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Zhang W, Tang Y, Wei L, Liu S, Wang W, Chi Y, Wang Y, Kang W, Huang W, Deng F, Li H, Ma H, Jiang L, Ding Z, Feng L, Li Y, Chen Y, Zhou H, Hu C, Jin J. Preoperative short-course radiotherapy followed by chemotherapy and PD-1 inhibitor administration for locally advanced rectal cancer: A study protocol of a randomized phase II/III trial (STELLAR II study). Colorectal Dis 2024. [PMID: 39020518 DOI: 10.1111/codi.17090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 06/04/2024] [Accepted: 06/17/2024] [Indexed: 07/19/2024]
Abstract
AIM For patients with locally advanced rectal cancer, previous STELLAR studies have shown that a new adjuvant treatment paradigm of short-course radiotherapy followed by neoadjuvant chemotherapy can achieve pathological complete response rates superior to those of standard care; however, the 3-year DFS is inferior to neoadjuvant concurrent radiotherapy. Recent studies have shown that immune checkpoint inhibitors may improve the prognosis of rectal cancer and have good synergy with radiotherapy. Therefore, neoadjuvant chemotherapy combined with immune checkpoint inhibitors after a short course of radiotherapy has the potential to further improve complete response rates and prognosis. METHOD The STELLAR II study is a multicentre, open label, two-arm randomized, phase II/III trial of short-course radiotherapy followed by neoadjuvant chemotherapy concurrent with immunotherapy for locally advanced rectal cancer. A total of 588 patients with locally advanced rectal cancer (LARC) will be randomly assigned to the experimental and control groups. The experimental group will receive short-course radiotherapy and neoadjuvant chemotherapy in combination with sindilizumab, while the control group will receive short-course radiotherapy and neoadjuvant chemotherapy. Both groups will subsequently receive either total rectal mesenteric resection or a watch & wait (W&W) strategy. The phase II primary endpoint is the complete remission rate, and the secondary endpoints include grade 3-4 adverse events, perioperative complications, R0 resection rate, overall survival, local recurrence rate, distant metastasis rate and quality of life score. A seamless phase II/III randomized controlled design will be used to investigate the effectiveness and safety of the TNT strategy with the addition of immunotherapy. The trial opened, and the first patient was recruited on 31 August 2022. Trial registration number and date of registration: ClinicalTrials.gov NCT05484024, 29 July 2022. DISCUSSION The STELLAR II trial will prospectively evaluate the efficacy of TNT treatment strategies that incorporate immune checkpoint inhibitors. The trial will yield important information to guide routine management of patients with local advanced rectal cancer.
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Affiliation(s)
- Wenjue Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Yuan Tang
- State Key Laboratory of Molecular Oncology, Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lichun Wei
- Department of Radiation Oncology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Shixin Liu
- Department of Radiation Oncology, Jilin Provincial Cancer Hospital, Changchun, China
| | - Wenling Wang
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yihebali Chi
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Centre/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Wang
- Department of Medical Oncology, National Cancer Centre/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Wenyan Kang
- Department of Radiology, National Cancer Centre/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Wenting Huang
- Department of Pathology, National Cancer Centre/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
- State Key Laboratory of Molecular Oncology, Department of Pathology, National Cancer Centre/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feiyan Deng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Haoyue Li
- State Key Laboratory of Molecular Oncology, Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huiying Ma
- State Key Laboratory of Molecular Oncology, Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - LiMing Jiang
- State Key Laboratory of Molecular Oncology, Department of Radiology, National Cancer Centre/National Clinical Research Centre 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 Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Lingling Feng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Yexiong Li
- State Key Laboratory of Molecular Oncology, Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinggang Chen
- Department of Colorectal Surgery, National Cancer Centre/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Haitao Zhou
- State Key Laboratory of Molecular Oncology, Department of Colorectal Surgery, National Cancer Centre/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Centre, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
- State Key Laboratory of Molecular Oncology, Department of Radiation Oncology, National Cancer Center/National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lin ZY, Zhang P, Chi P, Xiao Y, Xu XM, Zhang AM, Qiu XF, Wu JX, Yuan Y, Wang ZN, Qu XJ, Li X, Nie X, Yang M, Cai KL, Zhang WK, Huang Y, Sun Z, Hou ZG, Ma C, Cheng FZ, Tao KX, Zhang T. Neoadjuvant short-course radiotherapy followed by camrelizumab and chemotherapy in locally advanced rectal cancer (UNION): early outcomes of a multicenter randomized phase III trial. Ann Oncol 2024:S0923-7534(24)00746-4. [PMID: 38964714 DOI: 10.1016/j.annonc.2024.06.015] [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: 02/23/2024] [Revised: 04/18/2024] [Accepted: 06/19/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Neoadjuvant short-course radiotherapy (SCRT) followed by CAPOX and camrelizumab (a PD-1 monoclonal antibody) has shown potential clinical activity for locally advanced rectal cancer (LARC) in a phase II trial. This study aimed to further confirm the efficacy and safety of SCRT followed by CAPOX and camrelizumab compared to long-course chemoradiotherapy (LCRT) followed by CAPOX alone as neoadjuvant treatment for LARC. PATIENTS AND METHODS In this randomized, phase III trial, patients with T3-4/N+ rectal adenocarcinoma were randomly assigned (1:1) to receive SCRT or long-course chemoradiotherapy (LCRT), followed by 2 cycles of camrelizumab and CAPOX or CAPOX alone, respectively. After surgery, each arm underwent either 6 cycles of camrelizumab and CAPOX, followed by up to 17 doses of camrelizumab, or 6 cycles of CAPOX. The primary endpoint was pathological complete response (pCR) rate (ypT0N0) assessed by a blinded independent review committee. Key secondary endpoints tested hierarchically were 3-year event-free survival (EFS) rate and overall survival (OS). RESULTS Between July 2021 and March 2023, the intention-to-treat population comprised 113 patients in experimental arm and 118 patients in control arm, with surgery performed in 92% and 83.9%, respectively. At data cutoff (July 11, 2023), the pCR rate were 39.8% (95% CI, 30.7 to 49.5) in experimental arm compared to 15.3% (95% CI, 9.3 to 23.0) in control arm (difference, 24.6%; odds ratio, 3.7; 95% CI, 2.0 to 6.9; p < 0.001). In each arm, surgical complication rates were 40.0% and 40.8%, grade ≥ 3 treatment-related adverse events were 29.2% and 27.2%. 3-year EFS rate and OS continue to mature. CONCLUSIONS In LARC patients, neoadjuvant SCRT followed by camrelizumab plus CAPOX demonstrated a significantly higher pCR rate than LCRT followed by CAPOX, with a well-tolerated safety profile. SCRT followed by camrelizumab and chemotherapy can be recommended as a neoadjuvant treatment modality for these patients.
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Affiliation(s)
- Z Y Lin
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Key Laboratory of Precision Radiation Oncology, Wuhan, China; Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - P Zhang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - P Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Y Xiao
- Department of Basic Surgery, Peking Union Medical College Hospital, Beijing, China
| | - X M Xu
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China
| | - A M Zhang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Hebei University, Baoding, China
| | - X F Qiu
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, Xiamen, China
| | - J X Wu
- Radiotherapy Department of Abdominal Tumors, Fujian Cancer Hospital, Fuzhou, China
| | - Y Yuan
- Department of Medical Oncology, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Z N Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China
| | - X J Qu
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, China
| | - X Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - X Nie
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - M Yang
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - K L Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - W K Zhang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Y Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Z Sun
- Department of Basic Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Z G Hou
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - C Ma
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - F Z Cheng
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - K X Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - T Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Key Laboratory of Precision Radiation Oncology, Wuhan, China; Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Xia F, Wang Y, Wang H, Shen L, Xiang Z, Zhao Y, Zhang H, Wan J, Zhang H, Wang Y, Wu R, Wang J, Yang W, Zhou M, Zhou S, Chen Y, Zhang Z, Wu X, Xuan Y, Wang R, Sun Y, Tong T, Zhang X, Wang L, Huang D, Sheng W, Yan H, Yang X, Shen Y, Xu Y, Zhao R, Mo M, Cai G, Cai S, Xu Y, Zhang Z. Randomized Phase II Trial of Immunotherapy-Based Total Neoadjuvant Therapy for Proficient Mismatch Repair or Microsatellite Stable Locally Advanced Rectal Cancer (TORCH). J Clin Oncol 2024:JCO2302261. [PMID: 38950321 DOI: 10.1200/jco.23.02261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/17/2024] [Accepted: 04/17/2024] [Indexed: 07/03/2024] Open
Abstract
PURPOSE To assess whether the integration of PD-1 inhibitor with total neoadjuvant therapy (iTNT) can lead to an improvement in complete responses (CRs) and favors a watch-and-wait (WW) strategy in patients with proficient mismatch repair or microsatellite stable (pMMR/MSS) locally advanced rectal cancer (LARC). PATIENTS AND METHODS We conducted a prospective, multicenter, randomized, open-label, phase II trial using a pick-the-winner design. Eligible patients with clinical T3-4 and/or N+ rectal adenocarcinoma were randomly assigned to group A for short-course radiotherapy (SCRT) followed by six cycles of consolidation immunochemotherapy with capecitabine and oxaliplatin and toripalimab or to group B for two cycles of induction immunochemotherapy followed by SCRT and the rest four doses. Either total mesorectal excision or WW was applied on the basis of tumor response. The primary end point was CR which included pathological CR (pCR) after surgery and clinical CR (cCR) if WW was applicable, with hypothesis of an increased CR of 40% after iTNT compared with historical data of 25% after conventional TNT. RESULTS Of the 130 patients enrolled, 121 pMMR/MSS patients were evaluable (62 in group A and 59 in group B). At a median follow-up of 19 months, CR was achieved at 56.5% in group A and 54.2% in group B. Both groups fulfilled the predefined statistical hypothesis (P < .001). Both groups reported a pCR rate of 50%. Respectively, 15 patients in each group underwent WW and remained disease free. The most frequent grade 3 to 4 toxicities were thrombocytopenia and neutropenia. Patients in group A had higher rate of cCR (43.5% v 35.6%) at restaging and lower rate of grade 3 to 4 thrombocytopenia (24.2% v 33.9%) during neoadjuvant treatment. CONCLUSION The iTNT regimens remarkably improved CR rates in pMMR/MSS LARC compared with historical benchmark with acceptable toxicity. Up-front SCRT followed by immunochemotherapy was selected for future definitive study.
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Affiliation(s)
- Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hui Wang
- Department of Oncology, Tianjin Union Medical Center, Nankai University, Tianjin, China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zuolin Xiang
- Department of Radiation Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yutian Zhao
- Department of Radiation Oncology, The Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Juefeng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hui Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ruiyan Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jingwen Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wang Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Menglong Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shujuan Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yajie Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhiyuan Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xian Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan Xuan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Renjie Wang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yiqun Sun
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Tong Tong
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xun Zhang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Lei Wang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
- Institute of Pathology, Fudan University, Shanghai, China
| | - Dan Huang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
- Institute of Pathology, Fudan University, Shanghai, China
| | - Weiqi Sheng
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
- Institute of Pathology, Fudan University, Shanghai, China
| | - Hao Yan
- Department of Oncology, Tianjin Union Medical Center, Nankai University, Tianjin, China
| | - Xu Yang
- Department of Radiation Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuxin Shen
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Xu
- Department of Radiation Oncology, The Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Ruping Zhao
- Department of Radiation Oncology, Jia Hui International Hospital, Shanghai, China
- Department of Radiotherapy, Shuguang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, China
| | - Miao Mo
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Guoxiang Cai
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Sanjun Cai
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ye Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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4
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Morel D, Robert C, Paragios N, Grégoire V, Deutsch E. Translational Frontiers and Clinical Opportunities of Immunologically Fitted Radiotherapy. Clin Cancer Res 2024; 30:2317-2332. [PMID: 38477824 PMCID: PMC11145173 DOI: 10.1158/1078-0432.ccr-23-3632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/09/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
Ionizing radiation can have a wide range of impacts on tumor-immune interactions, which are being studied with the greatest interest and at an accelerating pace by the medical community. Despite its undeniable immunostimulatory potential, it clearly appears that radiotherapy as it is prescribed and delivered nowadays often alters the host's immunity toward a suboptimal state. This may impair the full recovery of a sustained and efficient antitumor immunosurveillance posttreatment. An emerging concept is arising from this awareness and consists of reconsidering the way of designing radiation treatment planning, notably by taking into account the individualized risks of deleterious radio-induced immune alteration that can be deciphered from the planned beam trajectory through lymphocyte-rich organs. In this review, we critically appraise key aspects to consider while planning immunologically fitted radiotherapy, including the challenges linked to the identification of new dose constraints to immune-rich structures. We also discuss how pharmacologic immunomodulation could be advantageously used in combination with radiotherapy to compensate for the radio-induced loss, for example, with (i) agonists of interleukin (IL)2, IL4, IL7, IL9, IL15, or IL21, similarly to G-CSF being used for the prophylaxis of severe chemo-induced neutropenia, or with (ii) myeloid-derived suppressive cell blockers.
