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Luo D, Zhong Q, Yue H, Wang J, Liang Q, Liu W, Zhu X. The predictors of lymphopenia and its effects on survival in locally advanced esophageal squamous cell carcinoma. Cancer Biol Ther 2024; 25:2371632. [PMID: 38946404 PMCID: PMC11218796 DOI: 10.1080/15384047.2024.2371632] [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: 12/15/2022] [Accepted: 06/19/2024] [Indexed: 07/02/2024] Open
Abstract
To investigate the impact of the effective radiation dose to immune cells (EDIC) and gross tumor volume (GTV) on lymphopenia and survival in patients with locally advanced esophageal squamous cell carcinoma (LAESCC). Between January 2013 and December 2020, 272 LAESCC patients were treated with definitive radiotherapy in two institutions. Based on radiation doses to the lungs, heart, and body region scanned, EDIC was calculated as an equal uniform dose to the total blood considering blood flow and fraction effect. The radiotherapy plan was used to calculate the GTVs. Lymphopenia was graded based on the lowest lymphocyte count during RT. The overall survival (OS), progress-free survival (PFS), and local recurrence-free survival (LRFS) were analyzed statistically. The lowest lymphocyte count was significantly correlated with EDIC (r= -0.389, p < .001) and GTV (r= -0.211, p < .001). Lymphopenia, EDIC, and GTV are risk factors for patients with ESCC. In a Kaplan-Meier analysis with EDIC and GTV as stratification factors, lymphopenia was not associated with OS in the EDIC>12.9 Gy group (p = .294)and EDIC ≤ 12.9 Gy group, and it was also not associated with OS in GTV>68.8 cm3 group (p = .242) and GTV ≤ 68.8 cm3 group(p = .165). GTV and EDIC had an impact on the relationship between lymphopenia and OS in patients with LAESCC undergoing definitive RT. Poorer OS, PFS, and LRFS are correlated with lymphopenia, higher EDIC, and larger GTV.
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Affiliation(s)
- Danjing Luo
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Qiulu Zhong
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Haiying Yue
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jue Wang
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qianfu Liang
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Wenqi Liu
- Department of Radiation Oncology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaodong Zhu
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
- Department of Oncology, Wuming Hospital of Guangxi Medical University, Nanning, China
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Guo L, Liu A, Geng X, Zhao Z, Nie Y, Wang L, Liu D, Li Y, Li Y, Li D, Wang Q, Li Z, Liu X, Li M. The role of spleen radiomics model for predicting prognosis in esophageal squamous cell carcinoma patients receiving definitive radiotherapy. Thorac Cancer 2024; 15:947-964. [PMID: 38480505 PMCID: PMC11045339 DOI: 10.1111/1759-7714.15276] [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: 02/06/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The spleen plays an important role in systemic antitumor immune response, but whether spleen imaging features have predictive effect for prognosis and immune status was unknown. The aim of this study was to investigate computed tomography (CT)-based spleen radiomics to predict the prognosis of patients with esophageal squamous cell carcinoma (ESCC) underwent definitive radiotherapy (dRT) and to try to find its association with systemic immunity. METHODS This retrospective study included 201 ESCC patients who received dRT. Patients were randomly divided into training (n = 142) and validation (n = 59) groups. The pre- and delta-radiomic features were extracted from enhanced CT images. LASSO-Cox regression was used to select the radiomics signatures most associated with progression-free survival (PFS) and overall survival (OS). Independent prognostic factors were identified by univariate and multivariate Cox analyses. The ROC curve and C-index were used to evaluate the predictive performance. Finally, the correlation between spleen radiomics and immune-related hematological parameters was analyzed by spearman correlation analysis. RESULTS Independent prognostic factors involved TNM stage, treatment regimen, tumor location, pre- or delta-Rad-score. The AUC of the delta-radiomics combined model was better than other models in the training and validation groups in predicting PFS (0.829 and 0.875, respectively) and OS (0.857 and 0.835, respectively). Furthermore, some spleen delta-radiomic features are significantly correlated with delta-ALC (absolute lymphocyte count) and delta-NLR (neutrophil-to-lymphocyte ratio). CONCLUSIONS Spleen radiomics is expected to be a useful noninvasive tool for predicting the prognosis and evaluating systemic immune status for ESCC patients underwent dRT.
