1
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Chen F, Zhou P, Ren G, Lee EKW, Liu Q, Shen Y, Wang Y, El Helali A, Jin JY, Fu P, Dai W, Lee AWM, Yu H, Spring Kong FM. Interpretable deep learning insights: Unveiling the role of 1 Gy volume on lymphopenia after radiotherapy in breast cancer. Radiother Oncol 2024; 197:110333. [PMID: 38772478 DOI: 10.1016/j.radonc.2024.110333] [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: 12/27/2023] [Revised: 04/18/2024] [Accepted: 05/07/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Lymphopenia is known for its significance on poor survivals in breast cancer patients. Considering full dosimetric data, this study aimed to develop and validate predictive models for lymphopenia after radiotherapy (RT) in breast cancer. MATERIAL AND METHODS Patients with breast cancer treated with adjuvant RT were eligible in this multicenter study. The study endpoint was lympopenia, defined as the reduction in absolute lymphocytes and graded lymphopenia after RT. The dose-volume histogram (DVH) data of related critical structures and clinical factors were taken into account for the development of dense neural network (DNN) predictive models. The developed DNN models were validated using external patient cohorts. RESULTS A total of 918 consecutive patients with invasive breast cancer enrolled. The training, testing, and external validating datasets consisted of 589, 203, and 126 patients, respectively. Treatment volumes at nearly all dose levels of the DVH were significant predictors for lymphopenia following RT, including volumes at very low-dose 1 Gy (V1) of organs at risk (OARs) including lung, heart and body, especially ipsilateral-lung V1. A final DNN model, combining full DVH dosimetric parameters of OARs and three key clinical factors, achieved a predictive accuracy of 75 % or higher. CONCLUSION This study demonstrated and externally validated the significance of full dosimetric data, particularly the volume of low dose at as low as 1 Gy of critical structures on lymphopenia after radiation in patients with breast cancer. The significance of V1 deserves special attention, as modern VMAT RT technology often has a relatively high value of this parameter. Further study is warranted for RT plan optimization.
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Affiliation(s)
- Fang Chen
- Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ping Zhou
- Department of Radiotherapy, The First Affiliated Hospital of Hainan Medical University, China
| | - Ge Ren
- Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Eric K W Lee
- Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Qin Liu
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yuanyuan Shen
- Department of Biomedical Engineering, Shenzhen University, Shenzhen, China
| | - Yang Wang
- Department of Biomedical Engineering, Shenzhen Polytechnic University, Shenzhen, China
| | - Aya El Helali
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jian-Yue Jin
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Wei Dai
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Anne W M Lee
- Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hao Yu
- Institute of Biomedical and Health Engineering, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.
| | - Feng-Ming Spring Kong
- Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
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2
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McCullum L, Shin J, Xing S, Beekman C, Schuemann J, Hong T, Duda D, Mohan R, Lin SH, Correa-Alfonso CM, Domal S, Withrow J, Bolch W, Paganetti H, Grassberger C. Predicting Severity of Radiation Induced Lymphopenia in Individual Proton Therapy Patients for Varying Dose Rate and Fractionation Using Dynamic 4-Dimensional Blood Flow Simulations. Int J Radiat Oncol Biol Phys 2023; 116:1226-1233. [PMID: 36739919 PMCID: PMC10363211 DOI: 10.1016/j.ijrobp.2023.01.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/11/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE Radiation-induced lymphopenia has gained attention recently as the result of its correlation with survival in a range of indications, particularly when combining radiation therapy (RT) with immunotherapy. The purpose of this study is to use a dynamic blood circulation model combined with observed lymphocyte depletion in patients to derive the in vivo radiosensitivity of circulating lymphocytes and study the effect of RT delivery parameters. METHODS AND MATERIALS We assembled a cohort of 17 patients with hepatocellular carcinoma treated with proton RT alone in 15 fractions (fx) using conventional dose rates (beam-on time [BOT], 120 seconds) for whom weekly absolute lymphocyte counts (ALCs) during RT and follow-up were available. We used HEDOS, a time-dependent, whole-body, blood flow computational framework, in combination with explicit liver blood flow modeling, to calculate the dose volume histograms for circulating lymphocytes for changing BOTs (1 second-300 seconds) and fractionations (5 fx, 15 fx). From this, we used the linear cell survival model and an exponential model to determine patient-specific lymphocyte radiation sensitivity, α, and recovery, σ, respectively. RESULTS The in vivo-derived patient-specific α had a median of 0.65 Gy-1 (range, 0.30-1.38). Decreasing BOT to 1 second led to an increased average end-of-treatment ALC of 27.5%, increasing to 60.3% when combined with the 5-fx regimen. Decreasing to 5 fx at the conventional dose rate led to an increase of 17.0% on average. The benefit of both increasing dose rate and reducing the number of fractions was patient specificࣧpatients with highly sensitive lymphocytes benefited most from decreasing BOT, whereas patients with slow lymphocyte recovery benefited most from the shorter fractionation regimen. CONCLUSIONS We observed that increasing dose rate at the same fractionation reduced ALC depletion more significantly than reducing the number of fractions. High-dose-rates led to an increased sparing of lymphocytes when shortening the fractionation regimen, particularly for patients with radiosensitive lymphocytes at elevated risk.
