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Klement RJ, Sweeney RA. Metabolic factors associated with the prognosis of oligometastatic patients treated with stereotactic body radiotherapy. Cancer Metastasis Rev 2023; 42:927-940. [PMID: 37261610 DOI: 10.1007/s10555-023-10110-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
Over the past two decades, it has been established that cancer patients with oligometastases, i.e., only a few detectable metastases confined to one or a few organs, may benefit from an aggressive local treatment approach such as the application of high-precision stereotactic body radiotherapy (SBRT). Specifically, some studies have indicated that achieving long-term local tumor control of oligometastases is associated with prolonged overall survival. This motivates investigations into which factors may modify the dose-response relationship of SBRT by making metastases more or less radioresistant. One such factor relates to the uptake of the positron emission tomography tracer 2-deoxy-2-[18F]fluoro-D-glucose (FDG) which reflects the extent of tumor cell glycolysis or the Warburg effect, respectively. Here we review the biological mechanisms how the Warburg effect drives tumor cell radioresistance and metastasis and draw connections to clinical studies reporting associations between high FDG uptake and worse clinical outcomes after SBRT for oligometastases. We further review the evidence for distinct metabolic phenotypes of metastases preferentially seeding to specific organs and their possible translation into distinct radioresistance. Finally, evidence that obesity and hyperglycemia also affect outcomes after SBRT will be presented. While delivered dose is the main determinant of a high local tumor control probability, there might be clinical scenarios when metabolic targeting could make the difference between achieving local control or not, for example when doses have to be compromised in order to spare neighboring high-risk organs, or when tumors are expected to be highly therapy-resistant due to heavy pretreatment such as chemotherapy and/or radiotherapy.
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Affiliation(s)
- Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Robert-Koch-Straße 10, 97422, Schweinfurt, Germany.
| | - Reinhart A Sweeney
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Robert-Koch-Straße 10, 97422, Schweinfurt, Germany
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Lazzeroni M, Toma-Dasu I, Ureba A, Schiavo F, Wiedenmann N, Bunea H, Thomann B, Baltas D, Mix M, Stoykow C, Sörensen A, Grosu AL. Quantification of Tumor Oxygenation Based on FMISO PET: Influence of Location and Oxygen Level of the Well-Oxygenated Reference Region. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1232:177-182. [PMID: 31893408 DOI: 10.1007/978-3-030-34461-0_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Tumor hypoxia may play a fundamental role in determining the radiotherapy outcome for several cancer types. Functional imaging with hypoxia specific radiotracers offers a way to visualize and quantify regions of increased radioresistance, which may benefit from dose escalation strategies. Conversion of the uptake in positron emission tomography (PET) images into oxygenation maps offers a way to quantitatively characterize the microenvironment. However, normalization of the uptake with respect to a well-oxygenated reference volume (WOV), which should be properly selected, is necessary when using conversion functions. This study aims at assessing the sensitivity of quantifying tumor oxygenation based on 18F-fluoromisonidazole (FMISO) PET with respect to the choice of the location and the oxygenation level of the WOV in head and neck cancer patients. WOVs varying not only in shape and location but also with respect to the assigned pO2 level were considered. pO2 values other than the standard 60 mmHg were selected according to the specific tissue type included in the volume. For comparison, the volume which would be considered as hypoxic based on a tissue-to-muscle ratio equal to 1.4 was also delineated, as conventionally done in clinical practice. Hypoxia mapping strategies are found highly sensitive to selection of the location of well-oxygenated region, but also on its assigned oxygenation level, which is crucial for hypoxia-guided adaptive dose escalation strategies.
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Affiliation(s)
- M Lazzeroni
- Department of Physics, Stockholm University, Stockholm, Sweden.