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Affiliation(s)
- Longxiang Guo
- Department of Radiation OncologyShandong Cancer Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Ao Liu
- Department of Radiation OncologyShandong Cancer Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
- Cheeloo College of Medicine, Shandong UniversityJinanChina
- Department of Radiation OncologyQilu Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Xiaotao Geng
- Department of Radiation OncologyWeifang People's HospitalWeifangChina
| | - Zongxing Zhao
- Department of Radiation OncologyLiaocheng People's Hospital, Shandong First Medical UniversityLiaochengChina
| | - Yu Nie
- Department of Tumor RadiotherapyShandong Second Provincial General HospitalJi'nanChina
| | - Lu Wang
- School of Clinical Medicine, Weifang Medical UniversityWeifangChina
| | - Defeng Liu
- Department of Radiation OncologyShandong Cancer Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
- Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Yi Li
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Yuanlin Li
- School of Clinical Medicine, Weifang Medical UniversityWeifangChina
| | - Dianxing Li
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Qiankun Wang
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Zhichao Li
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Xiuli Liu
- Department of Radiation OncologyShandong Cancer Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
- Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Minghuan Li
- Department of Radiation OncologyShandong Cancer Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
- Department of Radiation OncologyShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
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van Rossum PSN, Juan-Cruz C, Stam B, Rossi MMG, Lin SH, Abravan A, Belderbos JSA, Sonke JJ. Severe radiation-induced lymphopenia during concurrent chemoradiotherapy for stage III non-small cell lung cancer: external validation of two prediction models. Front Oncol 2023; 13:1278723. [PMID: 38023221 PMCID: PMC10665840 DOI: 10.3389/fonc.2023.1278723] [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: 08/16/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Severe radiation-induced lymphopenia (RIL) in patients undergoing chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC) is associated with decreased immunotherapy efficacy and survival. At The Christie and MD Anderson Cancer Center (MDACC), prediction models for lymphopenia were developed in lung and esophageal cancer patients, respectively. The aim of this study was to externally validate both models in patients with stage III NSCLC. Methods Patients who underwent concurrent CRT for stage III NSCLC in 2019-2021 were studied. Outcomes were grade ≥3 and grade 4 lymphopenia during CRT. The Christie model predictors for grade ≥3 lymphopenia included age, baseline lymphocyte count, radiotherapy duration, chemotherapy, mean heart and lung doses, and thoracic vertebrae V20Gy. MDACC predictors for grade 4 lymphopenia were age, baseline lymphocyte count, planning target volume (PTV), and BMI. The external performance of both models was assessed. Results Among 100 patients, 78 patients (78%) developed grade ≥3 lymphopenia, with grade 4 lymphopenia in 17 (17%). For predicting grade ≥3 lymphopenia, the Christie and MDACC models yielded c-statistics of 0.77 and 0.79, respectively. For predicting grade 4 lymphopenia, c-statistics were 0.69 and 0.80, respectively. Calibration for the Christie and MDACC models demonstrated moderate and good agreement, respectively. Conclusion The PTV-based MDACC prediction model for severe RIL demonstrated superior external performance in NSCLC patients compared to the dosimetry-based Christie model. As such, the MDACC model can aid in identifying patients at high risk for severe lymphopenia. However, to optimize radiotherapy planning, further improvement and external validation of dosimetry-based models is desired.
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Affiliation(s)
- Peter S. N. van Rossum
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Department of Radiation Oncology, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
| | - Celia Juan-Cruz
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Barbara Stam
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Maddalena M. G. Rossi
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Azadeh Abravan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - José S. A. Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
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Laurent PA, Deutsch É. [Radiation-induced lymphopenia: Lymphocytes as a new organ at risk]. Cancer Radiother 2023; 27:511-518. [PMID: 37661506 DOI: 10.1016/j.canrad.2023.06.017] [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: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 09/05/2023]
Abstract
Taking the immune system into account in the fight against tumors has upset the cancer treatment paradigm in the 21st century. Combination treatment strategies associating radiotherapy with immunotherapy are being increasingly implemented in clinical practice. In this context, lymphocytes, whether lymphocytes infiltrating the tumour, circulating blood lymphocytes or lymphocytes residing within the lymph nodes, are key players in cellular and humoral anti-tumor immunity. The significant radiosensitivity of lymphocytes was demonstrated in the early 1990s. Along with the cells of the digestive mucosa, lymphocytes are thus among the most radiosensitive cell types in the body. Compared to the old practices of external radiotherapy, current intensity modulated treatments have allowed a considerable improvement in acute and late toxicity, at the cost of a significant increase in the volume irradiated at low doses. This is not without consequence on the incidence of radiation-induced lymphopenia, with prognostic implications for many tumor types. Thus, in order not to hinder the action of antitumor immunity and the efficacy of immunotherapy, it is essential to consider lymphocytes as a new organ at risk in its own right. In this development, based on current data from the literature, we will begin by justifying the necessary prevention of radiation-induced lymphopenia, before providing the tools currently known to apprehend lymphocytes as a new multicompartments. Finally, we will broaden the perspective by outlining ways to develop research in this area.
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Affiliation(s)
- P A Laurent
- Service de radiothérapie oncologique, Gustave-Roussy Cancer Campus, Villejuif, France; Inserm, U1030 Molecular Radiation Therapy and Therapeutic Innovation, Gustave-Roussy Cancer Campus, université Paris-Saclay, Villejuif, France
| | - É Deutsch
- Service de radiothérapie oncologique, Gustave-Roussy Cancer Campus, Villejuif, France; Inserm, U1030 Molecular Radiation Therapy and Therapeutic Innovation, Gustave-Roussy Cancer Campus, université Paris-Saclay, Villejuif, France.
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McSweeney DM, Raby S, Radhakrishna G, Weaver J, Green A, Bromiley PA, van Herk M, McWilliam A. Low muscle mass measured at T12 is a prognostic biomarker in unresectable oesophageal cancers receiving chemoradiotherapy. Radiother Oncol 2023; 186:109764. [PMID: 37385375 DOI: 10.1016/j.radonc.2023.109764] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND PURPOSE Low muscle mass is an imaging biomarker of patient frailty that has been associated with increased toxicity and decreased survival in a number of cancers. Patients with unresectable oesophageal cancer receive chemoradiotherapy as standard of care. Muscle mass is not yet an established prognostic marker in this population. Muscle mass is usually assessed by segmenting skeletal muscle at the L3 vertebral level. But radiotherapy planning scans for oesophageal cancers do not always image this level, which has limited previous studies of body composition. Skeletal muscle is known to regulate immune function, but the association of muscle mass with lymphopenia in cancer patients has not been shown. MATERIALS AND METHODS We retrospectively analyse 135 oesophageal cancer patients who received chemoradiotherapy and investigate the prognostic value of skeletal muscle area assessed at T12. We also examine the association between muscle mass and radiation-induced lymphopenia. RESULTS We find that low muscle mass is associated with poorer overall survival (hazard ratio [95% confidence interval]: 0.72 [0.53-0.97]). However, this effect interacts with body mass index (BMI) such that the prognostic value of low muscle mass is removed by high BMI. In our study, patients with low muscle mass were more prone to radiation-induced lymphopenia (75% vs. 50% in patients with high muscle mass). A significant decrease in circulating lymphocytes was associated with poorer overall survival (hazard ratio [95% confidence interval]: 0.68 [0.47-0.99]). CONCLUSION Our study shows that assessing muscle mass at T12 is feasible and provides prognostic information. Low muscle mass at T12 is associated with poorer overall survival and increased risk of radiation-induced lymphopenia. Muscle mass provides additional information over performance status and BMI. Low BMI patients are most affected by low muscle mass, highlighting the importance of close nutritional support in this population.
