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Di Franco M, Zanoni L, Fortunati E, Fanti S, Ambrosini V. Radionuclide Theranostics in Neuroendocrine Neoplasms: An Update. Curr Oncol Rep 2024; 26:538-550. [PMID: 38581469 PMCID: PMC11063107 DOI: 10.1007/s11912-024-01526-5] [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] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW This paper aims to address the latest findings in neuroendocrine tumor (NET) theranostics, focusing on new evidence and future directions of combined diagnosis with positron emission tomography (PET) and treatment with peptide receptor radionuclide therapy (PRRT). RECENT FINDINGS Following NETTER-1 trial, PRRT with [177Lu]Lu-DOTATATE was approved by FDA and EMA and is routinely employed in advanced G1 and G2 SST (somatostatin receptor)-expressing NET. Different approaches have been proposed so far to improve the PRRT therapeutic index, encompassing re-treatment protocols, combinations with other therapies and novel indications. Molecular imaging holds a potential added value in characterizing disease biology and heterogeneity using different radiopharmaceuticals (e.g., SST and FDG) and may provide predictive and prognostic parameters. Response assessment criteria are still an unmet need and new theranostic pairs showed preliminary encouraging results. PRRT for NET has become a paradigm of modern theranostics. PRRT holds a favorable toxicity profile, and it is associated with a prolonged time to progression, reduction of symptoms, and improved patients' quality of life. In light of further optimization, different new strategies have been investigated, along with the development of new radiopharmaceuticals.
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Affiliation(s)
- Martina Di Franco
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
| | - Lucia Zanoni
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Emilia Fortunati
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Valentina Ambrosini
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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2
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Hoogenkamp DS, de Wit-van der Veen LJ, Huizing DMV, Tesselaar MET, van Leeuwaarde RS, Stokkel MPM, Lam MGEH, Braat AJAT. Advances in Radionuclide Therapies for Patients with Neuro-endocrine Tumors. Curr Oncol Rep 2024; 26:551-561. [PMID: 38598035 PMCID: PMC11062977 DOI: 10.1007/s11912-024-01521-w] [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] [Accepted: 03/21/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE OF REVIEW To provide insights into the role of peptide receptor radionuclide therapy (PRRT) in patients with advanced neuroendocrine tumors (NET) and an overview of possible strategies to combine PRRT with locoregional and systemic anticancer treatments. RECENT FINDINGS Research on combining PRRT with other treatments encompasses a wide variety or treatments, both local (transarterial radioembolization) and systemic therapies, chemotherapy (i.e., capecitabine and temozolomide), targeted therapies (i.e., olaparib, everolimus, and sunitinib), and immunotherapies (e.g., nivolumab and pembrolizumab). Furthermore, PRRT shows promising first results as a treatment prior to surgery. There is great demand to enhance the efficacy of PRRT through combination with other anticancer treatments. While research in this area is currently limited, the field is rapidly evolving with numerous ongoing clinical trials aiming to address this need and explore novel therapeutic combinations.
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Affiliation(s)
- Denise S Hoogenkamp
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands
| | - Linda J de Wit-van der Veen
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands
| | - Daphne M V Huizing
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands
| | - Margot E T Tesselaar
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rachel S van Leeuwaarde
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands
- Department of Endocrinology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel P M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands
| | - Marnix G E H Lam
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3584 CX, Utrecht, The Netherlands
| | - Arthur J A T Braat
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands.
- ENETS Center of Excellence NKI-AVL, The Netherlands Cancer Institute/UMC Utrecht, Amsterdam, The Netherlands.
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3584 CX, Utrecht, The Netherlands.
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Prebble AR, Latka B, Burdekin B, Leary D, Harris M, Regan D, Boss MK. Investigation of Gastrointestinal Toxicities Associated with Concurrent Abdominal Radiation Therapy and the Tyrosine Kinase Inhibitor Sunitinib in a Mouse Model. Int J Mol Sci 2024; 25:1838. [PMID: 38339116 PMCID: PMC10855812 DOI: 10.3390/ijms25031838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Tyrosine kinase inhibitors (TKIs) may be combined with radiation therapy (RT) to enhance tumor control; however, increased incidences of gastrointestinal (GI) toxicity have been reported with this combination. We hypothesize that toxicity is due to compromised intestinal healing caused by inhibition of vascular repair and proliferation pathways. This study explores underlying tissue toxicity associated with abdominal RT and concurrent sunitinib in a mouse model. Four groups of CD-1 mice were treated with 12 Gy abdominal RT, oral sunitinib, abdominal RT + sunitinib, or sham treatment. Mice received oral sunitinib or the vehicle via gavage for 14 days. On day 7, mice were irradiated with 12 Gy abdominal RT or sham treated. Mice were euthanized on day 14 and intestinal tract was harvested for semiquantitative histopathologic evaluation and immunohistochemical quantification of proliferation (Ki67) and vascular density (CD31). Non-irradiated groups had stable weights while abdominal irradiation resulted in weight loss, with mice receiving RT + SUN having greater weight loss than mice receiving RT alone. Semiquantitative analysis showed significant increases in inflammation in irradiated groups. The difference in the density of CD31+ cells was significantly increased in RT alone compared to SUN alone. Ki67+ density was not significant. In summary, we identify a lack of angiogenic response in irradiated GI tissues when abdominal RT is combined with a TKI, which may correlate with clinical toxicities seen in canine and human patients receiving combined treatment.
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Affiliation(s)
- Amber R. Prebble
- Veterinary Teaching Hospital, Colorado State University, Fort Collins, CO 80523, USA;
| | - Bailey Latka
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA (B.B.)
| | - Braden Burdekin
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA (B.B.)
| | - Del Leary
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, USA;
| | - Mac Harris
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA; (M.H.); (D.R.)
| | - Daniel Regan
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA; (M.H.); (D.R.)
| | - Mary-Keara Boss
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA (B.B.)
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Aggarwal P, Gunasekaran V, Sood A, Gupta K, Das CK, Mittal BR. Sunitinib in Tandem With 177 Lu-DOTATATE Therapy in Advanced Pancreatic Neuroendocrine Tumor : A New Treatment Approach. Clin Nucl Med 2024; 49:e85-e86. [PMID: 38109041 DOI: 10.1097/rlu.0000000000005018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
ABSTRACT Various systemic treatment options are available for advanced pancreatic neuroendocrine tumors (NETs); however, individual treatment may be suboptimally effective. Sunitinib inhibits multiple kinases and signaling pathways with delay in tumor growth, whereas peptide radioreceptor therapy (PRRT) delivers targeted radiation to the tumors in pancreatic NETs. There is a dearth of literature on the combined or tandem use of these systemic treatment modalities. We present a case of 40-year-old man with advanced pancreatic NET where PRRT or sunitinib as monotherapy had a suboptimal treatment response, but the use of sunitinib in tandem with 177 Lu-PRRT reinforced the response to the treatment.