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Affiliation(s)
- Lucas McCullum
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Jungwook Shin
- Radiation Epidemiology Branch, National Cancer Institute, Rockville, Maryland
| | - Stella Xing
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Chris Beekman
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Theodore Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dan Duda
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Radhe Mohan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Camilo M Correa-Alfonso
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | - Sean Domal
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | - Julia Withrow
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | - Wesley Bolch
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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3
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Franco R, Cao JQ, Yassa M, Hijal T. Safety of CDK4/6 Inhibitors Combined with Radiotherapy in Patients with Metastatic Breast Cancer: A Review of the Literature. Curr Oncol 2023; 30:5485-5496. [PMID: 37366898 DOI: 10.3390/curroncol30060415] [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: 03/14/2023] [Revised: 05/25/2023] [Accepted: 06/03/2023] [Indexed: 06/28/2023] Open
Abstract
Recent evidence suggests that cyclin-dependent kinase 4/6 (CDK4/6) inhibitors significantly improve progression-free survival and overall survival among metastatic breast cancer patients. However, given the effects on cell cycle arrest, there is potential for CDK4/6 inhibitors and radiotherapy (RT) to work synergistically, enhancing the effect and toxicities of RT. A comprehensive review of the literature on the combination of RT and CDK4/6 inhibitors was performed with 19 eligible studies included in the final analysis. A total of 373 patients who received radiotherapy combined with CDK4/6 inhibitors were evaluated across 9 retrospective studies, 4 case reports, 3 case series, and 3 letters to the editor. The CDK4/6 inhibitor used, RT target, and RT technique were assessed in terms of toxicities. This literature review demonstrates generally limited toxicities with the combination of CDK4/6 inhibitors and palliative radiotherapy to metastatic breast cancer patients. The current evidence is nonetheless limited, and further results of ongoing prospective clinical trials will help clarify whether these treatments can be safely combined.
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Affiliation(s)
- Rejane Franco
- Division of Radiation Oncology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Jeffrey Q Cao
- Division of Radiation Oncology, Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Michael Yassa
- Division of Radiation Oncology, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montreal, QC H1T 2M4, Canada
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
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4
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Kang MK. Implications of recent neoadjuvant clinical trials on the future practice of radiotherapy in locally advanced rectal cancer. World J Gastroenterol 2023; 29:1011-1025. [PMID: 36844136 PMCID: PMC9950859 DOI: 10.3748/wjg.v29.i6.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/08/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Over the last two decades, the standard treatment for locally advanced rectal cancer (LARC) has been neoadjuvant chemoradiotherapy plus total mesorectal excision followed by adjuvant chemotherapy. Total neoadjuvant treatment (TNT) and immunotherapy are two major issues in the treatment of LARC. In the two latest phase III randomized controlled trials (RAPIDO and PRODIGE23), the TNT approach achieved higher rates of pathologic complete response and distant metastasis-free survival than conventional chemoradiotherapy. Phase I/II clinical trials have reported promising response rates to neoadjuvant (chemo)-radiotherapy combined with immunotherapy. Accordingly, the treatment paradigm for LARC is shifting toward methods that increase the oncologic outcomes and organ preservation rate. However, despite the progress of these combined modality treatment strategies for LARC, the radiotherapy details in clinical trials have not changed significantly. To guide future radiotherapy for LARC with clinical and radiobiological evidence, this study reviewed recent neoadjuvant clinical trials evaluating TNT and immunotherapy from a radiation oncologist’s perspective.