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Affiliation(s)
- Dónal Michael McSweeney
- Division of Cancer Sciences, University of Manchester, Manchester M13 9PL, UK; Radiotherapy Related Research, The Christie Foundation Trust, Manchester M20 4BX, UK.
| | - Sophie Raby
- Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester M20 4BX, UK
| | - Ganesh Radhakrishna
- Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester M20 4BX, UK
| | - Jamie Weaver
- Department of Medical Oncology, The Christie Hospital NHS Foundation Trust, Manchester M20 4BX, UK
| | - Andrew Green
- Division of Cancer Sciences, University of Manchester, Manchester M13 9PL, UK; Radiotherapy Related Research, The Christie Foundation Trust, Manchester M20 4BX, UK
| | - Paul Alan Bromiley
- Division of Informatics, Imaging and Data Sciences, University of Manchester, M13 9PL, UK
| | - Marcel van Herk
- Division of Cancer Sciences, University of Manchester, Manchester M13 9PL, UK; Radiotherapy Related Research, The Christie Foundation Trust, Manchester M20 4BX, UK
| | - Alan McWilliam
- Division of Cancer Sciences, University of Manchester, Manchester M13 9PL, UK; Radiotherapy Related Research, The Christie Foundation Trust, Manchester M20 4BX, UK
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Chen X, Tian X, Zhang X, Deng Q, Wang M, Zhou X, Xu Y, Zhou L, Zou B, Liu Y, Ao R, Lu Y, Gong Y. Pericardial irradiation dose may be strongly associated with grade 4 lymphopenia and affect prognosis in patients with locally advanced esophageal cancer receiving definitive concurrent chemoradiotherapy. Thorac Cancer 2023; 14:2735-2744. [PMID: 37519061 PMCID: PMC10518230 DOI: 10.1111/1759-7714.15057] [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: 05/05/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND The immune system may influence prognosis, and lymphopenia is a frequent side effect of concurrent chemoradiotherapy (CCRT). Radical irradiation for locally advanced esophageal cancer (LA-EC) exposes significant vascular and heart volumes. In this study, we hypothesized that lymphopenia is linked to cardiac and pericardial doses and affects patient prognosis. METHODS AND MATERIALS We identified 190 LA-EC patients who received radical CCRT. Multivariate analysis (MVA) was performed to correlate clinical factors and dosimetric parameters with overall survival (OS). We collected lymphocyte-related variables and ratios before and during CCRT. MVA was performed to correlate hematologic toxicity with OS. The relationship between dosimetric parameters and G4 lymphopenia was determined using logistic stepwise regression. Finally, a nomogram of G4 lymphopenia was developed and validated externally. RESULTS Median follow-up time for all patients was 27.5 months. On MVA for OS, higher pericardial V30 (PV30 ) was linked to worse survival (HR: 1.013, 95% CI: 1.001-1.026, p = 0.039). The median OS stratified by PV30 > 55.3% and PV30 ≤ 55.3% was 24.0 months and 54.0 months, respectively (p = 0.004). G4 lymphopenia was shown to be linked with worse OS in the MVA of hematological toxicity with OS (HR: 2.042, 95% CI: 1.335-3.126, p = 0.001). Thirty of the 100 patients in the training set had G4 lymphopenia. Logistic stepwise regression was used to identify variables associated with G4 lymphopenia, and the final model consisted of stage-IVA (p = 0.017), platelet-to-lymphocyte ratio during CCRT (p = 0.008), Heart V50 (p = 0.046), and PV30 (p = 0.048). Finally, a nomogram predicting G4 lymphocytopenia were constructed and externally validated. The ROC curve showed an AUC for internal validation of 0.775 and external validation of 0.843. CONCLUSION Higher doses of pericardial radiation might affect LA-EC patients' prognosis by inducing G4 lymphopenia during CCRT. Further prospective studies are warranted to confirm these findings, especially in the era of immune-checkpoint inhibitor treatment.
