Impact of tumor hypoxia and anemia on radiation therapy outcomes

Significance of HIV status in cervical cancer patients receiving curative chemoradiation therapy, definitive radiation alone, or palliative radiation in Botswana

BACKGROUND

Cervical cancer associated with human papillomavirus has the highest cancer incidence and mortality for women in Botswana because of a high HIV prevalence and limited screening. This study investigates the significance of HIV on the overall survival (OS) of patients with locally advanced cervical cancer by various treatment categories (curative chemoradiation, definitive radiation [RT] alone, or palliative RT alone).

METHODS

This study included patients diagnosed with cervical cancer between 2013 and 2020, prospectively enrolled in the Botswana Prospective Cancer Cohort. OS based on HIV status and completion of planned treatment regimen was estimated by the Kaplan-Meier method. Comparisons of 2-year OS by HIV status was performed by the log-rank test, univariate and multivariable Cox analyses adjusting for cancer stage, RT dose, number of chemotherapy cycles, and baseline hemoglobin levels.

RESULTS

Of 1131 patients diagnosed with stage IB-IVB cervical cancer, 69.8% were women living with HIV (n = 789). For patients receiving curative chemoradiation, HIV status was not significantly associated with OS in unadjusted (p = .987) and adjusted (p = .578) analyses. For RT only treatment and definitive (high-dose) RT alone, HIV status was significantly associated with OS in unadjusted analysis (HR = 1.77, p = .002; HR = 1.95, p = .014), but not in adjusted analysis (p = .227, p = .73). For patients receiving palliative (low-dose) RT, HIV status was not associated with OS in unadjusted (p = .835) or adjusted analysis (p = .359).

CONCLUSIONS

In Botswana, a resource-limited setting, HIV status had no significant effect on 2-year OS in patients with cervical cancer with well-managed HIV receiving chemoradiation, RT alone, or palliative RT. This demonstrates that patients living with HIV receiving antiretroviral treatment can receive clinically appropriate treatment with no evidence that HIV may lead to poorer outcomes.

The Importance of Hypoxia-Related to Hemoglobin Concentration in Breast Cancer

The importance of hemoglobin (Hgb) as a novel prognostic biomarker in predicting clinical features of cancers has been the subject of intense interest. Anemia is common in various types of cancer including breast cancer (BC) and is considered to be attributed to tumoral hypoxia. Cancer microenvironments are hypoxic compared with normal tissues, and this hypoxia is associated with Hgb concentration. Recent preclinical documents propose a direct or indirect correlation of intratumoral hypoxia, specifically along with acidity, with Hgb concentration and anemia. Analysis of the prognostic value of Hgb in BC patients has demonstrated increased hypoxia in the intratumoral environment. A great number of studies demonstrated that lower concentrations of Hgb before or during common cancer treatments, such as radiation and chemotherapy, is an essential risk factor for poor prognostic and survival, as well as low quality of life in BC patients. This data suggests a potential correlation between anemia and hypoxia in BC. While low Hgb levels are detrimental to BC invasion and survival, identification of a distinct and exact threshold for low Hgb concentration is challenging and inaccurate. The optimal thresholds for Hgb and partial pressure of oxygen (pO2) vary based on different factors including age, gender, therapeutic approaches, and tumor types. While necessitating further investigations, understanding the correlation of Hgb levels with tumoral hypoxia and oxygenation could improve exploring strategies to overcome radio-chemotherapy related anemia in BC patients. This review highlights the collective association of Hgb concentration and hypoxia condition in BC progression.

Photoacoustic lifetime oxygen imaging of radiotherapy-induced tumor reoxygenation In Vivo

Purpose

Early detection and diagnosis of cancer is critical for achieving positive therapeutic outcomes. Biomarkers that can provide clinicians with clues to the outcome of a given therapeutic course are highly desired. Oxygen is a small molecule that is nearly universally present in biological tissues and plays a critical role in the effectiveness of radiotherapies by reacting with DNA radicals and subsequently impairing cellular repair of double strand breaks.Techniques for measuring oxygen in biological tissues often use blood oxygen saturation to approximate the oxygen partial pressure in surrounding tissues despite the complex, nonlinear, and dynamic relationship between these two separate oxygen populations.

Methods and materials

We combined a directly oxygen-sensitive, tumor-targeted, chemical contrast nanoelement with the photoacoustic lifetime-based (PALT) oxygen imaging technique to obtain image maps of oxygen in breast cancer tumors in vivo. The oxygen levels of patient-derived xenografts in a mouse model were characterized before and after a course of radiotherapy.

Results

We show that, independent of tumor size, radiotherapy induced an increase in the overall oxygenation levels of the tumor. Further, this increase in the oxygenation of the tumor significantly correlated with a positive response to radiotherapy, as demonstrated by a reduction in tumor volume over the twenty-day monitoring period following therapy and histological staining.

Conclusion

Our PALT imaging presented here is simple, fast, and non-invasive. Facilized by the PALT approach, imaging of tumor reoxygenation may be utilized as a simple, early indicator for evaluating cancer response to radiotherapy. Further characterization of the reoxygenation degree, temporal onset, and possible theragnostic implications are warranted.

Intravoxel incoherent motion magnetic resonance imaging to assess early tumor response to radiation therapy: Review and future directions

Early prediction of radiation response by imaging is a dynamic field of research and it can be obtained using a variety of noninvasive magnetic resonance imaging methods. Recently, intravoxel incoherent motion (IVIM) has gained interest in cancer imaging. IVIM carries both diffusion and perfusion information, making it a promising tool to assess tumor response. Here, we briefly introduced the basics of IVIM, reviewed existing studies of IVIM in various type of tumors during radiotherapy in order to show whether IVIM is a useful technique for an early assessment of radiation response. 31/40 studies reported an increase of IVIM parameters during radiotherapy compared to baseline. In 27 studies, this increase was higher in patients with good response to radiotherapy. Future directions including implementation of IVIM on MR-Linac and its limitation are discussed. Obtaining new radiologic biomarkers of radiotherapy response could open the way for a more personalized, biology-guided radiation therapy.

A Dosimetric Correlation Between Radiation Dose to Bone and Reduction of Hemoglobin Levels After Radiation Therapy for Prostate Cancer

PURPOSE

The aim of this work was to investigate the correlation between dose to pelvic bone marrow and anemia when treating prostate cancer (PC) with definitive radiation.

METHODS AND MATERIALS

Patients were selected from a prospective institutional database of patients with PC treated between 2008 and 2021. Pelvic bone (L3/L4 interface through ischial tuberosities) was contoured, and the dose to this structure was calculated. Doses were converted to 2-Gy equivalent doses using an α/β of 10. Exploratory analysis suggested dichotomizing into low-volume exposures of ≤1000 cc (LVE) and high-volume exposures of >1000 cc (HVE). Nonparametric kernel regressions were performed evaluating the effects of time, dose, and androgen deprivation therapy use on hemoglobin (Hgb) values. Reoptimization of plans was performed to evaluate the feasibility of adjusting significant dose levels.

RESULTS

A total of 203 patients were included in the final analysis. Median baseline Hgb was 14.9 g/dL (interquartile range, 14.1-15.6). Patients with bone marrow HVE ≥15 Gy were found to have significantly lower predicted Hgb levels compared with those with LVE at day 90: 12.8 g/dL (95% CI, 12.4-13.3) versus 14.5 g/dL (95% CI, 14.0-14.9), respectively (P < .05). When normalizing starting Hgb levels, HVE patients still had significantly lower predicted Hgb levels than LVE at day 90: 86.1% (95% CI, 83.2%-89.7%) versus 96.2% (95% CI, 92.4%-100%), respectively. Reoptimizing 20 plans with high volume of bone marrow receiving 15 Gy resulted in a mean reduction from 1422 cc to 997 cc without compromise of other organs at risk or target coverage.

CONCLUSIONS

Patients with >1000 cc of bone marrow receiving ≥15 Gy had significantly lower predicted Hgb levels than those with ≤1000 cc. Reoptimization of plans demonstrated that this dose constraint is achievable without impairing plan quality. This dose constraint can be considered to limit acute marrow toxicity in patients with PC.

