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Song YC, Chen SY, Zhao XR, Jing H, Fang H, Tang Y, Hu SY, Song YW, Jin J, Liu YP, Qi SN, Sun GY, Zhong QZ, Du XH, Liu J, Li YX, Wang SL. Prognostic value of lymphocytes in patients with breast cancer receiving radiotherapy after breast-conserving surgery: A post hoc analysis of a phase III randomized trial. Radiother Oncol 2024; 199:110390. [PMID: 38897316 DOI: 10.1016/j.radonc.2024.110390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/11/2024] [Accepted: 06/16/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE To evaluate the prognostic value of peripheral lymphocyte count (PLC) in the breast cancer patients after breast-conserving surgery (BCS) with radiotherapy (RT). METHODS AND MATERIALS This post hoc analysis was performed using data of 628 patients from a phase III, randomized controlled trial comparing hypofractionated RT (HFRT) with conventional fractionated RT (CFRT) after BCS. PLCs were obtained before, during, and after RT until the 1-year follow-up. The optimal cut-off PLCs were determined using the maxstat package in R. Survival rates were estimated using the Kaplan-Meier method and compared with the log-rank test. RESULTS A total of 275 (46.1 %) patients developed lymphopenia during RT, among them, 17 (2.8 %) had grade 3 lymphopenia and no one developed grade 4 lymphopenia. With a median follow-up of 110.8 months, patients with pre-RT PLCs of < 1.77 × 109/L had a significantly lower 10-year breast cancer-specific survival (BCSS) rate (P = 0.013) and overall survival (OS) rate (P = 0.026). Patients with a nadir PLC of < 1.35 × 109/L had a significantly poorer 10-year OS rate (P = 0.048). Multivariate analysis showed that a pre-RT PLC of < 1.77 × 109/L was an independent factor influencing BCSS and OS, while the effect of the nadir PLC did not remain significant. Neither PLC nor lymphopenia recovery at post-RT 1, 3, and 6 months and 1 year was associated with survival. CONCLUSIONS Radiation-induced lymphopenia in patients with breast cancer after BCS tends to be mild. The lower pre-RT PLC predicted poorer survival.
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Affiliation(s)
- Yu-Chun Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Si-Ye Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xu-Ran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shang-Ying Hu
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Guang-Yi Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qiu-Zi Zhong
- Department of Radiation Oncology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Xiang-Hui Du
- Department of Radiation Therapy, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, Zhejiang Province, China
| | - Juan Liu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
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Yu KK, Yeo A, Ngan S, Chu J, Chang D, Siva S, Wong A, Kron T, Hardcastle N, Gaudreault M, Chesson T, Williams S, Burns M, Chander S. Partially Ablative Body Radiotherapy (PABR): A novel approach for palliative radiotherapy of locally advanced bulky unresectable sarcomas. Radiother Oncol 2024; 194:110185. [PMID: 38412905 DOI: 10.1016/j.radonc.2024.110185] [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: 11/28/2023] [Revised: 02/03/2024] [Accepted: 02/22/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Locally advanced, bulky, unresectable sarcomas cause significant tumour mass effects, leading to burdensome symptoms. We have developed a novel Partially Ablative Body Radiotherapy (PABR) technique that delivers a high, ablative dose to the tumour core and a low, palliative dose to its periphery aiming to increase overall tumour response without significantly increasing treatment toxicity. AIM This study aims to report the safety and oncologic outcomes of PABR in patients with bulky, unresectable sarcomas. METHODS AND MATERIALS A total of 18 patients with histologically proven sarcoma treated with PABR from January 2020 to October 2023 were retrospectively reviewed. The primary endpoints were symptomatic and structural response rates. Secondary endpoints were overall survival, freedom from local progression, freedom from distant progression, and acute and late toxicity rates. RESULTS All patients had tumours ≥5 cm with a median tumour volume of 985 cc, and the most common symptom was pain. The median age is 72.5 years and 44.5 % were ECOG 2-3. The most common regimen used was 20 Gy in 5 fractions with an intratumoral boost dose of 50 Gy (83.3 %). After a median follow-up of 11 months, 88.9 % of patients exhibited a partial response with a mean absolute tumour volume reduction of 49.5 %. All symptomatic patients experienced symptom improvement. One-year OS, FFLP and FFDP were 61 %, 83.3 % and 34.8 %, respectively. There were no grade 3 or higher toxicities. CONCLUSION PABR for bulky, unresectable sarcomas appears to be safe and may provide good symptomatic response, tumour debulking, and local control. Further study is underway.
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Affiliation(s)
- Kelvin Ken Yu
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Benavides Cancer Institute, University of Santo Tomas Hospital, Manila, Philippines.
| | - Adam Yeo
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Samuel Ngan
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
| | - Julie Chu
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
| | - David Chang
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
| | - Shankar Siva
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Aaron Wong
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Tomas Kron
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria 3010, Australia; Centre for Medical Radiation Physics, University of Wollongong, NSW 2522, Australia
| | - Nicholas Hardcastle
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria 3010, Australia; Centre for Medical Radiation Physics, University of Wollongong, NSW 2522, Australia
| | - Mathieu Gaudreault
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria 3010, Australia; Centre for Medical Radiation Physics, University of Wollongong, NSW 2522, Australia
| | - Therese Chesson
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
| | - Siena Williams
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
| | - Mark Burns
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
| | - Sarat Chander
- Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria 3010, Australia
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Stenger-Weisser A, Unterkirhere O, Glanzmann C, Streller T, Logaritsch P, Studer G. Early and Intermediate Treatment Outcome After Postoperative External Beam Accelerated Partial Breast Irradiation in Patients With Early-Stage Breast Cancer. Pract Radiat Oncol 2024; 14:216-224. [PMID: 37925101 DOI: 10.1016/j.prro.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE To prospectively evaluate early and intermediate outcome after accelerated partial breast irradiation (APBI) in patients early-with stage breast cancer. METHODS AND MATERIALS Inclusion criteria were defined according to the APBI American Society for Radiation Oncology's ASTRO Evidence-Based Consensus Statement. The prescribed dose was 26 to 28 Gy in 5 fractions on 5 consecutive days. Regular follow-up visits with objective and subjective evaluation of treatment tolerance were performed after 0 and 2 weeks, 6 months, and at annual intervals. RESULTS Between February 2017 and January 2020, 175 patients with breast conserving surgery met the inclusion criteria for APBI. Mean age was 65.7 years (range, 46-88). Thirteen percent of patients received a diagnosis with carcinoma in situ, 55%, 35%, and 37% with T1a/b/c, and 10% with T2 stages, respectively. The mean volume of planning target volume (PTV) was 119 cc (range, 45-465), the ratio of mean PTV: whole breast volume ratio was 21% (7%-53%). Mean follow-up was 42 months (median, 45, range, 0-67). Acute toxicity after 2 weeks was low with 69%, 26%, and 5% grade 0, 1, and 2. In addition, 1-, 2-, 3-, 4-, and 5-year follow-up data were available from 146, 134, 107, 73, and 25 patients. Patient-reported cosmetic outcomes were assessed excellent or good in 97.9%, 98.5%, 98.1%, 98.6%, and 100%. Regarding grade 2 toxicities, as by now 3%, 2%, 2%, 0%, and 0% G2 fibrosis, 1%, 1%, 0%, 0%, and 0% G2 atrophy, no G2 skin telangiectasia or breast edema occurred. So far, none of the patients have experienced G3 toxicity or higher. The remaining patients had grade 0 or 1 toxicity only. Five ipsilateral breast recurrences (1 marginally to PTV, 4 out-of-field) and 5 distant recurrences were recorded by March 2023. The 4-year in-breast recurrence rate was 2.5%. Eight patients died, with 2 of them from disease. For all patients, the 4-year overall, cancer specific and disease-free survival rates were 97.1%, 99.4%, and 95.3%, respectively. CONCLUSIONS We showed high early- and intermediate-term treatment tolerance and disease control of APBI using 26 to 28 Gy in five fractions in one week in carefully selected patients with early breast cancer. APBI is highly appreciated by patients and efficient, as an additional advantage for busy centers.
