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Wenjun Ma
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China
| | - Xueqing Yan
- State Key Laboratory of Nuclear Physics and Technology, School of Physics, CAPT, Peking University, Beijing, China.,Collaborative Innovation Center of Extreme Optics, Shanxi University, Taiyuan, China
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Clinical Progress in Proton Radiotherapy: Biological Unknowns. Cancers (Basel) 2021; 13:cancers13040604. [PMID: 33546432 PMCID: PMC7913745 DOI: 10.3390/cancers13040604] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Proton radiation therapy is a more recent type of radiotherapy that uses proton beams instead of classical photon or X-rays beams. The clinical benefit of proton therapy is that it allows to treat tumors more precisely. As a result, proton radiotherapy induces less toxicity to healthy tissue near the tumor site. Despite the experience in the clinical use of protons, the response of cells to proton radiation, the radiobiology, is less understood. In this review, we describe the current knowledge about proton radiobiology. Abstract Clinical use of proton radiation has massively increased over the past years. The main reason for this is the beneficial depth-dose distribution of protons that allows to reduce toxicity to normal tissues surrounding the tumor. Despite the experience in the clinical use of protons, the radiobiology after proton irradiation compared to photon irradiation remains to be completely elucidated. Proton radiation may lead to differential damages and activation of biological processes. Here, we will review the current knowledge of proton radiobiology in terms of induction of reactive oxygen species, hypoxia, DNA damage response, as well as cell death after proton irradiation and radioresistance.
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Wang L, Fossati P, Paganetti H, Ma L, Gillison M, Myers JN, Hug E, Frank SJ. The Biological Basis for Enhanced Effects of Proton Radiation Therapy Relative to Photon Radiation Therapy for Head and Neck Squamous Cell Carcinoma. Int J Part Ther 2021; 8:3-13. [PMID: 34285931 PMCID: PMC8270087 DOI: 10.14338/ijpt-20-00070.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/09/2021] [Indexed: 12/24/2022] Open
Abstract
Head and neck squamous cell carcinomas (HNSCCs) often present as local-regionally advanced disease at diagnosis, for which a current standard of care is x-ray-based radiation therapy, with or without chemotherapy. This approach provides effective local regional tumor control, but at the cost of acute and late toxicity that can worsen quality of life and contribute to mortality. For patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (SCC) in particular, for whom the prognosis is generally favorable, de-escalation of the radiation dose to surrounding normal tissues without diminishing the radiation dose to tumors is desired to mitigate radiation-related toxic effects. Proton radiation therapy (PRT) may be an excellent de-escalation strategy because of its physical properties (that eliminate unnecessary radiation to surrounding tissues) and because of its biological properties (including tumor-specific variations in relative biological effectiveness [RBE] and linear energy transfer [LET]), in combination with concurrent systemic therapy. Early clinical evidence has shown that compared with x-ray-based radiation therapy, PRT offers comparable disease control with fewer and less severe treatment-related toxicities that can worsen the quality of life for patients with HNSCC. Herein, we review aspects of the biological basis of enhanced HNSCC cell response to proton versus x-ray irradiation in terms of radiation-induced gene and protein expression, DNA damage and repair, cell death, tumor immune responses, and radiosensitization of tumors.
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Affiliation(s)
- Li Wang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Piero Fossati
- Department of Radiation Oncology, MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Li Ma
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura Gillison
- Department of Thoracic-Head & Neck Med Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey N. Myers
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugen Hug
- Department of Radiation Oncology, MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Steven J. Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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21
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Szymonowicz KA, Chen J. Biological and clinical aspects of HPV-related cancers. Cancer Biol Med 2020; 17:864-878. [PMID: 33299640 PMCID: PMC7721094 DOI: 10.20892/j.issn.2095-3941.2020.0370] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/21/2020] [Indexed: 12/17/2022] Open
Abstract
Cancer-related diseases represent the second overall cause of death worldwide. Human papilloma virus (HPV) is an infectious agent which is mainly sexually transmitted and may lead to HPV-associated cancers in both men and women. Almost all cervical cancers are HPV-associated, however, an increasing number of head and neck cancers (HNCs), especially oropharyngeal cancer, can be linked to HPV infection. Moreover, anogenital cancers, including vaginal, vulvar, penial, and anal cancers, represent a subset of HPV-related cancers. Whereas testing and prevention of cervical cancer have significantly improved over past decades, anogenital cancers remain more difficult to confirm. Current clinical trials including patients with HPV-related cancers focus on finding proper testing for all HPV-associated cancers as well as improve the currently applied treatments. The HPV viral oncoproteins, E6 and E7, lead to degradation of, respectively, p53 and pRb resulting in entering the S phase without G1 arrest. These high-risk HPV viral oncogenes alter numerous cellular processes, including DNA repair, angiogenesis, and/or apoptosis, which eventually result in carcinogenesis. Additionally, a comprehensive analysis of gene expression and alteration among a panel of DNA double strand breaks (DSB) repair genes in HPV-negative and HPV-positive HNC cancers reveals differences pointing to HPV-dependent modifications of DNA repair processes in these cancers. In this review, we discuss the current knowledge regarding HPV-related cancers, current screening, and treatment options as well as DNA damage response-related biological aspects of the HPV infection and clinical trials.