Biotin-decorated hollow gold nanoshells for dual-modal imaging-guided NIR-II photothermal and radiosensitizing therapy toward breast cancer

Radiotherapy (RT) is dominantly used in breast cancer therapy but is facing fierce side effects because of the limited difference between tumor and normal tissues in response to ionizing radiation. Herein, we construct a core-shell nanoparticle of UiO-66-NH2@AuNS. Then the solid gold shell was etched into hollow AuNS (HAuNS) and further modified with biotin-PEG-SH (PEG-bio) to obtain HAuNS@PEG-bio. HAuNS@PEG-bio demonstrates effective near infrared II (NIR-II) region photothermal therapy (PTT) performance, and the increase of temperature at the tumor site promotes the blood circulation to alleviate the hypoxia in the tumor microenvironment (TME). Meanwhile, HAuNS exhibits strong X-ray absorption and deposition ability due to the high atomic coefficient of elemental Au (Z = 79) and hollowed-out structure. Through the dual radiosensitization of the high atomic coefficient of Au and the hypoxia alleviation from PTT of HAuNS, the breast cancer cells could undergo immunogenic cell death (ICD) to activate the immune response. At the in vivo level, HAuNS@PEG-bio performs NIR-II photothermal, radiosensitization, and ICD therapies through cellular targeting, guided by infrared heat and CT imaging. This work highlights that the constructed biotin-decorated hollow gold nanoshell has a promising potential as a diagnostic and treatment integration reagents for the breast cancer.

In situ hypoxia modulating nano-catalase for amplifying DNA damage in radiation resistive colon tumors

Radiation therapy (RT) is a mainstream clinical approach in cancer treatment. However, the therapeutic efficacy of RT is greatly hindered by the presence of excessive hydrogen peroxide (H2O2) in the hypoxic region of the solid tumor, thus leading to tumor recurrence and metastasis. Herein, a thioketal-linked amphiphilic nano-assembly (MTS) loaded with hydrophobic manganese oxide (HMO) nanoparticles (MTS@HMO) is examined as a promising multi-purpose reactive oxygen species (ROS)-catalytic nanozyme for transforming an RT-resistant hypoxic tumor microenvironment (TME) into an RT-susceptible one by scavenging ROS in the hypoxic core of the solid tumor. After intravenous injection, the MTS@HMO nano-assembly was able to sense and be degraded by the abundant ROS in the hypoxic TME, thereby releasing HMO particles for subsequent scavenging of H2O2. The oxygen generated during peroxide scavenging then relieved the hypoxic TME, thereby resulting in an increased sensitivity of the hypoxic tumor tissue towards RT. Moreover, the in situ hypoxic status was monitored via the T1-enhanced magnetic resonance (MR) imaging of the Mn2+ ions generated by the ROS-mediated degradation of HMO. The in vitro results demonstrated a significant H2O2 elimination and enhanced oxygen generation after the treatment of the MTS@HMO nano-assembly with tumor cells under hypoxic conditions, compared to the control MTS group. In addition, the combination of RT and pre-treatment with MTS@HMO nano-assembly significantly amplified the permanent DNA strand breaks in tumor cells compared to the control RT group. More importantly, the in vivo results proved that the systemic injection of the MTS@HMO nano-assembly prior to RT irradiation enhanced the RT-mediated tumor suppression and down-regulated the hypoxic marker of HIF-1α in the solid tumor compared to the control RT group. Overall, the present work demonstrates the great potential of the versatile ROS-catalytic hypoxia modulating strategy using the MTS@HMO nano-assembly to enhance the RT-induced antitumor efficacy in hypoxic solid tumors.

A Paradigm Shift in Primary Liver Cancer Therapy Utilizing Genomics, Molecular Biomarkers, and Artificial Intelligence

Primary liver cancer is the sixth most common cancer worldwide and the third leading cause of cancer-related death. Conventional therapies offer limited survival benefit despite improvements in locoregional liver-directed therapies, which highlights the underlying complexity of liver cancers. This review explores the latest research in primary liver cancer therapies, focusing on developments in genomics, molecular biomarkers, and artificial intelligence. Attention is also given to ongoing research and future directions of immunotherapy and locoregional therapies of primary liver cancers.

Model-based assessment of combination therapies - ranking of radiosensitizing agents in oncology

BACKGROUND

To increase the chances of finding efficacious anticancer drugs, improve development times and reduce costs, it is of interest to rank test compounds based on their potential for human use as early as possible in the drug development process. In this paper, we present a method for ranking radiosensitizers using preclinical data.

METHODS

We used data from three xenograft mice studies to calibrate a model that accounts for radiation treatment combined with radiosensitizers. A nonlinear mixed effects approach was utilized where between-subject variability and inter-study variability were considered. Using the calibrated model, we ranked three different Ataxia telangiectasia-mutated inhibitors in terms of anticancer activity. The ranking was based on the Tumor Static Exposure (TSE) concept and primarily illustrated through TSE-curves.

RESULTS

The model described data well and the predicted number of eradicated tumors was in good agreement with experimental data. The efficacy of the radiosensitizers was evaluated for the median individual and the 95% population percentile. Simulations predicted that a total dose of 220 Gy (5 radiation sessions a week for 6 weeks) was required for 95% of tumors to be eradicated when radiation was given alone. When radiation was combined with doses that achieved at least 8 [Formula: see text] of each radiosensitizer in mouse blood, it was predicted that the radiation dose could be decreased to 50, 65, and 100 Gy, respectively, while maintaining 95% eradication.

CONCLUSIONS

A simulation-based method for calculating TSE-curves was developed, which provides more accurate predictions of tumor eradication than earlier, analytically derived, TSE-curves. The tool we present can potentially be used for radiosensitizer selection before proceeding to subsequent phases of the drug discovery and development process.

Pathologic Response to Neoadjuvant Sequential Chemoradiation Therapy in Locally Advanced Breast Cancer: Preliminary, Translational Results from the French Neo-APBI-01 Trial

Background: Radiation therapy (RT), a novel approach to boost the anticancer immune response, has been progressively evaluated in the neoadjuvant setting in breast cancer (BC). Purpose: We aimed to evaluate immunity-related indicators of response to neoadjuvant chemoradiation therapy (NACRT) in BC for better treatment personalization. Patients and Methods: We analyzed data of the first 42 patients included in the randomized phase 2 Neo-APBI-01 trial comparing standard neoadjuvant chemotherapy (NACT) and NACRT regimen in locally advanced triple-negative (TN) and luminal B (LB) subtype BC. Clinicopathological parameters, blood counts and the derived parameters, total tumor-infiltrating lymphocytes (TILs) and their subpopulation, as well as TP53 mutation status, were assessed as predictors of response. Results: Twenty-one patients were equally assigned to each group. The pathologic complete response (pCR) was 33% and 38% in the NACT and NACRT groups, respectively, with a dose-response effect. Only one LB tumor reached pCR after NACRT. Numerous parameters associated with response were identified, which differed according to the assigned treatment. In the NACRT group, baseline hemoglobin of ≥13 g/dL and body mass index of <26 were strongly associated with pCR. Higher baseline neutrophils-to-lymphocytes ratio, total TILs, and T-effector cell counts were favorable for pCR. Conclusion: This preliminary analysis identified LB and low-TIL tumors as poor responders to the NACRT protocol, which delivered RT after several cycles of chemotherapy. These findings will allow for amending the selection of patients for the trial and help better design future trials of NACRT in BC.

Association between anemia and lumbar disc degeneration in patients with low back pain: an observational retrospective study

OBJECTIVE

The goal of this study was to evaluate the possible associations between anemia and morphologic features of lumbar disc degeneration (LDD) in subjects with low back pain.

MATERIALS AND METHODS

A total of 131 patients with normocytic or microcytic anemia (mean age 41.0 ± 6.4 yrs, BMI: 24.8 ± 3.3 kg/m², 12.2% men) and a matched control group of 131 patients without anemia (mean age 41.0 ± 6.4 yrs, BMI: 24.9 ± 3.1 kg/m², 12.2% men) were evaluated for LDD according to the Pfirrmann scoring system. The primary outcome was the difference of radiological features of LDD between two groups. The second outcome was the correlation between the hemoglobin (Hb) value and disc degeneration (DD). Statistical associations were assessed by Student's t-test, Chi-square test, and Spearman correlation.

RESULTS

Anemic patients had a significantly higher number of degenerated discs than non-anemic patients in the level of L2/3 and L3/4 (p < 0.05). We also found that the severe DD occurred more frequently in the level of L2/3, L3/4 and L5/S1 among anemic patients (p < 0.05). In addition, we noticed that the incidence of multilevel LDD happened much more frequently in patients with anemia (p < 0.05). The Hb value showed a borderline negative correlation with the total score of DD (p = 0.056).