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Affiliation(s)
| | | | | | - Kushal Gupta
- Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandan Krushna Das
- Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kawata Y, Watanabe K, Tokiya R, Miyaji Y, Shiotani A, Katsui K. Rectal ulcer associated with lenvatinib 15 years after definitive radiotherapy for prostate cancer: A case report. Oncol Lett 2024; 27:6. [PMID: 38028175 PMCID: PMC10665994 DOI: 10.3892/ol.2023.14139] [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: 07/20/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Lenvatinib is a multi-kinase inhibitor that blocks vascular endothelial growth factor, fibroblast growth factor and platelet-derived growth factor receptors. The present study describes a case of rectal ulceration triggered by lenvatinib treatment for hepatocellular carcinoma 15 years after definitive radiotherapy for prostate cancer. A 58-year-old man underwent definitive external beam radiotherapy and high-dose-rate brachytherapy for prostate cancer. A total of 15 years after radiotherapy for prostate cancer, the patient was diagnosed with hepatocellular carcinoma with multiple metastases. Treatment with 12 mg/day lenvatinib was commenced. A total of 4 months after starting lenvatinib therapy, the patient experienced persistent anal pain with a deep ulceration of the anterior wall of the lower rectum. As the pain did not improve, the patient chose to undergo a colostomy, resulting in the resolution of the anorectal pain. To the best of our knowledge, the present case report is the first to report on lenvatinib-induced rectal ulcers after radiotherapy.
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Affiliation(s)
- Yujiro Kawata
- Department of Radiology, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan
| | - Kenta Watanabe
- Department of Radiology, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan
| | - Ryoji Tokiya
- Department of Radiology, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan
| | - Yoshiyuki Miyaji
- Department of Urology, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan
| | - Akiko Shiotani
- Department of Gastroenterology and Hepatology, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan
| | - Kuniaki Katsui
- Department of Radiology, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan
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Makita K, Hamamoto Y, Kanzaki H, Nagasaki K, Takata N, Tsuruoka S, Uwatsu K, Kido T. Factors affecting local control of bone metastases from radioresistant tumors treated with palliative external beam radiotherapy. Discov Oncol 2023; 14:74. [PMID: 37212949 DOI: 10.1007/s12672-023-00651-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/06/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND This study aimed to evaluate the factors that affect the local control (LC) of bone metastases from radioresistant carcinomas (renal cell carcinoma, hepatocellular carcinoma [HCC], and colorectal carcinoma [CRC]) treated with palliative external-beam radiotherapy (EBRT). METHODS AND MATERIALS Between January 2010 and December 2020, 211 bone metastases in 134 patients were treated with EBRT in two hospitals (a cancer center and university hospital). Based on follow-up CT, these cases were reviewed retrospectively to evaluate LC at the EBRT site. RESULTS The median EBRT dose (BED10) was 39.0 Gy (range, 14.4-66.3 Gy). The median follow-up time of the imaging studies was 6 months (range, 1-107 months). The 0.5-year overall survival and LC rates of the EBRT sites were 73% and 73%, respectively. Multivariate analysis revealed that the primary sites (HCC/CRC), low EBRT dose (BED10) (≤ 39.0 Gy), and non-administration of post-EBRT bone modifying agents (BMAs) and/or antineoplastic agents (ATs) were statistically significant factors that negatively affected the LC of EBRT sites. In the absence of BMAs or ATs, the EBRT dose (BED10) escalation from 39.0 Gy improved the LC of EBRT sites. Based on ATs administration, the LC of EBRT sites was significantly affected by tyrosine kinase inhibitors and/or immune checkpoint inhibitors. CONCLUSIONS Dose escalation improves LC in bone metastases from radioresistant carcinomas. Higher EBRT doses are needed to treat patients for whom few effective systemic therapies remain available.
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Affiliation(s)
- Kenji Makita
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan.
- Departments of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama, Ehime, 791-0280, Japan.
| | - Yasushi Hamamoto
- Departments of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama, Ehime, 791-0280, Japan
| | - Hiromitsu Kanzaki
- Departments of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama, Ehime, 791-0280, Japan
| | - Kei Nagasaki
- Departments of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama, Ehime, 791-0280, Japan
| | - Noriko Takata
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Shintaro Tsuruoka
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kotaro Uwatsu
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
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Sunyach MP, Penel N, Montané L, Cassier PA, Largo AC, Sargos P, Blanc E, Pérol D, Blay JY. Sunitinib with concomitant radiation therapy in inoperable sarcomas: Final results from the dose escalation and expansion parts of a multicenter phase I study. Radiother Oncol 2022; 168:95-103. [DOI: 10.1016/j.radonc.2022.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/10/2022] [Accepted: 01/10/2022] [Indexed: 12/25/2022]
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8
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Ehling TJ, Klein MK, Smith L, Prescott D, Haney S, Looper J, LaDue T, Brawner W, Fidel J, Shiomitsu K, Green E, Saba C, Turek M, Farrelly J. A prospective, multi-centre, Veterinary Radiation Therapy Oncology Group study reveals potential efficacy of toceranib phosphate (Palladia) as a primary or adjuvant agent in the treatment of canine nasal carcinoma. Vet Comp Oncol 2021; 20:293-303. [PMID: 34655275 DOI: 10.1111/vco.12776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/04/2021] [Indexed: 01/28/2023]
Abstract
Radiation is the standard of care for dogs with nasal tumours. The addition of another therapy that could improve outcome without increasing toxicity is attractive. Medical therapy that could offer better outcome than maximally tolerated dose chemotherapy when radiation therapy (RT) is not possible or is declined is also attractive. This article reports the findings from a prospective, multi-centre, non-randomized, Veterinary Radiation Therapy Oncology Group clinical trial designed to evaluate whether toceranib phosphate (toceranib) has primary activity and if the addition of toceranib to RT could positively impact outcome. Owner's discretion determined enrolment in toceranib alone or toceranib + RT arm. Historical controls for radiation alone were selected from patients treated with identical RT and imaging protocols. Responses were evaluated with pre-treatment and week-16 CT scans. RT total dose of 42 Gy was completed in 10 fractions. Sixty-three dogs enrolled from 10 study sites. Overall response rates (CR + PR) were significantly improved in the toceranib + RT (79.4%) and RT alone (68.9%) arms over toceranib alone (22%) (p = .011). Clinical benefit rates (CR + PR + SD) were significantly improved in the toceranib + RT arm over the RT alone arm at 97.3% and 79.2% respectively (p = .036). Treatment with toceranib alone, toceranib + RT and RT alone resulted in median survival times of 298, 615 and 368 days respectively, but were not statistically significantly different (p = .0502). Adverse events associated with toceranib administration did not potentiate the RT side effect profile. Toceranib appears to have primary activity against nasal carcinoma.