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Affiliation(s)
| | - Olga Unterkirhere
- Radiation Oncology, Cantonal Teaching Hospital Lucerne, Luzern, Switzerland
| | | | - Tino Streller
- Radiation Oncology, Cantonal Teaching Hospital Lucerne, Luzern, Switzerland
| | | | - Gabriela Studer
- Radiation Oncology, Cantonal Teaching Hospital Lucerne, Luzern, Switzerland; Faculty of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
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Zhang Q, Fan S, Xu X, Du S, Zhu G, Jiang C, Xia SA, Li Q, Wang Q, Qian D, Zhang M, Xiao H, Chen G, Zeng Z, He J. Efficacy and Toxicity of Moderately Hypofractionated Radiation Therapy with Helical TomoTherapy Versus Conventional Radiation Therapy in Patients with Unresectable Stage III Non-Small Cell Lung Cancer Receiving Concurrent Chemotherapy: A Multicenter, Randomized Phase 3 Trial. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00450-4. [PMID: 38631536 DOI: 10.1016/j.ijrobp.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 03/08/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE The standard treatment schedule for unresectable stage III non-small cell lung cancer (NSCLC) is chemotherapy with concurrent radiation therapy (60 Gy delivered in 30 fractions), although moderately hypofractionated radiation therapy (Hypo-RT) has also been considered as an alternative strategy. This study aimed to compare the efficacy and toxicity of moderately Hypo-RT with helical TomoTherapy versus conventionally fractionated radiation therapy (Con-RT) in patients with unresectable stage III NSCLC receiving concurrent chemotherapy. METHODS AND MATERIALS In this randomized, multicenter, nonblinded phase 3 clinical trial, eligible patients were randomised at a 1:1 ratio to either the Hypo-RT group (60 Gy in 20 fractions) or Con-RT group (60 Gy in 30 fractions). All patients received 2 cycles of concurrent platinum-based chemotherapy plus 2 cycles of consolidation therapy. The primary endpoint was 3-year overall survival (OS) in the intention-to-treat population. The secondary endpoints were progression-free survival and treatment-related adverse events. RESULTS A total of 146 patients were enrolled from July 27, 2018, to November 1, 2021. The median follow-up was 46 months. The 3-year OS rates in the Hypo-RT and Con-RT groups were 58.4% and 38.4%, respectively (P = .02). The median OS from randomisation was 41 months in the Hypo-RT group and 30 months in the Con-RT group (hazard ratio, 0.61; 95% confidence interval, 0.40-0.94; P = .02). There was no significant difference in the rates of grade ≥2 treatment-related adverse events between the 2 groups. CONCLUSIONS Moderately Hypo-RT using helical TomoTherapy may improve OS in patients with unresectable stage III NSCLC, while maintaining toxicity rates.
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Affiliation(s)
- Qi Zhang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shaonan Fan
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Xu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shisuo Du
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guangying Zhu
- Department of Radiation Oncology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Chaoyang Jiang
- Department of Oncology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Shi-An Xia
- Department of Oncology, Xinhua Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qiwen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qifeng Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Dong Qian
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Ming Zhang
- Department of Radiation Oncology, Yunnan Cancer Hospital & the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Han Xiao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
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Wang J, Cui SP, Zhao Q, Gao Y, Ji Y, Liu Y, Miao JB, Fu YL, Hu B. Preoperative systemic immune-inflammation index-based nomogram for lung carcinoma following microwave ablation -a real world single center study. Front Oncol 2024; 14:1305262. [PMID: 38571504 PMCID: PMC10987766 DOI: 10.3389/fonc.2024.1305262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/23/2024] [Indexed: 04/05/2024] Open
Abstract
Background The preoperative inflammatory condition significantly influences the prognosis of malignancies. We aimed to investigate the potential significance of preoperative inflammatory biomarkers in forecasting the long-term results of lung carcinoma after microwave ablation (MWA). Method This study included patients who received MWA treatment for lung carcinoma from Jan. 2012 to Dec. 2020. We collected demographic, clinical, laboratory, and outcome information. To assess the predictive capacity of inflammatory biomarkers, we utilized the area under the receiver operating characteristic curve (AUC-ROC) and assessed the predictive potential of inflammatory biomarkers in forecasting outcomes through both univariate and multivariate Cox proportional hazard analyses. Results A total of 354 individuals underwent MWA treatment, of which 265 cases were included in this study, whose average age was 69.1 ± 9.7 years. The AUC values for the Systemic Inflammatory Response Index (SIRI) to overall survival (OS) and disease-free survival (DFS) were 0.796 and 0.716, respectively. The Cox proportional hazards model demonstrated a significant independent association between a high SIRI and a decreased overall survival (hazard ratio [HR]=2.583, P<0.001). Furthermore, a high SIRI independently correlated with a lower DFS (HR=2.391, P<0.001). We developed nomograms utilizing various independent factors to forecast the extended prognosis of patients. These nomograms exhibited AUC of 0.900, 0.849, and 0.862 for predicting 1-year, 3-year, and 5-year OS, respectively. Additionally, the AUC values for predicting 1-year, 3-year, and 5-year DFS were 0.851, 0.873, and 0.883, respectively. Conclusion SIRI has shown promise as a valuable long-term prognostic indicator for forecasting the outcomes of lung carcinoma patients following MWA.
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Affiliation(s)
| | | | | | | | | | | | | | - Yi-li Fu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Ma L, Deng L, Peng J, Yu J, Meng X. Chemotherapy-free radiotherapy combined with immune checkpoint inhibitors: a new regimen for locally advanced non-small cell lung cancer? Cancer Biol Med 2024; 20:j.issn.2095-3941.2023.0402. [PMID: 38318930 PMCID: PMC10845940 DOI: 10.20892/j.issn.2095-3941.2023.0402] [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: 11/01/2023] [Accepted: 12/22/2023] [Indexed: 02/07/2024] Open
Abstract
Maintenance immunotherapy after concurrent chemoradiotherapy remains the standard therapeutic approach in patients with unresectable locally advanced non-small cell lung cancer (LA-NSCLC). The efficacy of pembrolizumab without chemotherapy in stage IV NSCLC has incited interest in similar approaches for LA-NSCLC. Several recent investigations involving the synergistic potential of immunotherapy combined with radiotherapy (iRT) have generated encouraging results. This review discusses the existing studies and prospective directions of chemotherapy-free iRT strategies in unresectable LA-NSCLC. Although the initial findings of chemotherapy-free iRT strategies have shown promising efficacy, we must consider the methodologic limitations of current studies and the myriad of challenges that accompany the implementation of chemotherapy-free iRT. These challenges include determining the optimal dose and fractionation, precise target volume delineation, and identification of additional suitable patient cohorts. Furthermore, the feasibility of chemotherapy-free iRT as a novel treatment modality for select patients with LA-NSCLC is contingent upon validation through randomized phase III trials.
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Affiliation(s)
- Lin Ma
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430000, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, China
| | - Liufu Deng
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Jianfeng Peng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, China
| | - Jinming Yu
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430000, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, China
| | - Xiangjiao Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, China
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Kim YH, Choi YD, Ahn SJ, Kim YC, Oh IJ, Nam TK, Jeong JU, Song JY. Blood Lymphocytes as a Prognostic Factor for Stage III Non-Small Cell Lung Cancer with Concurrent Chemoradiation. Chonnam Med J 2024; 60:40-50. [PMID: 38304134 PMCID: PMC10828085 DOI: 10.4068/cmj.2024.60.1.40] [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: 10/25/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024] Open
Abstract
We aimed to identify blood lymphocytes as a prognostic factor for survival in patients with locally advanced stage III non-small cell lung cancer (NSCLC) treated with concurrent chemoradiotherapy (CCRT). This is a secondary study of 196 patients enrolled in the Korean Radiation Oncology Group 0903 phase III clinical trial to evaluate the prognostic significance of circulating blood lymphocyte levels. The median total lymphocyte count (TLC) reduction ratio during CCRT was 0.74 (range: 0.29-0.97). In multivariate analysis, patient age (p=0.014) and gross tumor volume (GTV, p=0.031) were significant factors associated with overall survival, while TLC reduction (p=0.018) and pretreatment neutrophil-to-lymphocyte ratio (NLR; p=0.010) were associated with progression-free survival (PFS). In multivariate logistic regression analysis, pretreatment NLR, GTV, and heart V20 were significantly associated with TLC reduction. Immunohistochemical analysis of programmed death ligand 1 and CD8 expression on T cells was performed on 84 patients. CD8 expression was not significantly associated with the pretreatment lymphocyte count (p=0.673), and PDL1 expression was not significantly associated with OS or PFS. Univariate analysis revealed that high CD8 expression in TILs was associated with favorable OS and was significantly associated with favorable PFS (p=0.032). TLC reduction during CCRT is a significant prognostic factor for PFS, and heart V20 is significantly associated with TLC reduction. Thus, in the era of immunotherapy, constraining the volume of the radiation dose to the whole heart must be prioritized for the better survival outcomes.