CONCLUSION

The results suggested that patients with anemia, and those without are radiologically different with varying patterns of DD. Patients with back pain and anemia were more likely to have extensive and severe DD. Although relevant mechanisms are not yet well understood, this study improved our understandings of the pathophysiology for LDD.

Prognostic factors of overall and prostate-specific antigen-progression-free survival in metastatic castration-resistant prostate cancer patients treated with 177 Lu-PSMA-617. A single-center prospective observational study

BACKGROUND

Metastatic castration-resistant prostate cancer (mCRPC) is characterized by heterogeneity among patients as well as therapy responses due to diverse genetic, epigenetic differences, and resistance mechanisms. At this stage of the disease, therapy modalities should be individualized in light of the patients' clinical state, symptoms, and genetic characteristics. In this prospective study, we aimed to evaluate the outcome of patients with mCRPC treated with ¹⁷⁷ Lutetium labeled PSMA-617 therapy (PSMA-RLT), as well as baseline and therapy-related parameters associated with survival.

METHODS

This prospective study included 52 patients who received two to six cycles of PSMA-RLT. Primary endpoints were overall survival (OS) and prostate-specific antigen (PSA)-progression-free survival (PFS). ¹⁸ F-Fluorodeoxyglucose (FDG) and ⁶⁸ Ga-PSMA (PSMA) Positron Emission Tomography/Computer Tomography (PET/CT) scans were performed for a comprehensive assessment of tumor burden and heterogeneity. Biochemical, imaging, clinical, and therapy-related parameters were analyzed with the Kaplan-Meier, log-rank, and Cox regression analyses to predict OS and PFS.

RESULTS

Median OS and PSA-PFS were 17.7 (95% confidence interval [CI]: 15.2-20.2) and 6.6 months (95% CI: 4.5-8.8), respectively. Primary resistance to PSMA-RLT (hazard ratio [HR]: 12.57, 95% CI: 2.4-65.2, p: 0.003), <30% PSA response rate after first cycle of PSMA-RLT (HR: 1.016, 95% CI: 1.006-1.03, p: 0.003), FDG > PSMA disease (HR: 4.9, 95% CI: 1.19-20.62, p: 0.03), PSA doubling time (PSA DT) of ≤2.4 months (HR: 15.7, 95% CI: 3.7-66.4, p: <0.0001), and low hemoglobin levels (HR: 0.59, 95% CI: 0.41-0.83, p: 0.003) were correlated with poor OS in the multivariate analysis. Bone scintigraphy >  PSMA disease (HR: 5.6; 95% CI: 1.8-17, p: 0.002) and high C-reactive protein (HR: 1.4, 95% CI: 1.1-1.7, p: 0.001) were significant predictive biomarkers for PFS in the multivariate analysis.

CONCLUSION

PSA response rate and pattern to PSMA-RLT are the most important predictors of survival in patients receiving PSMA-RLT. Being a strong predictive biomarker, combined FDG and PSMA PET can be helpful for the decision of PSMA-RLT eligibility.

Personalized Oncology by In Vivo Chemical Imaging: Photoacoustic Mapping of Tumor Oxygen Predicts Radiotherapy Efficacy

We hereby apply the approach of photoacoustic chemical imaging, performing an in vivo chemical analysis that is spatially resolved (200 μm) and in real time, to predict a given tumor's response to therapy. Using triple negative breast cancer as a model, we took photoacoustic images of tumors' oxygen distributions in patient-derived xenografts (PDXs) in mice using biocompatible, oxygen-sensitive tumor-targeted chemical contrast nanoelements (nanosonophores), which function as contrast agents for photoacoustic imaging. Following radiation therapy, we established a quantitatively significant correlation between the spatial distribution of the initial oxygen levels in the tumor and its spatial distribution of the therapy's efficacy: the lower the local oxygen, the lower the local radiation therapy efficacy. We thus provide a simple, noninvasive, and inexpensive method to both predict the efficacy of radiation therapy for a given tumor and identify treatment-resistant regions within the tumor's microenvironment.

Anemia and iron deficiency in cancer patients: the role of intravenous iron supplements (a literature review)

Anemia in patients with malignancies is a common disorder that has a markedly negative impact on quality of life and overall prognosis. The pathogenesis of anemia is complex and multifactorial, depending on the type and stage of malignancy, nutritional status, renal function, age and gender, cytostatic drug, dose, and chemotherapeutic regimen, with iron deficiency often being the main and potentially treatable factor for anemia. In cancer patients, it can be caused by various concomitant mechanisms, including bleeding (e.g., in malignant gastrointestinal tumors or after surgery), malnutrition, medication, and hepcidin-induced iron sequestration in macrophages, with subsequent iron-deficient erythropoiesis. The variety of clinical manifestations of anemia makes it challenging to establish universal criteria to develop optimal treatments. Current therapy for anemia in malignant tumors includes replacement therapy with an iron supplement, erythropoiesis-stimulating agents (erythropoietins), and blood transfusions. However, blood transfusions should be minimized due to the high risks and costs. Therapy with an iron supplement is an effective approach to correcting the iron deficiency. It can increase the efficacy of erythropoiesis-stimulating drugs and reduce the need for blood transfusions. Published guidelines suggest the wide use of intravenous iron supplements. This article discusses possible approaches to treating iron deficiency in cancer patients in various clinical settings. We build on current guidelines and emphasize the need for further research in this area.

Measurement of Cerebral Oxygen Extraction Fraction Using Quantitative BOLD Approach: A Review

Quantification of brain oxygenation and metabolism, both of which are indicators of the level of brain activity, plays a vital role in understanding the cerebral perfusion and the pathophysiology of brain disorders. Magnetic resonance imaging (MRI), a widely used clinical imaging technique, which is very sensitive to magnetic susceptibility, has the possibility of substituting positron emission tomography (PET) in measuring oxygen metabolism. This review mainly focuses on the quantitative blood oxygenation level-dependent (qBOLD) method for the evaluation of oxygen extraction fraction (OEF) in the brain. Here, we review the theoretic basis of qBOLD, as well as existing acquisition and quantification methods. Some published clinical studies are also presented, and the pros and cons of qBOLD method are discussed as well.

Promises and Challenges of Predictive Blood Biomarkers for Locally Advanced Rectal Cancer Treated with Neoadjuvant Chemoradiotherapy

The treatment of locally advanced rectal cancer (LARC) requires a multimodal approach combining neoadjuvant radiotherapy or chemoradiotherapy (CRT) and surgery. Predicting tumor response to CRT can guide clinical decision making and improve patient care while avoiding unnecessary toxicity and morbidity. Circulating biomarkers offer both the advantage to be easily accessed and followed over time. In recent years, biomarkers such as proteins, blood cells, or nucleic acids have been investigated for their predictive value in oncology. We conducted a comprehensive literature review with the aim to summarize the status of circulating biomarkers predicting response to CRT in LARC. Forty-nine publications, of which forty-seven full-text articles, one review and one systematic review, were retrieved. These studies evaluated circulating markers (CEA and CA 19-9), inflammatory biomarkers (CRP, albumin, and lymphocytes), hematologic markers (hemoglobin and thrombocytes), lipids and circulating nucleic acids (cell-free DNA [cfDNA], circulating tumor DNA [ctDNA], and microRNA [miRNA]). Post-CRT CEA levels had the most consistent association with tumor response, while cfDNA integrity index, MGMT promoter methylation, ERCC-1, miRNAs, and miRNA-related SNPs were identified as potential predictive markers. Although circulating biomarkers hold great promise, inconsistent results, low statistical power, and low specificity and sensibility prevent them from reliably predicting tumor response following CRT. Validation and standardization of methods and technologies are further required to confirm results.

Hepcidin as a Diagnostic Biomarker in Anaemic Lung Cancer Patients

We aim to describe the characteristics of hepcidin, IL-6, and TNF-α levels in anaemia of lung cancer patients with operative tumour as well as to investigate the potential diagnostic capabilities of hepcidin in combination with IL-6, TNF-α, and acute phase proteins. We present a retrospective study of 112 lung cancer patients (41 women and 71 men) who were surgically treated at the Lower Silesian Centre for Lung Diseases in Wroclaw, Poland. Serum blood samples were collected from all these patients prior to any surgical treatment and used to determine hepcidin, IL-6, TNF-α, SAA₁, and CRP concentrations. Patients were also examined with a complete blood count several times during their hospitalization. The female and male groups were divided based on the occurrence of anaemia during their hospitalization. Patients who developed anaemia post-operatively had significantly lower hepcidin concentrations than non-anaemic patients (p = 0.000694 in females with ≥3 complete blood count examinations and p = 0.007905 in males with 2 complete blood count examinations), whereas patients with anaemia since hospital admission had higher hepcidin concentrations. We observed two hepcidin roles related to two cancer anaemia pathogeneses: (1) higher hepcidin concentrations in patients with anaemia since hospital admission (anaemia of inflammation) and (2) lower hepcidin concentrations in patients who developed anaemia after surgery (anaemia of iron deficiency). Our data support the role of hepcidin, IL-6, and TNF-α in cancer-related anaemia and provide diagnostic values for predicting post-operative anaemia in lung cancer patients.