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Affiliation(s)
- Tara Jean Ehling
- Veterinary Health Center of Wentzville, Department of Veterinary Medicine and Surgery, University of Missouri, Wentzville, Missouri, USA.,Southwest Veterinary Oncology, Tucson, Arizona, USA
| | | | - Lauren Smith
- Southwest Veterinary Oncology, Tucson, Arizona, USA
| | | | - Siobhan Haney
- Hope Veterinary Specialists, Malvern, Pennsylvania, USA
| | - Jayme Looper
- Chicago Veterinary Internal Medicine & Oncology, Chicago, Illinois, USA
| | - Tracey LaDue
- Southeast Veterinary Oncology, Orange Park, Florida, USA
| | - William Brawner
- Department of Clinical Sciences at the College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Janean Fidel
- Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Keijiro Shiomitsu
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Eric Green
- Veterinary Clinical Sciences, Ohio State University, Columbus, Ohio, USA
| | - Corey Saba
- Department of Small Animal Medicine & Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Michelle Turek
- Department of Small Animal Medicine & Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
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9
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Yamazaki T, Young KH. Effects of radiation on tumor vasculature. Mol Carcinog 2021; 61:165-172. [PMID: 34644811 DOI: 10.1002/mc.23360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/08/2022]
Abstract
Radiation has been utilized as a direct cytotoxic tumorcidal modality, however, the effect of radiation on tumor vasculature influences response to anticancer therapies. Although numerous reports have demonstrated vascular changes in irradiated tumors, the findings and implications are extensive and at times contradictory depending on the radiation dose, timing, and models used. In this review, we focus on the radiation-mediated effects on tumor vasculature with respect to doses used, timing postradiation, vasculogenesis, adhesion molecule expression, permeability, and pericyte coverage, including the latest findings.
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Affiliation(s)
- Tomoko Yamazaki
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, USA
| | - Kristina H Young
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, USA.,Radiation Oncology Division, The Oregon Clinic, Portland, Oregon, USA
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Prebble AR, Weishaar KM, Thamm DH, Leary D, LaRue SM, Martin T, Boss MK. Increased incidence of gastrointestinal toxicity in canine cancer patients treated with concurrent abdominal radiation therapy and toceranib phosphate. Vet Comp Oncol 2021; 20:142-153. [PMID: 34310002 DOI: 10.1111/vco.12756] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 07/23/2021] [Indexed: 12/29/2022]
Abstract
Receptor tyrosine kinase inhibitors (TKIs) are used to treat human and canine cancers and may be combined with radiation therapy (RT) to enhance tumor control due their anticancer and antiangiogenic effects; however, recent case reports have emerged describing incidences of gastrointestinal toxicity when antiangiogenic therapies are combined with hypofractionated radiotherapy in human cancer patients. We evaluated the incidence of gastrointestinal (GI) toxicity in dogs receiving concurrent hypofractionated abdominal RT and the TKI toceranib (TOC) compared to those receiving abdominal RT alone, TOC alone, or concurrent non-abdominal RT and TOC. Medical records of canine cancer patients were retrospectively reviewed and identified dogs were included in the following treatment categories: dogs which received RT to a portion of the abdomen and concurrent TOC (n = 19), abdominal RT alone (n-29), TOC alone (n = 20), or non-abdominal RT plus TOC (n = 9). Toxicities were graded using the Veterinary Cooperative Oncology Group - Common Terminology Criteria for Adverse Events criteria and compared to published data on TOC-associated GI toxicity. Patients receiving TOC while undergoing abdominal RT had significantly increased rates of any grade of diarrhea (p = 0.002), hyporexia (p = 0.0045), and vomiting (p = 0.003), as well as severe hyporexia (p = 0.003) when compared across the treatment groups. This retrospective study reveals significantly increased incidences of GI toxicity when abdominal RT is combined with TOC in canine patients. These findings are in-line with the clinical concerns reported for increased normal tissue toxicity in human patients when antiangiogenics are combined with RT.
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Affiliation(s)
- Amber R Prebble
- Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Kristen M Weishaar
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Douglas H Thamm
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Del Leary
- Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Susan M LaRue
- Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Tiffany Martin
- Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Mary-Keara Boss
- Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
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11
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Angiogenesis and immune checkpoint dual blockade in combination with radiotherapy for treatment of solid cancers: opportunities and challenges. Oncogenesis 2021; 10:47. [PMID: 34247198 PMCID: PMC8272720 DOI: 10.1038/s41389-021-00335-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/02/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
Several immune checkpoint blockades (ICBs) capable of overcoming the immunosuppressive roles of the tumor immune microenvironment have been approved by the US Food and Drug Administration as front-line treatments of various tumor types. However, due to the considerable heterogeneity of solid tumor cells, inhibiting one target will only influence a portion of the tumor cells. One way to enhance the tumor-killing efficiency is to develop a multiagent therapeutic strategy targeting different aspects of tumor biology and the microenvironment to provide the maximal clinical benefit for patients with late-stage disease. One such strategy is the administration of anti-PD1, an ICB, in combination with the humanized monoclonal antibody bevacizumab, an anti-angiogenic therapy, to patients with recurrent/metastatic malignancies, including hepatocellular carcinoma, metastatic renal cell carcinoma, non-small cell lung cancer, and uterine cancer. Radiotherapy (RT), a critical component of solid cancer management, has the capacity to prime the immune system for an adaptive antitumor response. Here, we present an overview of the most recent published data in preclinical and clinical studies elucidating that RT could further potentiate the antitumor effects of immune checkpoint and angiogenesis dual blockade. In addition, we explore opportunities of triple combinational treatment, as well as discuss the challenges of validating biomarkers and the management of associated toxicity.