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Affiliation(s)
- Daphné Morel
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
| | - Charlotte Robert
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
- Paris-Saclay University, School of Medicine, Le Kremlin Bicêtre, France
| | - Nikos Paragios
- Therapanacea, Paris, France
- CentraleSupélec, Gif-sur-Yvette, France
| | - Vincent Grégoire
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Villejuif, France
- Paris-Saclay University, School of Medicine, Le Kremlin Bicêtre, France
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5
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Stepanenko AA, Sosnovtseva AO, Valikhov MP, Chernysheva AA, Abramova OV, Naumenko VA, Chekhonin VP. The need for paradigm shift: prognostic significance and implications of standard therapy-related systemic immunosuppression in glioblastoma for immunotherapy and oncolytic virotherapy. Front Immunol 2024; 15:1326757. [PMID: 38390330 PMCID: PMC10881776 DOI: 10.3389/fimmu.2024.1326757] [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: 10/23/2023] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Despite significant advances in our knowledge regarding the genetics and molecular biology of gliomas over the past two decades and hundreds of clinical trials, no effective therapeutic approach has been identified for adult patients with newly diagnosed glioblastoma, and overall survival remains dismal. Great hopes are now placed on combination immunotherapy. In clinical trials, immunotherapeutics are generally tested after standard therapy (radiation, temozolomide, and steroid dexamethasone) or concurrently with temozolomide and/or steroids. Only a minor subset of patients with progressive/recurrent glioblastoma have benefited from immunotherapies. In this review, we comprehensively discuss standard therapy-related systemic immunosuppression and lymphopenia, their prognostic significance, and the implications for immunotherapy/oncolytic virotherapy. The effectiveness of immunotherapy and oncolytic virotherapy (viro-immunotherapy) critically depends on the activity of the host immune cells. The absolute counts, ratios, and functional states of different circulating and tumor-infiltrating immune cell subsets determine the net immune fitness of patients with cancer and may have various effects on tumor progression, therapeutic response, and survival outcomes. Although different immunosuppressive mechanisms operate in patients with glioblastoma/gliomas at presentation, the immunological competence of patients may be significantly compromised by standard therapy, exacerbating tumor-related systemic immunosuppression. Standard therapy affects diverse immune cell subsets, including dendritic, CD4+, CD8+, natural killer (NK), NKT, macrophage, neutrophil, and myeloid-derived suppressor cell (MDSC). Systemic immunosuppression and lymphopenia limit the immune system's ability to target glioblastoma. Changes in the standard therapy are required to increase the success of immunotherapies. Steroid use, high neutrophil-to-lymphocyte ratio (NLR), and low post-treatment total lymphocyte count (TLC) are significant prognostic factors for shorter survival in patients with glioblastoma in retrospective studies; however, these clinically relevant variables are rarely reported and correlated with response and survival in immunotherapy studies (e.g., immune checkpoint inhibitors, vaccines, and oncolytic viruses). Our analysis should help in the development of a more rational clinical trial design and decision-making regarding the treatment to potentially improve the efficacy of immunotherapy or oncolytic virotherapy.
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Affiliation(s)
- Aleksei A. Stepanenko
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anastasiia O. Sosnovtseva
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Marat P. Valikhov
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anastasia A. Chernysheva
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Olga V. Abramova
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Victor A. Naumenko
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
| | - Vladimir P. Chekhonin
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center of Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russia
- Department of Medical Nanobiotechnology, Institute of Translational Medicine, N.I. Pirogov Russian National Research Medical University, The Ministry of Health of the Russian Federation, Moscow, Russia
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6
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Wan J, Wu R, Fu M, Shen L, Zhang H, Wang Y, Wang Y, Zhou S, Chen Y, Xia F, Zhang Z. TORCH-R trial protocol: hypofractionated radiotherapy combined with chemotherapy and toripalimab for locally recurrent rectal cancer: a prospective, single-arm, two-cohort, phase II trial. Front Oncol 2023; 13:1304767. [PMID: 38053659 PMCID: PMC10694348 DOI: 10.3389/fonc.2023.1304767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/31/2023] [Indexed: 12/07/2023] Open
Abstract
For patients with locally recurrent rectal cancer (LRRC), the response rate to chemoradiotherapy is 40%-50%. Additionally, only approximately 40%-50% of patients with recurrent rectal cancer are able to undergo R0 resection. Recent studies in locally advanced rectal cancer (LARC) have shown promising synergistic effects when combining immunotherapy (PD-1/PD-L1 antibodies) with neoadjuvant chemoradiotherapy (nCRT). Therefore, incorporating immunotherapy into the treatment regimen for LRRC patients has the potential to further improve response rates and prognosis. To investigate this, the TORCH-R trial was conducted. This prospective, single-arm, two-cohort, phase II trial focuses on the use of hypofractionated radiotherapy, chemotherapy, and immunotherapy in LRRC patients without or with oligometastases. The trial will include two cohorts: cohort A consists of rectal cancer patients who are treatment-naive for local recurrence, and cohort B includes patients with progressive disease after first-line chemotherapy. Cohort A and cohort B patients will receive 25-40 Gy/5 Fx irradiation or 15-30 Gy/5 Fx reirradiation for pelvic recurrence, respectively. Subsequently, they will undergo 18 weeks of chemotherapy, toripalimab, and stereotactic ablative radiotherapy (SABR) for all metastatic lesions between chemoimmunotherapy cycles. Decisions regarding follow-up of complete response (CR), radical surgery, sustained treatment of non-resection, or exiting the trial are made by a multidisciplinary team (MDT). The primary endpoint of this study is the local objective response rate (ORR). The secondary endpoints include the extrapelvic response rate, duration of response, local recurrence R0 resection rate, progression-free survival (PFS), overall survival (OS), and safety and tolerability. Notably, this trial represents the first clinical exploration of inducing hypofractionated radiotherapy, chemotherapy, and immunotherapy in LRRC patients. Clinical trial registration https://clinicaltrials.gov/study/NCT05628038, identifier NCT05628038.
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Affiliation(s)
- Juefeng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Ruiyan Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Miaomiao Fu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Hui Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Yan Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Shujuan Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Yajie Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
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Zhang J, Yang L, Li H, Chan JW, Lee EK, Liu M, Ma L, Liu Q, Jin JY, Fu P, Xu Z, Kong FM(S. Dosimetric Effect of Thymus and Thoracic Duct on Radiation-Induced Lymphopenia in Patients With Primary Lung Cancer Who Received Thoracic Radiation. Adv Radiat Oncol 2023; 8:101260. [PMID: 38047216 PMCID: PMC10692302 DOI: 10.1016/j.adro.2023.101260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 04/20/2023] [Indexed: 12/04/2023] Open
Abstract
Purpose Radiation-induced lymphopenia is a well-recognized factor for tumor control and survival in patients with cancer. This study aimed to determine the role of radiation dose to the thymus and thoracic duct on radiation-induced lymphopenia. Methods and Materials Patients with primary lung cancer treated with thoracic radiation therapy between May 2015 and February 2020 with whole blood count data were eligible. Clinical characteristics, including age, gender, histology, stage, chemotherapy regimen, radiation dosimetry, and absolute lymphocyte count (ALC) were collected. The thymus and thoracic duct were contoured by one investigator for consistency and checked by one senior physician. The primary endpoint was radiation-induced decrease in lymphocytes, defined as the difference in ALC (DALC) before and after radiation therapy. Results The data of a total of 116 consecutive patients were retrospectively retrieved. Significant correlations were found between DALC and several clinical factors. These factors include stage, chemotherapy or concurrent chemoradiation, biologically effective dose (BED), mean lung dose, mean body dose, effective dose to immune cells (EDIC), mean thymus dose (MTD), and mean thoracic duct dose (MTDD) (all P < .05). Ridge regression showed that DALC = 0.0063 × BED + 0.0172 × EDIC + 0.0002 × MTD + 0.0147 × MTDD + 0.2510 (overall P = .00025 and F = 5.85). The combination model has the highest area under the curve of 0.77 (P < .001) when fitting the logistic regression model on DALC categorized as binary endpoint. The sensitivity and specificity of the combined model were 89% and 58%, respectively. Conclusions This study demonstrated for the first time that radiation doses to the thymus and thoracic duct are strongly associated with radiation-induced lymphopenia patients with lung cancer. Further validation studies are needed to implement thymus and thoracic duct as organs at risk.
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Affiliation(s)
| | | | | | | | | | - Min Liu
- Department of Respiratory Medicine, Hongkong University-Shenzhen Hospital, Shenzhen, China
| | | | | | - Jian-Yue Jin
- Department of Radiation Oncology, University Hospitals/Seidman Cancer Center and Case Comprehensive Cancer Center, Mentor, Ohio
| | - Pingfu Fu
- Department of Radiation Oncology, University Hospitals/Seidman Cancer Center and Case Comprehensive Cancer Center, Mentor, Ohio
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Chen Y, Wang Y, Zhang H, Wan J, Shen L, Wang Y, Zhou M, Wu R, Yang W, Zhou S, Cai S, Li X, Zhang Z, Xia F. Short-course radiotherapy combined with chemotherapy and PD-1 inhibitor in low-lying early rectal cancer: study protocol for a single-arm, multicentre, prospective, phase II trial (TORCH-E). BMJ Open 2023; 13:e076048. [PMID: 37802608 PMCID: PMC10565143 DOI: 10.1136/bmjopen-2023-076048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION Current standard treatment for patients with early rectal cancer is radical surgical resection. Although radical surgery provides effective local tumour control, it also increases the mortality risk and considerable adverse effects, including bowel, bladder, sexual dysfunction and loss of anal function, especially in patients with low-lying rectal cancer. Recent studies have shown promising synergistic effects of the combination of programmed cell death-1 (PD-1)/programmed cell death-ligand 1 (PD-L1) inhibitors and radiotherapy in improving tumour regression. For patients who reach a clinical complete response (cCR) after neoadjuvant therapy, a 'Watch & Wait' (W&W) approach can be adopted to preserve anorectal function and improve quality of life. Thus, this study aims to explore the efficacy and safety of radiotherapy combined with chemotherapy and PD-1 antibody in patients with low early rectal cancer. METHODS AND ANALYSIS TORCH-E study is designed as a multicentre, prospective, phase II trial of short-course radiotherapy (SCRT) combined with chemotherapy and PD-1 inhibitor in patients with cT1-3bN0M0 low rectal cancer. The trial was initiated in December 2022 and is currently recruiting patients, with an anticipated completion of participant enrolment by June of the following year. The enrolled 34 patients will receive SCRT (25 Gy/5 Fx), followed by four cycles of capecitabine plus oxaliplatin chemotherapy and PD-1 antibody (toripalimab) and finally receive surgery or the W&W strategy. The primary endpoint is the complete response (CR) rate, that is, the rate of pathological complete response (pCR) plus cCR. The secondary endpoints include organ preservation rate, 3-year local recurrence-free survival rate, 3-year disease-free survival rate, 3-year overall survival rate, grade 3-4 adverse effects rate and patients' quality of life. ETHICS AND DISSEMINATION This trial has been approved by the Ethics Committee of Fudan University Shanghai Cancer Center. Trial results will be disseminated via peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT05555888 (ClinicalTrials.gov).
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Affiliation(s)
- Yajie Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Hui Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Juefeng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Yan Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Menglong Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Ruiyan Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Wang Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Shujuan Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Sanjun Cai
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xinxiang Li
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
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9
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Laurent PA, Deutsch É. [Radiation-induced lymphopenia: Lymphocytes as a new organ at risk]. Cancer Radiother 2023; 27:511-518. [PMID: 37661506 DOI: 10.1016/j.canrad.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 09/05/2023]
Abstract
Taking the immune system into account in the fight against tumors has upset the cancer treatment paradigm in the 21st century. Combination treatment strategies associating radiotherapy with immunotherapy are being increasingly implemented in clinical practice. In this context, lymphocytes, whether lymphocytes infiltrating the tumour, circulating blood lymphocytes or lymphocytes residing within the lymph nodes, are key players in cellular and humoral anti-tumor immunity. The significant radiosensitivity of lymphocytes was demonstrated in the early 1990s. Along with the cells of the digestive mucosa, lymphocytes are thus among the most radiosensitive cell types in the body. Compared to the old practices of external radiotherapy, current intensity modulated treatments have allowed a considerable improvement in acute and late toxicity, at the cost of a significant increase in the volume irradiated at low doses. This is not without consequence on the incidence of radiation-induced lymphopenia, with prognostic implications for many tumor types. Thus, in order not to hinder the action of antitumor immunity and the efficacy of immunotherapy, it is essential to consider lymphocytes as a new organ at risk in its own right. In this development, based on current data from the literature, we will begin by justifying the necessary prevention of radiation-induced lymphopenia, before providing the tools currently known to apprehend lymphocytes as a new multicompartments. Finally, we will broaden the perspective by outlining ways to develop research in this area.
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Affiliation(s)
- P A Laurent
- Service de radiothérapie oncologique, Gustave-Roussy Cancer Campus, Villejuif, France; Inserm, U1030 Molecular Radiation Therapy and Therapeutic Innovation, Gustave-Roussy Cancer Campus, université Paris-Saclay, Villejuif, France
| | - É Deutsch
- Service de radiothérapie oncologique, Gustave-Roussy Cancer Campus, Villejuif, France; Inserm, U1030 Molecular Radiation Therapy and Therapeutic Innovation, Gustave-Roussy Cancer Campus, université Paris-Saclay, Villejuif, France.