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Affiliation(s)
- Klaudia Anna Szymonowicz
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Junjie Chen
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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22
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Wang L, Cao J, Wang X, Lin E, Wang Z, Li Y, Li Y, Chen M, Wang X, Jiang B, Zhang R, Sahoo N, Zhang X, Zhu XR, Myers JN, Frank SJ. Proton and photon radiosensitization effects of niraparib, a PARP-1/-2 inhibitor, on human head and neck cancer cells. Head Neck 2020; 42:2244-2256. [PMID: 32323895 DOI: 10.1002/hed.26155] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/15/2020] [Accepted: 03/19/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Combining photon or proton radiotherapy with targeted therapy shows promise for head and neck cancer (HNSCC). The poly (adenosine diphosphate [ADP]-ribose) polymerase-1/2 inhibitor niraparib targets DNA damage repair (DDR). We evaluated the effects of niraparib in combination with photons or protons, and its effects on the relative biological effectiveness (RBE) of protons, in human HNSCC cell lines. METHODS Radiosensitivity was assessed and RBE was calculated with clonogenic survival assays; unrepaired DNA double-strand breaks were evaluated using immunocytochemical analysis of 53BP1 foci. RESULTS Niraparib reduced colony formation in two of the four cell lines tested (P < .05), enhanced radiosensitivity in all four cell lines, delayed DDR (P < .05), and increased proton vs photon RBE. CONCLUSION Niraparib enhanced the sensitivity of four HNSCC cell lines to both photons and protons and increased the RBE of protons, possibly by inhibiting DDR. Niraparib may enhance the effectiveness of both photon and proton radiotherapy for patients with HNSCC.
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Affiliation(s)
- Li Wang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jianzhong Cao
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xiaochun Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eric Lin
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeming Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yuting Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yupeng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mei Chen
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xianliang Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bo Jiang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ruiping Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey N Myers
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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23
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Fan D, Kang JJ, Fan M, Wang H, Lee A, Yu Y, Chen L, Jillian Tsai C, McBride SM, Riaz N, Gelblum DY, Neal BP, Fetten J, Dunn LA, Michel LS, Boyle JO, Cohen MA, Roman BR, Ganly I, Singh B, Wong RJ, Sherman EJ, Lee NY. Last-line local treatment with the Quad Shot regimen for previously irradiated head and neck cancers. Oral Oncol 2020; 104:104641. [PMID: 32182548 DOI: 10.1016/j.oraloncology.2020.104641] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Patients with prior irradiated head and neck cancer (HNC) who are ineligible for definitive retreatment have limited local palliative options. We report the largest series of the use of the Quad Shot (QS) regimen as a last-line local palliative therapy. MATERIALS AND METHODS We identified 166 patients with prior HN radiation therapy (RT) treated with QS regimen (3.7 Gy twice daily over 2 consecutive days at 4 weeks intervals per cycle, up to 4 cycles). Palliative response defined by symptom(s) relief or radiographic tumor reduction, locoregional progression free survival (LPFS), overall survival (OS) and radiation-related toxicity were assessed. RESULTS Median age was 66 years. Median follow-up for all patients was 6.0 months and 9.7 months for living patients. Overall palliative response rate was 66% and symptoms improved in 60% of all patients. Predictors of palliative response were > 2 year interval from prior RT and 3-4 QS cycles. Median LPFS was 5.1 months with 1-year LPFS 17.7%, and median OS was 6.4 months with 1-year OS 25.3%. On multivariate analysis, proton RT, KPS > 70, presence of palliative response and 3-4 QS cycles were associated with improved LPFS and improved OS. The overall Grade 3 toxicity rate was 10.8% (n = 18). No Grade 4-5 toxicities were observed. CONCLUSION Palliative QS is an effective last-line local therapy with minimal toxicity in patients with previously irradiated HNC. The administration of 3-4 QS cycles predicts palliative response, improved PFS, and improved OS. KPS > 70 and proton therapy are associated with survival improvements.
