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Corrigan KL, Xu T, Sasaki Y, Lin R, Chen AB, Welsh JW, Lin SH, Chang JY, Ning MS, Gandhi S, O'Reilly MS, Gay CM, Altan M, Lu C, Cascone T, Koutroumpakis E, Sheshadri A, Zhang X, Liao L, Zhu XR, Heymach JV, Nguyen QN, Liao Z. Survival outcomes and toxicity of adjuvant immunotherapy after definitive concurrent chemotherapy with proton beam radiation therapy for patients with inoperable locally advanced non-small cell lung carcinoma. Radiother Oncol 2024; 193:110121. [PMID: 38311031 PMCID: PMC10947851 DOI: 10.1016/j.radonc.2024.110121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Adjuvant immunotherapy (IO) following concurrent chemotherapy and photon radiation therapy confers an overall survival (OS) benefit for patients with inoperable locally advanced non-small cell lung carcinoma (LA-NSCLC); however, outcomes of adjuvant IO after concurrent chemotherapy with proton beam therapy (CPBT) are unknown. We investigated OS and toxicity after CPBT with adjuvant IO versus CPBT alone for inoperable LA-NSCLC. MATERIALS AND METHODS We analyzed 354 patients with LA-NSCLC who were prospectively treated with CPBT with or without adjuvant IO from 2009 to 2021. Optimal variable ratio propensity score matching (PSM) matched CPBT with CPBT + IO patients. Survival was estimated with the Kaplan-Meier method and compared with log-rank tests. Multivariable Cox proportional hazards regression evaluated the effect of IO on disease outcomes. RESULTS Median age was 70 years; 71 (20%) received CPBT + IO and 283 (80%) received CPBT only. After PSM, 71 CPBT patients were matched with 71 CPBT + IO patients. Three-year survival rates for CPBT + IO vs CPBT were: OS 67% vs 30% (P < 0.001) and PFS 59% vs 35% (P = 0.017). Three-year LRFS (P = 0.137) and DMFS (P = 0.086) did not differ. Receipt of adjuvant IO was a strong predictor of OS (HR 0.40, P = 0.001) and PFS (HR 0.56, P = 0.030), but not LRFS (HR 0.61, P = 0.121) or DMFS (HR 0.61, P = 0.136). There was an increased incidence of grade ≥3 esophagitis in the CPBT-only group (6% CPBT + IO vs 17% CPBT, P = 0.037). CONCLUSION This study, one of the first to investigate CPBT followed by IO for inoperable LA-NSCLC, showed that IO conferred survival benefits with no increased rates of toxicity.
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Affiliation(s)
- Kelsey L Corrigan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Yuki Sasaki
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ruitao Lin
- Department of Biostatics and Computational Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aileen B Chen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James W Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew S Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Saumil Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael S O'Reilly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carl M Gay
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mehmet Altan
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles Lu
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina Cascone
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Ajay Sheshadri
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Li Liao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John V Heymach
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Janopaul-Naylor JR, Cao Y, McCall NS, Switchenko JM, Tian S, Chen H, Stokes WA, Kesarwala AH, McDonald MW, Shelton JW, Bradley JD, Higgins KA. Definitive intensity modulated proton re-irradiation for lung cancer in the immunotherapy era. Front Oncol 2023; 12:1074675. [PMID: 36733369 PMCID: PMC9888533 DOI: 10.3389/fonc.2022.1074675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/29/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction As immunotherapy has improved distant metastasis-free survival (DMFS) in Non-Small Cell Lung Cancer (NSCLC), isolated locoregional recurrences have increased. However, management of locoregional recurrences can be challenging. We report our institutional experience with definitive intent re-irradiation using Intensity Modulated Proton Therapy (IMPT). Method Retrospective cohort study of recurrent or second primary NSCLC or LS-SCLC treated with IMPT. Kaplan-Meier method and log-rank test were used for time-to-event analyses. Results 22 patients were treated from 2019 to 2021. After first course of radiation (median 60 Gy, range 45-70 Gy), 45% received adjuvant immunotherapy. IMPT re-irradiation began a median of 28.2 months (8.8-172.9 months) after initial radiotherapy. The median IMPT dose was 60 GyE (44-60 GyE). 36% received concurrent chemotherapy with IMPT and 18% received immunotherapy after IMPT. The median patient's IMPT lung mean dose was 5.3 GyE (0.9-13.9 GyE) and 5 patients had cumulative esophagus max dose >100 GyE with 1-year overall survival (OS) 68%, 1-year local control 80%, 1-year progression free survival 45%, and 1-year DMFS 60%. Higher IMPT (HR 1.4; 95% CI 1.1-1.7, p=0.01) and initial radiotherapy mean lung doses (HR 1.3; 95% CI 1.0-1.6, p=0.04) were associated with worse OS. Two patients developed Grade 3 pneumonitis or dermatitis, one patient developed Grade 2 pneumonitis, and seven patients developed Grade 1 toxicity. There were no Grade 4 or 5 toxicities. Discussion Definitive IMPT re-irradiation for lung cancer can prolong disease control with limited toxicity, particularly in the immunotherapy era.