| | - I Toma-Dasu
- Department of Physics, Stockholm University, Stockholm, Sweden
| | - A Ureba
- Department of Physics, Stockholm University, Stockholm, Sweden
| | - F Schiavo
- Department of Information Engineering, University of Padova, Padova, Italy
| | - N Wiedenmann
- Department of Radiation Oncology, Medical Center, Medical Faculty Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, Freiburg, Germany
| | - H Bunea
- Department of Radiation Oncology, Medical Center, Medical Faculty Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, Freiburg, Germany
| | - B Thomann
- Department of Radiation Oncology, Medical Center, Medical Faculty Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, Freiburg, Germany
| | - D Baltas
- Department of Radiation Oncology, Medical Center, Medical Faculty Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, Freiburg, Germany
| | - M Mix
- Department of Nuclear Medicine, University Medical Center, Freiburg, Germany
| | - C Stoykow
- Department of Nuclear Medicine, University Medical Center, Freiburg, Germany
| | - A Sörensen
- Department of Nuclear Medicine, University Medical Center, Freiburg, Germany
| | - A L Grosu
- Department of Radiation Oncology, Medical Center, Medical Faculty Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, Freiburg, Germany
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Regula N, Honarvar H, Lubberink M, Jorulf H, Ladjevardi S, Häggman M, Antoni G, Buijs J, Velikyan I, Sörensen J. Carbon Flux as a Measure of Prostate Cancer Aggressiveness: [ 11C]-Acetate PET/CT. Int J Med Sci 2020; 17:214-223. [PMID: 32038105 PMCID: PMC6990881 DOI: 10.7150/ijms.39542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/12/2019] [Indexed: 01/15/2023] Open
Abstract
Purpose: Dynamic [11C]-acetate positron emission tomography (PET) can be used to study tissue perfusion and carbon flux simultaneously. In this study, the feasibility of the quantification of prostate cancer aggressiveness using parametric methods assessing [11C]-acetate kinetics was investigated in prostate cancer subjects. The underlying uptake mechanism correlated with [11C]-acetate influx and efflux measured in real-time in vitro in cell culture. Methods: Twenty-one patients with newly diagnosed low-to-moderate risk prostate cancer underwent magnetic resonance imaging (MRI) and dynamic [11C]-acetate PET/CT examinations of the pelvis. Parametric images of K1 (extraction × perfusion), k2 (oxidative metabolism) and VT (=K1/k2, anabolic metabolism defined as carbon retention) were constructed using a one-tissue compartment model with an arterial input function derived from pelvic arteries. Regions of interest (ROIs) of the largest cancer lesion in each patient and normal prostate tissue were drawn using information from MRI (T2 and DWI images), biopsy results, and post-surgical histopathology of whole prostate sections (n=7). In vitro kinetics of [11C]-acetate were studied on DU145 and PC3 cell lines using LigandTracer® White equipment for the measurement of the radioactivity uptake in real-time at 37°C. Results: Mean prostate specific antigen (PSA) was 8.33±3.92 ng/mL and median Gleason Sum 6 (range 5-7). K1, VT and standardized uptake values (SUVs) were significantly higher in cancerous prostate tissues compared to normal ones for all patients (p<0.001), while k2 was not (p=0.26). PSA values correlated to early SUVs (r=0.50, p=0.02) and K1 (r=0.48, p=0.03). Early and late SUVs correlated to VT (r>0.76, p<0.001) and K1 (r>0.64, p<0.005). In vitro studies demonstrated higher extraction and retention (p<0.01) of [11C]-acetate in the more aggressive PC3 cells. Conclusion: Parametric images could be used to visualize the [11C]-acetate kinetics of the prostate cancer exhibiting elevated extraction associated with the cancer aggressiveness. The influx rate of [11C]-acetate studied in cell culture also showed dependence on the cancer aggressiveness associated with elevated lipogenesis. Dynamic [11C]-acetate/PET demonstrated potential for prostate cancer aggressiveness estimation using parametric-based K1 and VT values.
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Affiliation(s)
- Naresh Regula
- Division of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Hadis Honarvar
- Division of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Mark Lubberink
- Division of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Medical Physics, Uppsala University Hospital, Uppsala, Sweden
| | - Håkan Jorulf
- Division of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Sam Ladjevardi
- Division of Urology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Michael Häggman
- Division of Urology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunnar Antoni
- Division of Molecular Imaging, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jos Buijs
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Irina Velikyan
- Division of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jens Sörensen
- Division of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,PET Centre, Uppsala University Hospital, Uppsala, Sweden
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Mathematical Description of Changes in Tumour Oxygenation from Repeated Functional Imaging. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [PMID: 30178345 DOI: 10.1007/978-3-319-91287-5_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Functional imaging of tumour hypoxia has been suggested as a tool for refining target definition and treatment optimization in radiotherapy. The approach, however, has been slow to be adopted clinically as most of the studies on the topic do not take into account the in-treatment changes of hypoxia. The present study aimed to introduce a function that quantifies the changes of oxygen distributions in repeated PET images taken during treatment. The proposed approach for determining the reoxygenation function was tested for feasibility on patients with head and neck cancer, repeatedly imaged with FMISO PET during radiotherapy. Reoxygenation functions were derived by solving the convolution between functions describing the oxygen distributions of successive images. The method was found to be mathematically feasible. The results indicate that the reoxygenation functions describing the change in oxygenation have distinct shapes prompting the hypothesis that oxygenation changes reflected by them might have predictive power for treatment outcome. Future studies on a larger patient population to search for predictive correlations based on the reoxygenation function are planned.