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Affiliation(s)
- Xianyan Chen
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Xiaoman Tian
- Department of OncologySichuan Provincial People's HospitalChengduChina
| | - Xuanwei Zhang
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Qianyue Deng
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Min Wang
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Xiaojuan Zhou
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Yong Xu
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Lin Zhou
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Bingwen Zou
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Yongmei Liu
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Rui Ao
- Department of OncologySichuan Provincial People's HospitalChengduChina
| | - You Lu
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Youling Gong
- Division of Thoracic Tumor Multidisciplinary Treatment, Cancer Center and State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduChina
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Fan X, Yang L, Qin W, Zou B, Fan B, Wang S, Wang L. Prophylactic cranial irradiation-related lymphopenia affects survival in patients with limited-stage small cell lung cancer. Heliyon 2023; 9:e16483. [PMID: 37251477 PMCID: PMC10220366 DOI: 10.1016/j.heliyon.2023.e16483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 05/31/2023] Open
Abstract
Background The study aimed to identify the relations of the absolute lymphocyte count (ALC) nadir during prophylactic cranial irradiation (PCI) and patient outcomes in limited-stage small cell lung cancer (LS-SCLC). Methods We analyzed 268 L S-SCLC patients who underwent PCI from 2012 to 2019. ALC values were collected prior, during, and 3 months post PCI. Kaplan-Meier and Cox regression analyses were performed to assess the relation of ALC to patient prognosis. Two nomograms were developed on the basis of clinical variables for survival prediction. Results Compared with the ALC before PCI (1.13 × 109 cells/L), the ALC nadir during PCI was significantly reduced by 0.68 × 109 cells/L (P < 0.001) and raised to 1.02 × 109 cells/L 3 months post PCI. Patients with a low ALC nadir during PCI (<0.68 × 109 cells/L) had inferior progression free survival (PFS) (median PFS: 17.2 m vs. 43.7 m, P = 0.019) and overall survival (OS) (median OS: 29.0 m vs 39.1 m, P = 0.012). Multivariate Cox analysis revealed that age, smoking history, clinical stage, and ALC nadir were independent OS (P = 0.006, P = 0.005, P < 0.001 and P = 0.027, respectively), as well as independent PFS predictors (P = 0.032, P = 0.012, P = 0.012 and P = 0.018, respectively). After internal cross-validation, the corrected concordance indices of the predictive nomograms for PFS and OS were 0.637 and 0.663, respectively. Conclusion LS-SCLC patients with a low ALC nadir during PCI likely have worse survival outcomes. Dynamic evaluation of the ALC during PCI is recommended for LS-SCLC patients.
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Affiliation(s)
- Xinyu Fan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250000, China
| | - Linlin Yang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250000, China
| | - Wenru Qin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250000, China
| | - Bing Zou
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250000, China
| | - Bingjie Fan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250000, China
| | - Shijiang Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250000, China
- Cheeloo College of Medicine, Shandong University, Jinan, 250000, China
| | - Linlin Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250000, China
- Cheeloo College of Medicine, Shandong University, Jinan, 250000, China
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Xu Z, Ke H, Zheng B, Lin C, Zhang Y, Wang L, Lin Y, Ye Y, Cai L, You M, Chen J, Xu Y. The Prognostic Significance of Nomogram-Based Pretreatment Inflammatory Indicators in Patients With Esophageal Squamous Cell Carcinoma Receiving Intensity-Modulated Radiotherapy. Cancer Control 2023; 30:10732748231185025. [PMID: 37339928 DOI: 10.1177/10732748231185025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND At present, there is no objective prognostic index available for patients with esophageal squamous cell carcinoma (ESCC) who underwent intensity-modulated radiotherapy (IMRT). This study is to develop a nomogram based on hematologic inflammatory indices for ESCC patients treated with IMRT. METHODS 581 patients with ESCC receiving definitive IMRT were enrolled in our retrospective study. Of which, 434 patients with treatment-naïve ESCC in Fujian Cancer Hospital were defined as the training cohort. Additional 147 newly diagnosed ESCC patients were used as the validation cohort. Independent predictors of overall survival (OS) were employed to establish a nomogram model. The predictive ability was evaluated by time-dependent receiver operating characteristic curves, the concordance index (C-index), net reclassification index (NRI), and integrated discrimination improvement (IDI). Decision curve analysis (DCA) was performed to assess the clinical benefits of the nomogram model. The entire series was divided into 3 risk subgroups stratified by the total nomogram scores. RESULTS Clinical TNM staging, primary gross tumor volume, chemotherapy, neutrophil-to-lymphocyte ratio and platelet lymphocyte ratio were independent predictors of OS. Nomogram was developed incorporating these factors. Compared with the 8th American Joint Committee on Cancer (AJCC) staging, the C-index for 5-year OS (.627 and .629) and the AUC value of 5-year OS (.706 and .719) in the training and validation cohorts (respectively) were superior. Furthermore, the nomogram model presented higher NRI and IDI. DCA also demonstrated that the nomogram model provided greater clinical benefit. Finally, patients with <84.8, 84.8-151.4, and >151.4 points were categorized into low-risk, intermediate-risk, and high-risk groups. Their 5-year OS rates were 44.0%, 23.6%, and 8.9%, respectively. The C-index was .625, which was higher than the 8th AJCC staging. CONCLUSIONS We have developed a nomogram model that enables risk-stratification of patients with ESCC receiving definitive IMRT. Our findings may serve as a reference for personalized treatment.