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12
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González A, Alonso-González C, González-González A, Menéndez-Menéndez J, Cos S, Martínez-Campa C. Melatonin as an Adjuvant to Antiangiogenic Cancer Treatments. Cancers (Basel) 2021; 13:3263. [PMID: 34209857 PMCID: PMC8268559 DOI: 10.3390/cancers13133263] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 02/07/2023] Open
Abstract
Melatonin is a hormone with different functions, antitumor actions being one of the most studied. Among its antitumor mechanisms is its ability to inhibit angiogenesis. Melatonin shows antiangiogenic effects in several types of tumors. Combination of melatonin and chemotherapeutic agents have a synergistic effect inhibiting angiogenesis. One of the undesirable effects of chemotherapy is the induction of pro-angiogenic factors, whilst the addition of melatonin is able to overcome these undesirable effects. This protective effect of the pineal hormone against angiogenesis might be one of the mechanisms underlying its anticancer effect, explaining, at least in part, why melatonin administration increases the sensitivity of tumors to the inhibitory effects exerted by ordinary chemotherapeutic agents. Melatonin has the ability to turn cancer totally resistant to chemotherapeutic agents into a more sensitive chemotherapy state. Definitely, melatonin regulates the expression and/or activity of many factors involved in angiogenesis which levels are affected (either positively or negatively) by chemotherapeutic agents. In addition, the pineal hormone has been proposed as a radiosensitizer, increasing the oncostatic effects of radiation on tumor cells. This review serves as a synopsis of the interaction between melatonin and angiogenesis, and we will outline some antiangiogenic mechanisms through which melatonin sensitizes cancer cells to treatments, such as radiotherapy or chemotherapy.
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Affiliation(s)
| | | | | | | | - Samuel Cos
- Department of Physiology and Pharmacology, School of Medicine, University of Cantabria and Instituto de Investigación Valdecilla (IDIVAL), 39011 Santander, Spain; (A.G.); (A.G.-G.); (J.M.-M.); (C.M.-C.)
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13
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Harada H, Shikama N, Wada H, Uchida N, Nozaki M, Hayakawa K, Yamada K, Nagakura H, Ogawa H, Miyazawa K, Katagiri H, Nakamura N. A phase II study of palliative radiotherapy combined with zoledronic acid hydrate for metastatic bone tumour from renal cell carcinoma. Jpn J Clin Oncol 2021; 51:100-105. [PMID: 32869095 DOI: 10.1093/jjco/hyaa158] [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: 05/01/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Palliative radiotherapy is the standard of care for bone metastases. However, skeletal-related events, defined as a pathologic fracture, paraplegia, surgery or radiotherapy for local recurrence, or severe pain in previously irradiated bone with radio-resistant histology type still present high incidence. The primary objective of this study was to determine whether zoledronic acid hydrate and palliative radiotherapy could prevent local skeletal-related events. METHODS Eligible patients with bone metastases from renal cell carcinoma were treated with zoledronic acid hydrate every 3 or 4 weeks and concurrent palliative radiotherapy of 30 Gy in 3 Gy fractions. The criteria for radiotherapy were established by the treating physician, but patients with complicated bone metastases (impending pathological fracture or spinal cord compression) which needed immediate surgery were excluded. The primary endpoint was the local skeletal-related event-free survival rate at 1 year. RESULTS Twenty-seven patients were included in the study. The median age was 65 (range, 50-84) years. Radiotherapy dose was 30 Gy for all patients except 1 whose radiotherapy was terminated due to brain metastasis progression at 18 Gy. Zoledronic acid hydrate was administered in a median of 12 (range, 0-34) times. The median follow-up period was 12 months and 19 months in patients who were still alive. Of 27 patients in the efficacy analysis, the 1-year local skeletal-related event-free rate was 77.6% (80% confidence interval, 66.2-89.0). Common grade 3 toxicities were hypocalcemia (1 [4%]), sGPT level increase (1 [4%]) and sGOT level increase (1 [4%]). There was no grade 4 or 5 toxicity. CONCLUSION Zoledronic acid hydrate administration and palliative radiotherapy were a well-tolerated and promising treatment reducing skeletal-related events for bone metastases from renal cell carcinoma.
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Affiliation(s)
- Hideyuki Harada
- Division of Radiation Therapy, Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hitoshi Wada
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Nobue Uchida
- Department of Radiation Oncology, Tottori University, Tottori, Japan
| | - Miwako Nozaki
- Dokkyo Medical Unversity, Saitama Medical Center, Saitama, Japan
| | - Kazushige Hayakawa
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Kanagawa, Japan.,Department of Radiation Oncology, NHO Disaster Medical Center, Tokyo, Japan
| | - Kazunari Yamada
- Department of Radiation Oncology, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Hisayasu Nagakura
- Department of Radiology, KKR Sapporo Medical Center, Hokkaido, Japan
| | - Hirofumi Ogawa
- Division of Radiation Therapy, Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazunari Miyazawa
- Department of Radiation Oncology, Showa General Hospital, Tokyo, Japan
| | - Hirohisa Katagiri
- Division of Orthopedic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naoki Nakamura
- Department of Radiation Oncology, St. Marianna University School of Medicine, Kanagawa, Japan
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14
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Fife K, Bang A. Combined Radiotherapy and New Systemic Therapies - Have We Moved Beyond Palliation? Clin Oncol (R Coll Radiol) 2020; 32:758-765. [PMID: 32863071 DOI: 10.1016/j.clon.2020.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
The new systemic therapies for cancer are having major impacts on the prognosis of patients with advanced cancers, some achieving long-term survival with targeted therapy or immune checkpoint inhibitors. Interactions of radiotherapy with the new systemic therapies are reviewed. Many agents increase radiosensitivity and particular caution is required combining BRAF inhibitors and radiotherapy because of significant toxicity. Most new systemic therapies can be used safely with palliative doses of radiotherapy, but it is important to be aware of overlapping toxicities depending on the site treated. DNA damage response modulators increase radiosensitivity and may potentially increase radiation toxicity but are at an earlier stage of development. Stereotactic ablative radiotherapy may produce further survival gains in patients responding to targeted therapy and immunotherapy.
