Normobaric oxygen treatment during radiotherapy for carcinoma of the uterine cervix. Results from a prospective controlled randomized trial

In Vivo Imaging Reveals Significant Tumor Vascular Dysfunction and Increased Tumor Hypoxia-Inducible Factor-1α Expression Induced by High Single-Dose Irradiation in a Pancreatic Tumor Model

PURPOSE

To investigate the effect of high-dose irradiation on pancreatic tumor vasculature and microenvironment using in vivo imaging techniques.

METHODS AND MATERIALS

A BxPC3 pancreatic tumor xenograft was established in a dorsal skinfold window chamber model and a subcutaneous hind leg model. Tumors were irradiated with a single dose of 4, 12, or 24 Gy. The dorsal skinfold window chamber model was used to assess tumor response, vascular function and permeability, platelet and leukocyte adhesion to the vascular endothelium, and tumor hypoxia for up to 14 days after 24-Gy irradiation. The hind leg model was used to monitor tumor size, hypoxia, and vascularity for up to 65 days after 24-Gy irradiation. Tumors were assessed histologically to validate in vivo observations.

RESULTS

In vivo fluorescence imaging revealed temporary vascular dysfunction in tumors irradiated with a single dose of 4 to 24 Gy, but most significantly with a single dose of 24 Gy. Vascular functional recovery was observed by 14 days after irradiation in a dose-dependent manner. Furthermore, irradiation with 24 Gy caused platelet and leukocyte adhesion to the vascular endothelium within hours to days after irradiation. Vascular permeability was significantly higher in irradiated tumors compared with nonirradiated controls 14 days after irradiation. This observation corresponded with increased expression of hypoxia-inducible factor-1α in irradiated tumors. In the hind leg model, irradiation with a single dose of 24 Gy led to tumor growth delay, followed by tumor regrowth.

CONCLUSIONS

Irradiation of the BxPC3 tumors with a single dose of 24 Gy caused transient vascular dysfunction and increased expression of hypoxia-inducible factor-1α. Such biological changes may impact tumor response to high single-dose and hypofractionated irradiation, and further investigations are needed to better understand the clinical outcomes of stereotactic body radiation therapy.

Hypoxic radiosensitization: adored and ignored

Since observations from the beginning of the last century, it has become well established that solid tumors may contain oxygen-deficient hypoxic areas and that cells in such areas may cause tumors to become radioresistant. Identifying hypoxic cells in human tumors has improved by the help of new imaging and physiologic techniques, and a substantial amount of data indicates the presence of hypoxia in many types of human tumors, although with a considerable heterogeneity among individual tumors. Controlled clinical trials during the last 40 years have indicated that this source of radiation resistance can be eliminated or modified by normobaric or hyperbaric oxygen or by the use of nitroimidazoles as hypoxic radiation sensitizers. More recently, attention has been given to hypoxic cytotoxins, a group of drugs that selectively or preferably destroys cells in a hypoxic environment. An updated systematic review identified 10,108 patients in 86 randomized trials designed to modify tumor hypoxia in patients treated with curative attempted primary radiation therapy alone. Overall modification of tumor hypoxia significantly improved the effect of radiotherapy, with an odds ratio of 0.77 (95% CI, 0.71 to 0.86) for the outcome of locoregional control and with an associated significant overall survival benefit (odds ratio = 0.87; 95% CI, 0.80 to 0.95). No significant influence was found on the incidence of distant metastases or on the risk of radiation-related complications. Ample data exist to support a high level of evidence for the benefit of hypoxic modification. However, hypoxic modification still has no impact on general clinical practice.

A critical overview of concurrent chemoradiotherapy in cervical cancer

In February 1999, the National Cancer Institute of the US National Institutes of Health issued a communication stating that concurrent chemoradiotherapy should be considered as standard treatment for cervical cancer. This statement was based on the publication of five randomized prospective trials. On the basis of a critical review of these papers and others that identified different results, questions, doubts, and concerns have arisen about this therapeutic method. We analyzed the quality of the control groups managed with the standard treatment, noting data that may have altered these results, as well as analyzing the quality of chemotherapy, radiotherapy, and treatment compliance. In light of this analysis, we believe that further trials should be carried out with fairly balanced prognostic factors to demonstrate beyond a doubt that concurrent chemoradiotherapy is superior to radiotherapy alone. In developing countries where resources are scarce, this type of tumor is found frequently. Concurrent chemoradiotherapy would involve increased costs and supportive care, taking away resources from other vital areas.

Carbogen breathing after irradiation enhances the effectiveness of tirapazamine in SiHa tumors but not SCCVII tumors in mice

The penetration of anticancer agents into tumor tissue has recently attracted considerable attention. This study examines the effect of carbogen breathing on the antitumor activity of tirapazamine combined with radiation. Our hypothesis is based on the observation that the diffusion of tirapazamine through tissue is dependent on oxygen tension. We postulated that carbogen breathing might enhance the ability of tirapazamine to diffuse to hypoxic cells located distal to functional blood vessels in tumors. We first determined that carbogen breathing caused no significant change in the pharmacokinetics of tirapazamine, suggesting that any effect of carbogen breathing on the activity of tirapazamine is not attributable to modulation of pharmacokinetics. Cell survival in SCCVII and SiHa tumors after 10 Gy X rays alone was similar. However, when tirapazamine was administered 30 min after radiation treatment under air-breathing conditions, cell killing was greater in SCCVII tumors compared to SiHa tumors. Carbogen breathing during the exposure to tirapazamine did not change the cell survival in SCCVII tumors, but it enhanced cell killing in the SiHa tumors. Interestingly, carbogen breathing during radiation treatment produced greater cell killing in the SiHa tumors than in the SCCVII tumors. The vascular architecture and type of hypoxia in the two tumors probably underlie the differences in the responses of the two tumors. These findings suggest that the effectiveness of tirapazamine and other hypoxic cytotoxins may be dependent on tumor type.