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Affiliation(s)
- Yong-Hyub Kim
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Yoo-Duk Choi
- Department of Pathology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Young-Chul Kim
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Jae-Uk Jeong
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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Cortiula F, Hendriks LEL, Wijsman R, Houben R, Steens M, Debakker S, Canters R, Trovò M, Sijtsema NM, Niezink AGH, Unipan M, Urban S, Michelotti A, Dursun S, Bootsma G, Hattu D, Nuyttens JJ, Moretti E, Taasti VT, De Ruysscher D. Proton and photon radiotherapy in stage III NSCLC: Effects on hematological toxicity and adjuvant immune therapy. Radiother Oncol 2024; 190:110019. [PMID: 38000689 DOI: 10.1016/j.radonc.2023.110019] [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: 09/01/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND AND PURPOSE Concurrent chemo-radiotherapy (CCRT) followed by adjuvant durvalumab is standard-of-care for fit patients with unresectable stage III NSCLC. Intensity modulated proton therapy (IMPT) results in different doses to organs than intensity modulated photon therapy (IMRT). We investigated whether IMPT compared to IMRT reduce hematological toxicity and whether it affects durvalumab treatment. MATERIALS AND METHODS Prospectively collected series of consecutive patients with stage III NSCLC receiving CCRT between 06.16 and 12.22 (staged with FDG-PET-CT and brain imaging) were retrospectively analyzed. The primary endpoint was the incidence of lymphopenia grade ≥ 3 in IMPT vs IMRT treated patients. RESULTS 271 patients were enrolled (IMPT: n = 71, IMRT: n = 200) in four centers. All patients received platinum-based chemotherapy. Median age: 66 years, 58 % were male, 36 % had squamous NSCLC. The incidence of lymphopenia grade ≥ 3 during CCRT was 67 % and 47 % in the IMRT and IMPT group, respectively (OR 2.2, 95 % CI: 1.0-4.9, P = 0.03). The incidence of anemia grade ≥ 3 during CCRT was 26 % and 9 % in the IMRT and IMPT group respectively (OR = 4.9, 95 % CI: 1.9-12.6, P = 0.001). IMPT was associated with a lower rate of Performance Status (PS) ≥ 2 at day 21 and 42 after CCRT (13 % vs. 26 %, P = 0.04, and 24 % vs. 39 %, P = 0.02). Patients treated with IMPT had a higher probability of receiving adjuvant durvalumab (74 % vs. 52 %, OR 0.35, 95 % CI: 0.16-0.79, P = 0.01). CONCLUSION IMPT was associated with a lower incidence of severe lymphopenia and anemia, better PS after CCRT and a higher probability of receiving adjuvant durvalumab.
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Affiliation(s)
- Francesco Cortiula
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Medical Oncology, University Hospital of Udine, Udine, Italy.
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Robin Wijsman
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ruud Houben
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Michelle Steens
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Sarah Debakker
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Richard Canters
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marco Trovò
- Department of Radiation Oncology, University Hospital of Udine, Udine, Italy
| | - Nanna M Sijtsema
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anne G H Niezink
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mirko Unipan
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Susanna Urban
- Department of Medical Oncology, University Hospital of Udine, Udine, Italy
| | - Anna Michelotti
- Department of Medical Oncology, University Hospital of Udine, Udine, Italy
| | - Safiye Dursun
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Gerben Bootsma
- Department of Pulmonary Diseases, Zuyderland Medical Centre, the Netherlands
| | - Djoya Hattu
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eugenia Moretti
- Medical Physics Unit, University Hospital of Udine, Udine, Italy
| | - Vicki T Taasti
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
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Yang G, Yoon HI, Lee J, Kim J, Kim H, Cho J, Lee CG, Chang JS, Cho Y, Kim JS, Kim KH. Risk of on-treatment lymphopenia is associated with treatment outcome and efficacy of consolidation immunotherapy in patients with non-small cell lung cancer treated with concurrent chemoradiotherapy. Radiother Oncol 2023; 189:109934. [PMID: 37783291 DOI: 10.1016/j.radonc.2023.109934] [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: 03/30/2023] [Revised: 09/22/2023] [Accepted: 09/23/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND AND PURPOSE The ability of the effective dose to immune cells (EDIC) and the pre-radiotherapy (RT) absolute lymphocyte count (ALC) to predict lymphopenia during RT, treatment outcomes, and efficacy of consolidation immunotherapy in patients with locally advanced non-small cell lung cancer was investigated. METHODS AND MATERIALS Among 517 patients treated with concurrent chemoradiotherapy, EDIC was calculated using the mean doses to the lungs, heart, and total body. The patients were grouped according to high and low EDIC and pre-RT ALC, and the correlations with radiation-induced lymphopenia and survival outcomes were determined. RESULTS Altogether, 195 patients (37.7%) received consolidation immunotherapy. The cutoff values of EDIC and pre-RT ALC for predicting severe lymphopenia were 2.89 Gy and 2.03 × 109 cells/L, respectively. The high-risk group was defined as EDIC ≥ 2.89 Gy and pre-RT ALC < 2.03 × 109 cells/L, while the low-risk group as EDIC < 2.89 Gy and pre-RT ALC ≥ 2.03 × 109 cells/L, and the rest of the patients as the intermediate-risk group. The incidences of severe lymphopenia during RT in the high-, intermediate-, and low-risk groups were 90.1%, 77.1%, and 52.3%, respectively (P < 0.001). The risk groups could independently predict both progression-free (P < 0.001) and overall survival (P < 0.001). The high-risk group showed a higher incidence of locoregional and distant recurrence (P < 0.001). Consolidation immunotherapy showed significant survival benefit in the low- and intermediate-risk groups but not in the high-risk group. CONCLUSIONS The combination of EDIC and pre-RT ALC predicted severe lymphopenia, recurrence, and survival. It may potentially serve as a biomarker for consolidation immunotherapy.
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Affiliation(s)
- Gowoon Yang
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Joongyo Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jihun Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eon-ju-ro, Gangnam-gu, Seoul 06273, Republic of Korea
| | - Hojin Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jaeho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eon-ju-ro, Gangnam-gu, Seoul 06273, Republic of Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Kyung Hwan Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea.
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10
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van Rossum PSN, Juan-Cruz C, Stam B, Rossi MMG, Lin SH, Abravan A, Belderbos JSA, Sonke JJ. Severe radiation-induced lymphopenia during concurrent chemoradiotherapy for stage III non-small cell lung cancer: external validation of two prediction models. Front Oncol 2023; 13:1278723. [PMID: 38023221 PMCID: PMC10665840 DOI: 10.3389/fonc.2023.1278723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Severe radiation-induced lymphopenia (RIL) in patients undergoing chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC) is associated with decreased immunotherapy efficacy and survival. At The Christie and MD Anderson Cancer Center (MDACC), prediction models for lymphopenia were developed in lung and esophageal cancer patients, respectively. The aim of this study was to externally validate both models in patients with stage III NSCLC. Methods Patients who underwent concurrent CRT for stage III NSCLC in 2019-2021 were studied. Outcomes were grade ≥3 and grade 4 lymphopenia during CRT. The Christie model predictors for grade ≥3 lymphopenia included age, baseline lymphocyte count, radiotherapy duration, chemotherapy, mean heart and lung doses, and thoracic vertebrae V20Gy. MDACC predictors for grade 4 lymphopenia were age, baseline lymphocyte count, planning target volume (PTV), and BMI. The external performance of both models was assessed. Results Among 100 patients, 78 patients (78%) developed grade ≥3 lymphopenia, with grade 4 lymphopenia in 17 (17%). For predicting grade ≥3 lymphopenia, the Christie and MDACC models yielded c-statistics of 0.77 and 0.79, respectively. For predicting grade 4 lymphopenia, c-statistics were 0.69 and 0.80, respectively. Calibration for the Christie and MDACC models demonstrated moderate and good agreement, respectively. Conclusion The PTV-based MDACC prediction model for severe RIL demonstrated superior external performance in NSCLC patients compared to the dosimetry-based Christie model. As such, the MDACC model can aid in identifying patients at high risk for severe lymphopenia. However, to optimize radiotherapy planning, further improvement and external validation of dosimetry-based models is desired.