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Affiliation(s)
- Zhiyang Xu
- Department of Thoracic Surgery, The School of Clinical Medicine, Fujian Medical University, The First Hospital of Putian, Putian, China
| | - Hongqian Ke
- Clinical Oncology School of Fujian Medical University, Fuzhou, China
| | - Binglin Zheng
- Clinical Oncology School of Fujian Medical University, Fuzhou, China
| | - Chuyan Lin
- Clinical Oncology School of Fujian Medical University, Fuzhou, China
| | - Yiping Zhang
- Clinical Oncology School of Fujian Medical University, Fuzhou, China
| | - Liyan Wang
- Clinical Oncology School of Fujian Medical University, Fuzhou, China
| | - Yu Lin
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Yuling Ye
- Clinical Oncology School of Fujian Medical University, Fuzhou, China
| | - Lifang Cai
- Department of Medical Oncology, The School of Clinical Medicine, Fujian Medical University, The First Hospital of Putian, Putian, China
| | - Mengxing You
- Department of Medical Oncology, The School of Clinical Medicine, Fujian Medical University, The First Hospital of Putian, Putian, China
| | - Junqiang Chen
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Yuanji Xu
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
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Proton and Carbon Ion Radiation Therapy Decreased Severe Lymphopenia by Reducing Thoracic Vertebra and Aortic Doses in Non-small Cell Lung Cancer Versus Intensity Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2022:S0360-3016(22)03677-X. [PMID: 36586495 DOI: 10.1016/j.ijrobp.2022.12.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 12/04/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Lymphopenia is a common adverse effect of radiation therapy (RT). Little is known about the difference in lymphopenia between intensity modulated (photon) radiation therapy (IMRT) and proton and carbon ion radiation therapy (PCIRT). This study aimed to investigate lymphopenia differences between IMRT and PCIRT in non-small cell lung cancer (NSCLC). METHODS AND MATERIALS Clinical and dosimetric parameters were collected from 343 patients who received definitive IMRT or PCIRT for NSCLC. Severe lymphopenia (SRL) was defined as an absolute lymphocyte count (ALC) ≤0.5 × 103 cells/μL. Overall survival (OS) was analyzed using the Kaplan-Meier method. Propensity score matching was performed between the IMRT and PCIRT groups. Least absolute shrinkage and selection operator analysis was used to select appropriate dosimetric parameters. Univariate and multivariate logistic regression analyses were conducted to identify the predictors of SRL. RESULTS Compared with the IMRT group, the PCIRT group was less likely to develop SRL (P < .001). Compared with the non-SRL group, the SRL group showed significant association with poorer OS, with a median survival time of 29.2 versus 15.0 months (P = .046). IMRT was an independent risk factor of SRL (P = .004). A lower ALC before RT (P = .030) and larger planning target volume (PTV) (P = .002) were also significant independent risk factors for SRL. Moreover, the majority of dosimetric parameters of organs at risk in PCIRT were lower than those in IMRT (P < .001). Thoracic vertebra V5 (P = .002) and aorta V5 (P = .026) were identified as independent risk predictors of SRL after adding dosimetric parameters to the regression model. CONCLUSIONS Compared with IMRT, PCIRT could reduce SRL incidence, possibly by limiting thoracic vertebra and aortic doses, and SRL was associated with poor outcomes in patients with NSCLC.
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Venkatesulu B, Giridhar P, Pujari L, Chou B, Lee JH, Block AM, Upadhyay R, Welsh JS, Harkenrider MM, Krishnan S, Verma V, En Hsieh C, Pradhan S, Small W, Solanki AA. Lymphocyte sparing normal tissue effects in the clinic (LymphoTEC): A systematic review of dose constraint considerations to mitigate radiation-related lymphopenia in the era of immunotherapy. Radiother Oncol 2022; 177:81-94. [PMID: 36334694 DOI: 10.1016/j.radonc.2022.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/07/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Radiation-related lymphopenia has been associated with suboptimal tumor control rates leading to inferior survival outcomes. To date, no standardized dose constraints are available to limit radiation dose to resident and circulating lymphocyte populations. We undertook this systemic review of the literature to provide a synopsis of the dosimetric predictors of radiation-related lymphopenia in solid malignancies. METHODOLOGY A systematic literature review of PubMed (National Institutes of Health), Cochrane Central (Cochrane collaboration), and Google Scholar was conducted with the following keywords: "radiation", "lymphopenia", "cancer", "dosimetric predictors" with an inclusion deadline of May 31, 2022. Studies that met prespecified inclusion criteria were designated either Good, Fair, or Poor Quality based on the Newcastle-Ottawa quality assessment. The dosimetric parameters derived from Good Quality studies were tabulated as LymphoTEC dose constraints. Dosimetric parameters derived from Fair and Poor-quality studies were grouped as optional. RESULTS An initial systematic search of the literature yielded 1,632 articles. After screening, a total of 48 studies met inclusion criteria and were divided into the following categories: central nervous system (CNS, 6), thoracic (11), gastrointestinal (26), gynecologic (2), head and neck, breast, and genitourinary (one each) cancers. Lung mean dose, heart mean dose, brain V25, spleen mean dose, estimated dose to immune cells, and bone marrow V10 were among the strongest predictors for severe lymphopenia related to radiotherapy. CONCLUSION Optimizing the delivery of radiation therapy to limit dose to lymphocyte-rich structures may curb the negative oncologic impact of lymphocyte depletion. The dose constraints described herein may be considered for prospective validation and future use in clinical trials to limit risk of radiation-related lymphopenia and possibly improve cancer-associated outcomes.
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Affiliation(s)
- BhanuPrasad Venkatesulu
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA.