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Affiliation(s)
- Min Kyu Kang
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, Daegu 40414, South Korea
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5
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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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6
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Yang L, Xu Z, Ma L, Liu Q, Chang AT, Wang Q, Zha J, Zhang J, Jiang X, Zhang J, Kong FM(S, Guo L. Early onset of severe lymphopenia during definitive radiotherapy correlates with mean body dose and predicts poor survival in cervical cancer. Cancer Biomark 2022; 34:149-159. [PMID: 35094986 PMCID: PMC9108612 DOI: 10.3233/cbm-210292] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND: Lymphopenia during definitive radiotherapy (RT) has been shown to reduce survival in patients with cervical cancer. However, there are few studies on the significance of onset time of lymphopenia during RT in patients with cervical cancer. OBJECTIVE: This study aimed to exam the prognostic significance of early onset of severe lymphopenia (EOSL) during definitive RT in patients with cervical cancer. METHODS: Newly diagnosed cervical cancer patients treated with definitive RT from January 2015 to December 2019 were eligible for this retrospective study. EOSL was defined as first onset of grade 3–4 lymphopenia ⩽ 3 weeks from the start of RT. Mean body dose (MBD) was the mean radiation dose absorbed by the body during the whole course of external beam RT (EBRT) and was directly obtained from the dose volume histogram (DVH) of the EBRT planning. Logistic regression analysis and restricted cubic spline (RCS) models were applied to assess relationships between clinicopathological factors and EOSL. Survival analysis was performed using Kaplan-Meier curves and log-rank test. A COX regression model was developed to predict overall survival (OS). RESULTS: A total of 104 patients were included and 59.6% had EOSL. MBD (P= 0.04), concurrent cisplatin (P= 0.011), and pre-RT absolute lymphocyte count (ALC) (P= 0.001) were associated with EOSL. A linear relationship (P for non-linearity = 0.803) between MBD and risk of EOSL was found. Patients with EOSL had decreased OS (2-yr 75.1% vs 91.1%, P= 0.021) and progression-free survival (PFS) (2-yr 71.2% vs 83.7%, P= 0.071). An OS prediction COX model was developed with C-index of 0.835 and AUC of 0.872. CONCLUSIONS: EOSL during definitive RT correlates with MBD and predicts poor survival in patients with cervical cancer.
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Affiliation(s)
- Li Yang
- Department of Pathology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Zhiyuan Xu
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Linyu Ma
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Qin Liu
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Amy T.Y. Chang
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
- Hong Kong Sanatorium and Hospital, Hong Kong, China
| | - Qian Wang
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jiandong Zha
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jinliang Zhang
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Xiaoqin Jiang
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jingjing Zhang
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Feng-Ming (Spring) Kong
- Clinical Oncology Center, the University of Hong Kong – Shenzhen Hospital, Shenzhen, Guangdong, China
- The University of Hong Kong Li Ka Shing Medical School, Hong Kong, China
| | - Linlang Guo
- Department of Pathology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
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7
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Xiang X, Li N, Ding Z, Dai Z, Jin J. Peripheral Lymphocyte Counts and Lymphocyte-Related Inflammation Indicators During Radiotherapy for Pelvic Malignancies: Temporal Characterization and Dosimetric Predictors. Technol Cancer Res Treat 2022; 21:15330338221116494. [PMID: 36114641 PMCID: PMC9486273 DOI: 10.1177/15330338221116494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: To identify the dosimetric predictors of lymphocytopenia
and retrospectively analyze the changing trend of peripheral lymphocyte counts
and lymphocyte-related inflammatory indicators in patients with simple pelvic
radiotherapy. Methods and Materials: We retrospectively reviewed
the clinical data of 188 patients with pelvic malignancies undergoing pelvic
radiotherapy. The absolute count of neutrophils, lymphocytes, monocytes, and
platelets at each time point was collected, and lymphocyte-related inflammation
indicators were obtained, including neutrophil-to-lymphocyte ratio (NLR),
lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and the
systemic immune-inflammation index (SII). The total pelvic bone (TPB) and the
body within the 5 Gy coverage were retrospectively delineated for each patient.