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Affiliation(s)
- James R. Janopaul-Naylor
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Yichun Cao
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Neal S. McCall
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeffrey M. Switchenko
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States
| | - Sibo Tian
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Haijian Chen
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - William A. Stokes
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Aparna H. Kesarwala
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Mark W. McDonald
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Joseph W. Shelton
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeffrey D. Bradley
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Kristin A. Higgins
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
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Pneumonitis after Stereotactic Thoracic Radioimmunotherapy with Checkpoint Inhibitors: Exploration of the Dose-Volume-Effect Correlation. Cancers (Basel) 2022; 14:cancers14122948. [PMID: 35740613 PMCID: PMC9221463 DOI: 10.3390/cancers14122948] [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: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Stereotactic body radiation therapy (SBRT) is widely applied for treatment of early stage lung cancer and pulmonary metastases. Modern immune checkpoint blockade (ICB) is progressively used in cancer treatment. Pneumonitis is a relevant side effect of both thoracic SBRT and ICB. Currently, it remains unclear whether we can presume the same radiation dose–volume–effect correlations and dose constraints for safe application of SBRT + ICB. We present a dose–volume–effect correlation analysis method using pneumonitis contours and dose–volume histograms (DVH). We showed dosimetric differences for pneumonitis volumes between SBRT + ICB and SBRT alone. We found a large extent of pneumonitis, even bilateral and apart from the radiation field for combined SBRT + ICB. We noticed a shift in pneumonitis DVHs towards lower doses and a trend towards decreased areas under the curve (AUC) for SBRT + ICB. This provides a direction for re-evaluation and potential adaptation of lung dose constraints for combined SBRT and ICB. Abstract Thoracic stereotactic body radiation therapy (SBRT) is extensively used in combination with immune checkpoint blockade (ICB). While current evidence suggests that the occurrence of pneumonitis as a side effect of both treatments is not enhanced for the combination, the dose–volume correlation remains unclear. We investigate dose–volume–effect correlations for pneumonitis after combined SBRT + ICB. We analyzed patient clinical characteristics and dosimetric data for 42 data sets for thoracic SBRT with ICB treatment (13) and without (29). Dose volumes were converted into 2 Gy equivalent doses (EQD2), allowing for dosimetric comparison of different fractionation regimes. Pneumonitis volumes were delineated and corresponding DVHs were analyzed. We noticed a shift towards lower doses for combined SBRT + ICB treatment, supported by a trend of smaller areas under the curve (AUC) for SBRT+ ICB (median AUC 1337.37 vs. 5799.10, p = 0.317). We present a DVH-based dose–volume–effect correlation method and observed large pneumonitis volumes, even with bilateral extent in the SBRT + ICB group. We conclude that further studies using this method with enhanced statistical power are needed to clarify whether adjustments of the radiation dose constraints are required to better estimate risks of pneumonitis after the combination of SBRT and ICB.
