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Pavarini M, Alborghetti L, Aimonetto S, Maggio A, Landoni V, Ferrari P, Bianculli A, Petrucci E, Cicchetti A, Farina B, Ubeira-Gabellini MG, Salmoiraghi P, Moretti E, Avuzzi B, Giandini T, Munoz F, Magli A, Sanguineti G, Magdalena Waskiewicz J, Rago L, Cante D, Girelli G, Vavassori V, Di Muzio NG, Rancati T, Cozzarini C, Fiorino C. Pelvic bone marrow dose-volume predictors of late lymphopenia following pelvic lymph node radiation therapy for prostate cancer. Radiother Oncol 2024; 195:110230. [PMID: 38503355 DOI: 10.1016/j.radonc.2024.110230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND AND PURPOSE Given the substantial lack of knowledge, we aimed to assess clinical/dosimetry predictors of late hematological toxicity on patients undergoing pelvic-nodes irradiation (PNI) for prostate cancer (PCa) within a prospective multi-institute study. MATERIALS AND METHODS Clinical/dosimetry/blood test data were prospectively collected including lymphocytes count (ALC) at baseline, mid/end-PNI, 3/6 months and every 6 months up to 5-year after PNI. DVHs of the Body, ileum (BMILEUM), lumbosacral spine (BMLS), lower pelvis (BMPELVIS), and whole pelvis (BMTOT) were extracted. Current analysis focused on 2-year CTCAEv4.03 Grade ≥ 2 (G2+) lymphopenia (ALC < 800/μL). DVH parameters that better discriminate patients with/without toxicity were first identified. After data pre-processing to limit overfitting, a multi-variable logistic regression model combining DVH and clinical information was identified and internally validated by bootstrap. RESULTS Complete data of 499 patients were available: 46 patients (9.2 %) experienced late G2+ lymphopenia. DVH parameters of BMLS/BMPELVIS/BMTOT and Body were associated to increased G2+ lymphopenia. The variables retained in the resulting model were ALC at baseline [HR = 0.997, 95 %CI 0.996-0.998, p < 0.0001], smoke (yes/no) [HR = 2.9, 95 %CI 1.25-6.76, p = 0.013] and BMLS-V ≥ 24 Gy (cc) [HR = 1.006, 95 %CI 1.002-1.011, p = 0.003]. When acute G3+ lymphopenia (yes/no) was considered, it was retained in the model [HR = 4.517, 95 %CI 1.954-10.441, p = 0.0004]. Performances of the models were relatively high (AUC = 0.87/0.88) and confirmed by validation. CONCLUSIONS Two-year lymphopenia after PNI for PCa is largely modulated by baseline ALC, with an independent role of acute G3+ lymphopenia. BMLS-V24 was the best dosimetry predictor: constraints for BMTOT (V10Gy < 1520 cc, V20Gy < 1250 cc, V30Gy < 850 cc), and BMLS (V24y < 307 cc) were suggested to potentially reduce the risk.