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Affiliation(s)
- Peter S. N. van Rossum
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Department of Radiation Oncology, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
| | - Celia Juan-Cruz
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Barbara Stam
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Maddalena M. G. Rossi
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Azadeh Abravan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - José S. A. Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
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11
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El Houat Y, Massard C, Quillien V, de Crevoisier R, Castelli J. Meta-analysis and Critical Review: Association Between Radio-induced Lymphopenia and Overall Survival in Solid Cancers. Adv Radiat Oncol 2022; 8:101038. [PMID: 36561078 PMCID: PMC9763695 DOI: 10.1016/j.adro.2022.101038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Immune system modulation, with the use of immune checkpoint inhibitors, has drastically changed the field of oncology. Strong preclinical data indicate that radiation therapy (RT) may enhance the response rate to such drugs via in situ vaccination, although these data do not consider immune radiotoxicity. This meta-analysis investigates whether radio-induced lymphopenia (RIL) is associated with overall survival (OS). Methods and Materials A systematic literature search and quantitative analysis were planned, conducted, and reported per the Preferred Reporting Items for Systematic Reviews and Meta-analyses and Quality of Reporting of Meta-analyses checklists. The literature from January 1990 to March 2021 was searched to identify clinical studies with OS data in patients treated with RT and presenting with lymphopenia. A random-effect model was employed for the meta-analysis. Heterogeneity was assessed using the I2 statistic. Publication bias was estimated using a P-curve analysis. Results A total of 56 studies with 13 223 patients and 11 types of cancers were selected. The mean follow-up time was 35.9 months. Over a third of patients had RIL (37.25%). After removing outlying studies (n = 14), the between-study heterogeneity variance was estimated at t2 = 0.018 (P = .01) with an I2 value of 36.0% (95% confidence interval, 6%-56%). The results showed that RIL was significantly associated with worse OS (hazard ratio: 1.70; 95% confidence interval, 1.55-1.86; P < .01; 95% prediction interval, 1.27-2.26). A subgroup analysis was performed based on the type of primary tumor, and a difference between the subgroups was found (P < .01). Based on the P-curve analysis, a significant evidential value was found, and no significant publication bias was identified among the studies. Conclusions RIL is a significant prognostic factor for mortality in virtually all solid cancers. Pooled-effect estimates indicate a significantly reduced risk of death in patients without RIL. Tailoring RT regimens to spare the immune system and updating dosimetric constraints for new organs at risk, such as major blood vessels, organs with rich blood supplies, bones, and all lymph node areas, may improve prognoses.
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12
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Venkatesulu B, Giridhar P, Pujari L, Chou B, Lee JH, Block AM, Upadhyay R, Welsh JS, Harkenrider MM, Krishnan S, Verma V, En Hsieh C, Pradhan S, Small W, Solanki AA. Lymphocyte sparing normal tissue effects in the clinic (LymphoTEC): A systematic review of dose constraint considerations to mitigate radiation-related lymphopenia in the era of immunotherapy. Radiother Oncol 2022; 177:81-94. [PMID: 36334694 DOI: 10.1016/j.radonc.2022.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/07/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Radiation-related lymphopenia has been associated with suboptimal tumor control rates leading to inferior survival outcomes. To date, no standardized dose constraints are available to limit radiation dose to resident and circulating lymphocyte populations. We undertook this systemic review of the literature to provide a synopsis of the dosimetric predictors of radiation-related lymphopenia in solid malignancies. METHODOLOGY A systematic literature review of PubMed (National Institutes of Health), Cochrane Central (Cochrane collaboration), and Google Scholar was conducted with the following keywords: "radiation", "lymphopenia", "cancer", "dosimetric predictors" with an inclusion deadline of May 31, 2022. Studies that met prespecified inclusion criteria were designated either Good, Fair, or Poor Quality based on the Newcastle-Ottawa quality assessment. The dosimetric parameters derived from Good Quality studies were tabulated as LymphoTEC dose constraints. Dosimetric parameters derived from Fair and Poor-quality studies were grouped as optional. RESULTS An initial systematic search of the literature yielded 1,632 articles. After screening, a total of 48 studies met inclusion criteria and were divided into the following categories: central nervous system (CNS, 6), thoracic (11), gastrointestinal (26), gynecologic (2), head and neck, breast, and genitourinary (one each) cancers. Lung mean dose, heart mean dose, brain V25, spleen mean dose, estimated dose to immune cells, and bone marrow V10 were among the strongest predictors for severe lymphopenia related to radiotherapy. CONCLUSION Optimizing the delivery of radiation therapy to limit dose to lymphocyte-rich structures may curb the negative oncologic impact of lymphocyte depletion. The dose constraints described herein may be considered for prospective validation and future use in clinical trials to limit risk of radiation-related lymphopenia and possibly improve cancer-associated outcomes.
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Affiliation(s)
- BhanuPrasad Venkatesulu
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA.
| | | | - Lincoln Pujari
- Department of Radiation Oncology, Tata memorial center, Varanasi, India
| | - Brian Chou
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Jae Han Lee
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Alec M Block
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - James S Welsh
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Matthew M Harkenrider
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Verma
- Department of Radiation Oncology, MD Anderson cancer center, Houston, Texas, USA
| | - Cheng En Hsieh
- Department of Radiation Oncology, Institute for Radiological Research, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taoyuan City, Taiwan; Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston and The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Satyajit Pradhan
- Department of Radiation Oncology, Tata memorial center, Varanasi, India
| | - William Small
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Abhishek A Solanki
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
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13
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Jing W, Xu T, Wu L, Lopez PB, Grassberger C, Ellsworth SG, Mohan R, Hobbs BP, Blumenschein GR, Tu J, Altan M, Lee P, Liao Z, Lin SH. Severe Radiation-Induced Lymphopenia Attenuates the Benefit of Durvalumab After Concurrent Chemoradiotherapy for NSCLC. JTO Clin Res Rep 2022; 3:100391. [PMID: 36089921 PMCID: PMC9449658 DOI: 10.1016/j.jtocrr.2022.100391] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/04/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Durvalumab after concurrent chemoradiation (CCRT) for NSCLC improves survival, but only in a subset of patients. We investigated the effect of severe radiation-induced lymphopenia (sRIL) on survival in these patients. Methods Outcomes after CCRT (2010–2019) or CCRT followed by durvalumab (2018–2019) were reviewed. RIL was defined by absolute lymphocyte count (ALC) nadir in samples collected at end of CCRT; sRIL was defined as nadir ALC less than 0.23 × 109/L (the lowest tertile). Progression-free survival (PFS) and overall survival (OS) were calculated by the Kaplan-Meier method. Cox proportional hazard modeling evaluated associations between clinical variables and survival. Results Of 309 patients, 192 (62%) received CCRT only and 117 (38%) CCRT plus durvalumab. Multivariable logistic regression analysis indicated that sRIL was associated with planning target volume (OR = 1.002, p = 0.001), stage IIIB disease (OR = 2.77, p = 0.04), and baseline ALC (OR = 0.36, p < 0.01). Durvalumab extended median PFS (23.3 versus 14.1 mo, p = 0.003) and OS (not reached versus 30.8 mo, p < 0.01). sRIL predicted poorer PFS and OS in both treatment groups. Among patients with sRIL, durvalumab did not improve survival (median = 24.6 mo versus 18.1 mo CCRT only, p = 0.079). On multivariable analyses, sRIL (OR = 1.81, p < 0.01) independently predicted poor survival. Conclusions Severe RIL compromises survival benefits from durvalumab after CCRT for NSCLC. Measures to mitigate RIL after CCRT may be warranted to enhance the benefit of consolidation durvalumab.
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Affiliation(s)
- Wang Jing
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Oncology, Jinan Central Hospital, Shandong First Medical University, Shandong, People’s Republic of China
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lirong Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Radiation Oncology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Pablo B. Lopez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clemens Grassberger
- Radiation-Drug Treatment Design Lab, Massachusetts General Hospital, Boston, Massachusetts
| | - Susannah G. Ellsworth
- Gastrointestinal Malignancies Service, Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Radhe Mohan
- Department of Population Health, The University of Texas at Austin, Austin, Texas
| | - Brian P. Hobbs
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George R. Blumenschein
- Department of Thoracic Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janet Tu
- Department of Thoracic Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mehmet Altan
- Department of Thoracic Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Percy Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Corresponding author. Address correspondence to: Steven H. Lin, MD, PhD, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030.
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Kang BH, Li X, Son J, Song C, Kang HC, Kim HJ, Wu HG, Lee JH. Prediction and clinical impact of delayed lymphopenia after chemoradiotherapy in locally advanced non-small cell lung cancer. Front Oncol 2022; 12:891221. [PMID: 36059659 PMCID: PMC9437922 DOI: 10.3389/fonc.2022.891221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction The dosimetric factors of radiotherapy have an acute impact on the host immune system during chemoradiotherapy (CRT) in locally advanced non-small cell lung cancer (NSCLC). However, even after CRT, a substantial number of patients remain immunosuppressed with delayed lymphopenia. Therefore, we aimed to evaluate clinical and dose-volumetric predictors of delayed lymphopenia after CRT in locally advanced NSCLC. Materials and methods We retrospectively reviewed 272 patients with locally advanced NSCLC who received definitive CRT from January 2012 to August 2020. Differential blood count data, including serum albumin values, were obtained at baseline, during and at first follow up after CRT. Acute and delayed lymphopenia events were defined as grade III/IV lymphopenia developed during or 4-12 weeks after CRT completion, which accounted for 84% and 10% of cases, respectively. Dose-volume histogram parameters for planned target volume, whole body, heart, lung, great vessels, spleen, esophagus and thoracic vertebral bodies were evaluated. Results Multivariate analysis revealed that patients with delayed lymphopenia were associated with inferior overall survival (HR 2.53, P = 0.001) and progression-free survival (HR 1.98, P = 0.006). However, there was no significant survival difference between groups stratified by acute lymphopenia. On multivariable logistic regression models, lung V5, baseline ALC, during-CRT ALC, and albumin nadir were significant predictors for delayed lymphopenia. Furthermore, the nomogram for delayed lymphopenia based on these variables had good discrimination (area under the curve, 0.905). Conclusions In this study, we investigated the prognostic significance of delayed lymphopenia and identified clinico-dosimetric parameters to predict delayed lymphopenia.