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10
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Paganetti H. A review on lymphocyte radiosensitivity and its impact on radiotherapy. Front Oncol 2023; 13:1201500. [PMID: 37601664 PMCID: PMC10435323 DOI: 10.3389/fonc.2023.1201500] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
It is well known that radiation therapy causes lymphopenia in patients and that this is correlated with a negative outcome. The mechanism is not well understood because radiation can have both immunostimulatory and immunosuppressive effects. How tumor dose conformation, dose fractionation, and selective lymph node irradiation in radiation therapy does affect lymphopenia and immune response is an active area of research. In addition, understanding the impact of radiation on the immune system is important for the design and interpretation of clinical trials combining radiation with immune checkpoint inhibitors, both in terms of radiation dose and treatment schedules. Although only a few percent of the total lymphocyte population are circulating, it has been speculated that their increased radiosensitivity may contribute to, or even be the primary cause of, lymphopenia. This review summarizes published data on lymphocyte radiosensitivity based on human, small animal, and in vitro studies. The data indicate differences in radiosensitivity among lymphocyte subpopulations that affect their relative contribution and thus the dynamics of the immune response. In general, B cells appear to be more radiosensitive than T cells and NK cells appear to be the most resistant. However, the reported dose-response data suggest that in the context of lymphopenia in patients, aspects other than cell death must also be considered. Not only absolute lymphocyte counts, but also lymphocyte diversity and activity are likely to be affected by radiation. Taken together, the reviewed data suggest that it is unlikely that radiation-induced cell death in lymphocytes is the sole factor in radiation-induced lymphopenia.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston MA, United States
- Harvard Medical School, Boston MA, United States
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11
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Sharon S, Daher-Ghanem N, Zaid D, Gough MJ, Kravchenko-Balasha N. The immunogenic radiation and new players in immunotherapy and targeted therapy for head and neck cancer. FRONTIERS IN ORAL HEALTH 2023; 4:1180869. [PMID: 37496754 PMCID: PMC10366623 DOI: 10.3389/froh.2023.1180869] [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: 03/06/2023] [Accepted: 06/27/2023] [Indexed: 07/28/2023] Open
Abstract
Although treatment modalities for head and neck cancer have evolved considerably over the past decades, survival rates have plateaued. The treatment options remained limited to definitive surgery, surgery followed by fractionated radiotherapy with optional chemotherapy, and a definitive combination of fractionated radiotherapy and chemotherapy. Lately, immunotherapy has been introduced as the fourth modality of treatment, mainly administered as a single checkpoint inhibitor for recurrent or metastatic disease. While other regimens and combinations of immunotherapy and targeted therapy are being tested in clinical trials, adapting the appropriate regimens to patients and predicting their outcomes have yet to reach the clinical setting. Radiotherapy is mainly regarded as a means to target cancer cells while minimizing the unwanted peripheral effect. Radiotherapy regimens and fractionation are designed to serve this purpose, while the systemic effect of radiation on the immune response is rarely considered a factor while designing treatment. To bridge this gap, this review will highlight the effect of radiotherapy on the tumor microenvironment locally, and the immune response systemically. We will review the methodology to identify potential targets for therapy in the tumor microenvironment and the scientific basis for combining targeted therapy and radiotherapy. We will describe a current experience in preclinical models to test these combinations and propose how challenges in this realm may be faced. We will review new players in targeted therapy and their utilization to drive immunogenic response against head and neck cancer. We will outline the factors contributing to head and neck cancer heterogeneity and their effect on the response to radiotherapy. We will review in-silico methods to decipher intertumoral and intratumoral heterogeneity and how these algorithms can predict treatment outcomes. We propose that (a) the sequence of surgery, radiotherapy, chemotherapy, and targeted therapy should be designed not only to annul cancer directly, but to prime the immune response. (b) Fractionation of radiotherapy and the extent of the irradiated field should facilitate systemic immunity to develop. (c) New players in targeted therapy should be evaluated in translational studies toward clinical trials. (d) Head and neck cancer treatment should be personalized according to patients and tumor-specific factors.
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Affiliation(s)
- Shay Sharon
- Department of Oral and Maxillofacial Surgery, Hadassah Medical Center, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Oral and Maxillofacial Surgery, Boston University and Boston Medical Center, Boston, MA, United States
| | - Narmeen Daher-Ghanem
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deema Zaid
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael J. Gough
- Earle A. Chiles Research Institute, Robert W. Franz Cancer Center, Providence Portland Medical Center, Portland, OR, United States
| | - Nataly Kravchenko-Balasha
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, Jerusalem, Israel
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12
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Dabaja B, Spiotto M. Radiation for hematologic malignancies: from cell killing to immune cell priming. Front Oncol 2023; 13:1205836. [PMID: 37384297 PMCID: PMC10299853 DOI: 10.3389/fonc.2023.1205836] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/30/2023] [Indexed: 06/30/2023] Open
Abstract
Over the past half-century, the role of radiotherapy has been revolutionized, in part, by a shift from intent to directly kill cancer cells to the goal of priming anti-tumor immune responses that attack both irradiated and non-irradiated tumors. Stimulation of anti-tumor immunity depends on the interplay between radiation, the tumor microenvironment, and the host immune system, which is a burgeoning concept in cancer immunology. While the interplay of radiotherapy and the immune system has been primarily studied in solid tumors, we are beginning to understand this interplay in hematological malignancies. The intent of this review is to lead readers through some of the important recent advances in immunotherapy and adoptive cell therapy, highlighting the best available evidence in support of incorporating radiation therapy and immunotherapy into the treatment of hematological malignancies. Evidence is presented regarding how radiation therapy 'converses' with the immune system to stimulate and enhance anti-tumor immune responses. This pro-immunogenic role of radiotherapy can be combined with monoclonal antibodies, cytokines and/or other immunostimulatory agents to enhance the regression of hematological malignancies. Furthermore, we will discuss how radiotherapy facilitates the effectiveness of cellular immunotherapies by acting as a "bridge" that facilitated CAR T cell engraftment and activity. These initial studies suggest radiotherapy may help catalyze a shift from using chemotherapy-intensive treatment to treatment that is "chemo-free" by combining with immunotherapy to target both the radiated and non-irradiated disease sites. This "journey" has opened the door for novel uses of radiotherapy in hematological malignancies due to its ability to prime anti-tumor immune responses which can augment immunotherapy and adoptive cell-based therapy.
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13
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Ex vivo analysis of radiation effects on tumor infiltrating immune cells using tumor explants. Methods Cell Biol 2023; 174:55-63. [PMID: 36710051 DOI: 10.1016/bs.mcb.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The response to radiation therapy incorporates both the direct impacts of radiation on cancer cells as well as the immune consequences that can help or hinder control of residual disease. Understanding the response of an individual patient's cancer to radiation, and the impact of radiation on the immune cell subsets present in the tumor prior to radiation therapy, can help identify potential predictors of outcome. Here, we describe a methodological approach to using an explant tumor model to characterize and study the immune cell subsets in murine tumors following exposure to ex vivo radiation treatment. The broader tumor environment incorporates distinct microenvironments consisting of tumor stroma and cancer cell nests, with limited interchange between these zones. Ex vivo analysis of tumor explants ensures that these environments remain intact and allows patient-specific response assessments with a broader range of treatment conditions to find optimal conditions and immunotherapy combinations. While this protocol describes the treatment of murine tumors, with minor variations the same protocol can be used to study and characterize various immune populations following radiation therapy in human tumors.
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14
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Benkhaled S, Peters C, Jullian N, Arsenijevic T, Navez J, Van Gestel D, Moretti L, Van Laethem JL, Bouchart C. Combination, Modulation and Interplay of Modern Radiotherapy with the Tumor Microenvironment and Targeted Therapies in Pancreatic Cancer: Which Candidates to Boost Radiotherapy? Cancers (Basel) 2023; 15:cancers15030768. [PMID: 36765726 PMCID: PMC9913158 DOI: 10.3390/cancers15030768] [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: 12/31/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/28/2023] Open
Abstract
Pancreatic ductal adenocarcinoma cancer (PDAC) is a highly diverse disease with low tumor immunogenicity. PDAC is also one of the deadliest solid tumor and will remain a common cause of cancer death in the future. Treatment options are limited, and tumors frequently develop resistance to current treatment modalities. Since PDAC patients do not respond well to immune checkpoint inhibitors (ICIs), novel methods for overcoming resistance are being explored. Compared to other solid tumors, the PDAC's tumor microenvironment (TME) is unique and complex and prevents systemic agents from effectively penetrating and killing tumor cells. Radiotherapy (RT) has the potential to modulate the TME (e.g., by exposing tumor-specific antigens, recruiting, and infiltrating immune cells) and, therefore, enhance the effectiveness of targeted systemic therapies. Interestingly, combining ICI with RT and/or chemotherapy has yielded promising preclinical results which were not successful when translated into clinical trials. In this context, current standards of care need to be challenged and transformed with modern treatment techniques and novel therapeutic combinations. One way to reconcile these findings is to abandon the concept that the TME is a well-compartmented population with spatial, temporal, physical, and chemical elements acting independently. This review will focus on the most interesting advancements of RT and describe the main components of the TME and their known modulation after RT in PDAC. Furthermore, we will provide a summary of current clinical data for combinations of RT/targeted therapy (tRT) and give an overview of the most promising future directions.
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Affiliation(s)
- Sofian Benkhaled
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
- Department of Radiation Oncology, UNIL-CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Cedric Peters
- Department of Radiation Oncology, AZ Turnhout, Rubensstraat 166, 2300 Turnhout, Belgium
| | - Nicolas Jullian
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
| | - Tatjana Arsenijevic
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
- Department of Gastroenterology, Hepatology and Digestive Oncology, Hopital Universitaire de Bruxelles H.U.B. CUB Hopital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Julie Navez
- Department of Hepato-Biliary-Pancreatic Surgery, Hopital Universitaire de Bruxelles H.U.B. CUB Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
| | - Luigi Moretti
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatology and Digestive Oncology, Hopital Universitaire de Bruxelles H.U.B. CUB Hopital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Christelle Bouchart
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
- Correspondence: ; Tel.: +32-25-413-800
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15
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Chemotherapy to potentiate the radiation-induced immune response. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2023; 376:143-173. [PMID: 36997268 DOI: 10.1016/bs.ircmb.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Chemoradiation (CRT) is a conventional therapy used in local cancers, especially when they are locally advanced. Studies have shown that CRT induces strong anti-tumor responses involving several immune effects in pre-clinical models and humans. In this review, we have described the various immune effects involved in CRT efficacy. Indeed, effects such as immunological cell death, activation and maturation of antigen-presenting cells, and activation of an adaptive anti-tumor immune response are attributed to CRT. As often described in other therapies, various immunosuppressive mechanisms mediated, in particular, by Treg and myeloid populations may reduce the CRT efficacy. We have therefore discussed the relevance of combining CRT with other therapies to potentiate the CRT-induced anti-tumor effects.
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Li Q, Han J, Yang Y, Chen Y. PD-1/PD-L1 checkpoint inhibitors in advanced hepatocellular carcinoma immunotherapy. Front Immunol 2022; 13:1070961. [PMID: 36601120 PMCID: PMC9806143 DOI: 10.3389/fimmu.2022.1070961] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Hepatocellular carcinoma (HCC) has a high prevalence and mortality rate worldwide. Sorafenib monotherapy has been the standard of first-line treatment for advanced HCC for a long time, but there are still many shortcomings. In recent years, with the deepening of research on tumor immune microenvironment, researchers have begun to explore new approaches in immunotherapy, and the introduction of immune checkpoint inhibitors has brought fundamental changes to the treatment of HCC. Programmed cell death protein 1 (PD-1) is an immune checkpoint molecule that plays an important role in down-regulating immune system function and promoting tolerance. Programmed cell death ligand 1 (PDL-1) is involved in tumor immune evasion by binding to PD-1, resulting in failure of treatment. Currently, immunotherapy targeting the PD-1/PD-L1 axis has achieved unprecedented success in HCC, but it also faces great challenges, with its low remission rate still to be solved. For most patients with HCC, the PD-1/PD-L1 pathway is not the only rate limiting factor of antitumor immunity, and blocking only the PD-1/PD-L1 axis is not enough to stimulate an effective antitumor immune response; thus, combination therapy may be a better option. In this study, changes in the immune microenvironment of HCC patients were reviewed to clarify the feasibility of anti-PD-1/PD-L1 therapy, and a series of monotherapy and combination therapy clinical trials were summarized to verify the safety and efficacy of this newly developed treatment in patients with advanced HCC. Furthermore, we focused on hyperprogressive disease and drug resistance to gain a better understanding of PD-1/PD-L1 blockade as a promising treatment.