| | | | - Lincoln Pujari
- Department of Radiation Oncology, Tata memorial center, Varanasi, India
| | - Brian Chou
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Jae Han Lee
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Alec M Block
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - James S Welsh
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Matthew M Harkenrider
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Verma
- Department of Radiation Oncology, MD Anderson cancer center, Houston, Texas, USA
| | - Cheng En Hsieh
- Department of Radiation Oncology, Institute for Radiological Research, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taoyuan City, Taiwan; Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston and The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Satyajit Pradhan
- Department of Radiation Oncology, Tata memorial center, Varanasi, India
| | - William Small
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Abhishek A Solanki
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
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Wang S, Zhang C, Wang Y, Luo K, Yang Y, Yang Y, Liu S, Li Q, Xi M. Risk factors and prognosis for esophageal fistula in patients with esophageal squamous cell carcinoma during radiotherapy. Esophagus 2022; 19:660-669. [PMID: 35419642 DOI: 10.1007/s10388-022-00919-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/23/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE To determine risk factors, treatment outcomes, and prognostic factors for esophageal fistula (EF) in patients with esophageal squamous cell carcinoma (ESCC) during radiotherapy. METHODS Between 2010 and 2018, 109 patients with EF during radiotherapy were retrospectively collected. A controlled cohort including 416 patients who received definitive chemoradiotherapy without EF was used to compare risk factors and survival outcomes. Univariate and multivariate logistic regression analyses were performed to identify predictors of EF. Propensity score matching (PSM) was applied to adjust for potential confounding factors. RESULTS Multivariate analysis demonstrated that sex, body mass index, alcohol history, esophageal ulceration, primary tumor length, T stage, and absolute lymphocyte count were independent risk factors for EF. After PSM, patients with EF showed remarkably worse prognosis than those without EF (median overall survival: 13.0 versus 20.5 months; P = 0.009). For patients with EF, serum albumin level (≥ 35 g/L), subsequent radiotherapy, and fistula closure were associated with significantly prolonged survival. In addition, esophageal-mediastinum fistula and subsequent radiotherapy were positive predictors for fistula closure. CONCLUSIONS We identified risk factors for radiotherapy-related EF and its unfavorable prognosis in patients with ESCC. Of them, patients with serum albumin level of ≥ 35 g/L, subsequent radiotherapy after EF, and fistula closure had a more favorable survival.
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Affiliation(s)
- Sifen Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Chao Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yuting Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Kongjia Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yuxian Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Yadi Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China
- Department of Imaging Diagnosis and Interventional Center, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Shiliang Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Qiaoqiao Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China.
| | - Mian Xi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, China.
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China.
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Yu H, Chen F, Lam KO, Yang L, Wang Y, Jin JY, EI Helali A, Kong FM(S. Potential Determinants for Radiation-Induced Lymphopenia in Patients With Breast Cancer Using Interpretable Machine Learning Approach. Front Immunol 2022; 13:768811. [PMID: 35799797 PMCID: PMC9253393 DOI: 10.3389/fimmu.2022.768811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Radiation-induced lymphopenia is known for its survival significance in patients with breast cancer treated with radiation therapy. This study aimed to evaluate the impact of radiotherapy on lymphocytes by applying machine learning strategies. We used Extreme Gradient Boosting (XGboost) to predict the event of lymphopenia (grade≥1) and conduced an independent validation. Then, we induced feature attribution analysis (Shapley additive explanation, SHAP) in explaining the XGboost models to explore the directional contribution of each feature to lymphopenia. Finally, we implemented the proof-of-concept clinical validation. The results showed that the XGboost models had rigorous generalization performances (accuracies 0.764 and ROC-AUC 0.841, respectively) in the independent cohort. The baseline lymphocyte counts are the most protective feature (SHAP = 5.226, direction of SHAP = -0.964). Baseline platelets and monocytes also played important protective roles. The usage of taxane only chemotherapy was less risk on lymphopenia than the combination of anthracycline and taxane. By the contribution analysis of dose, we identified that firstly lymphocytes were sensitive to a radiation dose less than 4Gy; secondly the irradiation volume was more important in promoting lymphopenia than the irradiation dose; thirdly the irradiation dose promoted the event of lymphopenia when the irradiation volume was fixed. Overall, our findings paved the way to clarifying the radiation dose volume effect. To avoid radiation-induced lymphopenia, irradiation volume should be kept to a minimum during the planning process, as long as the target coverage is not compromised.
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Affiliation(s)
- Hao Yu
- Institute of Biomedical and Health Engineering, Chinese Academy of Sciences Shenzhen Institutes of Advanced Technology, Shenzhen, China
| | - Fang Chen
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ka-On Lam
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Li Yang
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yang Wang
- Biomedical Engineering, Shenzhen Polytechnic, Shenzhen, China
| | - Jian-Yue Jin
- University Hospitals/Cleverland Medical Center, Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, United States
| | - Aya EI Helali
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Feng-Ming (Spring) Kong
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- *Correspondence: Feng-Ming (Spring) Kong,
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13
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Dai D, Tian Q, Yu G, Shui Y, Jiang H, Wei Q. Severe Radiation-Induced Lymphopenia Affects the Outcomes of Esophageal Cancer: A Comprehensive Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14123024. [PMID: 35740689 PMCID: PMC9221375 DOI: 10.3390/cancers14123024] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Radiotherapy is as an important part of esophageal cancer (EC) treatment. However, it often causes severe radiation-induced lymphopenia (RIL). The aim of the current study was to evaluate the influence of severe RIL on the outcomes of EC. A systematic review and meta-analysis including 17 studies was performed. Our meta-analysis found that severe RIL was associated with a lower pathologic complete response rate and inferior overall survival and progression-free survival of EC patients. The lymphocyte nadir was found during 4–6 weeks after the start of radiotherapy. A series of dosimetric factors and clinical factors associated with RIL were summarized. Our results provide important evidence for the clinical application of radiotherapy. Minimizing the dosimetric risk factors, especially in patients with clinical risk factors, might benefit their outcomes. Our results might also offer clues for the strategy of combining radiotherapy and immunotherapy in EC patients. Abstract The aim of the current study was to evaluate the influence of severe radiation-induced lymphopenia (RIL) on the outcomes of esophageal cancer (EC). A systematic review and meta-analysis was performed through the PRISMA guideline. Seventeen studies were included in the current systematic review, with eight included in the meta-analyses. Meta-analyses found that severe RIL was associated with lower pathologic complete response (pCR) rate (odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.30–0.66, I2 = 0%), inferior overall survival (OS) (hazard ratio (HR) = 1.50, 95% CI = 1.29–1.75, I2 = 6%), and worse progression-free survival (PFS) (HR = 1.70, 95% CI = 1.39–2.07, I2 = 0%) of EC patients. The lymphocyte nadir was found during 4–6 weeks after the start of radiotherapy. The leading dosimetric factors associated with severe RIL included larger PTV, higher dose to heart and body, and higher effective dose to the immune cells (EDIC). Clinical risk factors for RIL mainly comprised lower baseline ALC, higher tumor length and clinical stage, and distal EC. In conclusion, severe RIL might be associated with a lower pCR rate and worse OS and PFS of EC patients. Minimizing the dosimetric risk factors, especially in patients with clinical risk factors, might benefit their outcomes.