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Affiliation(s)
- Byung-Hee Kang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Xue Li
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jaeman Son
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Changhoon Song
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyun-Cheol Kang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Joo Ho Lee
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
- *Correspondence: Joo Ho Lee,
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Moderately Hypofractionated Proton Beam Therapy for Locally Advanced Non-Small Cell Lung Cancer: A New Way Forward for Dose Escalation? Int J Radiat Oncol Biol Phys 2022; 113:749-751. [PMID: 35772442 DOI: 10.1016/j.ijrobp.2022.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022]
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Borghetti P, Guerini AE, Sangalli C, Piperno G, Franceschini D, La Mattina S, Arcangeli S, Filippi AR. Unmet needs in the management of unresectable stage III non-small cell lung cancer: a review after the 'Radio Talk' webinars. Expert Rev Anticancer Ther 2022; 22:549-559. [PMID: 35450510 DOI: 10.1080/14737140.2022.2069098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Stage III non-small cell lung cancer (NSCLC) is a variable entity, encompassing bulky primary tumors, nodal involvement or both. Multidisciplinary evaluation is essential to discuss multiple treatment options, to outline optimal management and to examine the main debated topics and critical issues not addressed by current trials and guidelines that influence daily clinical practice. AREAS COVERED From March to May 2021, 5 meetings were scheduled in a webinar format titled 'Radio Talk' due to the COVID-19 pandemic; the faculty was composed of 6 radiation oncologists from 6 different Institutions of Italy, all of them were the referring radiation oncologist for lung cancer treatment at their respective departments and were or had been members of AIRO (Italian Association of Radiation Oncology) Thoracic Oncology Study Group. The topics covered included: pulmonary toxicity, cardiac toxicity, radiotherapy dose, fractionation and volumes, unfit/elderly patients, multidisciplinary management. EXPERT OPINION The debate was focused on the unmet needs triggered by case reports, personal experiences and questions; the answers were often not univocal, however, the exchange of opinion and the contribution of different centers confirmed the role of multidisciplinary management and the necessity that the most critical issues should be investigated in clinical trials.
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Affiliation(s)
- Paolo Borghetti
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Andrea Emanuele Guerini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Claudia Sangalli
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gaia Piperno
- Division of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Salvatore La Mattina
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Stefano Arcangeli
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Andrea Riccardo Filippi
- Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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Putora PM, De Ruysscher DK. Is Hypofractionation a Good Idea in Radiotherapy for Locally Advanced NSCLC? J Thorac Oncol 2022; 17:487-488. [DOI: 10.1016/j.jtho.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/27/2022] [Indexed: 11/26/2022]
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Zhao Q, Li T, Du S, He J, Zeng Z. Shortened Radiation Time Promotes Recovery From Radiation-induced Lymphopenia in Early-Stage Non-small Cell Lung Cancer Patients Treated With Stereotactic Body Radiation Therapy. Technol Cancer Res Treat 2022; 21:15330338221112287. [PMID: 35816375 PMCID: PMC9297706 DOI: 10.1177/15330338221112287] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: To evaluate the potential impact of radiation time on
radiation-induced lymphopenia (RIL) and subsequently recovery after stereotactic
body radiation therapy (SBRT) and to examine the associations between radiation
time and with patient outcomes in early-stage non-small cell lung cancer
(NSCLC). Methods: Clinical and laboratory records of subjects
consisted of 115 patients who had received SBRT for early-stage NSCLC. Clinical
and laboratory records were retrospective reviewed to assess the changes in
total lymphocyte counts (TLCs) following SBRT. Associations of TLCs kinetics
with the clinical and treatment features, and outcomes were analyzed.
Results: Most patients (100/115, 86.96%) experienced
significantly decreased median TLCs following SBRT (1700 vs 1100 cells/µL;
P < .001), and 52 patients (45.21%) met the criteria for
lymphopenia. Six months after SBRT, 44 patients (38.26%) had recovered. A
negative correlation between TLCs reduction and radiation time was observed
(r = −0.381, P < .001). According to
the receiver-operating characteristic curve analysis, the optimal cut-off value
for radiation time to was 3950 s to predict lymphocyte count recovery (LR)
following RIL was 3950 s (P < .001). Multivariate analyses
demonstrated that radiation time was significantly associated with LR (odds
ratio [OR], 0.113; 95% confidence interval [CI], 0.029-0.432;
P = .001) but not TLCs reduction (P = .575).
LR within 6 months after SBRT was associated with improved progression-free
survival in patients without non-lymphopenia (P = .034), but
had little effect in patients with lymphopenia (P = .405).
Conclusion: A longer radiation time was associated with a lower
rate of LR within 6 months after SBRT in patients with early-stage NSCLC. Given
the association of severe and persistent RIL with survival in NSCLC, further
study of the effect of radiation time on immune status is warranted.
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Affiliation(s)
- Qianqian Zhao
- Department of Radiation Oncology, 92323Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tingting Li
- Department of Radiation Oncology, 92323Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shisuo Du
- Department of Radiation Oncology, 92323Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian He
- Department of Radiation Oncology, 92323Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, 92323Zhongshan Hospital, Fudan University, Shanghai, China
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Xiang X, Li N, Ding Z, Dai Z, Jin J. Peripheral Lymphocyte Counts and Lymphocyte-Related Inflammation Indicators During Radiotherapy for Pelvic Malignancies: Temporal Characterization and Dosimetric Predictors. Technol Cancer Res Treat 2022; 21:15330338221116494. [PMID: 36114641 PMCID: PMC9486273 DOI: 10.1177/15330338221116494] [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] [Indexed: 11/24/2022] Open
Abstract
Purpose: To identify the dosimetric predictors of lymphocytopenia
and retrospectively analyze the changing trend of peripheral lymphocyte counts
and lymphocyte-related inflammatory indicators in patients with simple pelvic
radiotherapy. Methods and Materials: We retrospectively reviewed
the clinical data of 188 patients with pelvic malignancies undergoing pelvic
radiotherapy. The absolute count of neutrophils, lymphocytes, monocytes, and
platelets at each time point was collected, and lymphocyte-related inflammation
indicators were obtained, including neutrophil-to-lymphocyte ratio (NLR),
lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and the
systemic immune-inflammation index (SII). The total pelvic bone (TPB) and the
body within the 5 Gy coverage were retrospectively delineated for each patient.
Dose-volume histograms corresponding to the delivered volumetric arc therapy
plan were used to assess the dose volumes received by the TPB and body. A
paired-samples t-test or Wilcoxon signed-rank test for matched
pairs was applied for pairwise comparisons. We also established a stepwise
multiple linear regression model for the peripheral lymphocyte count (PLC) value
at the end of radiotherapy. Results: The PLC and lymphocyte-related
inflammatory indicators changed significantly after the start of radiotherapy
and persisted for 3-6 months after radiotherapy. The nadirs of PLC occurred at
RT-End, and the PLC was still significantly lower than the baseline value at
RT-3 months and RT-6 months. NLR, PLR, and SII at RT-End are about 3.5 times the
value at RT-Baseline, while LMR is one-fourth of the basal value. In a further
multiple stepwise linear regression analysis, the basal PLC (β = 0.156,
p ≤ .001), gender (β = 0.096, p = .005),
and TPB-V5 (β = −0.016, p ≤ .001) turned out to be the
predictor of the absolute value of lymphocytes at the end of radiotherapy.
Conclusions: The impact of pelvic radiotherapy on PLC and
lymphocyte-related inflammatory indicators is considerable and long-lasting.
Minimizing pelvic bone radiation exposure dose (5 Gy) may help to avoid severe
cases of lymphocytopenia.