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Affiliation(s)
- Qian Li
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jingjing Han
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yonglin Yang
- Department of Infectious Diseases, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou, China,*Correspondence: Yonglin Yang, ; Yu Chen,
| | - Yu Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China,*Correspondence: Yonglin Yang, ; Yu Chen,
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17
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Wang Y, Shen L, Wan J, Zhang H, Wu R, Wang J, Wang Y, Xu Y, Cai S, Zhang Z, Xia F. Neoadjuvant chemoradiotherapy combined with immunotherapy for locally advanced rectal cancer: A new era for anal preservation. Front Immunol 2022; 13:1067036. [PMID: 36569918 PMCID: PMC9772444 DOI: 10.3389/fimmu.2022.1067036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
For locally advanced (T3-4/N+M0) rectal cancer (LARC), neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME) is the standard treatment. It was demonstrated to decrease the local recurrence rate and increase the tumor response grade. However, the distant metastasis remains an unresolved issue. And the demand for anus preservation and better quality of life increases in recent years. Radiotherapy and immunotherapy can be supplement to each other and the combination of the two treatments has a good theoretical basis. Recently, multiple clinical trials are ongoing in terms of the combination of nCRT and immunotherapy in LARC. It was reported that these trials achieved promising short-term efficacy in both MSI-H and MSS rectal cancers, which could further improve the rate of clinical complete response (cCR) and pathological complete response (pCR), so that increase the possibility of 'Watch and Wait (W&W)' approach. However, the cCR and pCR is not always consistent, which occurs more frequent when nCRT is combined with immunotherapy. Thus, the efficacy evaluation after neoadjuvant therapy is an important issue for patient selection of W&W approach. Evaluating the cCR accurately needs the combination of multiple traditional examinations, new detective methods, such as PET-CT, ctDNA-MRD and various omics studies. And finding accurate biomarkers can help guide the risk stratification and treatment decisions. And large-scale clinical trials need to be performed in the future to demonstrate the surprising efficacy and to explore the long-term prognosis.
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Affiliation(s)
- Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Juefeng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Hui Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Ruiyan Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Jingwen Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Yan Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Ye Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Sanjun Cai
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China,*Correspondence: Fan Xia, ; Zhen Zhang,
| | - Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China,*Correspondence: Fan Xia, ; Zhen Zhang,
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18
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A Systematic Review on the Impact of Hypofractionated and Stereotactic Radiotherapy on Immune Cell Subpopulations in Cancer Patients. Cancers (Basel) 2022; 14:cancers14215190. [DOI: 10.3390/cancers14215190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 11/16/2022] Open
Abstract
We investigated how hypofractionated radiotherapy (HFRT) and stereotactic body radiotherapy (SBRT) may impact immune cells in different type of tumors. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed, Embase and Cochrane databases were searched. Overall, 11 studies met the inclusion criteria and were eligible for the present analysis. Both HFRT and SBRT have different impact on lymphocyte subpopulations, confirming their immunomodulatory effect which may have a crucial role in future combined treatment with new emergent therapies such as immunotherapy. Further studies are needed to shed more light on this emerging topic to ultimately improve patient care, treatment and clinical benefits for cancer patients.
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19
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Yamazaki T, Gunderson AJ, Gilchrist M, Whiteford M, Kiely MX, Hayman A, O'Brien D, Ahmad R, Manchio JV, Fox N, McCarty K, Phillips M, Brosnan E, Vaccaro G, Li R, Simon M, Bernstein E, McCormick M, Yamasaki L, Wu Y, Drokin A, Carnahan T, To Y, Redmond WL, Lee B, Louie J, Hansen E, Solhjem MC, Cramer J, Urba WJ, Gough MJ, Crittenden MR, Young KH. Galunisertib plus neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer: a single-arm, phase 2 trial. Lancet Oncol 2022; 23:1189-1200. [DOI: 10.1016/s1470-2045(22)00446-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/17/2022] [Accepted: 06/28/2022] [Indexed: 02/08/2023]
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20
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Gough MJ, Crittenden MR. The paradox of radiation and T cells in tumors. Neoplasia 2022; 31:100808. [PMID: 35691060 PMCID: PMC9194456 DOI: 10.1016/j.neo.2022.100808] [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: 01/10/2022] [Revised: 04/05/2022] [Accepted: 05/13/2022] [Indexed: 10/27/2022] Open
Abstract
In this review we consider what appears to be a paradox in immunotherapies based around radiation therapy. The paradox is based on three main points. 1. That T cells are needed for radiation's efficacy; 2. That tumor-specific T cells are enriched in the field of treatment; and 3. That radiation kills T cells in the treatment field. We discuss evidence of the effect of radiation on T cells in the field given their ongoing movement in and out of tissues and the tumor, and how the movement of T cells impacts the treated primary tumor and untreated distant metastases. Given this evidence, we revisit the paradox to understand how the extraordinary efficacy of radiation and immunity in preclinical models is dependent on this radiation sensitive cell.
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Affiliation(s)
- Michael J Gough
- Earle A. Chiles Research Institute, Robert W. Franz Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St., Portland, OR 97213, USA.
| | - Marka R Crittenden
- Earle A. Chiles Research Institute, Robert W. Franz Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St., Portland, OR 97213, USA; The Oregon Clinic, Portland, OR, 97213, USA
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21
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Donlon NE, Davern M, O’Connell F, Sheppard A, Heeran A, Bhardwaj A, Butler C, Narayanasamy R, Donohoe C, Phelan JJ, Lynam-Lennon N, Dunne MR, Maher S, O’Sullivan J, Reynolds JV, Lysaght J. Impact of radiotherapy on the immune landscape in oesophageal adenocarcinoma. World J Gastroenterol 2022; 28:2302-2319. [PMID: 35800186 PMCID: PMC9185220 DOI: 10.3748/wjg.v28.i21.2302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/19/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the contemporary era of cancer immunotherapy, an abundance of clinical and translational studies have reported radiotherapy (RT) and immunotherapies as a viable option for immunomodulation of many cancer subtypes, with many related clinical trials ongoing. In locally advanced disease, chemotherapy or chemoradiotherapy followed by surgical excision of the tumour remain the principal treatment strategy in oesophageal adenocarcinoma (OAC), however, the use of the host immune system to improve anti-tumour immunity is rapidly garnering increased support in the curative setting.
AIM To immunophenotype OAC patients’ immune checkpoint (IC) expression with and without radiation and evaluate the effects of checkpoint blockade on cell viability.
METHODS In the contemporary era of cancer immunotherapy, an abundance of studies have demonstrated that combination RT and IC inhibitors (ICIs) are effective in the immunomodulation of many cancer subtypes, with many related clinical trials ongoing. Although surgical excision and elimination of tumour cells by chemotherapy or chemoradiotherapy remains the gold standard approach in OAC, the propagation of anti-tumour immune responses is rapidly garnering increased support in the curative setting. The aim of this body of work was to immunophenotype OAC patients’ IC expression with and without radiation and to establish the impact of checkpoint blockade on cell viability. This study was a hybrid combination of in vitro and ex vivo models. Quantification of serum immune proteins was performed by enzyme-linked immunosorbent assay. Flow cytometry staining was performed to evaluate IC expression for in vitro OAC cell lines and ex vivo OAC biopsies. Cell viability in the presence of radiation with and without IC blockade was assessed by a cell counting kit-8 assay.
RESULTS We identified that conventional dosing and hypofractionated approaches resulted in increased IC expression (PD-1, PD-L1, TIM3, TIGIT) in vitro and ex vivo in OAC. There were two distinct subcohorts with one demonstrating significant upregulation of ICs and the contrary in the other cohort. Increasing IC expression post RT was associated with a more aggressive tumour phenotype and adverse features of tumour biology. The use of anti-PD-1 and anti-PD-L1 immunotherapies in combination with radiation resulted in a significant and synergistic reduction in viability of both radiosensitive and radioresistant OAC cells in vitro. Interleukin-21 (IL-21) and IL-31 significantly increased, with a concomitant reduction in IL-23 as a consequence of 4 Gray radiation. Similarly, radiation induced an anti-angiogenic tumour milieu with reduced expression of vascular endothelial growth factor-A, basic fibroblast growth factor, Flt-1 and placental growth factor.
CONCLUSION The findings of the current study demonstrate synergistic potential for the use of ICIs and ionising radiation to potentiate established anti-tumour responses in the neoadjuvant setting and is of particular interest in those with advanced disease, adverse features of tumour biology and poor treatment responses to conventional therapies.
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Affiliation(s)
- Noel E Donlon
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Maria Davern
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Fiona O’Connell
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Andrew Sheppard
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Aisling Heeran
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Anshul Bhardwaj
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Christine Butler
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Ravi Narayanasamy
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Claire Donohoe
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - James J Phelan
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Niamh Lynam-Lennon
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Margaret R Dunne
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Stephen Maher
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Jacintha O’Sullivan
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - John V Reynolds
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Joanne Lysaght
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
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22
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Chen F, Jin JY, Hui TSK, Jing H, Zhang H, Nong Y, Han Y, Wang W, Ma L, Yi F, Chen Q, Zhang Y, Fu P, Yang L, Xu Z, Kong FMS. Radiation Induced Lymphopenia Is Associated With the Effective Dose to the Circulating Immune Cells in Breast Cancer. Front Oncol 2022; 12:768956. [PMID: 35600350 PMCID: PMC9118537 DOI: 10.3389/fonc.2022.768956] [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: 09/05/2021] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
Background Lymphopenia is a known significant factor for treatment outcome in cancer patients, with underlying risk factor poorly understood in breast cancer. We hypothesize that the effective dose to the circulating immune cells (EDIC) which was related with lymphopenia in lung cancer will also have significant effect for radiation induced lymphopenia (RIL) in patients with breast cancer. Material and Methods Patients treated with adjuvant radiotherapy (RT) and with complete blood tests within one week from RT end/start (post/preRT) were eligible in this study. Radiation dosimetric factors were collected retrospectively, and EDIC for each patient was calculated based on the doses to lung, heart and total body according to the model description, as previously reported. RIL was defined by the CTCAE5.0 based on postRT peripheral lymphocyte count (PLC). Linear regression was first used to test the correlation between EDIC with post/preRT PLC ratio and postRT PLC, using all these as continuous variables. Normal tissue complication probability (NTCP) was used to develop models that predict the CTCAE graded RIL from EDIC. Results A total of 735 patients were eligible. The mean post/preRT PLC ratio was 0.66 (95% CI: 0.64-0.68) and mean EDIC of breast cancer was 1.70Gy (95% CI: 1.64-1.75). Both post/preRT PLC ratio and postRT PLC were significantly correlated with EDIC (P<0.001), with R2 of 0.246. For patients with normal preRT PLC, the post/preRT PLC ratio was better associated with EDIC, and postRT PLC was expressed as PLCpreRT × (0.89 – 0.16 × EDIC). For patients with preRT lymphopenia, postRT PLC was better associated with EDIC and it was 1.1 – 0.17 × EDIC. Using binned EDIC as the dose variable, the bootstrap validated NTCPs fit the data nicely with R2 of 0.93, 0.96, and 0.94 for grade-1, grade-2, and grade-3 RIL, respectively. The corresponding EDIC to induce 50% of grade-1, grade-2 and grade-3 RIL was 1.2, 2.1 and 3.7 Gy, respectively. Conclusion EDIC is a significant factor for RIL in patients with breast cancer, and may be used to compute the risk of lymphopenia in each individual patient with the use of the conventional NTCP modeling. External validation is needed before the EDIC can be used to guide RT plan.
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Affiliation(s)
- Fang Chen
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,Department of Clinical Oncology, Hong Kong University Li Ka Shing Medical School, Hong Kong, Hong Kong SAR, China
| | - Jian-Yue Jin
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - Timothy S K Hui
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Haiman Jing
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hong Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Yaqing Nong
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ying Han
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Weili Wang
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - Lingyu Ma
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Fan Yi
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Qingqing Chen
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yongsheng Zhang
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Li Yang
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhiyuan Xu
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Feng-Ming Spring Kong
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,Department of Clinical Oncology, Hong Kong University Li Ka Shing Medical School, Hong Kong, Hong Kong SAR, China
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23
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Venkatesulu BP, Chan DP, Giridhar P, Upadhyay R, Sharma A, Elghazawy H, Elumalai T, V P, Mallick S, Hsieh CE. A systematic review and meta-analysis of the impact of radiation-related lymphopenia on outcomes in pancreatic cancer. Future Oncol 2022; 18:1885-1895. [PMID: 35132868 DOI: 10.2217/fon-2021-0483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Background: Pancreatic cancer is a devastating disease with a 5-year survival rate of 5-10%. Radiation is commonly used in neoadjuvant and adjuvant settings to improve local control. Studies have shown that circulating lymphocyte count depletion after radiation has been associated with poor tumor control and inferior overall survival (OS) outcomes. Method: To better understand the impact of radiation-associated lymphopenia in pancreatic cancer, the authors undertook this systematic review and meta-analysis of clinical studies that have reported radiation-related lymphopenia in pancreatic cancer. Results: A systematic methodology search of PubMed, Embase and the Cochrane Library resulted in 2969 abstracts. Nine studies fulfilled the inclusion criteria. Six studies reported on outcomes in patients undergoing definitive chemoradiation and three studies comparing outcomes in stereotactic body radiotherapy versus definitive chemoradiation. The patients with severe lymphopenia were at increased risk of death with a pooled hazard ratio of 2.33 (95% CI: 1.79, 3.03; I2: 36%; p < 0.001) compared with patients with no severe lymphopenia. The odds of developing severe lymphopenia were 1.12 (95% CI: 0.45, 2.79; I2: 95%; p < 0.81). The pooled mean difference for OS was -6.80 months (95% CI: -10.35, -3.24; I2: 99%; p < 0.002), suggesting that patients who develop grade 3 or 4 lymphopenia have inferior median OS outcomes. Limiting the mean splenic dose to less than 9 Gy as well as various spleen dosimetric parameters such as visit (V)10 <32%, V15 <23% and V20 <15.4% can reduce the incidence of severe lymphopenia. Conclusion: Radiation-related lymphopenia is associated with an increased hazard of death and inferior median OS. Spleen dosimetric parameters correlate with the incidence of severe lymphopenia and with sub-optimal survival outcomes. There is a need to validate these findings in prospective studies.