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Affiliation(s)
- Maddalena Pavarini
- IRCCS San Raffaele Scientific Institute, Medical Physics Dept, Milano, Italy
| | - Lisa Alborghetti
- IRCCS San Raffaele Scientific Institute, Medical Physics Dept, Milano, Italy
| | - Stefania Aimonetto
- Ospedale Regionale Parini-AUSL Valle d'Aosta, Medical Physics Dept, Aosta, Italy
| | - Angelo Maggio
- Istituto di Candiolo - Fondazione del Piemonte per l'Oncologia IRCCS, Medical Physics Dept, Candiolo, Italy
| | - Valeria Landoni
- IRCCS Istituto Nazionale Tumori Regina Elena, UOSD Laboratorio di Fisica Medica e Sistemi Esperti, Roma, Italy
| | - Paolo Ferrari
- Comprensorio Sanitario di Bolzano, Medical Physics Dept, Bolzano, Italy
| | | | | | - Alessandro Cicchetti
- Fondazione IRCCS Istituto Nazionale dei Tumori, Unit of Data Science, Milano, Italy
| | - Bruno Farina
- Ospedale degli Infermi, Medical Physics Dept, Biella, Italy
| | | | | | - Eugenia Moretti
- Azienda sanitaria universitaria Friuli Centrale, Medical Physics Department, Udine, Italy
| | - Barbara Avuzzi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Radiotherapy Department, Milano, Italy
| | - Tommaso Giandini
- Fondazione IRCCS Istituto Nazionale dei Tumori, Medical Physics Department, Milano, Italy
| | - Fernando Munoz
- Ospedale Regionale Parini-AUSL Valle d'Aosta, Department of Radiation Oncology, Aosta, Italy
| | - Alessandro Magli
- Azienda Ospedaliero Universitaria S. Maria della Misericordia, Department of Radiotherapy, Udine, Italy
| | - Giuseppe Sanguineti
- IRCCS Regina Elena National Cancer Institute, Department of Radiation Oncology, Roma, Italy
| | | | - Luciana Rago
- IRCCS Crob, Radiotherapy, Rionero in Vulture, Italy
| | | | - Giuseppe Girelli
- Ospedale degli Infermi, Department of Radiotherapy, Biella, Italy
| | | | - Nadia Gisella Di Muzio
- Vita-Salute San Raffaele University, Milano, Italy; IRCCS San Raffaele Scientific Institute, Department of Radiation Oncology, Milano, Italy
| | - Tiziana Rancati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Unit of Data Science, Milano, Italy
| | - Cesare Cozzarini
- IRCCS San Raffaele Scientific Institute, Department of Radiation Oncology, Milano, Italy
| | - Claudio Fiorino
- IRCCS San Raffaele Scientific Institute, Medical Physics Dept, Milano, Italy.
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Schmidt DR, Gramatikov IMT, Sheen A, Williams CL, Hurwitz M, Dodge LE, Holupka E, Kiger WS, Cornwall-Brady MR, Huang W, Mak HH, Cormier KS, Condon C, Dane Wittrup K, Yilmaz ÖH, Stevenson MA, Down JD, Floyd SR, Roper J, Vander Heiden MG. Ablative radiotherapy improves survival but does not cure autochthonous mouse models of prostate and colorectal cancer. COMMUNICATIONS MEDICINE 2023; 3:108. [PMID: 37558833 PMCID: PMC10412558 DOI: 10.1038/s43856-023-00336-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Genetically engineered mouse models (GEMMs) of cancer are powerful tools to study mechanisms of disease progression and therapy response, yet little is known about how these models respond to multimodality therapy used in patients. Radiation therapy (RT) is frequently used to treat localized cancers with curative intent, delay progression of oligometastases, and palliate symptoms of metastatic disease. METHODS Here we report the development, testing, and validation of a platform to immobilize and target tumors in mice with stereotactic ablative RT (SART). Xenograft and autochthonous tumor models were treated with hypofractionated ablative doses of radiotherapy. RESULTS We demonstrate that hypofractionated regimens used in clinical practice can be effectively delivered in mouse models. SART alters tumor stroma and the immune environment, improves survival in GEMMs of primary prostate and colorectal cancer, and synergizes with androgen deprivation in prostate cancer. Complete pathologic responses were achieved in xenograft models, but not in GEMMs. CONCLUSIONS While SART is capable of fully ablating xenografts, it is unable to completely eradicate disease in GEMMs, arguing that resistance to potentially curative therapy can be modeled in GEMMs.
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Affiliation(s)
- Daniel R Schmidt
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Iva Monique T Gramatikov
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Allison Sheen
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Christopher L Williams
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Martina Hurwitz
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Laura E Dodge
- Harvard Medical School, Boston, MA, USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Edward Holupka
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - W S Kiger
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Milton R Cornwall-Brady
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Wei Huang
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Howard H Mak
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kathleen S Cormier
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Charlene Condon
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - K Dane Wittrup
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ömer H Yilmaz
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, USA
| | - Mary Ann Stevenson
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Julian D Down
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Jatin Roper
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Medicine, Division of Gastroenterology, and Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Matthew G Vander Heiden
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Dana-Farber Cancer Institute, Boston, MA, USA.