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Affiliation(s)
- K Fife
- Oncology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - A Bang
- Division of Radiation Oncology, University of British Columbia/BC Cancer, Victoria, British Columbia, Canada
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15
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Barillari G. The Anti-Angiogenic Effects of Anti-Human Immunodeficiency Virus Drugs. Front Oncol 2020; 10:806. [PMID: 32528888 PMCID: PMC7253758 DOI: 10.3389/fonc.2020.00806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 04/23/2020] [Indexed: 12/17/2022] Open
Abstract
The growth and metastasis of malignant tumors benefit from the formation of blood vessels within the tumor area. There, new vessels originate from angiogenesis (the sprouting of pre-existing neighboring vessels) and/or vasculogenesis (the mobilization of bone marrow-derived endothelial cell precursors which incorporate in tumor vasculature and then differentiate into mature endothelial cells). These events are induced by soluble molecules (the angiogenic factors) and modulated by endothelial cell interactions with the perivascular matrix. Given angiogenesis/vasculogenesis relevance to tumor progression, anti-angiogenic drugs are often employed to buttress surgery, chemotherapy or radiation therapy in the treatment of a wide variety of cancers. Most of the anti-angiogenic drugs have been developed to functionally impair the angiogenic vascular endothelial growth factor: however, this leaves other angiogenic factors unaffected, hence leading to drug resistance and escape. Other anti-angiogenic strategies have exploited classical inhibitors of enzymes remodeling the perivascular matrix. Disappointingly, these inhibitors have been found toxic and/or ineffective in clinical trials, even though they block angiogenesis in pre-clinical models. These findings are stimulating the identification of other anti-angiogenic compounds. In this regard, it is noteworthy that drugs utilized for a long time to counteract human immune deficiency virus (HIV) can directly and effectively hamper molecular pathways leading to blood vessel formation. In this review the mechanisms leading to angiogenesis and vasculogenesis, and their susceptibility to anti-HIV drugs will be discussed.
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Affiliation(s)
- Giovanni Barillari
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
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16
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Robinson-Garcia L, Ferreira da Silva J, Loizou JI. Synthetic Lethal Interactions for Kinase Deficiencies to DNA Damage Chemotherapeutics. Cancer Res 2019; 79:5693-5698. [PMID: 31387919 PMCID: PMC7611143 DOI: 10.1158/0008-5472.can-19-1364] [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: 04/30/2019] [Revised: 06/14/2019] [Accepted: 07/25/2019] [Indexed: 11/16/2022]
Abstract
Kinases are signaling enzymes that regulate diverse cellular processes. As such, they are frequently mutated in cancer and therefore represent important targets for drug discovery. However, until recently, systematic approaches to identify vulnerabilities and resistances of kinases to DNA-damaging chemotherapeutics have not been possible, partially due to the lack of appropriate technologies. With the advent of CRISPR-Cas9, a comprehensive study has investigated the cellular survival of more than 300 kinase-deficient isogenic cell lines to a diverse panel of DNA-damaging agents, enriched for chemotherapeutics. Here, we discuss how this approach has allowed for the rational development of combination therapies that are aimed at using synthetic lethal interactions between kinase deficiencies and DNA-damaging agents that are used as chemotherapeutics.
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Affiliation(s)
- Lydia Robinson-Garcia
- CeMM Research Centre for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Joana Ferreira da Silva
- CeMM Research Centre for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Joanna I Loizou
- CeMM Research Centre for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.
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17
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Wang E, Sorolla A. Sensitizing endometrial cancer to ionizing radiation by multi-tyrosine kinase inhibition. J Gynecol Oncol 2019; 31:e29. [PMID: 31912683 PMCID: PMC7189072 DOI: 10.3802/jgo.2020.31.e29] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/17/2019] [Accepted: 10/16/2019] [Indexed: 02/03/2023] Open
Abstract
Objective Endometrial carcinoma is the most frequent gynecological cancer. About 15% of these cancers are of high risk and radiotherapy still remains the most suitable treatment. In this context, agents able to promote radiosensitization are of great interest. Here, we describe for the first time the radiosensitization ability of sunitinib in endometrial carcinoma. Methods Four endometrial carcinoma cell lines were used for the study. The activation of apoptosis signalling pathways and tyrosine kinase receptors were analysed by Western blot, luciferase assays and Immunoprecipitation. Radiosensitization effects were assessed using clonogenic assays. p65 and phosphatase and tensin homolog (PTEN) were upregulated by lentiviral transduction. Results We discovered that ionizing radiation activates the pro-oncogenic proteins and signalling pathways KIT, protein kinase B (AKT), and nuclear factor kappa B (NF-κB) and these activations were abrogated by sunitinib, resulting in a radiosensitization effect. We found out that AKT pathway is greatly involved in this process as PTEN restoration in the PTEN-deficient cell line RL95-2 is sufficient to inhibit AKT, rendering these cells more susceptible to ionizing radiation and sunitinib-induced radiosensitization. In Ishikawa 3-H-12 cells, radiosensitization effects and inhibition of AKT were achieved by PTEN restoration plus treatment with the phosphoinositide-3-kinase inhibitor LY294002. This suggests that endometrial tumors could have different sensitivity degree to radiotherapy and susceptibility to sunitinib-induced radiosensitization depending on their AKT activation levels. Conclusions Our results provide the rationale of using sunitinib as neoadjuvant treatment prior radiotherapy which could be a starting point for the implementation of sunitinib and radiotherapy in the clinic for the treatment of recalcitrant endometrial cancers.
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Affiliation(s)
- Edina Wang
- Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, WA, Australia
| | - Anabel Sorolla
- Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, WA, Australia.
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18
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Tsao T, Beretov J, Ni J, Bai X, Bucci J, Graham P, Li Y. Cancer stem cells in prostate cancer radioresistance. Cancer Lett 2019; 465:94-104. [DOI: 10.1016/j.canlet.2019.08.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 01/08/2023]
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19
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Combination treatments to enhance peptide receptor radionuclide therapy of neuroendocrine tumours. Eur J Nucl Med Mol Imaging 2019; 47:907-921. [DOI: 10.1007/s00259-019-04499-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/21/2019] [Indexed: 12/11/2022]
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20
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Yi M, Jiao D, Qin S, Chu Q, Wu K, Li A. Synergistic effect of immune checkpoint blockade and anti-angiogenesis in cancer treatment. Mol Cancer 2019; 18:60. [PMID: 30925919 PMCID: PMC6441150 DOI: 10.1186/s12943-019-0974-6] [Citation(s) in RCA: 368] [Impact Index Per Article: 73.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/22/2019] [Indexed: 12/13/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) activates host's anti-tumor immune response by blocking negative regulatory immune signals. A series of clinical trials showed that ICI could effectively induce tumor regression in a subset of advanced cancer patients. In clinical practice, a main concerning for choosing ICI is the low response rate. Even though multiple predictive biomarkers such as PD-L1 expression, mismatch-repair deficiency, and status of tumor infiltrating lymphocytes have been adopted for patient selection, frequent resistance to ICI monotherapy has not been completely resolved. However, some recent studies indicated that ICI resistance could be alleviated by combination therapy with anti-angiogenesis treatment. Actually, anti-angiogenesis therapy not only prunes blood vessel which is essential to cancer growth and metastasis, but also reprograms the tumor immune microenvironment. Preclinical studies demonstrated that the efficacy of combination therapy of ICI and anti-angiogenesis was superior to monotherapy. In mice model, combination therapy could effectively increase the ratio of anti-tumor/pro-tumor immune cell and decrease the expression of multiple immune checkpoints more than PD-1. Based on exciting results from preclinical studies, many clinical trials were deployed to investigate the synergistic effect of the combination therapy and acquired promising outcome. This review summarized the latest understanding of ICI combined anti-angiogenesis therapy and highlighted the advances of relevant clinical trials.