Microbial cancer therapeutics: A promising approach

The success of conventional cancer therapeutics is hindered by associated dreadful side-effects of antibiotic resistance and the dearth of antitumor drugs' selectivity and specificity. Hence, the conceptual evolution of anti-cancerous therapeutic agents that selectively target cancer cells without impacting the healthy cells or tissues, has led to a new wave of scientific interest in microbial-derived bioactive molecules. Such strategic solutions may pave the way to surmount the shortcomings of conventional therapies and raise the potential and hope for the cure of wide range of cancer in a selective manner. This review aims to provide a comprehensive summary of anti-carcinogenic properties and underlying mechanisms of bioactive molecules of microbial origin, and discuss the current challenges and effective therapeutic application of combinatorial strategies to attain minimal systemic side-effects.

The emerging role of exosomes in radiotherapy

Presently, more than half of cancer patients receive radiotherapy to cure localized cancer, palliate symptoms, or control the progression of cancer. However, radioresistance and radiation-induced bystander effects (RIBEs) are still challenging problems in cancer treatment. Exosomes, as a kind of extracellular vesicle, have a significant function in mediating and regulating intercellular signaling pathways. An increasing number of studies have shown that radiotherapy can increase exosome secretion and alter exosome cargo. Furthermore, radiation-induced exosomes are involved in the mechanism of radioresistance and RIBEs. Therefore, exosomes hold great promise for clinical application in radiotherapy. In this review, we not only focus on the influence of radiation on exosome biogenesis, secretion and cargoes but also on the mechanism of radiation-induced exosomes in radioresistance and RIBEs, which may expand our insight into the cooperative function of exosomes in radiotherapy.

Baseline anemia predicts a poor prognosis in patients with non-small cell lung cancer with epidermal growth factor receptor mutations: a retrospective study

BACKGROUND

Anemia is relatively common in cancer patients, and baseline anemia is associated with poor survival in patients with non-small cell lung cancer (NSCLC). However, there is a lack of large-sample studies of patients with NSCLC with epidermal growth factor receptor (EGFR) mutations.

METHODS

We retrospectively analyzed anemia‑related data for patients with NSCLC and EGFR mutations who were admitted to Zhejiang Cancer Hospital from January 2013 to June 2019 and treated with targeted therapy. The patients' clinicopathological features were evaluated by χ² tests and the relationships between clinical characteristics and prognosis were investigated using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

A total of 2,029 patients treated with EGFR-tyrosine kinase inhibitors (TKIs) were finally enrolled in this study, of whom 24.6% had baseline anemia. Patients without baseline anemia had longer median overall survival (OS) than patients with baseline anemia (36.10 vs. 29.10 months, P = 0.001), and patients with grade < 2 anemia had longer median OS than those with grade ≥ 2 anemia (35.00 vs. 25.10 months, P < 0.001). Multivariate analyses identified baseline anemia as a factor predicting a poor prognosis in terms of OS in patients with EGFR mutations.

CONCLUSIONS

Baseline anemia is a significant factor predicting a poor prognosis in terms of OS in patients with NSCLC and EGFR mutations treated with targeted therapy. A higher grade of baseline anemia may also be related to shorter OS. And a higher risk of EGFR-mutated patients who had received targeted therapy could also be observed.

Cellular Hypoxia Mitigation by Dandelion-like Nanoparticles for Synergistic Photodynamic Therapy of Oral Squamous Cell Carcinoma

Hypoxia at the tumor site limits the therapeutic effects of photodynamic therapy (PDT) in oral squamous cell carcinoma (OSCC), which is an oxygen-consumption process. Inhibiting cellular oxygen consumption and reducing cellular ATP production are expected to enhance PDT. In this study, we designed and constructed dandelion-like size-shrinkable nanoparticles for tumor-targeted delivery of hypoxia regulator resveratrol (RES) and photodynamic agent chlorine e6 (CE6). Both drugs were co-encapsulated in small-sized micelles modified with EGFR targeting ligand GE11, which was further conjugated on hyaluronic nanogel (NG) to afford RC-GMN. After targeted accumulation in tumors mediated by GE11 and enhanced penetration and retention (EPR) effects, RC-GMN was degraded by hyaluronidase (HAase) and resulted in small-sized micelles, allowing for deep penetration and dual-receptor-mediated cellular internalization. Resveratrol inhibited cellular oxygen consumption and provided sufficient oxygen for PDT, which consequently activated PDT to produce reactive oxygen species (ROS). Notably, we found that autophagy was overactivated in PDT, which was further strengthened by the hypoxia regulator resveratrol, elevating autophagic cell death. The synergistic effects of resveratrol and CE6 promoted autophagic cell death and apoptosis in the enhanced PDT, resulting in stronger antitumor effects in the orthotopic OSCC model. Therefore, the facilitated delivery of hypoxia regulator enhanced PDT efficacy by elevating oxygen content in tumor cells and inducing autophagic cell death and apoptosis, which offers an alternative strategy for enhancing the PDT effects against OSCC.

Chronic hyperglycemia is an adverse prognostic factor for locoregional recurrence-free survival in small cell lung cancer patients treated with radical radiotherapy

BACKGROUND

Plasma glucose levels might be associated with the severity of tumor hypoxia in patients with cancer. In our previous study, we found that chronic hyperglycemia significantly increased the risk of locoregional recurrence in patients with non-small cell lung cancer treated with radical radiotherapy (RT). Here, we evaluated the association between plasma glucose levels in terms of hemoglobin A1c (HbA1c) and locoregional recurrence-free survival in patients with limited-stage small cell lung cancer treated with radical RT.

METHODS

We retrospectively analyzed the clinical data of 59 patients with small cell lung cancer. HbA1c levels were measured 1 week before the start of RT. Survival outcomes were analyzed according to HbA1c levels. Multivariable analysis was conducted to identify whether HbA1c level was a significant prognostic factor for survival.

RESULTS

The 1-, 2-, and 3-year locoregional recurrence-free survival rates were 90.9, 86.1, and 78.9%, respectively, in the low HbA1c group, and 45.1, 27.1, and 20.3%, respectively, in the high HbA1c group (p < 0.001). The 1-, 2-, and 3-year distant metastasis-free survival rates were 67.2, 57, and 57%, respectively, in the low HbA1c group, while it was 56.6, 24.9, and 24.9%, respectively, in the high HbA1c group (p = 0.024). HbA1c level remained a significant prognostic factor for locoregional recurrence-free survival in the multivariable analysis (p = 0.010).

CONCLUSIONS

Chronic hyperglycemia is a significant prognostic factor for locoregional recurrence-free survival in patients with limited-stage small cell lung cancer treated with radical RT. Routine monitoring of plasma glucose levels and aggressive glycemic control should be conducted to prevent locoregional recurrence.

Anemia was associated with multilevel lumbar disc degeneration in patients with low back pain: a single-center retrospective study

PURPOSE

It has not been determined which factors were related to multilevel lumbar disc degeneration (MLDD). The objective of this study was to determine the prevalence of MLDD among symptomatic patients using the magnetic resonance imaging method. The study also aimed to clarify the associations between MLDD and suspected risk factors through a multivariate model.

METHODS

A total of 530 young and middle-aged patients, suffered from low back pain were retrospectively assessed by 2 independent observers, who used sagittal T2-weighted MR imaging. Subjects were divided into two groups, MLDD group and non-MLDD group, according to the number of degenerated discs. Demographic and radiological data included age, gender, weight, height, body mass index, smoking status, alcohol drinking, lumbar lordosis, presence of hypertension (HT), diabetes mellitus and anemia.