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Affiliation(s)
- Xiaoyong Xiang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhen Ding
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhitao Dai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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20
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Outcomes of Image-Guided Moderately Hypofractionated Radiotherapy for Stage III Non-Small-Cell Lung Cancer. JOURNAL OF ONCOLOGY 2021; 2021:2721261. [PMID: 34887921 PMCID: PMC8651380 DOI: 10.1155/2021/2721261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/07/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022]
Abstract
Objective To evaluate the efficacy and toxicity of hypofractionated radiotherapy (hypo-RT) for stage III non-small-cell lung cancer (NSCLC) in the Chinese population. Methods Eighty-six stage III NSCLC patients who received hypo-RT (60 Gy/20 fractions, BED = 78.00 Gy: 73 patients; 62.5 Gy/25 fractions, BED = 78.13 Gy: 13 patients) were recruited. Fifty-seven patients who received conventional radiotherapy (60 Gy/30 fractions, BED = 72.00 Gy) during the same period were enrolled as the control group. All hypo-RT treatments were conducted using image-guided technology. The efficacy and toxicity of the treatment were compared between the two groups. Results The median duration of follow-up was 23.0 months (range: 4.0–82.0 months). Univariate and multivariate analyses of all 143 stage III NSCLC patients revealed that hypo-RT was an independent factor for progression-free survival (PFS) and overall survival (OS). The median PFS and OS of hypo-RT were significantly higher than in the conventional RT group (PFS: 14.30, 11.00 months, p=0.035; OS: 43.30, 31.50 months, p=0.045). The incidence rates of symptomatic radiation pneumonitis and radiation esophagitis (≥grade 2) were 17.77% and 27.91%, respectively, in the hypo-RT group. Compared to the conventional radiation therapy group (22.81% and 19.30%, respectively), no significant differences were found between the two common side effects (p=0.662 and p=0.241, respectively). Conclusion For Chinese stage III NSCLC patients, image-guided hypo-RT offers favorable prognosis, and the treatment toxicity was totally acceptable. This radiation modality deserves further prospective clinical trials.
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21
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Biswas T, Gawdi R, Jindal C, Iyer S, Kang KH, Bajor D, Machtay M, Choi YM, Efird JT. Pretreatment neutrophil-to-lymphocyte ratio as an important prognostic marker in stage III locally advanced non-small cell lung cancer: confirmatory results from the PROCLAIM phase III clinical trial. J Thorac Dis 2021; 13:5617-5626. [PMID: 34795912 PMCID: PMC8575807 DOI: 10.21037/jtd-21-1018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022]
Abstract
Background Neutrophil-to-lymphocyte ratio (NLR) is an important pretreatment marker of systemic inflammation and tumor aggressiveness. Increased levels of this ratio have been associated with reduced survival in several observational studies of lung cancer. However, supporting analyses from large clinical trial data are lacking. Methods To validate the prognostic role of NLR, the current study evaluated data from a randomized phase III study (PROCLAIM; clinicaltrial.gov ID: NCT00686959) of patients with stage IIIA/B, unresectable, non-squamous, non-small cell lung cancer (NSCLC), originally comparing combination pemetrexed-cisplatin chemoradiotherapy with etoposide-cisplatin chemoradiotherapy. Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for survival were estimated using a Cox proportional hazards model. Models were adjusted for age, race, sex, stage, treatment, and body mass index (BMI). Patients were followed for a median of 24 months. Results Increased NLR levels at baseline were associated with reduced overall (PTrend <0.0001) and progression-free survival (PTrend <0.005). A similar but decreasing linear trend was not observed for lymphocytes count alone. Conclusions These findings provide substantiating evidence that NLR, which is routinely available from standard blood testing of patients diagnosed with NSCLC, is an important inflammation-based prognostic marker for survival among patients with locally advanced disease undergoing chemoradiation. Future research will benefit by assessing the prognostic potential of NLR in the context of genetic mutations and molecular markers.
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Affiliation(s)
- Tithi Biswas
- Department of Radiation Oncology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Rohin Gawdi
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Sharanya Iyer
- Department of Radiation Oncology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Kylie H Kang
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, MO, USA
| | - David Bajor
- Medical Oncology, Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Mitchell Machtay
- Department of Radiation Oncology, Penn State University, Hershey, PA, USA
| | | | - Jimmy T Efird
- Cooperative Studies Program Epidemiology Center, Health Services Research and Development, DVAHCS, Durham, NC, USA
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22
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The Influence of Severe Radiation-Induced Lymphopenia on Overall Survival in Solid Tumors: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2021; 111:936-948. [PMID: 34329738 DOI: 10.1016/j.ijrobp.2021.07.1695] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/10/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Emerging evidence suggests a detrimental prognostic association between radiation-induced lymphopenia (RIL) and pathologic response, progression-free survival, and overall survival (OS) in patients who undergo radiation therapy for cancer. The aim of this study was to systematically review and meta-analyze the prognostic impact of RIL on OS in patients with solid tumors. METHODS AND MATERIALS PubMed/MEDLINE and Embase were systematically searched. The analysis included intervention and prognostic studies that reported on the prognostic relationship between RIL and survival in patients with solid tumors. An overall pooled adjusted hazard ratio (aHR) was calculated using a random-effects model. Subgroup analyses for different patient-, tumor-, treatment-, and study-related characteristics were performed using meta-regression. RESULTS Pooling of 21 cohorts within 20 eligible studies demonstrated a statistically significant association between OS and grade ≥3 versus grade 0-2 RIL (n = 16; pooled aHR, 1.65; 95% confidence interval [CI], 1.43-1.90) and grade 4 RIL versus grade 0-3 (n = 5; aHR, 1.53; 95% CI, 1.24-1.90). Moderate heterogeneity among aHRs was observed, mostly attributable to overestimated aHRs in 7 studies likely subject to model-overfitting. Subgroup analysis showed significant prognostic impact of grade ≥3 RIL in 4 brain tumor (aHR, 1.63; 95% CI, 1.06-2.51), 4 lung cancer (aHR, 1.52; 95% CI, 1.01-2.29), and 3 pancreatic cancer (aHR, 1.92; 95% CI, 1.10-3.36) cohorts. CONCLUSIONS This meta-analysis demonstrates a significant detrimental prognostic association between grade ≥3 lymphopenia and OS in patients receiving radiation therapy for solid tumors. This finding appears consistent for tumors of the brain, thorax, and upper abdomen and provides an imperative to further elucidate the potential survival benefit of lymphopenia-mitigating strategies.
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23
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Khalifa J, Mazieres J, Gomez-Roca C, Ayyoub M, Moyal ECJ. Radiotherapy in the Era of Immunotherapy With a Focus on Non-Small-Cell Lung Cancer: Time to Revisit Ancient Dogmas? Front Oncol 2021; 11:662236. [PMID: 33968769 PMCID: PMC8097090 DOI: 10.3389/fonc.2021.662236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/23/2021] [Indexed: 12/15/2022] Open
Abstract
Radiation-induced immune effects have been extensively deciphered over the last few years, leading to the concept of the dual immune effect of radiotherapy with both immunostimulatory and immunosuppressive effects. This explains why radiotherapy alone is not able to drive a strong anti-tumor immune response in most cases, hence underlining the rationale for combining both radiotherapy and immunotherapy. This association has generated considerable interest and hundreds of trials are currently ongoing to assess such an association in oncology. However, while some trials have provided unprecedented results or shown much promise, many hopes have been dashed. Questions remain, therefore, as to how to optimize the combination of these treatment modalities. This narrative review aims at revisiting the old, well-established concepts of radiotherapy relating to dose, fractionation, target volumes and organs at risk in the era of immunotherapy. We then propose potential innovative approaches to be further assessed when considering a radio-immunotherapy association, especially in the field of non-small-cell lung cancer (NSCLC). We finally propose a framework to optimize the association, with pragmatic approaches depending on the stage of the disease.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
| | - Julien Mazieres
- Department of Pulmonology, Centre Hospitalo-Universitaire Larrey, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Carlos Gomez-Roca
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Department of Medical Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Maha Ayyoub
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Elizabeth Cohen-Jonathan Moyal
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
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24
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Prognosis of severe lymphopenia after postoperative radiotherapy in non-small cell lung cancer: Results of a long-term follow up study. Clin Transl Radiat Oncol 2021; 28:54-61. [PMID: 33778173 PMCID: PMC7985216 DOI: 10.1016/j.ctro.2021.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/19/2021] [Accepted: 02/27/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose To investigate the incidence and prognosis of severe radiation-induced lymphopenia (sRIL) after postoperative radiotherapy (PORT) for resected NSCLC. Patients and methods Between 1998 and 2017, 170 patients treated with PORT for NSCLC were retrospectively reviewed. Lymphopenia was divided into tertiles with severe lymphopenia defined as absolute lymphocyte counts (ALC) < 0.37 × 103/ul. Results sRIL was observed in 32.3% of patients. Multivariable logistic regression analysis indicated sRIL was associated with planning target volume radiation fraction numbers (OR 1.09, p = 0.005) and total lung mean dose (OR 1.12, p = 0.006). With a median follow-up time of 12.2 years, the median progression-free survival and overall survival were 14.8 months and 28.4 months respectively in patients with sRIL, vs. 21.7 months (p = 0.008) and 48.3 months (p = 0.01) respectively in patients without sRIL. Multivariable analyses indicated sRIL significantly decreased OS (HR 1.95, p < 0.01). Since PORT for stage I-II NSCLC was done largely for positive margins, which may confound the contribution of severe RIL, we analyzed stage III separately and found that sRIL also significantly decreased OS (HR 1.88, p = 0.004) in multivariable analysis. Conclusion For this long-term outcome study, severe RIL correlated with total lung mean dose and radiation fractionation numbers, and was a strong prognostic factor for poor survival in PORT patients, particularly in patients with stage III NSCLC, highlighting the importance of an intact immune system for post-radiation immunologic disease surveillance.