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Hu Y, Paris S, Barsoumian H, Abana CO, He K, Sezen D, Wasley M, Masrorpour F, Chen D, Yang L, Dunn JD, Gandhi S, Nguyen QN, Cortez MA, Welsh JW. A radioenhancing nanoparticle mediated immunoradiation improves survival and generates long-term antitumor immune memory in an anti-PD1-resistant murine lung cancer model. J Nanobiotechnology 2021; 19:416. [PMID: 34895262 PMCID: PMC8666086 DOI: 10.1186/s12951-021-01163-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Combining radiotherapy with PD1 blockade has had impressive antitumor effects in preclinical models of metastatic lung cancer, although anti-PD1 resistance remains problematic. Here, we report results from a triple-combination therapy in which NBTXR3, a clinically approved nanoparticle radioenhancer, is combined with high-dose radiation (HDXRT) to a primary tumor plus low-dose radiation (LDXRT) to a secondary tumor along with checkpoint blockade in a mouse model of anti-PD1-resistant metastatic lung cancer. Methods Mice were inoculated with 344SQR cells in the right legs on day 0 (primary tumor) and the left legs on day 3 (secondary tumor). Immune checkpoint inhibitors (ICIs), including anti-PD1 (200 μg) and anti-CTLA4 (100 μg) were given intraperitoneally. Primary tumors were injected with NBTXR3 on day 6 and irradiated with 12-Gy (HDXRT) on days 7, 8, and 9; secondary tumors were irradiated with 1-Gy (LDXRT) on days 12 and 13. The survivor mice at day 178 were rechallenged with 344SQR cells and tumor growth monitored thereafter. Results NBTXR3 + HDXRT + LDXRT + ICIs had significant antitumor effects against both primary and secondary tumors, improving the survival rate from 0 to 50%. Immune profiling of the secondary tumors revealed that NBTXR3 + HDXRT + LDXRT increased CD8 T-cell infiltration and decreased the number of regulatory T (Treg) cells. Finally, none of the re-challenged mice developed tumors, and they had higher percentages of CD4 memory T cells and CD4 and CD8 T cells in both blood and spleen relative to untreated mice. Conclusions NBTXR3 nanoparticle in combination with radioimmunotherapy significantly improves anti-PD1 resistant lung tumor control via promoting antitumor immune response. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12951-021-01163-1.
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Affiliation(s)
- Yun Hu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Sébastien Paris
- Department of Translational Science, Nanobiotix, Paris, France
| | - Hampartsoum Barsoumian
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Chike O Abana
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Kewen He
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Duygu Sezen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA.,Department of Radiation Oncology, Koc University School of Medicine, Istanbul, Turkey
| | - Mark Wasley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Fatemeh Masrorpour
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Dawei Chen
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Liangpeng Yang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Joe D Dunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Saumil Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - Maria Angelica Cortez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA
| | - James W Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Boulevard, Houston, TX, 77030, USA.
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Elegbede AA, Gibson AJ, Fung AS, Cheung WY, Dean ML, Bebb DG, Pabani A. A Real-World Evaluation of Atezolizumab Plus Platinum-Etoposide Chemotherapy in Patients With Extensive-Stage SCLC in Canada. JTO Clin Res Rep 2021; 2:100249. [PMID: 34877555 PMCID: PMC8628038 DOI: 10.1016/j.jtocrr.2021.100249] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/25/2021] [Accepted: 10/19/2021] [Indexed: 01/20/2023] Open
Abstract
Introduction The real-world data evaluating treatment outcomes of atezolizumab plus carboplatin-etoposide chemotherapy (atezolizumab) for extensive-stage SCLC (ESCLC) are lacking. Our objective was to evaluate real-world outcomes of ESCLC treated with atezolizumab. Methods A retrospective analysis of provincial patients with ESCLC who started first-line (1L) systemic treatment was conducted. We primarily evaluated the progression-free survival (PFS) and overall survival (OS) outcomes in association with atezolizumab compared with platinum-etoposide chemotherapy (chemotherapy) while adjusting for relevant demographic and clinical factors. Adverse events (AEs) during 1L were evaluated. Results A total of 67 patients were identified. Of the 34 patients who received atezolizumab, 24% had Eastern Cooperative Oncology Group performance status greater than or equal to 2, approximately 50% were more than or equal to 65 years, 21% received cisplatin-etoposide chemotherapy before atezolizumab, and 12% had thoracic radiation (tRT). Within the atezolizumab versus chemotherapy group, the median PFS equals to 6.0 versus 4.3 months (p = 0.03) whereas OS = 12.8 versus 7.1 months (p = 0.01). Relative to chemotherapy, the hazard ratio (95% confidence interval) for PFS was 0.53 (0.28–1.02) and OS was 0.42 (0.20–0.88) with atezolizumab. tRT compared with no tRT receipt correlated with reduced death risk (hazard ratio [95% confidence interval] = 0.33 [0.13–0.88]). AE-related treatment withdrawal with atezolizumab was 32% and 15% with chemotherapy (p = 0.02). Within the tRT subgroup, 25% versus 20% in atezolizumab versus chemotherapy group, respectively, discontinued 1L owing to AE. Conclusions This is the first real-world study revealing comparable survival with that in the IMpower133 trial. Treatment discontinuation from AEs was higher with atezolizumab among Canadian patients with ESCLC. Our data suggest safe use of tRT and chemoimmunotherapy, but its efficacy for ESCLC warrants further study.