RESULTS

There were 309 men and 221 women with an average age of 37.5  ±  8.5 years. In general, 37.7% of patients were diagnosed with disc degeneration (DD) at more than two levels. Triple level DD was the most common pattern and was more prevalent in women (p <0.05). Using multivariate analyses, age (odds ratio [OR]: 1.14; 95% confidence interval [CI] 1.11-1.18; p <0.001), hypertension (OR: 2.67; 95% CI 1.38-5.16; p = 0.03) and anemia (OR: 3.84; 95% CI 2.03-7.28; p <0.001) were significantly associated with MLDD.

CONCLUSION

Despite the young age of this cohort, MLDD is common among patients with low back pain. A significant independent association exists between age, HT, anemia and multilevel disc degeneration in the lumbar region.

SND1 Promotes Radioresistance in Cervical Cancer Cells by Targeting the DNA Damage Response

Background: Radiotherapy is one of the most effective therapeutic strategies for cervical cancer patients, although radioresistance-mediated residual and recurrent tumors are the main cause of treatment failure. However, the mechanism of tumor radioresistance is still elusive. DNA damage response pathways are key determinants of radioresistance. The purpose of this study was to investigate the role and mechanism of SND1 in radioresistance of cervical cancer. Methods: A stable HeLa cell line with SND1 knockout (HeLa-KO) was generated through a modified CRISPR/Cas9 double-nicking gene editing system. The stable CaSki cell lines with SND1 knockdown (CaSki-Ctrl, CaSki-SND1-sh-1, CaSki-SND1-sh-2) were constructed through lentivirus transfection with the pSil-SND1-sh-1 and pSil-SND1-sh-2 plasmids. Results: It was observed that SND1 deficiency significantly increased the radiosensitivity of cervical cancer cells. It was also found that silencing SND1 promotes radiation-induced apoptosis. Significantly, the cells with a loss of SND1 function exhibited inefficient ataxia telangiectasia mutated pathway activation, subsequently impairing DNA repair and G2/M checkpoint arrest. In addition, threonine 103 is an important phosphorylation site of SND1 under DNA damaging stress. Conclusion: Collectively, the results of this study reveal a potent radiosensitizing effect of silencing SND1 or T103 mutation on cervical cancer cells, providing novel insights into potential therapeutic strategies for cervical cancer treatment.

Recent Advancements in Mitochondria-Targeted Nanoparticle Drug Delivery for Cancer Therapy

Mitochondria are critical subcellular organelles that produce most of the adenosine triphosphate (ATP) as the energy source for most eukaryotic cells. Moreover, recent findings show that mitochondria are not only the "powerhouse" inside cells, but also excellent targets for inducing cell death via apoptosis that is mitochondria-centered. For several decades, cancer nanotherapeutics have been designed to specifically target mitochondria with several targeting moieties, and cause mitochondrial dysfunction via photodynamic, photothermal, or/and chemo therapies. These strategies have been shown to augment the killing of cancer cells in a tumor while reducing damage to its surrounding healthy tissues. Furthermore, mitochondria-targeting nanotechnologies have been demonstrated to be highly efficacious compared to non-mitochondria-targeting platforms both in vitro and in vivo for cancer therapies. Moreover, mitochondria-targeting nanotechnologies have been intelligently designed and tailored to the hypoxic and slightly acidic tumor microenvironment for improved cancer therapies. Collectively, mitochondria-targeting may be a promising strategy for the engineering of nanoparticles for drug delivery to combat cancer.

Modulation of the Tumor Microenvironment with Trastuzumab Enables Radiosensitization in HER2+ Breast Cancer

Simple Summary

Trastuzumab and radiation are used clinically to treat HER2-overexpressing breast cancers; however, the mechanistic synergy of anti-HER2 and radiation therapy has not been investigated. In this study, we identify that a subtherapeutic dose of trastuzumab sensitizes the tumor microenvironment to fractionated radiation. This results in longitudinal sustained response by triggering a state of innate immune activation through reduced DNA damage repair and increased tumor oxygenation. As positron emission tomography imaging can be used to longitudinally evaluate changes in tumor hypoxia, synergy of combination therapies is the result of both cellular and molecular changes in the tumor microenvironment.

Abstract

DNA damage repair and tumor hypoxia contribute to intratumoral cellular and molecular heterogeneity and affect radiation response. The goal of this study is to investigate anti-HER2-induced radiosensitization of the tumor microenvironment to enhance fractionated radiotherapy in models of HER2+ breast cancer. This is monitored through in vitro and in vivo studies of phosphorylated γ-H2AX, [¹⁸F]-fluoromisonidazole (FMISO)-PET, and transcriptomic analysis. In vitro, HER2+ breast cancer cell lines were treated with trastuzumab prior to radiation and DNA double-strand breaks (DSB) were quantified. In vivo, HER2+ human cell line or patient-derived xenograft models were treated with trastuzumab, fractionated radiation, or a combination and monitored longitudinally with [¹⁸F]-FMISO-PET. In vitro DSB analysis revealed that trastuzumab administered prior to fractionated radiation increased DSB. In vivo, trastuzumab prior to fractionated radiation significantly reduced hypoxia, as detected through decreased [¹⁸F]-FMISO SUV, synergistically improving long-term tumor response. Significant changes in IL-2, IFN-gamma, and THBS-4 were observed in combination-treated tumors. Trastuzumab prior to fractionated radiation synergistically increases radiotherapy in vitro and in vivo in HER2+ breast cancer which is independent of anti-HER2 response alone. Modulation of the tumor microenvironment, through increased tumor oxygenation and decreased DNA damage response, can be translated to other cancers with first-line radiation therapy.

Radiosensitizing Effect of Bromelain Using Tumor Mice Model via Ki-67 and PARP-1 Inhibition

Recent reports have shown that bromelain (BL), a pineapple extract, acts as an adjuvant therapy in cancer treatment and prevention of carcinogenesis. The present study was designed to investigate the possible mechanisms by which BL could radiosensitize tumor cells in vitro and in a mouse tumor model. BL has shown a significant reduction in the viability of the radioresistant human breast carcinoma (MCF-7) cell line using cell proliferation assay. The in vivo study was designed using the Ehrlich model in female albino mice, treated with BL (6 mg/kg b. wt., intraperitoneal, once daily for 10 days) 1 hour before exposure to a fractionated dose of gamma radiation (5 Gy, 1 Gy for 5 subsequent days). The radiosensitizing effect of BL was evident in terms of a significant reduction in tumor volume, poly ADP ribose polymerase-1 (PARP-1), the proliferation marker Ki-67 and nuclear factor kappa activated B cells (NF-κB) with a significant elevation in the reactive oxygen species (ROS) content and lipid peroxidation (LPO) in tumor cells. The present findings offer a novel insight into the radiosensitizing effect of BL and its potential application in the radiotherapy course.

Theoretical Evaluation of the Impact of Hyperthermia in Combination with Radiation Therapy in an Artificial Immune-Tumor-Ecosystem

Simple Summary

Radio-sensitizing effects of moderate or mild hyperthermia (heating up tumor cells up to 41–43 °C) in combination with radiotherapy (thermoradiotherapy) have been evaluated for decades. However, how this combination might modulate an anti-tumor immune response is not well known. To investigate the dynamic behavior of immune–tumor ecosystems in different scenarios, a model representing an artificial adaptive immune system in silico is used. Such a model may be far removed from the real situation in the patient, but it could serve as a laboratory to investigate fundamental principles of dynamics in such systems under well-controlled conditions and it could be used to generate and refine hypothesis supporting the design of clinical trials. Regarding the results of the presented computer simulations, the main effect is governed by the cellular radio-sensitization. In addition, the application of hyperthermia during the first radiotherapy fractions seems to be more effective.

Abstract

There is some evidence that radiotherapy (RT) can trigger anti-tumor immune responses. In addition, hyperthermia (HT) is known to be a tumor cell radio-sensitizer. How HT could enhance the anti-tumor immune response produced by RT is still an open question. The aim of this study is the evaluation of potential dynamic effects regarding the adaptive immune response induced by different combinations of RT fractions with HT. The adaptive immune system is considered as a trainable unit (perceptron) which compares danger signals released by necrotic or apoptotic cell death with the presence of tumor- and host tissue cell population-specific molecular patterns (antigens). To mimic the changes produced by HT such as cell radio-sensitization or increase of the blood perfusion after hyperthermia, simplistic biophysical models were included. To study the effectiveness of the different RT+HT treatments, the Tumor Control Probability (TCP) was calculated. In the considered scenarios, the major effect of HT is related to the enhancement of the cell radio-sensitivity while perfusion or heat-based effects on the immune system seem to contribute less. Moreover, no tumor vaccination effect has been observed. In the presented scenarios, HT boosts the RT cell killing but it does not fundamentally change the anti-tumor immune response.