Dose-volume histograms corresponding to the delivered volumetric arc therapy
plan were used to assess the dose volumes received by the TPB and body. A
paired-samples t-test or Wilcoxon signed-rank test for matched
pairs was applied for pairwise comparisons. We also established a stepwise
multiple linear regression model for the peripheral lymphocyte count (PLC) value
at the end of radiotherapy. Results: The PLC and lymphocyte-related
inflammatory indicators changed significantly after the start of radiotherapy
and persisted for 3-6 months after radiotherapy. The nadirs of PLC occurred at
RT-End, and the PLC was still significantly lower than the baseline value at
RT-3 months and RT-6 months. NLR, PLR, and SII at RT-End are about 3.5 times the
value at RT-Baseline, while LMR is one-fourth of the basal value. In a further
multiple stepwise linear regression analysis, the basal PLC (β = 0.156,
p ≤ .001), gender (β = 0.096, p = .005),
and TPB-V5 (β = −0.016, p ≤ .001) turned out to be the
predictor of the absolute value of lymphocytes at the end of radiotherapy.
Conclusions: The impact of pelvic radiotherapy on PLC and
lymphocyte-related inflammatory indicators is considerable and long-lasting.
Minimizing pelvic bone radiation exposure dose (5 Gy) may help to avoid severe
cases of lymphocytopenia.
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Affiliation(s)
- Xiaoyong Xiang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhen Ding
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhitao Dai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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8
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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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Yu Y, Fu P, Jin JY, Gao S, Wang W, Machtay M, Wang L, Kong FMS, Yu J. Impact of effective dose to immune cells (EDIC) on lymphocyte nadir and survival in limited-stage SCLC. Radiother Oncol 2021; 162:26-33. [PMID: 34139210 DOI: 10.1016/j.radonc.2021.06.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Effective dose to immune cell (EDIC), an estimated radiation dose to the circulating lymphocytes, is of significance for overall survival (OS) in non-small cell lung cancer. This study aimed to validate the EDIC's OS effect on limited-stage small cell lung cancer (LS-SCLC). METHOD AND MATERIALS This study included LS-SCLC patients received definitive chemo-radiation in one single center from 2012 to 2017. All patients had multiple complete-blood-count tests including lymphocyte count at pre-, during- and end- radiotherapy. EDIC, computed according to doses of the lung, heart, and the total body, was assessed for its correlation with lymphocyte nadir, OS and progression free survival (PFS). RESULTS Of 503 eligible patients, the mean EDIC was 7.34 Gy. The mean lymphocyte nadir was 0.48 × 109 cells/L, significantly lower than 1.65 × 109 cells/L at pre-radiotherapy (p < 0.001). EDIC was significantly correlated with lymphocyte nadir under both univariate (p < 0.001) and multivariable linear regression (p < 0.001). Multivariable analysis showed EDIC (HR = 0.1072, p = 0.005) and lymphocyte nadir (HR = 0.345, p = 0.003) were both significant for OS. EDIC was also significant for PFS (HR = 1.046, p = 0.026). The C-indexes of OS prediction were 0.593, 0.617, 0.676, and 0.684, for lymphocyte nadir alone, EDIC alone, combined lymphocyte nadir model, and combined EDIC model, respectively. CONCLUSIONS This study demonstrated that EDIC is an independent predictor for lymphocyte nadir, PFS and OS. EDIC may serve as a predictor for lymphocyte nadir and a surrogate marker for OS in LS-SCLC. More attention should be paid to EDIC to decease the lymphocyte toxicity and improve survival.
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Affiliation(s)
- Yishan Yu
- School of Medicine, Shandong University, Jinan, China; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Jian-Yue Jin
- Department of Radiation Oncology, Seidman Cancer Center, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Siming Gao
- School of Medicine, Shandong University, Jinan, China; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Weili Wang
- Department of Radiation Oncology, Seidman Cancer Center, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Mitchell Machtay
- Department of Radiation Oncology, Seidman Cancer Center, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Linlin Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, Seidman Cancer Center, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA; Department of Clinical Oncology, Hong Kong University Li Ka Shing Medical School, Hong Kong University Shenzhen Hospital, Hong Kong/Shenzhen, China.
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.