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Affiliation(s)
- Anifat A Elegbede
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Amanda J Gibson
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Andrea S Fung
- Cancer Centre of Southeastern Ontario, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Winson Y Cheung
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Tom Baker Cancer Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Michelle L Dean
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - D Gwyn Bebb
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Tom Baker Cancer Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Aliyah Pabani
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Tom Baker Cancer Centre, Alberta Health Services, Calgary, Alberta, Canada
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Heinzerling JH, Mileham KF, Simone CB. The utilization of immunotherapy with radiation therapy in lung cancer: a narrative review. Transl Cancer Res 2021; 10:2596-2608. [PMID: 35116573 PMCID: PMC8797746 DOI: 10.21037/tcr-20-2241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022]
Abstract
Despite decreasing smoking rates, lung cancer remains the leading cause of death from cancer in the United States. Radiation therapy has been established as an effective locoregional therapy for both early stage and locally advanced disease and is known to stimulate local immune response. Past treatment paradigms have established the role of combining cytotoxic chemotherapy regimens and radiation therapy to help address the local and systemic nature of lung cancer. However, these regimens have limitations in their tolerability due to toxicity. Additionally, cytotoxic chemotherapy has limited efficacy in preventing systemic spread of lung cancer. Newer systemic agents such as immune checkpoint inhibitors have shown improved survival in metastatic and locally advanced lung cancer and have the advantage of more limited toxicity profiles compared to cytotoxic chemotherapy. Furthermore, improved overall response rates and systemic tumor responses have been observed with the combination of radiation therapy and immunotherapy, leading to numerous active clinical trials evaluating the combination of immune checkpoint inhibition with radiotherapy. This comprehensive review discusses the current clinical data and ongoing studies evaluating the combination of radiation therapy and immunotherapy in both non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC).
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Affiliation(s)
- John H. Heinzerling
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, NC, USA
| | | | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- New York Proton Center, New York, NY, USA
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Abstract
Lung cancer is a leading cause of cancer-related mortality despite continued advances in diagnostic and therapeutic strategies. Although the development of immune checkpoint inhibitors has revolutionized the treatment landscape for advanced non-small cell lung cancer, many patients either have primary resistance to these agents or eventually develop secondary resistance necessitating a change to an alternate therapy. Understanding novel patterns of response to immunotherapy is crucial in determining appropriate selection and sequencing of treatment. Chemotherapy remains the standard of care in immunotherapy-refractory disease, but multiple trials are ongoing to explore the role of combination radioimmunotherapy and rechallenging with immunotherapy either alone or in combination with other antineoplastic agents.
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Fitzgerald K, Simone CB. Combining Immunotherapy with Radiation Therapy in Non-Small Cell Lung Cancer. Thorac Surg Clin 2020; 30:221-239. [PMID: 32327181 DOI: 10.1016/j.thorsurg.2020.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immune checkpoint inhibitors have recently been demonstrated to improve survival in metastatic and locally advanced non-small cell lung cancer (NSCLC). Radiation therapy has a well-established role in the treatment of NSCLC and has more recently been shown to be immunostimulatory, with the potential to enhance the efficacy of immunotherapy. This comprehensive review details the current roles of radiation therapy and immune checkpoint inhibitors in NSCLC, discusses the intersection of these two modalities and their potential to have combined synergistic responses, and highlights existing preclinical and clinical data and ongoing clinical trials of combined immunotherapy and radiotherapy across all NSCLC stages.
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Affiliation(s)
- Kelly Fitzgerald
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 First Avenue, Mezzanine Level, New York, NY 10065, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 First Avenue, Mezzanine Level, New York, NY 10065, USA; New York Proton Center, 225 East 126th Street, New York, NY 10035, USA.