Anemia is a Prognostic Factor for Overall Survival Rate in Patients with Non-Small Cell Lung Cancer Treated with Stereotactic Body Radiation Therapy

Purpose

Anemia has been associated with poor prognosis in patients with cancer across several cancer types. It has been identified as a prognostic factor in patients with non-small cell lung cancer (NSCLC) who have undergone surgery or chemoradiotherapy. However, there are only a few reports that have evaluated the prognostic significance of anemia in patients with NSCLC undergoing stereotactic body radiation therapy (SBRT).

Patients and Methods

A total of 77 patients were enrolled in this study. The pretreatment hemoglobin (Hb) levels, within 2 weeks before SBRT, were available for all patients. The median age of the participants (56 men, 21 women) was 80 (range, 50–90) years. The median Hb level was 12.8 (range, 7.8–18.3) g/dL. The median follow-up period was 24 (range, 1–87) months.

Results

Local recurrence was observed in 8 (10.4%) cases during the follow-up period. The 1- and 2-year local control (LC) rates were 94.8% and 86.4%, respectively. Seventeen (22.1%) patients died during the follow-up period. The 1- and 2-year overall survival (OS) rates were 93.1% and 85.2%, respectively. Univariate analysis identified anemia and body mass index as significant prognostic factors for predicting OS. On multivariate analysis, anemia was confirmed to be the only significant factor (p = 0.02469).

Conclusion

Our data suggest that anemia is a prognostic factor for predicting the OS rate in patients with early-stage NSCLC treated with SBRT.

Study of the Radiosensitizing and Radioprotective Efficacy of Bromelain (a Pineapple Extract): In Vitro and In Vivo

This study hypothesizes that, bromelain (BL) acts as radiosensitizer of tumor cells and that it protects normal cells from radiation effects. In vitro and in vivo studies have been carried out to prove that assumption. In vitro MTT cell proliferation assay has shown that the irradiated Ehrlich ascites carcinoma (EAC) cell line could be sensitized by BL pretreatment. In vivo: animals were randomly divided into 5 groups, Group 1: control (PBS i.p for 10 days), Group 2: Ehrlich solid tumor (EST) bearing mice, Group 3: EST + γ-radiation (fractionated dose, 1 Gy × 5), Group 4: EST + BL (6 mg/kg, i.p), daily for 10 days, Group 5: EST + BL for 10 days followed by γ-irradiation (1 Gy × 5). The size and weight of tumors in gamma-irradiated EST bearing mice treated with BL decreased significantly with a significant amelioration in the histopathological examination. Besides, BL mitigated the effect of γ-irradiation on the liver relative gene expression of poly ADP ribose polymerase-1 (PARP1), nuclear factor kappa activated B cells (NF-κB), and peroxisome proliferator-activated receptor α (PPAR-α), and it restored liver function via amelioration of paraoxonase1 (PON1) activity, reactive oxygen species (ROS) content, lipid peroxidation (LPO) and serum aspartate transaminase (AST), alanine transaminase (ALT), and albumin (ALB). It is concluded that BL can be considered as a radio-sensitizer and radio-protector, suggesting a possible role in reducing radiation exposure dose during radiotherapy.

Targeted and Non-Targeted Mechanisms for Killing Hypoxic Tumour Cells-Are There New Avenues for Treatment?

Purpose: A major issue in radiotherapy is the relative resistance of hypoxic cells to radiation. Historic approaches to this problem include the use of oxygen mimetic compounds to sensitize tumour cells, which were unsuccessful. This review looks at modern approaches aimed at increasing the efficacy of targeting and radiosensitizing hypoxic tumour microenvironments relative to normal tissues and asks the question of whether non-targeted effects in radiobiology may provide a new “target”. Novel techniques involve the integration of recent technological advancements such as nanotechnology, cell manipulation, and medical imaging. Particularly, the major areas of research discussed in this review include tumour hypoxia imaging through PET imaging to guide carbogen breathing, gold nanoparticles, macrophage-mediated drug delivery systems used for hypoxia-activate prodrugs, and autophagy inhibitors. Furthermore, this review outlines several features of these methods, including the mechanisms of action to induce radiosensitization, the increased accuracy in targeting hypoxic tumour microenvironments relative to normal tissue, preclinical/clinical trials, and future considerations. Conclusions: This review suggests that the four novel tumour hypoxia therapeutics demonstrate compelling evidence that these techniques can serve as powerful tools to increase targeting efficacy and radiosensitizing hypoxic tumour microenvironments relative to normal tissue. Each technique uses a different way to manipulate the therapeutic ratio, which we have labelled “oxygenate, target, use, and digest”. In addition, by focusing on emerging non-targeted and out-of-field effects, new umbrella targets are identified, which instead of sensitizing hypoxic cells, seek to reduce the radiosensitivity of normal tissues.

Photothermal photodynamic therapy and enhanced radiotherapy of targeting copolymer-coated liquid metal nanoparticles on liver cancer

The maximized therapeutic efficacy in tumor treatment can be achieved with combination therapy. Herein, a metronidazole (MN) and RGD peptides were linked with the copolymer chains of polyacrylic acid (PAA) and polyethylene glycol (PEG) by condensation and Michael addition reactions, respectively, named as RGD-PEG-PAA-MN. Subsequently, liquid-metal (LM) nanoparticles broken by ultrasonication were coated with modified copolymer, forming RGD-PEG-PAA-MN@LM nanoparticles. These nanoparticles with the degradation under an acidic condition could target to tumor cells, and LM of these composited nanoparticles could not only efficiently convert the photoenergy of near infrared (NIR) into thermal energy, but also produce more reactive oxygen species under NIR or X ray irradiation. Furthermore, MN in the composited nanoparticles could enhance their radiation sensitivity of tumor tissues with hypoxia condition. The synergic effect of these nanoparticles on cancer limitation after the sequential radiations of NIR and X ray was significantly higher than the single radiation. In the experiments of tumor bearing mice, the volume of the tumor in RGD-PEG-PAA-MN@LM group at 14th day after two radiations of NIR and X-ray were significantly smaller than LM group, and the tumor of RGD-PEG-PAA-MN@LM group at 14th day after two radiations almost disappeared, suggesting better synergistic effect of RGD-PEG-PAA-MN@LM nanoparticles on photothermal conversion, photodynamics under two irradiations and their enhanced sensitization of X-ray radiation. Our results indicated that the prepared nanoparticles would be applied in the combinational therapy of liver tumor by the photothermal, photodynamic and sensitized radiation.

Tumor microenvironment and radioresistance

Metastasis is not the result of a random event, as cancer cells can sustain and proliferate actively only in a suitable tissue microenvironment and then form metastases. Since Dr. Stephen Paget in the United Kingdom proposed the seed and soil hypothesis of cancer metastasis based on the analogy that plant seeds germinate and grow only in appropriate soil, considerable attention has focused on both extracellular environmental factors that affect the growth of cancer cells and the tissue structure that influences the microenvironment. Malignant tumor tissues consist of not only cancer cells but also a wide variety of other cells responsible for the inflammatory response, formation of blood vessels, immune response, and support of the tumor tissue architecture, forming a complex cellular society. It is also known that the amounts of oxygen and nutrients supplied to each cell differ depending on the distance from tumor blood vessels in tumor tissue. Here, we provide an overview of the tumor microenvironment and characteristics of tumor tissues, both of which affect the malignant phenotypes and radioresistance of cancer cells, focusing on the following keywords: diversity of oxygen and nutrient microenvironment in tumor tissue, inflammation, immunity, and tumor vasculature.

The Prognostic Value of Pre-treatment Hemoglobin (Hb) in Patients With Advanced or Metastatic Gastric Cancer Treated With Immunotherapy

Background

Biomarkers such as prevailing PD-L1 expression and TMB have been proposed as a way of predicting the outcome of immunotherapy in patients with advanced gastric cancer (AGC) and metastatic gastric cancer (MGC). Our study aims to investigate whether there is a link between pretreatment hemoglobin (Hb) levels and survival to immunotherapy in patients with AGC and MGC.

Methods

We retrospectively reviewed patients with AGC or MGC treated at the oncology department of the Chinese PLA general hospital receiving PD-1 inhibitor. The Propensity Score Matching (PSM) (1:1) was performed to balance potential baseline confounding factors. Progression-free survival (PFS) and overall survival (OS) was analyzed among different Hb level (normal Hb group and decreased Hb group). Objective response rate (ORR), disease control rate (DCR) were also analyzed. Univariate analysis and multivariate analysis were performed further to validate the prognostic value of Hb level.