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Affiliation(s)
- Dongjun Dai
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; (D.D.); (Q.T.); (G.Y.); (Y.S.)
| | - Qiaoying Tian
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; (D.D.); (Q.T.); (G.Y.); (Y.S.)
| | - Genhua Yu
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; (D.D.); (Q.T.); (G.Y.); (Y.S.)
| | - Yongjie Shui
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; (D.D.); (Q.T.); (G.Y.); (Y.S.)
| | - Hao Jiang
- Anhui Campus of the Second Affiliated Hospital, Zhejiang University School of Medicine, Bengbu 233000, China
- Department of Radiation Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233000, China
- Correspondence: (H.J.); (Q.W.)
| | - Qichun Wei
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; (D.D.); (Q.T.); (G.Y.); (Y.S.)
- Anhui Campus of the Second Affiliated Hospital, Zhejiang University School of Medicine, Bengbu 233000, China
- Correspondence: (H.J.); (Q.W.)
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14
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Damen PJ, Kroese TE, Peters M, Lin SH, Verhoeff JJ, van Rossum PS. In Reply to Chow and Simone. Int J Radiat Oncol Biol Phys 2022; 113:236-237. [DOI: 10.1016/j.ijrobp.2022.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 10/18/2022]
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Wang Q, Qiu Q, Zhang Z, Zhang J, Yang G, Liu C, Li B. Bone marrow dosimetric analysis of lymphopenia in patients with esophageal squamous cell carcinoma treated with chemoradiotherapy. Cancer Med 2021; 10:5847-5858. [PMID: 34363346 PMCID: PMC8419783 DOI: 10.1002/cam4.4131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND We analyzed the relationship among peripheral blood lymphocytes, exposed sternum and vertebra body bone marrow (BM), and overall survival (OS) to find BM dosimetric parameters of lymphopenia during chemoradiotherapy (CRT) for patients with esophageal squamous cell carcinoma (ESCC). METHODS We examined 476 ESCC patients from January 2012 to January 2015, all of whom received concurrent or sequential CRT. Absolute lymphocyte counts (ALC) during radiotherapy (RT) of each patient were collected from the routine workup at the following RT times: pretreatment ALC (ALC0), at 1-5, 6-10, 11-15, 16-20, and 21-25, and more than 26 sessions (called ALC1-6, respectively). The sternum and vertebral body BM were delineated in accordance with uniform standards, and the irradiated volumes were calculated by dose-volume histograms (DVH). The Kaplan-Meier method and Cox proportional hazards regression were used to analyze the survival of the patients. Comparisons of DVH were performed using the Mann-Whitney U test or two-sample t-test where appropriate. RESULTS A relative volume of sternum BM irradiated by more than 20 Gy could clearly affect the peripheral blood lymphocytes. The V20 of sternum BM and V50 of vertebra body BM were related to the OS of the patients, and the level of ALC2 (at 6-10 times of RT) could predict the outcomes of patients. The Cox regression analyses showed that the 218 patients with ALC2 ≥ 0.8 × 109 /L had a significantly higher OS (47.0 months vs. 30.9 months, p < 0.0001) than the 258 patients with ALC2 < 0.8×109 /L. CONCLUSION In patients with ESCC, the relative volume of sternum BM irradiated by more than 20 Gy was associated with lymphocytes. Patients with ALC2 ≥ 0.8 × 109 /L had a significantly higher OS. The V20 of the sternum BM, the V50 of the vertebra body BM, and the level of ALC2 were significant prognostic factors in patients with ESCC.