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9
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Simone CB, Aide N, Alavi A. PET Imaging for Immunotherapy and Radiation Therapy. PET Clin 2020; 15:xiii-xiv. [DOI: 10.1016/j.cpet.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Iravani A, Turgeon GA, Akhurst T, Callahan JW, Bressel M, Everitt SJ, Siva S, Hofman MS, Hicks RJ, Ball DL, Mac Manus MP. PET-detected pneumonitis following curative-intent chemoradiation in non-small cell lung cancer (NSCLC): recognizing patterns and assessing the impact on the predictive ability of FDG-PET/CT response assessment. Eur J Nucl Med Mol Imaging 2019; 46:1869-1877. [PMID: 31190177 DOI: 10.1007/s00259-019-04388-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/31/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Inflammatory FDG uptake in the lung (PET-pneumonitis) following curative-intent radiotherapy (RT)/chemo-RT (CRT) in non-small cell lung cancer (NSCLC) can pose a challenge in FDG-PET/CT response assessment. The aim of this study is to describe different patterns of PET-pneumonitis to guide the interpretation of FDG-PET/CT and investigate its association with tumor response and overall survival (OS). METHODS Retrospective analysis was performed on 87 NSCLC patients in three prospective trials who were treated with radical RT (n = 7) or CRT (n = 80), with baseline and post-treatment FDG-PET/CT. Visual criteria were performed for post-treatment FDG-PET/CT response assessment. The grading of PET-pneumonitis was based on relative lung uptake intensity compared to organs of reference and classified as per Deauville score from grade 1-5. Distribution patterns of PET-pneumonitis were defined as follows: A) patchy/sub-pleural; B) diffuse (involving more than a segment); and C) peripheral (diffusely surrounding a photopenic region). RESULTS Follow-up FDG-PET/CT scans were performed approximately 3 months (median, 89 days; interquartile range, 79-93) after RT. Overall, PET-pneumonitis was present in 62/87 (71%) of patients, with Deauville 2 or 3 in 12/62 (19%) and 4 or 5 in 50/62 (81%) of patients. The frequency of patterns A, B and C of PET-pneumonitis was 19/62 (31%), 20/62 (32%) and 23/62 (37%), respectively. No association was found between grade or pattern of PET-pneumonitis and overall response at follow-up PET/CT (p = 0.27 and p = 0.56, respectively). There was also no significant association between PET-pneumonitis and OS (hazard ratio [HR], 1.3; 95% confidence interval [CI], 0.6-2.5; p = 0.45). Early FDG-PET/CT response assessment, however, was prognostic for OS (HR, 1.7; 95% CI, 1.2-2.2; p < 0.001). CONCLUSION PET-pneumonitis is common in early post-CRT/RT, but pattern recognition may assist in response assessment by FDG-PET/CT. While FDG-PET/CT is a powerful tool for response assessment and prognostication, PET-pneumonitis does not appear to confound early response assessment or to independently predict OS.
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Affiliation(s)
- Amir Iravani
- Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Guy-Anne Turgeon
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Tim Akhurst
- Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Jason W Callahan
- Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Mathias Bressel
- Department of Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Sarah J Everitt
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Radiation Therapy, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Medical Imaging and Radiation Sciences, Faculty of Medicine and Dentistry, Monash University, Clayton, VIC, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael S Hofman
- Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Rodney J Hicks
- Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - David L Ball
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael P Mac Manus
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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The Combination of Stereotactic Body Radiation Therapy and Immunotherapy in Primary Liver Tumors. JOURNAL OF ONCOLOGY 2019; 2019:4304817. [PMID: 31182960 PMCID: PMC6512065 DOI: 10.1155/2019/4304817] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023]
Abstract
Treatment recommendations for primary liver malignancies, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), are complex and require a multidisciplinary approach. Despite surgical options that are potentially curative, options for nonsurgical candidates include systemic therapy, radiotherapy (RT), transarterial chemoembolization (TACE), and radiofrequency ablation (RFA). Stereotactic Body Radiation Therapy (SBRT) is now in routine use for the treatment of lung cancer, and there is growing evidence supporting its use in liver tumors. SBRT has the advantage of delivering ablative radiation doses in a limited number of fractions while minimizing the risk of radiation-induced liver disease (RILD) through highly conformal treatment plans. It should be considered in a multidisciplinary setting for the management of patients with unresectable, locally advanced primary liver malignancies and limited treatment options. Recently, the combination of immunotherapy with SBRT has been proposed to improve antitumor effects through engaging the immune system. This review aims at shedding light on the novel concept of the combination strategy of immune-radiotherapy in liver tumors by exploring the evidence surrounding the use of SBRT and immunotherapy for the treatment of HCC and CCA.