Results

We included 137 patients with AGC and MGC who received PD-1 inhibitors (including Pembrolizumab, Nivolumab, Sintilimab, Toripalimab) in this study. After PSM matching, there were no significant differences between the two groups for baseline characteristics. Within the matched cohort, the median PFS was 7.8 months in the normal Hb level group and 4.3 months in the decreased Hb group (HR 95% CI 0.5(0.31, 0.81), P=0.004). The OS was 14.4 months with normal Hb level as compared with 8.2 months with decreased Hb level(HR 95% CI 0.59(0.37, 0.94), P=0.024). The ORR was 40.7% and DCR was 83.0% in the normal Hb group, while the ORR was 25.5% and DCR was 85.1% in the decreased Hb group. No significant differences were found in the ORR and DCR between the two groups (P=0.127, P=0.779). Univariate analysis and multivariate analysis showed that Hb level was only independent predictor for PFS and baseline Hb level was significant prognostic factor influencing the OS. Only when patients had normal Hb level, anti-pd-1 monotherapy or combined with chemotherapy was superior to anti-pd-1 plus anti-angiogenic therapy with respect to PFS (10.3 m vs 2.8 m, HR 95% CI 0.37(0.15, 0.95), P=0.031) and OS(15 m vs 5.7 m, HR 95% CI 0.21 (0.08, 0.58), P=0.001).

Conclusions

Our study have demonstrated that pretreatment Hb level was an independent prognostic biomarker in term of PFS and OS with immunotherapy for AGC and MGC patients. Correction of anemia for GC patients as immunotherapy would be a strategy to improve the survival. More data was warranted to further influence this finding.

Photodynamic Therapy-Current Limitations and Novel Approaches

Photodynamic therapy (PDT) mostly relies on the generation of singlet oxygen, via the excitation of a photosensitizer, so that target tumor cells can be destroyed. PDT can be applied in the settings of several malignant diseases. In fact, the earliest preclinical applications date back to 1900’s. Dougherty reported the treatment of skin tumors by PDT in 1978. Several further studies around 1980 demonstrated the effectiveness of PDT. Thus, the technique has attracted the attention of numerous researchers since then. Hematoporphyrin derivative received the FDA approval as a clinical application of PDT in 1995. We have indeed witnessed a considerable progress in the field over the last century. Given the fact that PDT has a favorable adverse event profile and can enhance anti-tumor immune responses as well as demonstrating minimally invasive characteristics, it is disappointing that PDT is not broadly utilized in the clinical setting for the treatment of malignant and/or non-malignant diseases. Several issues still hinder the development of PDT, such as those related with light, tissue oxygenation and inherent properties of the photosensitizers. Various photosensitizers have been designed/synthesized in order to overcome the limitations. In this Review, we provide a general overview of the mechanisms of action in terms of PDT in cancer, including the effects on immune system and vasculature as well as mechanisms related with tumor cell destruction. We will also briefly mention the application of PDT for non-malignant diseases. The current limitations of PDT utilization in cancer will be reviewed, since identifying problems associated with design/synthesis of photosensitizers as well as application of light and tissue oxygenation might pave the way for more effective PDT approaches. Furthermore, novel promising approaches to improve outcome in PDT such as selectivity, bioengineering, subcellular/organelle targeting, etc. will also be discussed in detail, since the potential of pioneering and exceptional approaches that aim to overcome the limitations and reveal the full potential of PDT in terms of clinical translation are undoubtedly exciting. A better understanding of novel concepts in the field (e.g. enhanced, two-stage, fractional PDT) will most likely prove to be very useful for pursuing and improving effective PDT strategies.

Yttrium-90 Radioembolization and Tumor Hypoxia: Gas-challenge BOLD Imaging in the VX2 Rabbit Model of Hepatocellular Carcinoma

RATIONALE AND OBJECTIVES

To use a rapid gas-challenge blood oxygen-level dependent magnetic resonance imaging exam to evaluate changes in tumor hypoxia after ⁹⁰Y radioembolization (Y90) in the VX2 rabbit model.

MATERIALS AND METHODS

White New Zealand rabbits (n = 11) provided a Y90 group (n = 6 rabbits) and untreated control group (n = 5 rabbits). R2* maps were generated with gas-challenges (O₂/room air) at baseline, 1 week, and 2 weeks post-Y90. Laboratory toxicity was evaluated at baseline, 24 hours, 72 hours, 1 hours, and 2 weeks. Histology was used to evaluate tumor necrosis on hematoxylin and eosin and immunofluorescence imaging was used to assess microvessel density (CD31) and proliferative index (Ki67).

RESULTS

At baseline, median tumor volumes and time to imaging were similar between groups (p = 1.000 and p = 0.4512, respectively). The median administered dose was 50.4 Gy (95% confidence interval:44.8-55.9). At week 2, mean tumor volumes were 5769.8 versus 643.7 mm³ for control versus Y90 rabbits, respectively (p = 0.0246). At two weeks, ΔR2* increased for control tumors to 12.37 ± 12.36sec^-1 and decreased to 4.48 ± 9.00sec^-1 after Y90. The Pearson correlation coefficient for ΔR2* at baseline and percent increase in tumor size by two weeks was 0.798 for the Y90 group (p = 0.002). There was no difference in mean microvessel density for control versus Y90 treated tumors (p = 0.6682). The mean proliferative index was reduced in Y90 treated tumors at 30.5% versus 47.5% for controls (p = 0.0071).

CONCLUSION

The baseline ΔR2* of tumors prior to Y90 may be a predictive imaging biomarker of tumor response and treatment of these tumors with Y90 may influence tumor oxygenation over time.

"Anemia and Response to Neoadjuvant Chemotherapy in Breast Cancer Patients"

We analyzed the effect of anemia on tumor response of patients with primary invasive breast cancer (BC) receiving neoadjuvant chemotherapy (NACT). The patient collective was very homogenous; finally, 74 BC patients with identical medication and duration of NACT were enrolled. After completion of NACT, 49 patients (66.2%) had a post-NACT Hb level <12 g/dl. In the anemic group, we found a tendency of lower median tumor response compared to nonanemic patients at this time (15 versus 17 mm, retrospectively, p = 0.18). Age at diagnosis significantly correlated with the difference of Hb [before initiation - after completion of NACT] (correlation coefficient = 0.40, p < 0.001).

Monitoring expiratory carbon monoxide to study the effect of complete smoking cessation on definitive radiation therapy for early stage glottic carcinoma

BACKGROUND

Previous studies reported that cigarette smoking during radiation therapy was associated with unfavorable outcomes in various cancers using medical interviewing or monitoring of cotinine. Here, we evaluated the effect of smoking cessation on definitive radiation therapy for early stage glottic carcinoma by monitoring expiratory carbon monoxide (CO).

MATERIAL AND METHODS

We enrolled 103 patients with early glottic carcinoma (T1N0/T2N0 = 79/24) who underwent conventional radiotherapy between 2005 and 2016. The median age was 70 years. Pathologically, all patients had squamous cell carcinoma. Since 2009, we confirmed smoking cessation before radiation therapy by medical interviews. Since 2014, we measured expiratory CO to strictly monitor smoking cessation. The patients were divided according to diagnosis years: 'no cessation' (2005-2008), 'incomplete cessation' (2009-2013), and 'complete cessation' (2014-2016). We retrospectively analyzed the local recurrence rate and disease-free survival (DFS).

RESULTS

The median follow-up period was 60.1 months (range, 1.9-110.0 months). The 2-year local recurrence rate in the 'complete cessation' group was 5.3% and tended to be lower than that in the 'incomplete cessation' group (13.7%) and 'no cessation' group (21.2%). Multivariate analysis revealed that 'no cessation' was a risk factor for DFS (hazard ratio [HR] = 4.25) and local recurrence rate (HR = 16.5, p < .05) compared to 'complete cessation.'

DISCUSSION

We confirmed that the 'complete cessation' group had better prognosis than the 'no cessation' group by monitoring expiratory CO during radiation therapy for early stage glottic carcinoma. Moreover, monitoring expiratory CO was easier and more suitable than conventional methods for evaluating smoking cessation because it provided real-time measurements.