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Affiliation(s)
- Ming Yi
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Shuang Qin
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Qian Chu
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Kongming Wu
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Anping Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
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21
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Goedegebuure RSA, de Klerk LK, Bass AJ, Derks S, Thijssen VLJL. Combining Radiotherapy With Anti-angiogenic Therapy and Immunotherapy; A Therapeutic Triad for Cancer? Front Immunol 2019; 9:3107. [PMID: 30692993 PMCID: PMC6339950 DOI: 10.3389/fimmu.2018.03107] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/17/2018] [Indexed: 12/19/2022] Open
Abstract
Radiotherapy has been used for the treatment of cancer for over a century. Throughout this period, the therapeutic benefit of radiotherapy has continuously progressed due to technical developments and increased insight in the biological mechanisms underlying the cellular responses to irradiation. In order to further improve radiotherapy efficacy, there is a mounting interest in combining radiotherapy with other forms of therapy such as anti-angiogenic therapy or immunotherapy. These strategies provide different opportunities and challenges, especially with regard to dose scheduling and timing. Addressing these issues requires insight in the interaction between the different treatment modalities. In the current review, we describe the basic principles of the effects of radiotherapy on tumor vascularization and tumor immunity and vice versa. We discuss the main strategies to combine these treatment modalities and the hurdles that have to be overcome in order to maximize therapeutic effectivity. Finally, we evaluate the outstanding questions and present future prospects of a therapeutic triad for cancer.
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Affiliation(s)
- Ruben S A Goedegebuure
- Amsterdam UMC, Location VUmc, Medical Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonie K de Klerk
- Amsterdam UMC, Location VUmc, Medical Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Adam J Bass
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States.,Cancer Program, The Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Sarah Derks
- Amsterdam UMC, Location VUmc, Medical Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Victor L J L Thijssen
- Amsterdam UMC, Location VUmc, Medical Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands.,Amsterdam UMC, Location VUmc, Radiation Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands
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22
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Arcangeli S, Jereczek-Fossa BA, Alongi F, Aristei C, Becherini C, Belgioia L, Buglione M, Caravatta L, D'Angelillo RM, Filippi AR, Fiore M, Genovesi D, Greco C, Livi L, Magrini SM, Marvaso G, Mazzola R, Meattini I, Merlotti A, Palumbo I, Pergolizzi S, Ramella S, Ricardi U, Russi E, Trovò M, Sindoni A, Valentini V, Corvò R. Combination of novel systemic agents and radiotherapy for solid tumors - part I: An AIRO (Italian association of radiotherapy and clinical oncology) overview focused on treatment efficacy. Crit Rev Oncol Hematol 2018; 134:87-103. [PMID: 30658886 DOI: 10.1016/j.critrevonc.2018.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 02/07/2023] Open
Abstract
Over the past century, technologic advances have promoted the evolution of radiation therapy into a precise treatment modality allowing for the maximal administration of dose to tumors while sparing normal tissues. In parallel with this technological maturation, the rapid expansion in understanding the basic biology and heterogeneity of cancer has led to the development of several compounds that target specific pathways. Many of them are in advanced steps of clinical development for combination treatments with radiotherapy, and can be incorporated into radiation oncology practice for a personalized approach to maximize the therapeutic gain. This review describes the rationale for combining novel agents with radiation, and provides an overview of the current landscape focused on treatment efficacy.
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Affiliation(s)
- Stefano Arcangeli
- Department of Radiation Oncology, Policlinico S. Gerardo and University of Milan "Bicocca", Milan, Italy.
| | | | - Filippo Alongi
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, and University of Brescia, Brescia, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Perugia General Hospital, Perugia, Italy
| | - Carlotta Becherini
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Liliana Belgioia
- Department of Radiation Oncology, Ospedale Policlinico San Martino and University of Genoa, Genoa, Italy
| | - Michela Buglione
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Luciana Caravatta
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti, Chieti, Italy
| | | | | | - Michele Fiore
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Domenico Genovesi
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Carlo Greco
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Lorenzo Livi
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Stefano Maria Magrini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Giulia Marvaso
- Deparment of Radiation Oncology of IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Rosario Mazzola
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, and University of Brescia, Brescia, Italy
| | - Icro Meattini
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Anna Merlotti
- Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Perugia General Hospital, Perugia, Italy
| | - Stefano Pergolizzi
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy
| | - Sara Ramella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Elvio Russi
- Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy
| | - Marco Trovò
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata of Udine, Udine, Italy
| | - Alessandro Sindoni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Valentini
- Gemelli Advanced Radiation Therapy Center, Fondazione Policlinico Universitario "A. Gemelli", Catholic University of Sacred Heart, Rome, Italy
| | - Renzo Corvò
- Department of Radiation Oncology, Ospedale Policlinico San Martino and University of Genoa, Genoa, Italy
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23
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Guipaud O, Jaillet C, Clément-Colmou K, François A, Supiot S, Milliat F. The importance of the vascular endothelial barrier in the immune-inflammatory response induced by radiotherapy. Br J Radiol 2018; 91:20170762. [PMID: 29630386 DOI: 10.1259/bjr.20170762] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Altered by ionising radiation, the vascular network is considered as a prime target to limit normal tissue damage and improve tumour control in radiotherapy (RT). Irradiation damages and/or activates endothelial cells, which then participate in the recruitment of circulating cells, especially by overexpressing cell adhesion molecules, but also by other as yet unknown mechanisms. Radiation-induced lesions are associated with infiltration of immune-inflammatory cells from the blood and/or the lymph circulation. Damaged cells from the tissues and immune-inflammatory resident cells release factors that attract cells from the circulation, leading to the restoration of tissue balance by fighting against infection, elimination of damaged cells and healing of the injured area. In normal tissues that surround the tumours, the development of an immune-inflammatory reaction in response to radiation-induced tissue injury can turn out to be chronic and deleterious for the organ concerned, potentially leading to fibrosis and/or necrosis of the irradiated area. Similarly, tumours can elicit an immune-inflammation reaction, which can be initialised and amplified by cancer therapy such as radiotherapy, although immune checkpoints often allow many cancers to be protected by inhibiting the T-cell signal. Herein, we have explored the involvement of vascular endothelium in the fate of healthy tissues and tumours undergoing radiotherapy. This review also covers current investigations that take advantage of the radiation-induced response of the vasculature to spare healthy tissue and/or target tumours better.