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Affiliation(s)
| | - Dennis Pai Chan
- Department of Radiation Oncology, Loyola University, Chicago, 60153 IL, USA
| | - Prashanth Giridhar
- Department of Radiation Oncology, National Cancer Institute, New Delhi, India
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Amrish Sharma
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Hagar Elghazawy
- Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Abbaseya, Cairo, Egypt
| | - Thiraviyam Elumalai
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Pragathee V
- Department of Internal Medicine, Karpagam Faculty of Medical Sciences & Research, Coimbatore, Tamil Nadu, India
| | - Supriya Mallick
- Department of Radiation Oncology, National Cancer Institute, New Delhi, India
| | - Cheng En Hsieh
- Department of Radiation Oncology, Institute for Radiological Research, Chang Gung Memorial Hospital at Linkou & Chang Gung University, Taoyuan City, Taiwan
- Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston & The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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24
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Wang Y, Shen L, Wan J, Zhang H, Wu R, Wang J, Wang Y, Xu Y, Cai S, Zhang Z, Xia F. Short-course radiotherapy combined with CAPOX and Toripalimab for the total neoadjuvant therapy of locally advanced rectal cancer: a randomized, prospective, multicentre, double-arm, phase II trial (TORCH). BMC Cancer 2022; 22:274. [PMID: 35291966 PMCID: PMC8922781 DOI: 10.1186/s12885-022-09348-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/28/2022] [Indexed: 12/15/2022] Open
Abstract
Background For patients with locally advanced (T3-4/N +) rectal cancer (LARC), the standard treatment is neoadjuvant chemoradiotherapy combined with total mesorectal resection, which greatly decreases local recurrence but does not improve overall survival. For patients who achieve a complete clinical response (cCR) after nCRT, a “Watch & Wait” (W&W) approach can be received to improve quality of life. Currently, total neoadjuvant therapy (TNT) has been demonstrated to increase the complete response rate and achieve early control of distant metastasis. Recent studies have shown promising synergistic effects of the combination of immunotherapy (PD-1/PD-L1 antibodies) and radiotherapy. Thus, for LARC patients, the combination of immunotherapy and TNT is likely to further improve the rate of complete response and prognosis. The disparities between induction therapy and consolidation therapy need to be investigated. Methods TORCH is a randomized, prospective, multicentre, double-arm, phase II trial of short-course radiotherapy (SCRT) combined with chemotherapy and immunotherapy in LARC. 130 LARC patients will be treated with the TNT approach and assigned to the consolidation arm and induction arm. The consolidation arm will receive SCRT, followed by 6 cycles of capecitabine plus oxaliplatin (CAPOX) and Toripalimab. The induction arm will first receive 2 cycles of CAPOX and Toripalimab, then receive SCRT, followed by 4 cycles of CAPOX and Toripalimab. Both groups will receive curative surgery or the W&W strategy. The primary endpoint is the complete response rate (rate of pCR plus cCR). The secondary endpoints include the grade 3–4 acute adverse effects rate, 3-year disease-free survival (DFS) rate, 3-year local recurrence-free survival (LRFS) rate, 3-year OS rate, rate of surgical complications and quality of life (QoL) scores. The “pick the winner” method is used to investigate the better treatment regimen. The trial was opened on 13th April 2021, and the first patient was recruited on 6th May 2021. Discussion TORCH will investigate whether SCRT combined with chemotherapy and Toripalimab can achieve better complete response rates, good tolerance and prognosis in LARC patients. This is the first clinical trial to compare the efficacy of induced immunotherapy and consolidative immunotherapy based on the TNT strategy. Trial registration Trial Registration Number and Date of Registration: ClinicalTrials.gov NCT04518280, August 15, 2020.
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Affiliation(s)
- Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Juefeng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Hui Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Ruiyan Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Jingwen Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Yan Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Ye Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Sanjun Cai
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China. .,Shanghai Key Laboratory of Radiation Oncology, Shanghai, China.
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Dosimetric Modeling of Lymphopenia in Patients With Metastatic Cancer Receiving Palliative Radiation and PD-1 Immune Checkpoint Inhibitors. Adv Radiat Oncol 2022; 7:100880. [PMID: 35097241 PMCID: PMC8783121 DOI: 10.1016/j.adro.2021.100880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/09/2021] [Indexed: 01/02/2023] Open
Abstract
Purpose Methods and Materials Results Conclusions
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26
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Ledys F, Kalfeist L, Galland L, Limagne E, Ladoire S. Therapeutic Associations Comprising Anti-PD-1/PD-L1 in Breast Cancer: Clinical Challenges and Perspectives. Cancers (Basel) 2021; 13:5999. [PMID: 34885109 PMCID: PMC8656936 DOI: 10.3390/cancers13235999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 12/12/2022] Open
Abstract
Despite a few cases of long-responder patients, immunotherapy with anti-PD-(L)1 has so far proved rather disappointing in monotherapy in metastatic breast cancer, prompting the use of synergistic therapeutic combinations incorporating immunotherapy by immune-checkpoint inhibitors. In addition, a better understanding of both the mechanisms of sensitivity and resistance to immunotherapy, as well as the immunological effects of the usual treatments for breast cancer, make it possible to rationally consider this type of therapeutic combination. For several years, certain treatments, commonly used to treat patients with breast cancer, have shown that in addition to their direct cytotoxic effects, they may have an impact on the tumor immune microenvironment, by increasing the antigenicity and/or immunogenicity of a "cold" tumor, targeting the immunosuppressive microenvironment or counteracting the immune-exclusion profile. This review focuses on preclinical immunologic synergic mechanisms of various standard therapeutic approaches with anti-PD-(L)1, and discusses the potential clinical use of anti-PD-1/L1 combinations in metastatic or early breast cancer.
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Affiliation(s)
- Fanny Ledys
- Platform of Transfer in Cancer Biology, Georges-François Leclerc Center, 21000 Dijon, France; (F.L.); (L.K.); (L.G.); (E.L.)
- School of Medicine and Pharmacy, University of Burgundy Franche-Comté, 21000 Dijon, France
- UMR INSERM 1231, Lipides Nutrition Cancer, 21000 Dijon, France
| | - Laura Kalfeist
- Platform of Transfer in Cancer Biology, Georges-François Leclerc Center, 21000 Dijon, France; (F.L.); (L.K.); (L.G.); (E.L.)
- School of Medicine and Pharmacy, University of Burgundy Franche-Comté, 21000 Dijon, France
- UMR INSERM 1231, Lipides Nutrition Cancer, 21000 Dijon, France
| | - Loick Galland
- Platform of Transfer in Cancer Biology, Georges-François Leclerc Center, 21000 Dijon, France; (F.L.); (L.K.); (L.G.); (E.L.)
- Department of Medical Oncology, Georges-François Leclerc Center, 21000 Dijon, France
| | - Emeric Limagne
- Platform of Transfer in Cancer Biology, Georges-François Leclerc Center, 21000 Dijon, France; (F.L.); (L.K.); (L.G.); (E.L.)
- School of Medicine and Pharmacy, University of Burgundy Franche-Comté, 21000 Dijon, France
- UMR INSERM 1231, Lipides Nutrition Cancer, 21000 Dijon, France
| | - Sylvain Ladoire
- Platform of Transfer in Cancer Biology, Georges-François Leclerc Center, 21000 Dijon, France; (F.L.); (L.K.); (L.G.); (E.L.)
- School of Medicine and Pharmacy, University of Burgundy Franche-Comté, 21000 Dijon, France
- UMR INSERM 1231, Lipides Nutrition Cancer, 21000 Dijon, France
- Department of Medical Oncology, Georges-François Leclerc Center, 21000 Dijon, France
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27
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Chen F, Yu H, Zhang H, Nong Y, Wang Q, Jing H, Han Y, Wu J, Zhou Z, Yang L, Xu Z, Liu Y, Fu P, Jin JY, Hsue V, Chang A, Kong FMS. Risk factors for radiation induced lymphopenia in patients with breast cancer receiving adjuvant radiotherapy. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1288. [PMID: 34532425 PMCID: PMC8422134 DOI: 10.21037/atm-21-2150] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/25/2021] [Indexed: 12/31/2022]
Abstract
Background This study aimed to investigate radiation-induced lymphopenia and its potential risk factors in patients with breast cancer receiving adjuvant radiotherapy. Methods Breast cancer patients received adjuvant radiotherapy (RT) at our hospital with peripheral lymphocyte counts (PLC) at pre-and immediately after RT (post-RT) were eligible. The primary endpoints were any grade of lymphopenia post-RT and nadir-PLC/pre-PLC <0.8. Patient characteristics, tumor factors, and treatment factors were collected for risk assessment. Data are presented as mean and 95% confidence interval (CI) unless otherwise specified. Matched analysis was used to compare the statistical significance between different RT techniques. Results A total of 735 consecutive patients met the study criteria. The mean PLC was 1.58×109/L before and 0.99×109/L post-RT (P<0.001). At the end of RT, 60.5% of patients had lymphopenia. Univariate and multivariable logistic analyses showed that RT technique involving RapidArc, mean lung dose, and chemotherapy were significant risk factors (P<0.05) for lymphopenia. RT technique was the only significant risk factor (P<0.05) for nadir-PLC/pre-PLC <0.8. Patients treated with RapidArc had a significantly greater reduction of PLC along with greater V5 of the lungs, even after matching mean lung dose and radiated volume. Conclusions Lymphopenia is common in patients with breast cancer after adjuvant RT. RT technique is the only significant factor for lymphopenia and nadir-PLC/pre-PLC <0.8, suggesting the significance of RT technique choice to minimize lymphopenia and improve treatment outcomes.
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Affiliation(s)
- Fang Chen
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hao Yu
- Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hong Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yaqing Nong
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Qian Wang
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Haiman Jing
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ying Han
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Junjie Wu
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zheng Zhou
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li Yang
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhiyuan Xu
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yaya Liu
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Jian-Yue Jin
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH, USA
| | - Victor Hsue
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Amy Chang
- Comprehensive Oncology Center, Hong Kong Sanatorium & Hospital, Hong Kong, China
| | - Feng-Ming Spring Kong
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,Department of Clinical Oncology, Hong Kong University Li Ka Shing Medical School, Hong Kong, China
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Khandekar MJ, Keane FK. Radiation Dose and Fractionation in Locally Advanced Lung Cancer: A Simple Question With a Complicated Answer. JAMA Oncol 2021; 7:1505-1506. [PMID: 34383023 DOI: 10.1001/jamaoncol.2021.3180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Melin J Khandekar
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
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29
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Merkel Cell Carcinoma of the Head and Neck: Epidemiology, Pathogenesis, Current State of Treatment and Future Directions. Cancers (Basel) 2021; 13:cancers13143506. [PMID: 34298720 PMCID: PMC8305628 DOI: 10.3390/cancers13143506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/07/2021] [Accepted: 07/07/2021] [Indexed: 12/12/2022] Open
Abstract
Merkel cell carcinoma (MCC) is a rare, cutaneous neuroendocrine malignancy with increasing incidence. The skin of the head and neck is a common subsite for MCC with distinctions in management from other anatomic areas. Given the rapid pace of developments regarding MCC pathogenesis (Merkel cell polyoma virus (MCPyV)-positive or virus-negative, cell of origin), diagnosis, staging and treatment, and up to date recommendations are critical for optimizing outcomes. This review aims to summarize currently available literature for MCC of the head and neck. The authors reviewed current literature, including international guidelines regarding MCC pathogenesis, epidemiology, diagnosis, staging, and treatment. Subsequently recommendations were derived including the importance of baseline imaging, MCPyV serology testing, primary site surgery, nodal evaluation, radiotherapy, and the increasing role of immune modulating agents in MCC. MCPyV serology testing is increasingly important with potential distinctions in treatment response and surveillance between virus-positive and virus-negative MCC. Surgical management continues to balance optimizing local control with minimal morbidity. Similarly, radiotherapy continues to have importance in the adjuvant, definitive, and palliative setting for MCC of the head and neck. Immunotherapy has changed the paradigm for advanced MCC, with increasing work focusing on optimizing outcomes for non-responders and high-risk patients, including those with immunosuppression.
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Wang Q, Li S, Qiao S, Zheng Z, Duan X, Zhu X. Changes in T Lymphocyte Subsets in Different Tumors Before and After Radiotherapy: A Meta-analysis. Front Immunol 2021; 12:648652. [PMID: 34220806 PMCID: PMC8242248 DOI: 10.3389/fimmu.2021.648652] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/01/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose Radiation therapy (RT) induces an immune response, but the relationship of this response with tumor type is not fully understood. This meta-analysis further elucidated this relationship by analyzing the changes in T lymphocyte subsets in different tumors before and after radiotherapy. Methods We searched English-language electronic databases including PubMed, EMBASE, and the Cochrane Library to collect studies on the changes in peripheral blood CD3+ T lymphocytes, CD4+ T lymphocytes, and CD8+ T lymphocytes before and after radiotherapy in tumor patients from January 2015 to April 2021. The quality of the included literature was evaluated using the NOS scale provided by the Cochrane Collaboration, and statistical software RevMan 5.4 was used to analyze the included literature. P<0.05 was considered to indicate statistical significance. Results A total of 19 studies in 16 articles involving 877 tumor patients were included. All data were collected within 1 month before or after radiotherapy. Meta-analysis showed that numbers of CD3+ T lymphocytes (SMD: -0.40; 95% CI [-0.75, -0.04]; p = 0.03) and CD4+ T lymphocytes (SMD: -0.43; 95% CI: [-0.85, -0.02]; p = 0.04) were significantly reduced after radiotherapy compared with before treatment, but there was no statistically significant difference for CD8+ T lymphocytes (SMD: 0.33; 95% CI: [-0.88, 0.74]; p = 0.12). Subgroup analysis showed that peripheral blood T lymphocytes decreased in head and neck cancer. However, in prostate cancer and breast cancer, there was no significant change in peripheral blood. 1 month after radiotherapy, it has a potential proliferation and activation effect on lymphocytes in esophageal cancer and lung cancer. The results showed that CD8+T lymphocytes increased in peripheral blood after SBRT. Radiotherapy alone reduced CD3+ T lymphocyte numbers. Conclusions Within 1 month of radiotherapy, patients have obvious immunological changes, which can cause apoptosis and reduction of T lymphocytes, and affect the balance of peripheral blood immune cells. The degree of immune response induced by radiotherapy differed between tumor types.