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Klement RJ. Fasting, Fats, and Physics: Combining Ketogenic and Radiation Therapy against Cancer. Complement Med Res 2017; 25:102-113. [DOI: 10.1159/000484045] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Radiotherapy (RT) is a mainstay in the treatment of solid tumors and works by physicochemical reactions inducing oxidative stress in cells. Because in practice the efficacy of RT is limited by its toxicity to normal tissues, any strategy that selectively increases the radiosensitivity of tumor cells or boosts the radioresistance of normal cells is a valuable adjunct to RT. In this review, I summarize preclinical and clinical data supporting the hypothesis that ketogenic therapy through fasting and/or ketogenic diets can be utilized as such an adjunct in order to improve the outcome after RT, in terms of both higher tumor control and lower normal-tissue complication probability. The first effect relates to the metabolic shift from glycolysis towards mitochondrial metabolism, which selectively increases reactive oxygen species (ROS) production and impairs adenoside triphosphate (ATP) production in tumor cells. The second effect is based on the differential stress resistance phenomenon describing the reprogramming of normal cells, but not tumor cells, from proliferation towards maintenance and stress resistance when glucose and growth factor levels are decreased and ketone body levels are elevated. Underlying both effects are metabolic differences between normal and tumor cells. Ketogenic therapy is a non-toxic and cost-effective complementary treatment option that exploits these differences and deserves further clinical investigation.
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Tesselaar E, Flejmer AM, Farnebo S, Dasu A. Changes in skin microcirculation during radiation therapy for breast cancer. Acta Oncol 2017; 56:1072-1080. [PMID: 28281359 DOI: 10.1080/0284186x.2017.1299220] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The majority of breast cancer patients who receive radiation treatment are affected by acute radiation-induced skin changes. The assessment of these changes is usually done by subjective methods, which complicates the comparison between different treatments or patient groups. This study investigates the feasibility of new robust methods for monitoring skin microcirculation to objectively assess and quantify acute skin reactions during radiation treatment. MATERIAL AND METHODS Laser Doppler flowmetry, laser speckle contrast imaging, and polarized light spectroscopy imaging were used to measure radiation-induced changes in microvascular perfusion and red blood cell concentration (RBC) in the skin of 15 patients undergoing adjuvant radiation therapy for breast cancer. Measurements were made before treatment, once a week during treatment, and directly after the last fraction. RESULTS In the treated breast, perfusion and RBC concentration were increased after 1-5 fractions (2.66-13.3 Gy) compared to baseline. The largest effects were seen in the areola and the medial area. No changes in perfusion and RBC concentration were seen in the untreated breast. In contrast, Radiation Therapy Oncology Group (RTOG) scores were increased only after 2 weeks of treatment, which demonstrates the potential of the proposed methods for early assessment of skin changes. Also, there was a moderate to good correlation between the perfusion (r = 0.52) and RBC concentration (r = 0.59) and the RTOG score given a week later. CONCLUSION We conclude that radiation-induced microvascular changes in the skin can be objectively measured using novel camera-based techniques before visual changes in the skin are apparent. Objective measurement of microvascular changes in the skin may be valuable in the comparison of skin reactions between different radiation treatments and possibly in predicting acute skin effects at an earlier stage.