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Khalifa J, Mazieres J, Gomez-Roca C, Ayyoub M, Moyal ECJ. Radiotherapy in the Era of Immunotherapy With a Focus on Non-Small-Cell Lung Cancer: Time to Revisit Ancient Dogmas? Front Oncol 2021; 11:662236. [PMID: 33968769 PMCID: PMC8097090 DOI: 10.3389/fonc.2021.662236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/23/2021] [Indexed: 12/15/2022] Open
Abstract
Radiation-induced immune effects have been extensively deciphered over the last few years, leading to the concept of the dual immune effect of radiotherapy with both immunostimulatory and immunosuppressive effects. This explains why radiotherapy alone is not able to drive a strong anti-tumor immune response in most cases, hence underlining the rationale for combining both radiotherapy and immunotherapy. This association has generated considerable interest and hundreds of trials are currently ongoing to assess such an association in oncology. However, while some trials have provided unprecedented results or shown much promise, many hopes have been dashed. Questions remain, therefore, as to how to optimize the combination of these treatment modalities. This narrative review aims at revisiting the old, well-established concepts of radiotherapy relating to dose, fractionation, target volumes and organs at risk in the era of immunotherapy. We then propose potential innovative approaches to be further assessed when considering a radio-immunotherapy association, especially in the field of non-small-cell lung cancer (NSCLC). We finally propose a framework to optimize the association, with pragmatic approaches depending on the stage of the disease.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
| | - Julien Mazieres
- Department of Pulmonology, Centre Hospitalo-Universitaire Larrey, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Carlos Gomez-Roca
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Department of Medical Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Maha Ayyoub
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Elizabeth Cohen-Jonathan Moyal
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
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11
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Steenbrugge J, De Jaeghere EA, Meyer E, Denys H, De Wever O. Splenic Hematopoietic and Stromal Cells in Cancer Progression. Cancer Res 2020; 81:27-34. [PMID: 32998999 DOI: 10.1158/0008-5472.can-20-2339] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/31/2020] [Accepted: 09/24/2020] [Indexed: 11/16/2022]
Abstract
Tumor-derived secretory factors orchestrate splenic hematopoietic and stromal cells to fuel metastasis. The spleen acts as a reservoir site for hematopoietic stem and progenitor cells, which are rapidly exploited as myeloid-derived suppressor cells at the cost of tumor-reactive lymphoid cells. Splenic erythroid progenitor cells and mesenchymal stromal cells contribute directly and indirectly to both tumor immune escape and the metastatic cascade. Animal models provide valuable mechanistic insights, but their translation to a clinical setting highlights specific challenges and open issues. In this review, we envision the exploitation of the spleen as a source for novel biomarkers and therapeutic approaches.
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Affiliation(s)
- Jonas Steenbrugge
- Laboratory of Biochemistry, Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Emiel A De Jaeghere
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
- Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
- Gynecologic Pelvic Oncology Network Ghent (GYPON), Ghent, Belgium
| | - Evelyne Meyer
- Laboratory of Biochemistry, Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Hannelore Denys
- Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
- Gynecologic Pelvic Oncology Network Ghent (GYPON), Ghent, Belgium
| | - Olivier De Wever
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium.
- Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
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12
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Ratosa I, Orazem M, Scoccimarro E, Steinacher M, Dominici L, Aquilano M, Cerbai C, Desideri I, Ribnikar D, Marinko T, Livi L, Meattini I. Cyclin-Dependent Kinase 4/6 Inhibitors Combined With Radiotherapy for Patients With Metastatic Breast Cancer. Clin Breast Cancer 2020; 20:495-502. [PMID: 32622736 DOI: 10.1016/j.clbc.2020.05.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) represent the standard treatment for hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer. Data about the balance between efficacy and toxicity of combined palliative radiotherapy (RT) and CDK4/6 inhibition are lacking. PATIENTS AND METHODS We undertook a review of 46 patients with metastatic breast cancer on systemic treatment with CDK4/6i who underwent 62 metastases-directed RT. Clinical, laboratory, and RT treatment planning data were collected. Statistical analyses included Student t test, paired sample t test, and logistic regression modeling. RESULTS Thirty patients (65.2%) received palbociclib, 15 (32.6%) received ribociclib, and one patient received abemaciclib (2.2%). Median total prescribed RT dose was 20 Gy (range, 8-63 Gy). Sites of RT were bone (n = 50; 80.7%), visceral (n = 7; 11.3%), or brain metastases (n = 3; 4.8%), as well as primary tumor of the breast (n = 2; 3.2%). Overall, the rates of grade 3 or higher adverse events (AEs) were 6.5%, 4.3%, 15.2%, and 23.9% before the start of RT, during RT, 2 and 6 weeks after RT completion, respectively. We found no correlation between dose distribution to organs at risk and the development of AEs. The local control rates for the entire cohort were 98% at 6 months and 90% at 12 months. Overall, pain relief (complete or partial) was experienced by 80% (24/30) of patients who initially reported pain at the treated metastatic site. CONCLUSION We observed a modest increase in the rates of grade 3 or higher AEs after combined RT and CDK4/6i, with maintained efficacy of concomitant RT.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia.