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Affiliation(s)
- Qin Wang
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shangbiao Li
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Simiao Qiao
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhihao Zheng
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaotong Duan
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoxia Zhu
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Leidner R, Crittenden M, Young K, Xiao H, Wu Y, Couey MA, Patel AA, Cheng AC, Watters AL, Bifulco C, Morris G, Rushforth L, Nemeth S, Urba WJ, Gough M, Bell RB. Neoadjuvant immunoradiotherapy results in high rate of complete pathological response and clinical to pathological downstaging in locally advanced head and neck squamous cell carcinoma. J Immunother Cancer 2021; 9:jitc-2021-002485. [PMID: 33963014 PMCID: PMC8108690 DOI: 10.1136/jitc-2021-002485] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Checkpoint inhibitors targeting programmed death receptor-1 (PD-1) have been tested in the neoadjuvant setting for the treatment of locoregionally advanced head and neck squamous cell carcinoma (HNSCC); however, response rates are modest. We hypothesized that adding stereotactic body radiation therapy (SBRT) to anti-PD-1 would be safe prior to definitive surgical resection and would enhance pathological response compared with historical cohorts of patients with locoregionally advanced HNSCC treated with checkpoint inhibitor alone. METHODS The Neoadjuvant Immuno-Radiotherapy Trial was an investigator-initiated single institution phase Ib clinical trial that enrolled patients with previously untreated locally advanced HPV-positive and HPV-negative HNSCC between 2018 and 2019. Eligible patients were treated with neoadjuvant SBRT at a total dose of either 40 Gy in 5 fractions or 24 Gy in 3 fractions, delivered in a 1-week timespan, with or without nivolumab, prior to definitive surgical resection. Patients were then planned for treatment with adjuvant nivolumab for 3 months. The primary safety endpoint was unplanned delay in surgery considered to be at least possibly related to neoadjuvant treatment. The primary efficacy endpoints included pathological complete response (pCR), major pathological response (mPR), and the rate of clinical to pathological downstaging after neoadjuvant treatment. RESULTS Twenty-one patients underwent neoadjuvant treatment, which was well tolerated and did not delay surgery, thus meeting the primary endpoint. Tissue responses were characterized by robust inflammatory infiltrates in the regression bed, plasma cells and cholesterol clefts. Among the entire study group, the mPR and pCR rate was 86% and 67%, respectively. Clinical to pathological downstaging occurred in 90% of the patients treated. CONCLUSION These data demonstrate that radiation delivered only to the gross tumor volume combined with immunotherapy was safe, resulted in a high rate of mPR and should be further evaluated as a locally focused neoadjuvant therapy for patients with head and neck cancer. TRIAL REGISTRATION NUMBER This study is registered with clinicaltrials.gov (NCT03247712) and is active, but closed to patient accrual.
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Affiliation(s)
- Rom Leidner
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA
| | - Marka Crittenden
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA.,Division of Radiation Oncology, The Oregon Clinic, Portland, Oregon, USA
| | - Kristina Young
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA.,Division of Radiation Oncology, The Oregon Clinic, Portland, Oregon, USA
| | - Hong Xiao
- Department of Pathology, Providence Health and Services- Oregon, Portland, Oregon, USA
| | - Yaping Wu
- Department of Pathology, Providence Health and Services- Oregon, Portland, Oregon, USA
| | | | - Ashish A Patel
- Providence Cancer Institute, Portland, Oregon, USA.,Head and Neck Institute, Portland, Oregon, USA
| | | | | | - Carlo Bifulco
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA.,Department of Pathology, Providence Health and Services- Oregon, Portland, Oregon, USA
| | - George Morris
- Earle A Chiles Research Institute, Portland, Oregon, USA
| | | | | | - Walter J Urba
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA
| | - Michael Gough
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA
| | - R Bryan Bell
- Providence Cancer Institute, Portland, Oregon, USA .,Earle A Chiles Research Institute, Portland, Oregon, USA
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Marciscano AE, Haimovitz-Friedman A, Lee P, Tran PT, Tomé WA, Guha C, (Spring) Kong FM, Sahgal A, El Naqa I, Rimner A, Marks LB, Formenti SC, DeWeese TL. Immunomodulatory Effects of Stereotactic Body Radiation Therapy: Preclinical Insights and Clinical Opportunities. Int J Radiat Oncol Biol Phys 2021; 110:35-52. [DOI: 10.1016/j.ijrobp.2019.02.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 12/14/2022]
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Nie Z, Zhao P, Shang Y, Sun B. Nomograms to predict the prognosis in locally advanced oral squamous cell carcinoma after curative resection. BMC Cancer 2021; 21:372. [PMID: 33827452 PMCID: PMC8028060 DOI: 10.1186/s12885-021-08106-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/24/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Oral squamous cell carcinoma (OSCC) is the dominant histologic type of oral cancer. Locally advanced OSCC remains a major therapeutic challenge. Our study aimed to develop and validate nomograms predicting survival prognosis in patients with locally advanced oral squamous cell carcinoma (OSCC) after curative resection. METHODS A total of 269 consecutive patients with primary OSCC who received curative resection between September 2007 and March 2020 were retrospectively enrolled in our study. Patients were randomly assigned to the training cohort (n = 201) or the validation cohort (n = 68). Multivariate Cox regression analyses were conducted to determine independent prognostic factors for overall survival (OS) and cancer specific survival (CSS) in the training set, which were used to develop nomogram models estimating 3-, and 5-year OS and CSS. We also evaluated the nomograms using concordance indices (c-index), calibration curves, and decision curve analyses (DCA), and compared those with the AJCC 8th staging system. The results were externally validated in the validation cohort. RESULTS Age, Kaplan-Feinstein (KFI) index, pT, the number of positive nodes and systemic inflammatory index (SII) were significant prognostic predictors for OS and CSS. The OS nomogram had c-index values of 0.712 in the training set and 0.697 in the validation set, while the CSS nomogram exhibited c-index values of 0.709 in the training set and 0.675 in the validation set. These data were superior to those of AJCC 8th staging system, suggesting high discriminative ability of the nomograms. Calibration curves exhibited good agreement between observed and predicted survival. DCA curves indicated the nomograms were with potential clinical usefulness. These results were validated in the validation set. CONCLUSIONS The novel nomograms incorporating clinically available characteristics for OS and CSS prediction were developed in the locally advanced OSCC patients after curative surgery. Validation revealed good discrimination and calibration, indicating the clinical utility of the nomograms in the individualized prognosis prediction of locally advanced OSCC after curative surgery.
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Affiliation(s)
- Zhiliang Nie
- First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Pengcheng Zhao
- School of Stomatology, Dalian Medical University, Dalian, Liaoning, China
| | - Yishan Shang
- Dalian Municipal Women and Children's Medical Center, Dalian, Liaoning, China
| | - Bo Sun
- The Second Hospital of Dalian Medical University, Dalian, Liaoning, China.
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Azoulay M, Chang SD, Gibbs IC, Hancock SL, Pollom EL, Harsh GR, Adler JR, Harraher C, Li G, Hayden Gephart M, Nagpal S, Thomas RP, Recht LD, Jacobs LR, Modlin LA, Wynne J, Seiger K, Fujimoto D, Usoz M, von Eyben R, Choi CYH, Soltys SG. A phase I/II trial of 5-fraction stereotactic radiosurgery with 5-mm margins with concurrent temozolomide in newly diagnosed glioblastoma: primary outcomes. Neuro Oncol 2021; 22:1182-1189. [PMID: 32002547 DOI: 10.1093/neuonc/noaa019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We sought to determine the maximum tolerated dose (MTD) of 5-fraction stereotactic radiosurgery (SRS) with 5-mm margins delivered with concurrent temozolomide in newly diagnosed glioblastoma (GBM). METHODS We enrolled adult patients with newly diagnosed glioblastoma to 5 days of SRS in a 3 + 3 design on 4 escalating dose levels: 25, 30, 35, and 40 Gy. Dose limiting toxicity (DLT) was defined as Common Terminology Criteria for Adverse Events grades 3-5 acute or late CNS toxicity, including adverse radiation effect (ARE), the imaging correlate of radiation necrosis. RESULTS From 2010 to 2015, thirty patients were enrolled. The median age was 66 years (range, 51-86 y). The median target volume was 60 cm3 (range, 14.7-137.3 cm3). DLT occurred in 2 patients: one for posttreatment cerebral edema and progressive disease at 3 weeks (grade 4, dose 40 Gy); another patient died 1.5 weeks following SRS from postoperative complications (grade 5, dose 40 Gy). Late grades 1-2 ARE occurred in 8 patients at a median of 7.6 months (range 3.2-12.6 mo). No grades 3-5 ARE occurred. With a median follow-up of 13.8 months (range 1.7-64.4 mo), the median survival times were: progression-free survival, 8.2 months (95% CI: 4.6-10.5); overall survival, 14.8 months (95% CI: 10.9-19.9); O6-methylguanine-DNA methyltransferase hypermethylated, 19.9 months (95% CI: 10.5-33.5) versus 11.3 months (95% CI: 8.9-17.6) for no/unknown hypermethylation (P = 0.03), and 27.2 months (95% CI: 11.2-48.3) if late ARE occurred versus 11.7 months (95% CI: 8.9-17.6) for no ARE (P = 0.08). CONCLUSIONS The per-protocol MTD of 5-fraction SRS with 5-mm margins with concurrent temozolomide was 40 Gy in 5 fractions. ARE was limited to grades 1-2 and did not statistically impact survival.
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Affiliation(s)
- Melissa Azoulay
- Department of Radiation Oncology, Stanford University, Stanford, California, USA.,Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Steven D Chang
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Steven L Hancock
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Griffith R Harsh
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - John R Adler
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Ciara Harraher
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | | | - Seema Nagpal
- Department of Neurology, Stanford University, Stanford, California, USA
| | - Reena P Thomas
- Department of Neurology, Stanford University, Stanford, California, USA
| | - Lawrence D Recht
- Department of Neurology, Stanford University, Stanford, California, USA
| | - Lisa R Jacobs
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Leslie A Modlin
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Jacob Wynne
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Kira Seiger
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Dylann Fujimoto
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Melissa Usoz
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Rie von Eyben
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Clara Y H Choi
- Department of Radiation Oncology, Stanford University, Stanford, California, USA.,Department of Radiation Oncology, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
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Kong Y, Ma Y, Zhao X, Pan J, Xu Z, Zhang L. Optimizing the Treatment Schedule of Radiotherapy Combined With Anti-PD-1/PD-L1 Immunotherapy in Metastatic Cancers. Front Oncol 2021; 11:638873. [PMID: 33859942 PMCID: PMC8042160 DOI: 10.3389/fonc.2021.638873] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/15/2021] [Indexed: 12/25/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) targeting programmed cell death protein-1 (PD-1), and programmed cell death ligand-1 (PD-L1) have been approved for a variety of malignant tumors and are widely used to treat patients with metastatic disease. However, the efficacy of PD-1 inhibitors is limited due to tumor heterogeneity, high tumor burden, and "cold" tumor microenvironment. Radiotherapy can improve the anti-tumor effects of PD-1/PD-L1 inhibitors in various ways. As a new radiotherapy method, stereotactic body radiotherapy (SBRT) or hypofractionated radiotherapy (HFRT) provides higher doses per fraction to the target lesions, thus achieving immune activation effects and overcoming tumor resistance to anti-PD-1/PD-L1 treatment, which significantly improves the local and distant control of tumors. However, for different metastatic situations, radiotherapy plays different roles in the combination therapy. In oligometastatic status, radiotherapy can be used as a local radical treatment aiming to eliminate cancers in cooperation with systemic PD-1 inhibitors. In other circumstances, like bulky metastasis or multiple metastatic tumors, radiotherapy can be used as adjuvant to systemic immunotherapy. This review focuses on the underlying mechanisms and optimization strategies for the combination of radiotherapy and anti-PD-1/PD-L1 therapy in metastatic disease.