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Affiliation(s)
- Dan Fan
- Department of Radiation Oncology, Xiangya Hospital, Central South University, Changsha, Hunan, China; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jung J Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ming Fan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Huili Wang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Anna Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Linda Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian P Neal
- ProCure Proton Therapy Center, Somerset, NJ, USA
| | - James Fetten
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lara A Dunn
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Loren S Michel
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jay O Boyle
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc A Cohen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bhuvanesh Singh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard J Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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24
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Arnold CR, Mangesius J, Skvortsova II, Ganswindt U. The Role of Cancer Stem Cells in Radiation Resistance. Front Oncol 2020; 10:164. [PMID: 32154167 PMCID: PMC7044409 DOI: 10.3389/fonc.2020.00164] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
Cancer stem cells (CSC) are a distinct subpopulation within a tumor. They are able to self-renew and differentiate and possess a high capability to repair DNA damage, exhibit low levels of reactive oxygen species (ROS), and proliferate slowly. These features render CSC resistant to various therapies, including radiation therapy (RT). Eradication of all CSC is a requirement for an effective antineoplastic treatment and is therefore of utmost importance for the patient. This makes CSC the prime targets for any therapeutic approach. Albeit clinical data is still scarce, experimental data and first clinical trials give hope that CSC-targeted treatment has the potential to improve antineoplastic therapies, especially for tumors that are known to be treatment resistant, such as glioblastoma. In this review, we will discuss CSC in the context of RT, describe known mechanisms of resistance, examine the possibilities of CSC as biomarkers, and discuss possible new treatment approaches.
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Affiliation(s)
- Christoph Reinhold Arnold
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Julian Mangesius
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ira-Ida Skvortsova
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria.,EXTRO-Lab, Tyrolean Cancer Research Institute, Innsbruck, Austria
| | - Ute Ganswindt
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
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25
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Wang L, Yang L, Han S, Zhu J, Li Y, Wang Z, Fan YH, Lin E, Zhang R, Sahoo N, Li Y, Zhang X, Wang X, Li T, Zhu XR, Zhu H, Heymach JV, Myers JN, Frank SJ. Patterns of protein expression in human head and neck cancer cell lines differ after proton vs photon radiotherapy. Head Neck 2020; 42:289-301. [PMID: 31710172 DOI: 10.1002/hed.26005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/26/2019] [Accepted: 10/18/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Proton radiotherapy (PRT) may be a less toxic alternative to photon radiotherapy (XRT) for patients with head and neck squamous cell carcinoma (HNSCC). However, the molecular responses of HNSCC cells to PRT vs XRT are unclear. METHODS Proteomics analyses of protein expression profiles by reverse-phase protein arrays were done for two human papillomavirus [HPV]-negative and two HPV+ cell lines. Expression patterns of 175 proteins involved in several signaling pathways were tested. RESULTS Compared with PRT, XRT tended to induce lower expression of DNA damage repair-and cell cycle arrest-related proteins and higher expression of cell survival- and proliferation-related proteins. CONCLUSIONS Under these experimental conditions, PRT and XRT induced different protein expression and activation profiles. Further preclinical verification is needed, as are studies of tumor pathway mutations as biomarkers for choice of treatment or as radiosensitization targets to improve the response of HNSCC to PRT or XRT.
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Affiliation(s)
- Li Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Liuqing Yang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shichao Han
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jinming Zhu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yuting Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeming Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - You-Hong Fan
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ruiping Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yupeng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaochun Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tengfei Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaorong R Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hongtu Zhu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John V Heymach
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey N Myers
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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