| | - Miha Orazem
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Erika Scoccimarro
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Mateja Steinacher
- Department of Oncology, University Medical Centre Maribor, Maribor, Slovenia
| | - Luca Dominici
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Michele Aquilano
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Cecilia Cerbai
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Isacco Desideri
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Domen Ribnikar
- Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Tanja Marinko
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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13
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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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14
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Lambin P, Lieverse RIY, Eckert F, Marcus D, Oberije C, van der Wiel AMA, Guha C, Dubois LJ, Deasy JO. Lymphocyte-Sparing Radiotherapy: The Rationale for Protecting Lymphocyte-rich Organs When Combining Radiotherapy With Immunotherapy. Semin Radiat Oncol 2020; 30:187-193. [PMID: 32381298 PMCID: PMC8412054 DOI: 10.1016/j.semradonc.2019.12.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There is now strong clinical and preclinical evidence that lymphocytes, for example, CD8+ T cells, are key effectors of immunotherapy and that irradiation of large blood vessels, the heart, and lymphoid organs (including nodes, spleen, bones containing bone marrow, and thymus in children) causes transient or persistent lymphopenia. Furthermore, there is extensive clinical evidence, across multiple cancer sites and treatment modalities, that lymphopenia correlates strongly with decreased overall survival. At the moment, we lack quantitative evidence to establish the relationship between dose-volume and dose-rate to critical normal structures and lymphopenia. Therefore, we propose that data should be systematically recorded to characterise a possible quantitative relationship. This might enable us to improve the efficacy of radiotherapy and develop strategies to predict and prevent treatment-related lymphopenia. In anticipation of more quantitative data, we recommend the application of the principle of As Low As Reasonably Achievable to lymphocyte-rich regions for radiotherapy treatment planning to reduce the radiation doses to these structures, thus moving toward "Lymphocyte-Sparing Radiotherapy."
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Affiliation(s)
- Philippe Lambin
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.
| | - Relinde I Y Lieverse
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Franziska Eckert
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Damiënne Marcus
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Cary Oberije
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Alexander M A van der Wiel
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Chandan Guha
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY
| | - Ludwig J Dubois
- The D-Lab and The M-Lab, Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
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15
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Sun GY, Wang SL, Song YW, Jin J, Wang WH, Liu YP, Ren H, Fang H, Tang Y, Zhao XR, Song YC, Yu ZH, Liu XF, Li YX. Radiation-Induced Lymphopenia Predicts Poorer Prognosis in Patients With Breast Cancer: A Post Hoc Analysis of a Randomized Controlled Trial of Postmastectomy Hypofractionated Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 108:277-285. [PMID: 32147519 DOI: 10.1016/j.ijrobp.2020.02.633] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE The aim of this study was to determine whether radiation-induced lymphopenia affects the survival of patients with breast cancer. METHODS AND MATERIALS Post hoc analysis was conducted on data from 598 patients with breast cancer from a randomized controlled trial comparing postmastectomy hypofractionated radiation therapy (HFRT; 43.5 Gy in 15 fractions over 3 weeks) with conventional fractionated radiation therapy (CFRT; 50 Gy in 25 fractions over 5 weeks). Mean peripheral lymphocyte count (PLC) at different time points in the 2 groups was compared by the t test. Disease-free survival and overall survival were analyzed by the Kaplan-Meier method and compared between groups by the log-rank test. RESULTS Baseline PLC (pre-PLC) was comparable between HFRT and CFRT patients (1.60 ± 0.57 × 109/L vs 1.56 ± 0.52 × 109/L; P = .33). In both groups, the PLC declined steadily during the course of radiation therapy but started to recover at 1 month after radiation therapy. Incidence of lymphopenia was significantly lower in HFRT patients (45.4% vs 55.7%; P = .01). Nadir-PLC was significantly higher in HFRT patients (1.08 ± 0.37 × 109/L vs 0.97 ± 0.31× 109/L; P < .001), as was the nadir-PLC/pre-PLC ratio (0.72 ± 0.28 vs 0.67 ± 0.28; P = .02). Median follow-up was 57.6 months (interquartile range, 38.5-81.4). The 5-year disease-free survival was significantly lower in patients with a nadir-PLC/pre-PLC ratio <0.8 than in those with a ratio ≥0.8 (71.8% vs 82.6%; P = .01); however, overall survival was comparable between the groups (85.8% vs 90.6%; P = .24). CONCLUSIONS The risk of radiation-induced lymphopenia in patients with breast cancer is lower with HFRT than with CFRT. A low nadir-PLC/pre-PLC ratio may predict poor prognosis.