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Affiliation(s)
- Yuehong Kong
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institution of Radiotherapy and Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Combined Radiotherapy and Immunotherapy of Cancer, Suzhou, China
| | - Yifu Ma
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institution of Radiotherapy and Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Combined Radiotherapy and Immunotherapy of Cancer, Suzhou, China
| | - Xiangrong Zhao
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institution of Radiotherapy and Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Combined Radiotherapy and Immunotherapy of Cancer, Suzhou, China
| | - Jie Pan
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi Xu
- Department of Medical Affairs, ICON Plc, Beijing, China
| | - Liyuan Zhang
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institution of Radiotherapy and Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Combined Radiotherapy and Immunotherapy of Cancer, Suzhou, China
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Fang PQ, Gunther JR, Wu SY, Dabaja BS, Nastoupil LJ, Ahmed S, Neelapu SS, Pinnix CC. Radiation and CAR T-cell Therapy in Lymphoma: Future Frontiers and Potential Opportunities for Synergy. Front Oncol 2021; 11:648655. [PMID: 33842363 PMCID: PMC8027336 DOI: 10.3389/fonc.2021.648655] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/16/2021] [Indexed: 12/28/2022] Open
Abstract
CAR T-cell therapy has revolutionized the treatment approach to patients with relapsed/refractory hematologic malignancies; however, there continues to be opportunity for improvement in treatment toxicity as well as response durability. Radiation therapy can play an important role in combined modality treatments for some patients undergoing CAR T-cell therapy in various clinical settings. In this review, we discuss the current evidence for RT in the setting of CAR T-cell therapy for patients with hematologic malignancies and propose potential opportunities for future investigation of RT and CAR T-cell treatment synergy. Future research frontiers include investigation of hypotheses including radiation priming of CAR T-cell mediated death, pre-CAR T-cell tumor debulking with radiation therapy, and selection of high risk patients for early radiation salvage after CAR T cell therapy.
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Affiliation(s)
- Penny Q Fang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jillian R Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Susan Y Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Loretta J Nastoupil
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sairah Ahmed
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sattva S Neelapu
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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37
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Medler TR, Blair TC, Crittenden MR, Gough MJ. Defining Immunogenic and Radioimmunogenic Tumors. Front Oncol 2021; 11:667075. [PMID: 33816320 PMCID: PMC8017281 DOI: 10.3389/fonc.2021.667075] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/02/2021] [Indexed: 12/21/2022] Open
Abstract
In the cancer literature tumors are inconsistently labeled as ‘immunogenic’, and experimental results are occasionally dismissed since they are only tested in known ‘responsive’ tumor models. The definition of immunogenicity has moved from its classical definition based on the rejection of secondary tumors to a more nebulous definition based on immune infiltrates and response to immunotherapy interventions. This review discusses the basis behind tumor immunogenicity and the variation between tumor models, then moves to discuss how these principles apply to the response to radiation therapy. In this way we can identify radioimmunogenic tumor models that are particularly responsive to immunotherapy only when combined with radiation, and identify the interventions that can convert unresponsive tumors so that they can also respond to these treatments.
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Affiliation(s)
- Terry R Medler
- Earle A. Chiles Research Institute, Providence Cancer Institute, Providence Portland Medical Center, Portland, OR, United States
| | - Tiffany C Blair
- Earle A. Chiles Research Institute, Providence Cancer Institute, Providence Portland Medical Center, Portland, OR, United States.,Molecular Microbiology and Immunology, OHSU, Portland, OR, United States
| | - Marka R Crittenden
- Earle A. Chiles Research Institute, Providence Cancer Institute, Providence Portland Medical Center, Portland, OR, United States.,Molecular Microbiology and Immunology, OHSU, Portland, OR, United States.,The Oregon Clinic, Portland, OR, United States
| | - Michael J Gough
- Earle A. Chiles Research Institute, Providence Cancer Institute, Providence Portland Medical Center, Portland, OR, United States.,Molecular Microbiology and Immunology, OHSU, Portland, OR, United States
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Paganetti H, Beltran C, Both S, Dong L, Flanz J, Furutani K, Grassberger C, Grosshans DR, Knopf AC, Langendijk JA, Nystrom H, Parodi K, Raaymakers BW, Richter C, Sawakuchi GO, Schippers M, Shaitelman SF, Teo BKK, Unkelbach J, Wohlfahrt P, Lomax T. Roadmap: proton therapy physics and biology. Phys Med Biol 2021; 66. [DOI: 10.1088/1361-6560/abcd16] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022]
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Donlon NE, Power R, Hayes C, Davern M, Reynolds JV, Lysaght J. Radiation and Immunotherapy in Upper Gastrointestinal Cancers: The Current State of Play. Int J Mol Sci 2021; 22:ijms22031071. [PMID: 33499003 PMCID: PMC7865314 DOI: 10.3390/ijms22031071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
Radiotherapy remains one of the contemporary cornerstones of cancer treatment in the neoadjuvant, curative, adjuvant and palliative settings, either in isolation or as a multimodal approach. Moreover, recent advances in targeted immune checkpoint therapy have firmly established immunotherapy as the fourth pillar in cancer therapy alongside surgery, chemotherapy and notably radiotherapy. There is emerging evidence to suggest both radioresistance and reduced efficacy of immune checkpoint blockade (ICB) are potentiated by the tumour microenvironment (TME) and in fact modulating aspects of this immunosuppressive milieu is instrumental to unlocking anti-tumour immunity. The response rates of Upper Gastrointestinal (UGI) malignancies to ICB remains modest at 10–15%, compared to melanoma at 20–40%. Harnessing the effects of radiotherapy through remodelling of the TME using ICB as a radiosensitisor is an avenue showing promise. Here we explore the rationale behind combining radiotherapy with ICB, as a symbiotic relationship in shifting the balance in favour of anti-tumour immunity. We discuss the effects of radiotherapy on immunogenic cell death, the concept of the abscopal effect, the importance of the cGAS STING pathway, and their relevance in the context of the tumour microenvironment. Furthermore, dosing and timing of radiotherapy and ICB is now being evaluated for its synergistic effects on host tumour immunity, and we review the ongoing efforts and current available literature for single agent and dual agent ICB in combination multimodal therapy for both locally advanced operable and metastatic disease of the upper gastrointestinal tract.
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Affiliation(s)
- Noel E. Donlon
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Robert Power
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Conall Hayes
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Maria Davern
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - John V. Reynolds
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Joanne Lysaght
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
- Correspondence:
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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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Osipov A, Blair AB, Liberto J, Wang J, Li K, Herbst B, Xu Y, Li S, Niu N, Rashid R, Ding D, Liu Y, Wang Z, Wolfgang CL, Burkhart RA, Laheru D, Zheng L. Inhibition of focal adhesion kinase enhances antitumor response of radiation therapy in pancreatic cancer through CD8+ T cells. Cancer Biol Med 2021; 18:206-214. [PMID: 33628595 PMCID: PMC7877172 DOI: 10.20892/j.issn.2095-3941.2020.0273] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/29/2020] [Indexed: 12/11/2022] Open
Abstract
Objective: Pancreatic ductal adenocarcinoma (PDAC) is a deadly malignancy, due in large part to its resistance to conventional therapies, including radiotherapy (RT). Despite RT exerting a modest antitumor response, it has also been shown to promote an immunosuppressive tumor microenvironment. Previous studies demonstrated that focal adhesion kinase inhibitors (FAKi) in clinical development inhibit the infiltration of suppressive myeloid cells and T regulatory (T regs) cells, and subsequently enhance effector T cell infiltration. FAK inhibitors in clinical development have not been investigated in combination with RT in preclinical murine models or clinical studies. Thus, we investigated the impact of FAK inhibition on RT, its potential as an RT sensitizer and immunomodulator in a murine model of PDAC. Methods: We used a syngeneic orthotopic murine model to study the effect of FAKi on hypofractionated RT. Results: In this study we showed that IN10018, a small molecular FAKi, enhanced antitumor response to RT. Antitumor activity of the combination of FAKi and RT is T cell dependent. FAKi in combination with RT enhanced CD8+ T cell infiltration significantly in comparison to the radiation or FAKi treatment alone (P < 0.05). FAKi in combination with radiation inhibited the infiltration of granulocytes but enhanced the infiltration of macrophages and T regs in comparison with the radiation or FAKi treatment alone (P < 0.01). Conclusions: These results support the clinical development of FAKi as a radiosensitizer for PDAC and combining FAKi with RT to prime the tumor microenvironment of PDAC for immunotherapy.
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Affiliation(s)
- Arsen Osipov
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Alex B Blair
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Juliane Liberto
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Jianxin Wang
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Keyu Li
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Brian Herbst
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Yao Xu
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Shiqi Li
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Nan Niu
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Rufiaat Rashid
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Ding Ding
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Yanan Liu
- InxMed Shanghai, Shanghai 201202, China
| | | | - Christopher L Wolfgang
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Richard A Burkhart
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Daniel Laheru
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Lei Zheng
- The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
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Abstract
Immunotherapy (IO) has become a standard treatment in patients with metastatic and locally advanced non-small cell lung cancer (NSCLC), and is now being tested in patients with early stage disease. IO agents currently in use for lung cancer target PD-1, PD-L1, and CTLA-4. While survival and tumor control have improved with IO, many patients have limited or short responses to IO. Therefore, methods to improve the systemic response to IO are needed. Radiation therapy (RT) is an integral component of lung cancer treatment, and may improve systemic response to IO by increasing antigen presentation, increasing co-stimulatory signaling, increasing T-cells recruitment, upregulating PD-L1, increasing tumor stromal lymphocyte infiltration, and altering the microenvironment. IO after definitive chemoradiation is now standard treatment in unresectable stage III NSCLC following publication of the PACIFIC clinical trial. For early stage NSCLC, IO is being investigated in conjunction with stereotactic body radiotherapy (SBRT). The benefit of adding RT to IO in patients with metastatic disease may be especially pronounced in patients with low baseline PD-L1 expression, potentially when delivered as a short course of SBRT, as supported by the PEMBRO-RT clinical trial. Current and ongoing clinical trials are evaluating the optimal radiation dose, timing, and sequencing of RT with IO.
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Affiliation(s)
- William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Haidong Dong
- Departments of Urology and Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Zhao X, Kong Y, Zhang L. Anti-PD-1 Immunotherapy Combined With Stereotactic Body Radiation Therapy and GM-CSF as Salvage Therapy in a PD-L1-Negative Patient With Refractory Metastatic Esophageal Squamous Cell Carcinoma: A Case Report and Literature Review. Front Oncol 2020; 10:1625. [PMID: 33014817 PMCID: PMC7493754 DOI: 10.3389/fonc.2020.01625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal squamous cell carcinoma (ESCC) is a malignancy with poor prognosis, which is often diagnosed at a late stage. Effective treatment options are limited when patients fail standard systemic therapy. The application of PD-1 inhibitors have led to a paradigm shift in the treatment of ESCC, but its efficacy as monotherapy is limited. Previous studies have shown that the antitumor effects may be reinforced when a PD-1 inhibitor is combined with radiotherapy or GM-CSF. This study aimed to report a case of a patient about advanced unresectable ESCC negative expression of PD-L1, who experienced tumor progression after chemoradiotherapy and targeted therapy.A significant systemic effect was seen after PD-1 inhibitor combined with GM-CSF and stereotactic body radiotherapy (SBRT) for metastatic lesions, however, severe pneumonia occurred after the triple-combination therapy. This study also reviewed several reports about the efficacy and safety of combination therapy.
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Affiliation(s)
- Xiangrong Zhao
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China
| | - Yuehong Kong
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China
| | - Liyuan Zhang
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China
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44
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Abravan A, Faivre-Finn C, Kennedy J, McWilliam A, van Herk M. Radiotherapy-Related Lymphopenia Affects Overall Survival in Patients With Lung Cancer. J Thorac Oncol 2020; 15:1624-1635. [PMID: 32553694 DOI: 10.1016/j.jtho.2020.06.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Lymphopenia after radiotherapy has an adverse effect on the patient's outcome. However, the relationship between radiotherapy dose delivery and lymphopenia is not fully understood. This work used image-based data mining to identify anatomical regions where the received dose is correlated with severe lymphopenia. METHODS A total of 901 patients with lung cancer were analyzed. A Cox model was used to assess prognostic factors of overall survival (OS). Two matched groups were defined-patients with lymphopenia of grade 3 or higher and patients without lymphopenia of grade 3-based on tumor volume, baseline lymphocytes, and prescribed dose. Then, data mining was used to identify regions where dose correlates significantly with lymphopenia of grade 3 or higher. For this, dose matrices were aligned using registration of the computed tomography images to one reference patient. Mean dose distributions were obtained for the two groups, and organs of significance were detected. Dosimetric parameters from the identified organs that had the highest correlation with lymphocytes at nadir were selected. Multivariable analysis was conducted for lymphopenia of grade 3 or higher on the full lung cohort, and the model was tested on 305 patients with esophageal cancer. RESULTS Adjusted Cox regression revealed that lymphopenia of grade 3 or higher is an independent factor of OS. The anatomical regions identified were the heart, lung, and thoracic vertebrae. Dosimetric parameters for lymphopenia included thoracic vertebrae V20, mean lung dose, and mean heart dose, which were further validated in the esophageal cancer cohort. CONCLUSIONS We report that severe lymphopenia during radiotherapy is a poor prognostic factor for OS in patients with lung cancer and could be mitigated by minimizing thoracic vertebrae V20, mean lung dose, and mean heart dose to limit the irradiation of stem cells and blood pool.