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25
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Friedrich T, Henthorn N, Durante M. Modeling Radioimmune Response-Current Status and Perspectives. Front Oncol 2021; 11:647272. [PMID: 33796470 PMCID: PMC8008061 DOI: 10.3389/fonc.2021.647272] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/25/2021] [Indexed: 12/13/2022] Open
Abstract
The combination of immune therapy with radiation offers an exciting and promising treatment modality in cancer therapy. It has been hypothesized that radiation induces damage signals within the tumor, making it more detectable for the immune system. In combination with inhibiting immune checkpoints an effective anti-tumor immune response may be established. This inversion from tumor immune evasion raises numerous questions to be solved to support an effective clinical implementation: These include the optimum immune drug and radiation dose time courses, the amount of damage and associated doses required to stimulate an immune response, and the impact of lymphocyte status and dynamics. Biophysical modeling can offer unique insights, providing quantitative information addressing these factors and highlighting mechanisms of action. In this work we review the existing modeling approaches of combined ‘radioimmune’ response, as well as associated fields of study. We propose modeling attempts that appear relevant for an effective and predictive model. We emphasize the importance of the time course of drug and dose delivery in view to the time course of the triggered biological processes. Special attention is also paid to the dose distribution to circulating blood lymphocytes and the effect this has on immune competence.
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Affiliation(s)
- Thomas Friedrich
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany
| | - Nicholas Henthorn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Marco Durante
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany.,Institute for Solid State Physics, Technical University Darmstadt, Darmstadt, Germany
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26
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Upadhyay R, Venkatesulu BP, Giridhar P, Kim BK, Sharma A, Elghazawy H, Dhanireddy B, Elumalai T, Mallick S, Harkenrider M. Risk and impact of radiation related lymphopenia in lung cancer: A systematic review and meta-analysis. Radiother Oncol 2021; 157:225-233. [PMID: 33577865 DOI: 10.1016/j.radonc.2021.01.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/17/2021] [Accepted: 01/24/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Despite the modern advances in treatment techniques, the survival of locally advanced lung cancer patients continues to remain poor. Circulating lymphocytes have an important role to play in local immune response to RT as well as immune checkpoint inhibitors, and radiation related lymphopenia has been associated with inferior survival in various tumors. METHODS We undertook this systematic review and meta-analysis to evaluate the literature on risk and impact of lymphopenia in thoracic tumors. A systematic methodology search of the PubMed, Embase and Cochrane library was performed and eligible studies selected based on pre-defined inclusion and exclusion criteria. Review Manager Version 5.4.1 was used for the meta-analysis. RESULTS Fourteen studies were included in the final systematic review and 10 in the quantitative analysis. Overall mean incidence of severe lymphopenia (absolute lymphocyte count < 500) was 64.24%. The patients with severe lymphopenia were at increased risk of death with a pooled HR of 1.59 (95% CI: 1.40, 1.81, I2 = 17%, P < 0.001) and progression with a pooled HR of 2.1 (95% CI: 1.57, 2.81, I2 = 59%, P < 0.001) compared to patients with no severe lymphopenia. Dosimetric parameters including gross tumor volume, lung V5 and heart V5 were predictive of lymphopenia, while advanced age, lower baseline lymphocyte counts, higher stage and large tumor size were other risk factors. Models predicting estimated radiation dose to lymphocytes were a good surrogate for treatment outcomes. CONCLUSION Radiation related lymphopenia is associated with increased hazard of progression and death in lung cancer. Minimizing the lung and heart dose, especially in patients with concurrent other risk factors can reduce lymphopenia and potentially improve treatment outcomes in these patients.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States.
| | | | - Prashanth Giridhar
- Department of Radiation Oncology, National Cancer Institute, New Delhi, India
| | - B K Kim
- Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston and The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Amrish Sharma
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Hagar Elghazawy
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Thiraviyam Elumalai
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Supriya Mallick
- Department of Radiation Oncology, National Cancer Institute, New Delhi, India
| | - Matthew Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Maywood, United States
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27
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Koukourakis MI, Giatromanolaki A. Lymphopenia and intratumoral lymphocytic balance in the era of cancer immuno-radiotherapy. Crit Rev Oncol Hematol 2021; 159:103226. [PMID: 33482348 DOI: 10.1016/j.critrevonc.2021.103226] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/15/2020] [Accepted: 01/16/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The immune response has been recognized as a major tumor-eradication component of radiotherapy. OBJECTIVE This review studies, under a clinical perspective, two contrasting effects of radiotherapy, namely immunosuppression and radiovaccination. MATERIALS AND METHODS We critically reviewed the available clinical and experimental experience on radiotherapy-induced lymphopenia. RESULTS Radiation-induced tumor damage promotes radio-vaccination, enhances cytotoxic immune responses, and potentiates immunotherapy. Nevertheless, radiotherapy induces systemic and intratumoral lymphopenia. The above effects are directly related to radiotherapy fractionation and field size/location, and tumor characteristics. DISCUSSION Hypofractionated stereotactic and accelerated irradiation better promotes radio-vaccination and produces less severe lymphopenia. Adopting cytoprotective policies and combining lympho-stimulatory agents or agents blocking regulatory lymphocyte activity are awaited to unmask the radio-vaccination effect, enhancing the efficacy immuno-radiotherapy. CONCLUSION Radiation-induced lymphopenia and immunosuppression are important issues that should be considered in the design of immuno-radiotherapy clinical trials.
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Affiliation(s)
- Michael I Koukourakis
- Department of Radiotherapy/Oncology, Medical School, Democritus University of Thrace, Alexandroupolis 68100, Greece.
| | - Alexandra Giatromanolaki
- Department of Pathology, Medical School, Democritus University of Thrace, Alexandroupolis 68100, Greece
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28
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Hu M, Xu Q, Yang S, Han S, Zhu Y, Lin Q, Sun X, Liu H, Xu Y. Pretreatment systemic inflammation response index (SIRI) is an independent predictor of survival in unresectable stage III non-small cell lung cancer treated with chemoradiotherapy: a two-center retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1310. [PMID: 33209890 PMCID: PMC7661896 DOI: 10.21037/atm-20-6484] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Circulating immune cells influence the efficacy of cancer therapy. This study aimed to investigate the prognostic values of different peripheral blood leukocyte (PBL) biomarkers in non-small lung cancer (NSCLC) patients treated with chemoradiotherapy. Methods An independent cohort of 176 stage III NSCLC patients who were diagnosed at Shanghai Pulmonary Hospital and Zhejiang Cancer Hospital between April, 2010, and September, 2018, and had available pretreatment peripheral blood tests was enrolled. The patients were all treated with concurrent or sequential chemoradiotherapy according to international clinical guidelines, with conventional fractionated radical radiotherapy. The receiver operating characteristic curve and the Youden index were used to determine the optional cutoff values of PBL biomarkers for distinguishing prognosis. Univariate and multivariate Cox proportional hazards regression analyses were performed to identify the factors significantly correlated with overall survival. Results The cohort had a median follow-up time of 21.7 (3.1–121) months. The 3- and 5-year OS rates of all patients were 34.7% and 27.5%, respectively. Univariate analysis showed that gender (P=0.011), smoking (P=0.011), tumor-node-metastasis (TNM) stage (P=0.002), pretreatment peripheral blood neutrophil-to-leukocyte ratio (P=0.013), and systemic inflammation response index (SIRI, P<0.001) were all correlated with OS in NSCLC patients. Moreover, multivariate analysis revealed that TNM stage (HR =1.541, 95% CI: 1.166–2.036, P=0.010) and SIRI (HR =1.868, 95% CI: 1.016–3.436, P=0.018) were significantly and independently associated with OS. However, the median OS of stage IIIB NSCLC patients with low SIRI (≤2.0) was longer than that of stage IIIA NSCLC patients with high SIRI (>2.0) (33.9±4.1 vs. 19.6±2.5 months). Conclusions Pretreatment peripheral blood SIRI was found to be a simple independent predictor of OS in stage III NSCLC patients who underwent chemoradiotherapy. As a novel prognostic marker, the prognostic value of the SIRI is superior to that of the NLR. Low SIRI could be a better prognostic stratification factor for NSCLC patients with different TNM stages.