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Affiliation(s)
- Guang-Yi Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Hu Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Ren
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu-Ran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Chun Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Hao Yu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Fan Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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16
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Zhao Q, Li T, Chen G, Zeng Z, He J. Prognosis and Risk Factors of Radiation-Induced Lymphopenia in Early-Stage Lung Cancer Treated With Stereotactic Body Radiation Therapy. Front Oncol 2020; 9:1488. [PMID: 32039000 PMCID: PMC6993213 DOI: 10.3389/fonc.2019.01488] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 12/11/2019] [Indexed: 01/21/2023] Open
Abstract
Background: To investigate the role of stereotactic body RT (SBRT) in decreased total peripheral lymphocyte count (TLC) in patients with early-stage lung cancer and to explore possible risk factors for RT-induced lymphopenia. Materials and Methods: We analyzed the TLCs and lymphocyte subsets of 76 patients in our prospective clinical database who received SBRT for early-stage lung cancer treatment. Relationships between clinical factors or dosimetric parameters and TLC were evaluated using Spearman's correlation analysis and Chi-square tests for continuous and categorical variables, respectively. Multivariate linear regression analysis was used to control for confounding factors. Kaplan–Meier analysis with a log-rank test and a multivariate Cox regression model were used for survival analysis. Results: Most patients (64/76, 84.2%) experienced decreased absolute lymphocyte counts following SBRT, as well as shifts in lymphocyte subset distributions. Spearman's correlation coefficients between post-SBRT TLC and the percentage of the lung and heart receiving 5 to 50 Gy (in 5 Gy increments) shown that most lung DVH parameters [V(10)-V(50)] were significantly negatively correlated with post-SBRT TLC, while only heart V(5), V(20), V(25), V(30), and V(45) were significant. Univariate analyses revealed that a lower Pre-SBRT TLC level, higher mean lung dose, longer treatment duration, and longer TBT were significantly associated with a lower Post-SBRT TLC level (all P < 0.05). Stepwise multivariate linear regression, which incorporated all of the significantly clinical variables and SBRT-related parameters in univariate analysis, revealed that lower pre -SBRT TLC (P < 0.001), higher heart V5 (P = 0.002), and longer total beam-on time (TBT) (P = 0.001) were the independent risk factors for decrease in post-SBRT TLC. Patients with lower post-SBRT TLC and longer TBT exhibited significantly inferior progression-free survival (PFS) (P < 0.001 and P = 0.013) and overall survival (P = 0.006 and P = 0.043). Conclusions: G2 and more severe lymphopenia after SBRT might be an independent prognostic factor for poorer outcome in early-stage lung cancer. Lowering heart V5 and TBT when designing SBRT plans may spare circulating lymphocytes and have the potential to further improve survival outcomes.