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Affiliation(s)
- Azadeh Abravan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jason Kennedy
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Alan McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Marcel van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Abraham J, Botto S, Mizuno N, Pryke K, Gall B, Boehm D, Sali TM, Jin H, Nilsen A, Gough M, Baird J, Chakhtoura M, Subra C, Trautmann L, Haddad EK, DeFilippis VR. Characterization of a Novel Compound That Stimulates STING-Mediated Innate Immune Activity in an Allele-Specific Manner. Front Immunol 2020; 11:1430. [PMID: 32733475 PMCID: PMC7360819 DOI: 10.3389/fimmu.2020.01430] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
The innate immune response to cytosolic DNA involves transcriptional activation of type I interferons (IFN-I) and proinflammatory cytokines. This represents the culmination of intracellular signaling pathways that are initiated by pattern recognition receptors that engage DNA and require the adaptor protein Stimulator of Interferon Genes (STING). These responses lead to the generation of cellular and tissue states that impair microbial replication and facilitate the establishment of long-lived, antigen-specific adaptive immunity. Ultimately this can lead to immune-mediated protection from infection but also to the cytotoxic T cell-mediated clearance of tumor cells. Intriguingly, pharmacologic activation of STING-dependent phenotypes is known to enhance both vaccine-associated immunogenicity and immune-based anti-tumor therapies. Unfortunately, the STING protein exists as multiple variant forms in the human population that exhibit differences in their reactivity to chemical stimuli and in the intensity of molecular signaling they induce. In light of this, STING-targeting drug discovery efforts require an accounting of protein variant-specific activity. Herein we describe a small molecule termed M04 that behaves as a novel agonist of human STING. Importantly, we find that the molecule exhibits a differential ability to activate STING based on the allelic variant examined. Furthermore, while M04 is inactive in mice, expression of human STING in mouse cells rescues reactivity to the compound. Using primary human cells in ex vivo assays we were also able to show that M04 is capable of simulating innate responses important for adaptive immune activation such as cytokine secretion, dendritic cell maturation, and T cell cross-priming. Collectively, this work demonstrates the conceivable utility of a novel agonist of human STING both as a research tool for exploring STING biology and as an immune potentiating molecule.
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Affiliation(s)
- Jinu Abraham
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Sara Botto
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Nobuyo Mizuno
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Kara Pryke
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Bryan Gall
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Dylan Boehm
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Tina M. Sali
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Haihong Jin
- Veterans Affairs Medical Center, Portland, OR, United States
| | - Aaron Nilsen
- Veterans Affairs Medical Center, Portland, OR, United States
| | - Michael Gough
- Integrated Therapies Laboratory, Earle A. Chiles Research Institute, Portland, OR, United States
| | - Jason Baird
- Integrated Therapies Laboratory, Earle A. Chiles Research Institute, Portland, OR, United States
| | - Marita Chakhtoura
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Caroline Subra
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Lydie Trautmann
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
| | - Elias K. Haddad
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Victor R. DeFilippis
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, United States
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46
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Wang X, Wang P, Zhao Z, Mao Q, Yu J, Li M. A review of radiation-induced lymphopenia in patients with esophageal cancer: an immunological perspective for radiotherapy. Ther Adv Med Oncol 2020; 12:1758835920926822. [PMID: 32518598 PMCID: PMC7252357 DOI: 10.1177/1758835920926822] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/24/2020] [Indexed: 12/16/2022] Open
Abstract
Radiotherapy is a frequently utilized therapeutic modality in the treatment of esophageal cancer (EC). Even though extensive studies are carried out in radiotherapy for EC, the design of the clinical target volume and the radiation dose is not satisfactorily uniform. Radiotherapy acts as a double-edged sword on the immune system; it has both an immunostimulatory effect and an immunosuppressive effect. Radiation-induced lymphopenia and its potential association with tumor control and survival outcomes remain to be understood. The advent of immunotherapy has renewed the focus on preserving a pool of functioning lymphocytes in the circulation. In this review, we summarize the potential impact mechanisms of radiotherapy on peripheral blood lymphocytes and the prognostic role of radiation-induced lymphopenia in patients with EC. We also propose the concept of organs-at-risk of lymphopenia and discuss potential strategies to mitigate its effects on patients with EC. From an immunological perspective, we put forward the hypothesis that optimizing radiation modalities, radiation target volume schemes, and radiation doses could help to reduce radiation-induced lymphopenia risks and maximize the immunomodulatory role of radiotherapy. An optimized radiotherapy plan may further enhance the feasibility and effectiveness of combining immunotherapy with radiotherapy for EC.
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Affiliation(s)
- Xin Wang
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Peiliang Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Zongxing Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Qingfeng Mao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Minghuan Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong province 250117, China
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Cesaire M, Le Mauff B, Rambeau A, Toutirais O, Thariat J. [Mechanisms of radiation-induced lymphopenia and therapeutic impact]. Bull Cancer 2020; 107:813-822. [PMID: 32451070 DOI: 10.1016/j.bulcan.2020.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 01/29/2023]
Abstract
Radiation induced lymphopenia is frequent and can be severe and durable. Although lymphocytes have long been known as highly radiosensitive cells, it is poorly characterized. Radiation-induced lymphopenia seems to affect lymphocyte subpopulations differently and seems to be influenced by radiation modalities. The depth and duration of lymphopenia depend on the location of the irradiation and the volumes of treatment. Importantly, radiation-induced lymphopenia has been associated with poorer prognosis in several tumor types. The knowledge about radiation-induced lymphopenia might lead to a rethinking of the modalities of radiotherapy and new approaches to restore lymphocytes counts.
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Affiliation(s)
- Mathieu Cesaire
- Centre François-Baclesse/ARCHADE, département de radiothérapie, 3, avenue General Harris, 14000 Caen, France
| | - Brigitte Le Mauff
- Normandie University, UNICAEN, sérine protéases et physiopathologie de l'unité neurovasculaire, Inserm U919, Caen, France; University Hospital of Caen, Department of Immunology, Caen, France
| | - Audrey Rambeau
- Centre François-Baclesse/ARCHADE, département de radiothérapie, 3, avenue General Harris, 14000 Caen, France
| | - Olivier Toutirais
- Normandie University, UNICAEN, sérine protéases et physiopathologie de l'unité neurovasculaire, Inserm U919, Caen, France; University Hospital of Caen, Department of Immunology, Caen, France
| | - Juliette Thariat
- Centre François-Baclesse/ARCHADE, département de radiothérapie, 3, avenue General Harris, 14000 Caen, France; Laboratoire de physique corpusculaire IN2P3/ENSICAEN - UMR6534, Caen, France; Normandie University, UNICAEN, Caen, France.
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48
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Kumar S, Chmura S, Robinson C, Lin SH, Gadgeel SM, Donington J, Feliciano J, Stinchcombe TE, Werner-Wasik M, Edelman MJ, Moghanaki D. Alternative Multidisciplinary Management Options for Locally Advanced NSCLC During the Coronavirus Disease 2019 Global Pandemic. J Thorac Oncol 2020; 15:1137-1146. [PMID: 32360578 PMCID: PMC7194660 DOI: 10.1016/j.jtho.2020.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently accelerating. Patients with locally advanced NSCLC (LA-NSCLC) may require treatment in locations where resources are limited, and the prevalence of infection is high. Patients with LA-NSCLC frequently present with comorbidities that increase the risk of severe morbidity and mortality from COVID-19. These risks may be further increased by treatments for LA-NSCLC. Although guiding data is scarce, we present an expert thoracic oncology multidisciplinary (radiation oncology, medical oncology, surgical oncology) consensus of alternative strategies for the treatment of LA-NSCLC during a pandemic. The overarching goals of these approaches are the following: (1) reduce the number of visits to a health care facility, (2) reduce the risk of exposure to severe acute respiratory syndrome–coronavirus-2, (3) attenuate the immunocompromising effects of lung cancer therapies, and (4) provide effective oncologic therapy. Patients with resectable disease can be treated with definitive nonoperative management if surgical resources are limited or the risks of perioperative care are high. Nonoperative options include chemotherapy, chemoimmunotherapy, and radiation therapy with sequential schedules that may or may not affect long-term outcomes in an era in which immunotherapy is available. The order of treatments may be on the basis of patient factors and clinical resources. Whenever radiation therapy is delivered without concurrent chemotherapy, hypofractionated schedules are appropriate. For patients who are confirmed to have COVID-19, usually, cancer therapies may be withheld until symptoms have resolved with negative viral test results. The risk of severe treatment-related morbidity and mortality is increased for patients undergoing treatment for LA-NSCLC during the COVID-19 pandemic. Adapting alternative treatment strategies as quickly as possible may save lives and should be implemented through communication with the multidisciplinary cancer team.
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Affiliation(s)
- Sameera Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
| | - Steven Chmura
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Steven H Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Shirish M Gadgeel
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Josephine Feliciano
- Department of Medical Oncology, Johns Hopkins University, Baltimore, Maryland
| | | | - Maria Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Martin J Edelman
- Department of Hematology and Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Drew Moghanaki
- Department of Radiation Oncology, Emory University, Atlanta Veterans Affairs Health Care System, Atlanta, Georgia
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So TH, Chan SK, Chan WL, Choi H, Chiang CL, Lee V, Lam TC, Wong I, Law S, Kwong D, Ming Spring Kong F, Jin JY, Lam KO. Lymphopenia and Radiation Dose to Circulating Lymphocytes With Neoadjuvant Chemoradiation in Esophageal Squamous Cell Carcinoma. Adv Radiat Oncol 2020; 5:880-888. [PMID: 33089018 PMCID: PMC7560564 DOI: 10.1016/j.adro.2020.03.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose We hypothesized that radiation-induced lymphopenia could be predicted by the effective dose to the circulating immune cells (EDIC) in advanced esophageal squamous cell carcinoma treated with trimodality therapy according to the Dutch ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) trial regimen. To test this hypothesis, we examined the effect of EDIC on the degree of lymphocyte drop (lymphocyte nadir). Methods and Materials Patients with advanced nonmetastatic esophageal squamous cell carcinoma treated in a single tertiary cancer center from 2012 to 2018 were eligible for this study. All patients had to have a radiation therapy plan available for EDIC computation and received neoadjuvant chemoradiation according to the Dutch CROSS trial regimen before radical esophagectomy. The EDIC was calculated as a function of integral doses to the lung, heart, and total body with a verified mathematical model. The association between EDIC and lymphocyte nadir was studied, and the relationships of overall survival (OS) with lymphocyte nadir and EDIC were assessed using multivariable Cox regression model. Results This analysis included 92 eligible consecutive patients (77 men and 15 women). The mean EDIC was 2.8 Gy (range, 0.6-4.4). EDIC was significantly correlated with lymphocyte nadir (Spearman coefficient = –0.505; P < .01), and lymphocyte nadir was a significant independent factor for shorter OS (hazard ratio = 0.63; P < .001). Lymphocyte nadir was also the most significant factor in determining OS among other clinical parameters. Exploratory analysis showed significant OS differences between EDIC groups (<2, 2-4, and >4 Gy). The 2–year OS rates were 66.7%, 42.7%, and 16.7% for EDIC <2, 2 to 4, and >4 Gy, respectively. Conclusions There was a significant correlation between radiation dose to circulating immune cells and lymphocyte nadir, which in turn affected OS in patients with advanced nonmetastatic esophageal squamous cell carcinoma treated by trimodality therapy.
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Affiliation(s)
- Tsz Him So
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Sik Kwan Chan
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Wing Lok Chan
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Horace Choi
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Chi Leung Chiang
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Victor Lee
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Tai Chung Lam
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | - Ian Wong
- Department of Surgery, the University of Hong Kong, Hong Kong
| | - Simon Law
- Department of Surgery, the University of Hong Kong, Hong Kong
| | - Dora Kwong
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
| | | | - Jian Yue Jin
- Department of Radiation Oncology, University Hospitals/Seidman Cancer Center and Case Comprehensive Cancer Center, Mentor, Ohio
| | - Ka On Lam
- Department of Clinical Oncology, the University of Hong Kong, Hong Kong
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50
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Gough MJ, Sharon S, Crittenden MR, Young KH. Using Preclinical Data to Design Combination Clinical Trials of Radiation Therapy and Immunotherapy. Semin Radiat Oncol 2020; 30:158-172. [PMID: 32381295 PMCID: PMC7213059 DOI: 10.1016/j.semradonc.2019.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunotherapies are rapidly entering the clinic as approved treatments for diverse cancer pathologies. Radiation therapy is an integral partner in cancer therapy, commonly as part of complicated multimodality approaches that optimize patient outcomes. Preclinical studies have demonstrated that the success of radiation therapy in tumor control is due in part to immune mechanisms, and that outcomes following radiation therapy can be improved through combination with a range of immunotherapies. However, preclinical models of cancer are very different from patient tumors, and the way these preclinical tumors are treated is often very different from standard of care treatment of patients. This review examines the preclinical and clinical data for the role of the immune system in radiation therapy outcomes, and how to integrate preclinical findings into clinical trials, using ongoing studies as examples.
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Affiliation(s)
- Michael J Gough
- Earle A. Chiles Research Institute, Providence Cancer Institute, Providence Portland Medical Center, Portland, OR.
| | - Shay Sharon
- Department of Oral and Maxillofacial Surgery, Hadassah and Hebrew University Medical Center, Jerusalem, ISRAEL
| | - Marka R Crittenden
- Earle A. Chiles Research Institute, Providence Cancer Institute, Providence Portland Medical Center, Portland, OR; The Oregon Clinic, Portland, OR
| | - Kristina H Young
- Earle A. Chiles Research Institute, Providence Cancer Institute, Providence Portland Medical Center, Portland, OR; The Oregon Clinic, Portland, OR
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