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Affiliation(s)
- Min Hu
- Department of Radiotherapy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qinghua Xu
- Department of Radiotherapy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shuangyan Yang
- Department of Radiotherapy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shuiyun Han
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Yaoyao Zhu
- Department of Radiotherapy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qingren Lin
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Xiaojiang Sun
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - Hui Liu
- Department of Radiotherapy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yaping Xu
- Department of Radiotherapy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Sung W, Grassberger C, McNamara AL, Basler L, Ehrbar S, Tanadini-Lang S, Hong TS, Paganetti H. A tumor-immune interaction model for hepatocellular carcinoma based on measured lymphocyte counts in patients undergoing radiotherapy. Radiother Oncol 2020; 151:73-81. [PMID: 32679308 DOI: 10.1016/j.radonc.2020.07.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE The impact of radiation therapy on the immune system has recently gained attention particularly when delivered in combination with immunotherapy. However, it is unclear how different treatment fractionation regimens influence the interaction between the immune system and radiation. The goal of this work was to develop a mathematical model that quantifies both the immune stimulating as well as the immunosuppressive effects of radiotherapy and simulates the effects of different fractionation regimens based on patient data. METHODS AND MATERIALS The framework describes the temporal evolution of tumor cells, lymphocytes, and inactivated dying tumor cells releasing antigens during radiation therapy, specifically modeling how recruited lymphocytes inhibit tumor progression. The parameters of the model were partly taken from the literature and in part extracted from blood samples (circulating lymphocytes: CLs) collected from hepatocellular carcinoma patients undergoing radiotherapy and their outcomes. The dose volume histograms to circulating lymphocytes were calculated with a probability-based model. RESULTS Based on the fitted parameters, the model enabled a study into the depletion and recovery of CLs in patients as a function of fractionation regimen. Our results quantify the ability of short fractionation regimens to lead to shorter periods of lymphocyte depletion and predict faster recovery after the end of treatment. The model shows that treatment breaks between fractions can prolong the period of lymphocyte depletion and should be avoided. CONCLUSIONS This study introduces a mathematical model for tumor-immune interactions using clinically extracted radiotherapy patient data, which can be applied to design trials aimed at minimizing lymphocyte depleting effects in radiation therapy.
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Affiliation(s)
- Wonmo Sung
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, United States
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, United States
| | - Aimee Louise McNamara
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, United States
| | - Lucas Basler
- Department of Radiation Oncology, Paul Scherrer Institut, Villigen, Switzerland
| | - Stefanie Ehrbar
- Department of Radiation Oncology, University Hospital Zurich, Switzerland
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, United States
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, United States.
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van Diessen JN, Kwint MH, Sonke JJ, Belderbos JS. In response to Park, et al. Radiother Oncol 2020; 147:245-246. [DOI: 10.1016/j.radonc.2020.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 11/16/2022]
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Sun GY, Wang SL, Song YW, Jin J, Wang WH, Liu YP, Ren H, Fang H, Tang Y, Zhao XR, Song YC, Yu ZH, Liu XF, Li YX. Radiation-Induced Lymphopenia Predicts Poorer Prognosis in Patients With Breast Cancer: A Post Hoc Analysis of a Randomized Controlled Trial of Postmastectomy Hypofractionated Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 108:277-285. [PMID: 32147519 DOI: 10.1016/j.ijrobp.2020.02.633] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE The aim of this study was to determine whether radiation-induced lymphopenia affects the survival of patients with breast cancer. METHODS AND MATERIALS Post hoc analysis was conducted on data from 598 patients with breast cancer from a randomized controlled trial comparing postmastectomy hypofractionated radiation therapy (HFRT; 43.5 Gy in 15 fractions over 3 weeks) with conventional fractionated radiation therapy (CFRT; 50 Gy in 25 fractions over 5 weeks). Mean peripheral lymphocyte count (PLC) at different time points in the 2 groups was compared by the t test. Disease-free survival and overall survival were analyzed by the Kaplan-Meier method and compared between groups by the log-rank test. RESULTS Baseline PLC (pre-PLC) was comparable between HFRT and CFRT patients (1.60 ± 0.57 × 109/L vs 1.56 ± 0.52 × 109/L; P = .33). In both groups, the PLC declined steadily during the course of radiation therapy but started to recover at 1 month after radiation therapy. Incidence of lymphopenia was significantly lower in HFRT patients (45.4% vs 55.7%; P = .01). Nadir-PLC was significantly higher in HFRT patients (1.08 ± 0.37 × 109/L vs 0.97 ± 0.31× 109/L; P < .001), as was the nadir-PLC/pre-PLC ratio (0.72 ± 0.28 vs 0.67 ± 0.28; P = .02). Median follow-up was 57.6 months (interquartile range, 38.5-81.4). The 5-year disease-free survival was significantly lower in patients with a nadir-PLC/pre-PLC ratio <0.8 than in those with a ratio ≥0.8 (71.8% vs 82.6%; P = .01); however, overall survival was comparable between the groups (85.8% vs 90.6%; P = .24). CONCLUSIONS The risk of radiation-induced lymphopenia in patients with breast cancer is lower with HFRT than with CFRT. A low nadir-PLC/pre-PLC ratio may predict poor prognosis.
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Affiliation(s)
- Guang-Yi Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Hu Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Ren
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu-Ran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Chun Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Hao Yu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Fan Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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A framework for modeling radiation induced lymphopenia in radiotherapy. Radiother Oncol 2020; 144:105-113. [DOI: 10.1016/j.radonc.2019.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 11/17/2022]
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Zhuang Y, Yuan BY, Chen GW, Zhao XM, Hu Y, Zhu WC, Zeng ZC, Chen YX. Association Between Circulating Lymphocyte Populations and Outcome After Stereotactic Body Radiation Therapy in Patients With Hepatocellular Carcinoma. Front Oncol 2019; 9:896. [PMID: 31552194 PMCID: PMC6748162 DOI: 10.3389/fonc.2019.00896] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/28/2019] [Indexed: 12/28/2022] Open
Abstract
Background and Objective: Radiation-induced lymphopenia has a tangible impact on overall survival (OS) in multiple solid tumors. We investigated the association between circulating lymphocyte populations (CLPs) before and after stereotactic body radiation therapy (SBRT) and OS in patients with hepatocellular carcinoma (HCC). Materials and Methods: Seventy-eight HCC patients treated with SBRT between January 2013 and June 2017 were retrospectively analyzed. Baseline and post-treatment total peripheral lymphocyte counts (TPLCs) and values of different CLPs were obtained and analyzed for clinical outcomes. Univariate and multivariate Cox regression analyses were used to explore the independent prognostic factors for patient survival. Results: The one-, two- and three-year OS rates were 94.8, 75.9, and 63.3%, respectively. The mean TPLCs before and 10 days after SBRT were 1.4 × 109/L and 0.7 × 109/L, respectively. The TPLC recovered to its baseline value 1 year after SBRT. Multivariate analysis results revealed that variables, including tumor necrosis factor-alpha (TNF-α) level <5.5 ng/mL and post-treatment TPLC <0.45 × 109/L were independent factors for inferior OS. Further analysis showed that the values of CLPs, including CD3+, CD4+, CD8+, CD19+, and CD16+56+ cells dropped profoundly 10 days after SBRT, among which CD19+ B cell count was mostly depleted and gradually recovered after 2 months. Univariate analysis showed that both baseline and post-treatment TPLC and CLP (except post-treatment B cell) counts were significantly associated with patient OS (p < 0.05 for each). Further stratified analysis performed according to OS at 2 years demonstrated that the CD16+CD56+ NK cell counts remained significantly elevated in patients with better survival (OS > 2 years) compared to those in short-term survivors at 10 days, 1 month, and 2 months after SBRT (p < 0.05 for each). In addition, there were significant differences in TPLC and CD8+ T cell counts in patients with long-term and short-term OS at 2 months after SBRT (p < 0.05). Conclusions: Peripheral lymphopenia after SBRT might be an independent prognostic factor for poorer outcome in HCC patients. Post-treatment lymphocyte subsets, including CD8+ T cell and NK cell counts were also associated with 2-year OS rates.
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Affiliation(s)
- Yuan Zhuang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bao-Ying Yuan
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gen-Wen Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Mei Zhao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Hu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Chao Zhu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhao-Chong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Xing Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
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