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Barsky AR, Cengel KA, Katz SI, Sterman DH, Simone CB. First-ever Abscopal Effect after Palliative Radiotherapy and Immuno-gene Therapy for Malignant Pleural Mesothelioma. Cureus 2019; 11:e4102. [PMID: 31057996 PMCID: PMC6476617 DOI: 10.7759/cureus.4102] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Malignant pleural mesothelioma (MPM) is a highly aggressive disease, with few, if any, curative interventions. While there is growing interest in using immunotherapy and immuno-gene therapy to treat MPM, very limited data currently exist for combining these modalities with radiotherapy. Preclinical data suggest that radiotherapy may be combined with immunotherapy to produce disease regression, with abscopal effects in mice with MPM. We report the first-ever case of abscopal effect in a patient with MPM, following radiotherapy and immuno-gene therapy. The patient was a 67-year-old male with prior asbestos exposure who presented with progressive dyspnea and thoracic pain. He underwent partial right pleurectomy, pleural biopsy, and talc pleurodesis, with pathology revealing epithelioid MPM. A subsequent chest computed tomography (CT) scan and fluoro-deoxyglucose positron-emission tomography (FDG-PET) CT scan showed extensive, right-sided, fluoro-deoxyglucose (FDG) avid mass-like pleural thickening encasing the right lung, with likely mediastinal extension, nodal metastases, and vascular compression. He enrolled in a clinical trial in which he received intrapleural interferon-alpha gene therapy but needed to discontinue therapy due to supraventricular tachycardia and superior vena cava syndrome induced from tumor burden. He was emergently treated with palliative radiotherapy to 30 Gy in 10 fractions. He was then started on pemetrexed and cisplatin chemotherapy. His subsequent chest CT scan two months after radiotherapy completion showed a dramatic treatment response within, as well as outside of, the irradiated field. After completion of radiotherapy, he did experience radiation esophagitis requiring nasogastric tube placement. Herein, we highlight the feasibility and efficacy of combining immuno-gene therapy with palliative radiotherapy to produce a substantial treatment response and an abscopal effect in a patient with unresectable MPM.
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Affiliation(s)
- Andrew R Barsky
- Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Keith A Cengel
- Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Sharyn I Katz
- Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Daniel H Sterman
- Internal Medicine, New York University School of Medicine, New York, USA
| | - Charles B Simone
- Radiation Oncology, University of Maryland School of Medicine, Baltimore, USA
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Wirsdörfer F, de Leve S, Jendrossek V. Combining Radiotherapy and Immunotherapy in Lung Cancer: Can We Expect Limitations Due to Altered Normal Tissue Toxicity? Int J Mol Sci 2018; 20:ijms20010024. [PMID: 30577587 PMCID: PMC6337556 DOI: 10.3390/ijms20010024] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 02/08/2023] Open
Abstract
In recent decades, technical advances in surgery and radiotherapy, as well as breakthroughs in the knowledge on cancer biology, have helped to substantially improve the standard of cancer care with respect to overall response rates, progression-free survival, and the quality of life of cancer patients. In this context, immunotherapy is thought to have revolutionized the standard of care for cancer patients in the long term. For example, immunotherapy approaches such as immune checkpoint blockade are currently increasingly being used in cancer treatment, either alone or in combination with chemotherapy or radiotherapy, and there is hope from the first clinical trials that the appropriate integration of immunotherapy into standard care will raise the success rates of cancer therapy to a new level. Nevertheless, successful cancer therapy remains a major challenge, particularly in tumors with either pronounced resistance to chemotherapy and radiation treatment, a high risk of normal tissue complications, or both, as in lung cancer. Chemotherapy, radiotherapy and immunotherapy have the capacity to evoke adverse effects in normal tissues when administered alone. However, therapy concepts are usually highly complex, and it is still not clear if combining immunotherapy with radio(chemo)therapy will increase the risk of normal tissue complications, in particular since normal tissue toxicity induced by chemotherapy and radiotherapy can involve immunologic processes. Unfortunately, no reliable biomarkers are available so far that are suited to predict the unique normal tissue sensitivity of a given patient to a given treatment. Consequently, clinical trials combining radiotherapy and immunotherapy are attracting major attention, not only regarding efficacy, but also with regard to safety. In the present review, we summarize the current knowledge of radiation-induced and immunotherapy-induced effects in tumor and normal tissue of the lung, and discuss the potential limitations of combined radio-immunotherapy in lung cancer with a focus on the suspected risk for enhanced acute and chronic normal tissue toxicity.
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Affiliation(s)
- Florian Wirsdörfer
- Institute of Cell Biology (Cancer Research), University Hospital Essen, 45147 Essen, Germany.
| | - Simone de Leve
- Institute of Cell Biology (Cancer Research), University Hospital Essen, 45147 Essen, Germany.
| | - Verena Jendrossek
- Institute of Cell Biology (Cancer Research), University Hospital Essen, 45147 Essen, Germany.
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