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Affiliation(s)
- Olivier Guipaud
- 1 Human Health Department, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), PSE-SANTE, SERAMED, LRMed , Fontenay-aux-Roses , France
| | - Cyprien Jaillet
- 1 Human Health Department, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), PSE-SANTE, SERAMED, LRMed , Fontenay-aux-Roses , France
| | - Karen Clément-Colmou
- 2 Département de Radiothérapie, Institut de Cancérologie de l'Ouest , Nantes St-Herblain , France.,3 Oncology and New Concept in Oncology Department, Centre de Recherche en Cancérologie et Immunologie Nantes-Angers (CRCiNA), Unité U1232, Institut de Recherche en Santé de l'Université de Nantes , Nantes , France
| | - Agnès François
- 1 Human Health Department, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), PSE-SANTE, SERAMED, LRMed , Fontenay-aux-Roses , France
| | - Stéphane Supiot
- 2 Département de Radiothérapie, Institut de Cancérologie de l'Ouest , Nantes St-Herblain , France.,3 Oncology and New Concept in Oncology Department, Centre de Recherche en Cancérologie et Immunologie Nantes-Angers (CRCiNA), Unité U1232, Institut de Recherche en Santé de l'Université de Nantes , Nantes , France
| | - Fabien Milliat
- 1 Human Health Department, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), PSE-SANTE, SERAMED, LRMed , Fontenay-aux-Roses , France
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24
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Fiore M, D Apos Angelillo RM, Greco C, Fioroni I, Ippolito E, Santini D, Ramella S. Radiotherapy and Vascular Endothelial Growth Factor Receptor-Tyrosine Kinase Inhibitors in Renal Cancer. Chemotherapy 2018; 63:83-89. [PMID: 29554654 DOI: 10.1159/000488252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 03/08/2018] [Indexed: 12/25/2022]
Abstract
Treatment of metastatic renal cell carcinoma (mRCC) has seen substantial progress over the last decade. A number of targeted therapies have been shown to improve clinical outcome. Vascular endothelial growth factor receptor (VEGFR)-tyrosine kinase inhibitors (TKIs) are an effective option in treating mRCC. RCC is traditionally perceived to be a radioresistant malignancy with a limited role of radiotherapy (RT) in the management of localized disease. While RCC appears to be radioresistant using conventionally fractionated RT, preclinical data suggest increased radiosensitivity when an ablative, hypofractionated schedule is used. RT is a common treatment for metastases; therefore, it is important to understand how best to use the combination of RT with targeted therapies. Preclinical studies have suggested that the combination of anti-angiogenic drugs with RT enhances the therapeutic effect compared with ionizing radiation alone. However, clinical data gave rise to warnings due to an increased incidence of severe gastrointestinal side effects. This article reviews the literature behind the preclinical and clinical data of the combination of RT with VEGFR-TKIs currently approved for RCC (sunitinib, sorafenib, pazopanib, and axitinib), with a focus on dose schedules as well as efficacy and toxicity.
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Affiliation(s)
- Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | | | - Carlo Greco
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Iacopo Fioroni
- Medical Oncology Unit, Campus Bio-Medico University, Rome, Italy
| | - Edy Ippolito
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Daniele Santini
- Medical Oncology Unit, Campus Bio-Medico University, Rome, Italy
| | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
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25
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Arnold KM, Flynn NJ, Raben A, Romak L, Yu Y, Dicker AP, Mourtada F, Sims-Mourtada J. The Impact of Radiation on the Tumor Microenvironment: Effect of Dose and Fractionation Schedules. CANCER GROWTH AND METASTASIS 2018; 11:1179064418761639. [PMID: 29551910 PMCID: PMC5846913 DOI: 10.1177/1179064418761639] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/23/2017] [Indexed: 02/06/2023]
Abstract
In addition to inducing lethal DNA damage in tumor and stromal cells, radiation can alter the interactions of tumor cells with their microenvironment. Recent technological advances in planning and delivery of external beam radiotherapy have allowed delivery of larger doses per fraction (hypofractionation) while minimizing dose to normal tissues with higher precision. The effects of radiation on the tumor microenvironment vary with dose and fractionation schedule. In this review, we summarize the effects of conventional and hypofractionated radiation regimens on the immune system and tumor stroma. We discuss how these interactions may provide therapeutic benefit in combination with targeted therapies. Understanding the differential effects of radiation dose and fractionation can have implications for choice of combination therapies.
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Affiliation(s)
- Kimberly M Arnold
- Center for Translational Cancer Research, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA.,Department of Medical Laboratory Sciences, University of Delaware, Newark, DE, USA
| | - Nicole J Flynn
- Center for Translational Cancer Research, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA.,Department of Biological Sciences, University of Delaware, Newark, DE, USA
| | - Adam Raben
- Department of Radiation Oncology, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA
| | - Lindsay Romak
- Department of Radiation Oncology, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA
| | - Yan Yu
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Firas Mourtada
- Department of Radiation Oncology, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA.,Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jennifer Sims-Mourtada
- Center for Translational Cancer Research, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA.,Department of Medical Laboratory Sciences, University of Delaware, Newark, DE, USA.,Department of Biological Sciences, University of Delaware, Newark, DE, USA
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26
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Hamming LC, Slotman BJ, Verheul HMW, Thijssen VL. The clinical application of angiostatic therapy in combination with radiotherapy: past, present, future. Angiogenesis 2017; 20:217-232. [PMID: 28364160 PMCID: PMC5437175 DOI: 10.1007/s10456-017-9546-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 03/14/2017] [Indexed: 12/14/2022]
Abstract
Although monotherapy with angiostatic drugs is still far from effective, there is abundant evidence that angiostatic therapy can improve the efficacy of conventional treatments like radiotherapy. This has instigated numerous efforts to optimize and clinically implement the combination of angiostatic drugs with radiation treatment. The results from past and present clinical trials that explored this combination therapy indeed show encouraging results. However, current findings also show that the combination has variable efficacy and is associated with increased toxicity. This indicates that combining radiotherapy with angiostatic drugs not only holds opportunities but also provides several challenges. In the current review, we provide an update of the most recent insights from clinical trials that evaluated the combination of angiostatic drugs with radiation treatment. In addition, we discuss the outstanding questions for future studies in order to improve the clinical benefit of combining angiostatic therapy with radiation therapy.