Flipside of the Coin: Iron Deficiency and Colorectal Cancer

Iron deficiency, with or without anemia, is the most frequent hematological manifestation in individuals with cancer, and is especially common in patients with colorectal cancer. Iron is a vital micronutrient that plays an essential role in many biological functions, in the context of which it has been found to be intimately linked to cancer biology. To date, however, whereas a large number of studies have comprehensively investigated and reviewed the effects of excess iron on cancer initiation and progression, potential interrelations of iron deficiency with cancer have been largely neglected and are not well-defined. Emerging evidence indicates that reduced iron intake and low systemic iron levels are associated with the pathogenesis of colorectal cancer, suggesting that optimal iron intake must be carefully balanced to avoid both iron deficiency and iron excess. Since iron is vital in the maintenance of immunological functions, insufficient iron availability may enhance oncogenicity by impairing immunosurveillance for neoplastic changes and potentially altering the tumor immune microenvironment. Data from clinical studies support these concepts, showing that iron deficiency is associated with inferior outcomes and reduced response to therapy in patients with colorectal cancer. Here, we elucidate cancer-related effects of iron deficiency, examine preclinical and clinical evidence of its role in tumorigenesis, cancer progression and treatment response. and highlight the importance of adequate iron supplementation to limit these outcomes.

Application of Radiosensitizers in Cancer Radiotherapy

Radiotherapy (RT) is a cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors. Although great success has been achieved on radiotherapy, there is still an intractable challenge to enhance radiation damage to tumor tissue and reduce side effects to healthy tissue. Radiosensitizers are chemicals or pharmaceutical agents that can enhance the killing effect on tumor cells by accelerating DNA damage and producing free radicals indirectly. In most cases, radiosensitizers have less effect on normal tissues. In recent years, several strategies have been exploited to develop radiosensitizers that are highly effective and have low toxicity. In this review, we first summarized the applications of radiosensitizers including small molecules, macromolecules, and nanomaterials, especially those that have been used in clinical trials. Second, the development states of radiosensitizers and the possible mechanisms to improve radiosensitizers sensibility are reviewed. Third, the challenges and prospects for clinical translation of radiosensitizers in oncotherapy are presented.

Effect of anaemia on the response to preoperative chemoradiotherapy for rectal cancer

BACKGROUNDS

Radiation therapy with concurrent chemotherapy is an important treatment for rectal cancer, especially for advanced stage disease. Low serum haemoglobin levels are accepted as a negative indicator in the response to radiation therapy. This study aimed to evaluate the relationship between anaemia and the response to preoperative chemoradiotherapy for rectal cancer and its effect on oncologic outcomes.

METHODS

We retrospectively reviewed medical records of primary rectal cancer patients who were treated with preoperative chemoradiotherapy followed by total mesorectal excision between January 2011 and December 2015. Anaemia was defined as serum haemoglobin levels ≤9 g/dL before or during radiotherapy. Patients were divided into good and poor responders according to pathologic tumour regression grades. The effect of anaemia on the response to radiation therapy, recurrence-free survival and overall survival were analysed after subgroup analysis.

RESULTS

Overall, 301 and 394 patients were categorized into good and poor responder groups, respectively. Proportions of anaemia patients were higher in the poor responder group than in the good responder group (7.6% versus 4.0%, P = 0.042). Anaemia was associated with less pathologic complete regression but was not a risk factor for worse recurrence-free or overall survival. There was no significant difference in survival between patients with and without anaemia.

CONCLUSION

Haemoglobin levels ≤9 g/dL before or during radiotherapy were risk factors for achieving pathologic complete regression after preoperative chemoradiotherapy for rectal cancer. However, anaemia was not independently associated with worse survival outcomes.

5-Aminolevulinic acid radiodynamic therapy for treatment of high-grade gliomas: A systematic review

INTRODUCTION

Radiodynamic therapy (RDT) involves administration of a radiosensitizing agent and its subsequent activation by ionizing radiation for destruction of neoplastic cells.

MATERIALS AND METHODS

A comprehensive evaluation of the literature was performed to review the history of RDT using porphyrins for solid tumors, the cellular mechanisms of action, immunomodulatory effects, and both preclinical and clinical studies for use in high-grade gliomas (HGGs). This manuscript was prepared in accordance with the PRISMA guidelines.

RESULTS

A total of 271 articles were considered for initial review. After removal of duplicates, articles not unrelated to specific topic, and exclusion of commentary articles, a total of 11 articles were subject to full analysis that included in vivo, in vitro, and human studies. Porphyrins such as 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) selectively accumulate in neoplastic cells and are currently used for fluorescent-guided surgical resection and photodynamic therapy (PDT) of HGG and other brain tumors. 5-ALA is also shown to act as a radiosensitizer by increasing oxidative stress in neoplastic cell mitochondria and enhancing the host immune response. Postoperative radiation therapy is currently the standard of care for treatment of HGG.

CONCLUSION

RDT remains a promising adjuvant therapy for HGGs and requires further investigation. Clinical trials of 5-ALA RDT for HGG are needed to evaluate the optimum timing, dosing and effectiveness.

Study of Synergistic and Protective Effects of Three Different Polar Saffron Extracts and Photon Radiation on Human Colorectal Cancer Cells (HT-29) and Normal Human Fibroblasts

Background: There are some hypotheses about radiation-sensitizing and radiation-protective effects of antioxidants. Saffron, dried stigmas of Crocus sativus L., is a precious medicinal plant that contains an impressive variety of plant compounds such as crocin, crocetin, and safranal that act as antioxidants. The present study examined the cytotoxic effects of saffron extracts with different polarity and their synergism or protective effects with radiation on a colorectal cancer cell line (HT-29) and normal human fibroblasts. Objectives: The aim was to find a natural agent to improve radiotherapy efficacy. Methods: HT-29 colorectal cancer cells and normal human fibroblasts were cultured in RPMI1640 medium, incubated with different concentrations of different saffron extracts (50-250 µg/ml), and then were exposed to a dose of 8 Gy of X-rays. The cytotoxicity effect was determined by the MTT assay. Results: Saffron extracts decreased cell viability in HT-29 colorectal cancer cells and normal human fibroblasts as a concentration-dependent manner. Combination radiotherapy with polar saffron extract in most doses showed synergistic effects on HT-29 cell death while it did not show any distinctive synergistic effect in normal cells. Semi-polar and non-Polar extracts just in low doses had synergistic effects on tumor cells. These two extracts did not show any protective effects on normal cells. Conclusions: Among the various saffron extracts, polar saffron extract and low doses of non-polar saffron extract in combination with radiation increase radiation sensitivity and cell death in tumor cells, while they do not increase radiation sensitivity in normal cells and even protect normal cells to some extent.

Recent Research on Methods to Improve Tumor Hypoxia Environment

Cancer is a major disease burden worldwide. In recent years, in addition to surgical resection, radiotherapy and chemotherapy are recognized as the most effective methods for treating solid tumors. These methods have been introduced to treat tumors of different origins and stages clinically. However, due to insufficient blood flow and oxygen (O2) supply in solid tumors, hypoxia is caused, leading to decreased sensitivity of tumor cells and poor therapeutic effects. In addition, hypoxia will also lead to resistance to most anticancer drugs, accelerate malignant progress, and increase metastasis. In solid tumors, adequate O2 supply and adequate delivery of anticancer drugs are essential to improve radiotherapy and chemotherapy sensitivity. In recent decades, the researches on relieving tumor hypoxia have attracted researchers' extensive attention and achieved good results. However, as far as we know, there is no detailed review of the researches on alleviating tumor hypoxia. Therefore, in this contribution, we hope to give an overview of the researches on methods to improve tumor hypoxia environment and summarize their effect and application in tumor therapy, to provide a methodological reference for the research and development of new antitumor agents.

Advanced nanomaterials for hypoxia tumor therapy: challenges and solutions

In recent years, nanomaterials and nanotechnology have emerged as vital factors in the medical field with a unique contribution to cancer medicine. Given the increasing number of cancer patients, it is necessarily required to develop innovative strategies and therapeutic modalities to tackle hypoxia, which forms a hallmark and great barrier in treating solid tumors. The present review details the challenges in nanotechnology-based hypoxia, targeting the strategies and solutions for better therapeutic performances. The interaction between hypoxia and tumor is firstly introduced. Then, we review the recently developed engineered nanomaterials towards multimodal hypoxia tumor therapies, including chemotherapy, radiotherapy, and sonodynamic treatment. In the next part, we summarize the nanotechnology-based strategies for overcoming hypoxia problems. Finally, current challenges and future directions are proposed for successfully overcoming the hypoxia tumor problems.