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Affiliation(s)
- Qianqian Zhao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tingting Li
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
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Schad MD, Dutta SW, Muller DM, Wijesooriya K, Showalter TN. Radiation-related Lymphopenia after Pelvic Nodal Irradiation for Prostate Cancer. Adv Radiat Oncol 2019; 4:323-330. [PMID: 31011677 PMCID: PMC6460292 DOI: 10.1016/j.adro.2019.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/23/2018] [Accepted: 01/16/2019] [Indexed: 01/11/2023] Open
Abstract
Purpose Given the uncertainty with regard to the effectiveness of pelvic nodal irradiation (PNI) for prostate cancer, we aimed to determine whether patients with prostate cancer who are treated with PNI are at a higher risk of developing radiation-related lymphopenia (RRL). Methods and materials The electronic charts of 886 consecutive patients treated with radiation therapy for prostate cancer between 2006 and 2018 at our institution were retrospectively analyzed. Qualifying patients were those with total lymphocyte counts within 1 year before and 3 to 24 months after the start of radiation therapy. Lymphopenia was the primary outcome, and overall survival and biochemical progression-free survival were secondary outcomes. Results Thirty-six patients with and 95 patients without PNI qualified for inclusion. In the PNI cohort, 61.1% of patients developed RRL (median follow-up total lymphocyte count < 1000 cells/μL) versus 26.3% of non-PNI patients (P < .001). On univariate analysis, initial prostate-specific antigen level, baseline lymphopenia, treatment modality, PNI status, increased planned target volume, and androgen deprivation therapy administration were all significant predictors of RRL (P < .05). On multivariate analysis, PNI status was a significant predictor of RRL (hazard ratio [HR], 3.42; 95% confidence interval [CI], 1.22-9.61; P < .001), as were initial prostate-specific antigen values (HR, 1.05; 95% CI, 1.00-1.11; P = .006) and baseline lymphopenia (HR, 8.32; 95% CI, 2.19-31.6; P = .007). RRL was not predictive for biochemical progression-free survival, distant metastasis, or overall survival on multivariate analysis, but the number of events was likely insufficient for these analyses. Conclusions The higher risk of RRL among patients with PNI comports with other papers that show that increased treatment volumes are associated with higher rates of RRL. Mounting evidence for the adverse effects of RRL on clinical outcomes supports the significance of our findings and suggests that further studies are needed on RRL as a potential harm of PNI that may affect the interpretation of results from clinical trials of PNI.
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Affiliation(s)
| | | | | | | | - Timothy N. Showalter
- Corresponding author. Department of Radiation Oncology, University of Virginia School of Medicine, 1240 Lee Street, P.O. Box 800383, Charlottesville, VA 22908.
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Saito T, Toya R, Yoshida N, Shono T, Matsuyama T, Ninomura S, Watakabe T, Sasaki Y, Baba H, Oya N. Spleen Dose-Volume Parameters as a Predictor of Treatment-related Lymphopenia During Definitive Chemoradiotherapy for Esophageal Cancer. In Vivo 2019; 32:1519-1525. [PMID: 30348711 DOI: 10.21873/invivo.11409] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 12/24/2022]
Abstract
AIM Our study sought to identify dosimetric predictors of treatment-related lymphopenia during chemoradiotherapy for esophageal cancer. MATERIALS AND METHODS Patients with esophageal cancer who had received definitive chemoradiotherapy at our Institution were retrospectively assessed. The absolute volume of the spleen, body, and bone marrow that had received 5, 10, 20, and 30 Gy and the mean splenic dose were recorded. RESULTS Multivariate linear regression analysis revealed that docetaxel use and spleen dose-volume parameters (V5, V10, V20, V30, and mean splenic dose) were significant independent factors negatively influencing the absolute lymphocyte count at nadir. An increase of 1 Gy in mean splenic dose predicted a 2.9% decrease in nadir absolute lymphocyte count. Univariable logistic regression analysis showed that the mean splenic dose was a significant predictor of grade 4 lymphopenia. None of the body or bone marrow dose-volume parameters significantly predicted lymphopenia. CONCLUSION Higher spleen dose-volume parameters were associated with severe lymphopenia during chemoradiotherapy.
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Affiliation(s)
- Tetsuo Saito
- Department of Radiation Oncology, Kumamoto University Hospital, Kumamoto, Japan
| | - Ryo Toya
- Department of Radiation Oncology, Kumamoto University Hospital, Kumamoto, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takashi Shono
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tomohiko Matsuyama
- Department of Radiation Oncology, Kumamoto University Hospital, Kumamoto, Japan
| | - Satoshi Ninomura
- Department of Radiation Oncology, Kumamoto University Hospital, Kumamoto, Japan
| | - Takahiro Watakabe
- Department of Radiation Oncology, Kumamoto University Hospital, Kumamoto, Japan
| | - Yutaka Sasaki
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Natsuo Oya
- Department of Radiation Oncology, Kumamoto University Hospital, Kumamoto, Japan
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