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Affiliation(s)
- Lisanne C Hamming
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Victor L Thijssen
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.
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27
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Zaware N, Kisliuk R, Bastian A, Ihnat MA, Gangjee A. Synthesis and evaluation of 5-(arylthio)-9H-pyrimido[4,5-b]indole-2,4-diamines as receptor tyrosine kinase and thymidylate synthase inhibitors and as antitumor agents. Bioorg Med Chem Lett 2017; 27:1602-1607. [PMID: 28258797 PMCID: PMC5398096 DOI: 10.1016/j.bmcl.2017.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/07/2017] [Accepted: 02/08/2017] [Indexed: 02/05/2023]
Abstract
In an effort to optimize the structural requirements for combined cytostatic and cytotoxic effects in single agents, a series of 5-(arylthio)-9H-pyrimido[4,5-b]indole-2,4-diamines 3-7 were synthesized and evaluated as inhibitors of receptor tyrosine kinases (RTKs) as well as thymidylate synthase (TS). The synthesis of these compounds involved the nucleophilic displacement of the common intermediate 5-bromo/5-chloro-9H-pyrimido[4,5-b]indole-2,4-diamine with appropriate aryl thiols. A novel four step synthetic scheme to the common intermediate was developed which is more efficient relative to the previously reported six-step sequence. Biological evaluation of these compounds indicated dual activity in RTKs and human TS (hTS). In the VEGFR-2 assay, compound 5 was equipotent to the standard compound semaxanib and was better than standard TS inhibitor pemetrexed, in the hTS assay. Compounds 3, 6 and 7 were nanomolar inhibitors of hTS and were several fold better than pemetrexed.
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Affiliation(s)
- Nilesh Zaware
- Division of Medicinal Chemistry, Graduate School of Pharmaceutical Sciences, Duquesne University, 600 Forbes Avenue, Pittsburgh, PA 15282, United States
| | - Roy Kisliuk
- Department of Biochemistry, Tufts University School of Medicine, Boston, MA 02111, United States
| | - Anja Bastian
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, United States
| | - Michael A Ihnat
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, United States
| | - Aleem Gangjee
- Division of Medicinal Chemistry, Graduate School of Pharmaceutical Sciences, Duquesne University, 600 Forbes Avenue, Pittsburgh, PA 15282, United States.
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28
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Kleibeuker EA, Fokas E, Allen PD, Kersemans V, Griffioen AW, Beech J, Im JH, Smart SC, Castricum KC, van den Berg J, Schulkens IA, Hill SA, Harris AL, Slotman BJ, Verheul HM, Muschel RJ, Thijssen VL. Low dose angiostatic treatment counteracts radiotherapy-induced tumor perfusion and enhances the anti-tumor effect. Oncotarget 2016; 7:76613-76627. [PMID: 27780936 PMCID: PMC5363534 DOI: 10.18632/oncotarget.12814] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/13/2016] [Indexed: 12/15/2022] Open
Abstract
The extent of tumor oxygenation is an important factor contributing to the efficacy of radiation therapy (RTx). Interestingly, several preclinical studies have shown benefit of combining RTx with drugs that inhibit tumor blood vessel growth, i.e. angiostatic therapy. Recent findings show that proper scheduling of both treatment modalities allows dose reduction of angiostatic drugs without affecting therapeutic efficacy. We found that whilst low dose sunitinib (20 mg/kg/day) did not affect the growth of xenograft HT29 colon carcinoma tumors in nude mice, the combination with either single dose RTx (1x 5Gy) or fractionated RTx (5x 2Gy/week, up to 3 weeks) substantially hampered tumor growth compared to either RTx treatment alone. To better understand the interaction between RTx and low dose angiostatic therapy, we explored the effects of RTx on tumor angiogenesis and tissue perfusion. DCE-MRI analyses revealed that fractionated RTx resulted in enhanced perfusion after two weeks of treatment. This mainly occurred in the center of the tumor and was accompanied by increased tissue viability and decreased hypoxia. These effects were accompanied by increased expression of the pro-angiogenic growth factors VEGF and PlGF. DCE-MRI and contrast enhanced ultrasonography showed that the increase in perfusion and tissue viability was counteracted by low-dose sunitinib. Overall, these data give insight in the dynamics of tumor perfusion during conventional 2 Gy fractionated RTx and provide a rationale to combine low dose angiostatic drugs with RTx both in the palliative as well as in the curative setting.
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Affiliation(s)
- Esther A. Kleibeuker
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
| | - Emmanouil Fokas
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Philip D. Allen
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Veerle Kersemans
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Arjan W. Griffioen
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
| | - John Beech
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Jaehong H. Im
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Sean C. Smart
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Kitty C. Castricum
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
| | - Jaap van den Berg
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
| | - Iris A. Schulkens
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
| | - Sally A. Hill
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Adrian L. Harris
- Department of Molecular Oncology, University of Oxford, Oxford, UK
| | - Ben J. Slotman
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
| | - Henk M. Verheul
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
| | - Ruth J. Muschel
- Oxford Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK
| | - Victor L. Thijssen
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan, HV Amsterdam, The Netherlands
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29
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Antiangiogenesis and vascular disrupting agents in cancer: circumventing resistance and augmenting their therapeutic utility. Future Med Chem 2016; 8:443-62. [DOI: 10.4155/fmc.16.6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Angiogenesis is a process essential for tumor growth and metastasis. Inhibition of angiogenesis as an anticancer strategy has shown only moderately improved results and is beset with practical limitations, despite theoretical therapeutic advantages. Inevitably resistance develops, through redundancy of signaling pathways and selection for subclonal populations adapted for hypoxic conditions, with more invasive phenotypes. Antiangiogenic-targeted therapies may find improved efficacy in combination therapies; with others in this class, that directly or indirectly target separate pathways or different components of the same pathway, or with a separate class of tumor vasculature-disrupting agents. This review discusses the challenges and strategies for optimization of combination therapies including metronomic administration of drugs and the need for suitable prognostic and surrogate response biomarkers.
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