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Affiliation(s)
- Qian Wang
- Cheeloo College of MedicineShandong UniversityJinanChina
- Department of Radiation OncologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Qingtao Qiu
- Department of Radiation OncologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Zicheng Zhang
- Department of Radiation OncologyShenzhen Traditional Chinese Medicine HospitalThe Fourth Clinical Medical of Guangzhou University of Chinese MedicineShenzhenGuangdongChina
| | - Jing Zhang
- Cheeloo College of MedicineShandong UniversityJinanChina
| | - Guanghui Yang
- Cheeloo College of MedicineShandong UniversityJinanChina
| | - Chengxin Liu
- Cheeloo College of MedicineShandong UniversityJinanChina
- Department of Radiation OncologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Baosheng Li
- Department of Radiation OncologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanChina
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Kroese TE, Jairam J, Ruurda JP, Lin SH, Mohan R, Mook S, Haitjema S, Hoefer I, Haj Mohammad N, Peters M, van Hillegersberg R, van Rossum PSN. Severe lymphopenia acquired during chemoradiotherapy for esophageal cancer: Incidence and external validation of a prediction model. Radiother Oncol 2021; 163:192-198. [PMID: 34453954 DOI: 10.1016/j.radonc.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The incidence of grade 4 lymphopenia in patients treated with chemoradiotherapy (CRT) according to Chemoradiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) regimen is unclear. The primary aim was to determine the incidence of grade 4 lymphopenia during CROSS for esophageal cancer. Secondary aims were to externally validate a prediction model for grade 4 lymphopenia and compare overall survival between patients with and without grade 4 lymphopenia. METHODS Patients who underwent CRT for esophageal cancer between 2014 and 2019 were eligible for inclusion. Patients with a planned radiation dose of 41.4 Gy (CROSS) or 50.4 Gy ("extended-CROSS") and concurrent carboplatin and paclitaxel were included. The primary outcome was the incidence of grade 4 lymphopenia during CRT defined according to Common Terminology Criteria for Adverse Events version 5.0 (i.e. lymphocyte count nadir < 0.2 µL). The secondary outcome measures were the prediction model's external performance (i.e. discrimination and calibration). Overall survival for patients with versus without grade 4 lymphopenia was compared using Kaplan-Meier analysis. RESULTS A total of 219 patients were included of whom 176 patients (80%) underwent CROSS and 43 patients (20%) extended-CROSS. The incidence of grade 4 lymphopenia was 11% in CROSS and 33% in extended-CROSS (p < 0.001). External discrimination yielded a c-statistic of 0.80 (95% confidence interval: 0.70-0.89). External calibration of the model was poor in CROSS but fair in extended-CROSS. Adjusted calibration using intercept correction (adjusted for the lower a-priori risk for grade 4 lymphopenia in CROSS) showed fair agreement between the observed and predicted risk for grade 4 lymphopenia. Median overall survival in patients with versus without grade 4 lymphopenia was 12.7 versus 42.5 months (p = 0.045). CONCLUSION The incidence of grade 4 lymphopenia is significantly higher in esophageal cancer patients receiving extended-CROSS compared to those receiving CROSS. The prediction model demonstrated good external performance in the setting of the CROSS-regimen and could be used to identify patients at high-risk for grade 4 lymphopenia who might be eligible for lymphopenia-mitigating strategies.
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Affiliation(s)
- Tiuri E Kroese
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Jasvir Jairam
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Saskia Haitjema
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Imo Hoefer
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Peter S N van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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The Influence of Severe Radiation-Induced Lymphopenia on Overall Survival in Solid Tumors: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2021; 111:936-948. [PMID: 34329738 DOI: 10.1016/j.ijrobp.2021.07.1695] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/10/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Emerging evidence suggests a detrimental prognostic association between radiation-induced lymphopenia (RIL) and pathologic response, progression-free survival, and overall survival (OS) in patients who undergo radiation therapy for cancer. The aim of this study was to systematically review and meta-analyze the prognostic impact of RIL on OS in patients with solid tumors. METHODS AND MATERIALS PubMed/MEDLINE and Embase were systematically searched. The analysis included intervention and prognostic studies that reported on the prognostic relationship between RIL and survival in patients with solid tumors. An overall pooled adjusted hazard ratio (aHR) was calculated using a random-effects model. Subgroup analyses for different patient-, tumor-, treatment-, and study-related characteristics were performed using meta-regression. RESULTS Pooling of 21 cohorts within 20 eligible studies demonstrated a statistically significant association between OS and grade ≥3 versus grade 0-2 RIL (n = 16; pooled aHR, 1.65; 95% confidence interval [CI], 1.43-1.90) and grade 4 RIL versus grade 0-3 (n = 5; aHR, 1.53; 95% CI, 1.24-1.90). Moderate heterogeneity among aHRs was observed, mostly attributable to overestimated aHRs in 7 studies likely subject to model-overfitting. Subgroup analysis showed significant prognostic impact of grade ≥3 RIL in 4 brain tumor (aHR, 1.63; 95% CI, 1.06-2.51), 4 lung cancer (aHR, 1.52; 95% CI, 1.01-2.29), and 3 pancreatic cancer (aHR, 1.92; 95% CI, 1.10-3.36) cohorts. CONCLUSIONS This meta-analysis demonstrates a significant detrimental prognostic association between grade ≥3 lymphopenia and OS in patients receiving radiation therapy for solid tumors. This finding appears consistent for tumors of the brain, thorax, and upper abdomen and provides an imperative to further elucidate the potential survival benefit of lymphopenia-mitigating strategies.
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Wang JL, Ma R, Kong W, Zhao R, Wang YY. Lymphopenia in Esophageal Cancer: What Have We Learned? Front Oncol 2021; 11:625963. [PMID: 33791213 PMCID: PMC8006429 DOI: 10.3389/fonc.2021.625963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/01/2021] [Indexed: 02/03/2023] Open
Abstract
Lymphopenia caused by disease or treatment is frequent in patients with cancer, which seriously affects the prognosis of these patients. Immune checkpoint inhibitors (ICIs) have garnered attention as one of the most promising strategies for the treatment of esophageal cancer (EC). The status of the immune system, such as, the lymphocyte count, is now considered to be an important biomarker for ICI treatments. Recognition of the significant impact of the lymphocyte count on the survival of patients with EC in the era of immunotherapy has revived interest in understanding the causes of lymphopenia and in developing strategies to predict, prevent and eliminate the adverse effect of lymphopenia. Here, we review what we have learned about lymphopenia in EC, including the prognostic and predictive value of lymphopenia in patients with EC, the predictors of lymphopenia, and the strategies to ameliorate the effect of lymphopenia in patients with EC.
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Affiliation(s)
- Jia-Lin Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Rong Ma
- Graduate School, Ningxia Medical University, Yinchuan, China
| | - Wei Kong
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Ren Zhao
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Yan-Yang Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
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