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Affiliation(s)
- Erik Tesselaar
- Department of Radiation Physics and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Anna M. Flejmer
- Department of Oncology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Simon Farnebo
- Department of Hand and Plastic Surgery and Burns and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Alexandru Dasu
- Department of Radiation Physics and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- The Skandion Clinic, Uppsala, Sweden
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Towards multidimensional radiotherapy: key challenges for treatment individualisation. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:934380. [PMID: 25834635 PMCID: PMC4365339 DOI: 10.1155/2015/934380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 09/03/2014] [Indexed: 12/03/2022]
Abstract
Functional and molecular imaging of tumours have offered the possibility of redefining the target in cancer therapy and individualising the treatment with a multidimensional approach that aims to target the adverse processes known to impact negatively upon treatment result. Following the first theoretical attempts to include imaging information into treatment planning, it became clear that the biological features of interest for targeting exhibit considerable heterogeneity with respect to magnitude, spatial, and temporal distribution, both within one patient and between patients, which require more advanced solutions for the way the treatment is planned and adapted. Combining multiparameter information from imaging with predictive information from biopsies and molecular analyses as well as in treatment monitoring of tumour responsiveness appears to be the key approach to maximise the individualisation of treatment. This review paper aims to discuss some of the key challenges for incorporating into treatment planning and optimisation the radiobiological features of the tumour derived from pretreatment PET imaging of tumour metabolism, proliferation, and hypoxia and combining them with intreatment monitoring of responsiveness and other predictive factors with the ultimate aim of individualising the treatment towards the maximisation of response.
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Klement RJ. Restricting carbohydrates to fight head and neck cancer-is this realistic? Cancer Biol Med 2014; 11:145-61. [PMID: 25364576 PMCID: PMC4197426 DOI: 10.7497/j.issn.2095-3941.2014.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 07/13/2014] [Indexed: 12/14/2022] Open
Abstract
Head and neck cancers (HNCs) are aggressive tumors that typically demonstrate a high glycolytic rate, which results in resistance to cytotoxic therapy and poor prognosis. Due to their location these tumors specifically impair food intake and quality of life, so that prevention of weight loss through nutrition support becomes an important treatment goal. Dietary restriction of carbohydrates (CHOs) and their replacement with fat, mostly in form of a ketogenic diet (KD), have been suggested to accommodate for both the altered tumor cell metabolism and cancer-associated weight loss. In this review, I present three specific rationales for CHO restriction and nutritional ketosis as supportive treatment options for the HNC patient. These are (1) targeting the origin and specific aspects of tumor glycolysis; (2) protecting normal tissue from but sensitizing tumor tissue to radiation- and chemotherapy induced cell kill; (3) supporting body and muscle mass maintenance. While most of these benefits of CHO restriction apply to cancer in general, specific aspects of implementation are discussed in relation to HNC patients. While CHO restriction seems feasible in HNC patients the available evidence indicates that its role may extend beyond fighting malnutrition to fighting HNC itself.
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Affiliation(s)
- Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital, Schweinfurt 97421, Germany
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Modelling tumour oxygenation, reoxygenation and implications on treatment outcome. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2013; 2013:141087. [PMID: 23401721 PMCID: PMC3557613 DOI: 10.1155/2013/141087] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/26/2012] [Indexed: 11/18/2022]
Abstract
Oxygenation is an important component of the tumour microenvironment, having a significant impact on the progression and management of cancer. Theoretical determination of tissue oxygenation through simulations of the oxygen transport process is a powerful tool to characterise the spatial distribution of oxygen on the microscopic scale and its dynamics and to study its impact on the response to radiation. Accurate modelling of tumour oxygenation must take into account important aspects that are specific to tumours, making the quantitative characterisation of oxygenation rather difficult. This paper aims to discuss the important aspects of modelling tumour oxygenation, reoxygenation, and implications for treatment.
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Zhu A, Marcus DM, Shu HKG, Shim H. Application of metabolic PET imaging in radiation oncology. Radiat Res 2012; 177:436-48. [PMID: 22339451 DOI: 10.1667/rr2702.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Positron emission tomography (PET) is a noninvasive imaging technique that provides functional or metabolic assessment of normal tissue or disease conditions and is playing an increasing role in cancer radiotherapy planning. (18)F-Fluorodeoxyglucose PET imaging (FDG-PET) is widely used in the clinic for tumor imaging due to increased glucose metabolism in most types of tumors; its role in radiotherapy management of various cancers is reviewed. In addition, other metabolic PET imaging agents at various stages of preclinical and clinical development are reviewed. These agents include radiolabeled amino acids such as methionine for detecting increased protein synthesis, radiolabeled choline for detecting increased membrane lipid synthesis, and radiolabeled acetate for detecting increased cytoplasmic lipid synthesis. The amino acid analogs choline and acetate are often more specific to tumor cells than FDG, so they may play an important role in differentiating cancers from benign conditions and in the diagnosis of cancers with either low FDG uptake or high background FDG uptake. PET imaging with FDG and other metabolic PET imaging agents is playing an increasing role in complementary radiotherapy planning.
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Affiliation(s)
- Aizhi Zhu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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