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3
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Magné N, Daguenet E, Bouleftour W, Conraux L, Tinquaut F, Grangeon K, Moreno-Acosta P, Suchaud JP, Rancoule C, Guy JB. Impact of Radiation Therapy on Biological Parameters in Cancer Patients: Sub-analysis from the RIT Prospective Epidemiological Study. Cancer Invest 2023; 41:109-118. [PMID: 36278830 DOI: 10.1080/07357907.2022.2139838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Scarce data investigate the impact of radiotherapy (RT) on biology markers. An analysis of ancillary study of RIT (Radiation Impact on Thromboembolic events) prospective trial was carried out. All patients with non-metastatic solid tumors and treated with radiotherapy and/or brachytherapy in curative and consenting to have blood samples were included. A significant decrease in white blood count, (i.e. lymphocytes, monocytes, neutrophils and basophils) and platelet counts was observed after RT and maintained at 6 months. Whereas, eosinophils, D-dimers and hemoglobin levels were affected respectively 3 months and 6 months after RT initiation. Conversely, red cells count and CRP level were not affected by RT. This study is an advocacy to develop an understanding of basic immune system in relation with RT.
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Affiliation(s)
- Nicolas Magné
- Department of Radiation Oncology, Saint Priest en Jarez, France.,Department of Research and Teaching in Oncology, Saint Priest en Jarez, France.,Molecular and cellular radiobiology Lab, CNRS UMR 5822, Institut de Physique Nucléaire de Lyon, IPNL, Lyon Medicine University, Lyon, France
| | - Elisabeth Daguenet
- Department of Research and Teaching in Oncology, Saint Priest en Jarez, France
| | - Wafa Bouleftour
- Department of Research and Teaching in Oncology, Saint Priest en Jarez, France
| | - Laurine Conraux
- Department of Radiation Oncology, Saint Priest en Jarez, France.,Department of Research and Teaching in Oncology, Saint Priest en Jarez, France
| | - Fabien Tinquaut
- Department of Research and Teaching in Oncology, Saint Priest en Jarez, France
| | - Kevin Grangeon
- Department of Research and Teaching in Oncology, Saint Priest en Jarez, France
| | - Pablo Moreno-Acosta
- Research Group in Radiobiology Clinical, Molecular and Cellular, National Cancer Institute, Bogota, Colombia
| | | | - Chloé Rancoule
- Department of Radiation Oncology, Saint Priest en Jarez, France.,Department of Research and Teaching in Oncology, Saint Priest en Jarez, France
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Joseph N, Cicchetti A, McWilliam A, Webb A, Seibold P, Fiorino C, Cozzarini C, Veldeman L, Bultijnck R, Fonteyne V, Talbot CJ, Symonds PR, Johnson K, Rattay T, Lambrecht M, Haustermans K, De Meerleer G, Elliott RM, Sperk E, Herskind C, Veldwijk M, Avuzzi B, Giandini T, Valdagni R, Azria D, Jacquet MPF, Charissoux M, Vega A, Aguado-Barrera ME, Gómez-Caamaño A, Franco P, Garibaldi E, Girelli G, Iotti C, Vavassori V, Chang-Claude J, West CML, Rancati T, Choudhury A. High weekly integral dose and larger fraction size increase risk of fatigue and worsening of functional outcomes following radiotherapy for localized prostate cancer. Front Oncol 2022; 12:937934. [PMID: 36387203 PMCID: PMC9645430 DOI: 10.3389/fonc.2022.937934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction We hypothesized that increasing the pelvic integral dose (ID) and a higher dose per fraction correlate with worsening fatigue and functional outcomes in localized prostate cancer (PCa) patients treated with external beam radiotherapy (EBRT). Methods The study design was a retrospective analysis of two prospective observational cohorts, REQUITE (development, n=543) and DUE-01 (validation, n=228). Data were available for comorbidities, medication, androgen deprivation therapy, previous surgeries, smoking, age, and body mass index. The ID was calculated as the product of the mean body dose and body volume. The weekly ID accounted for differences in fractionation. The worsening (end of radiotherapy versus baseline) of European Organisation for Research and Treatment of Cancer EORTC) Quality of Life Questionnaire (QLQ)-C30 scores in physical/role/social functioning and fatigue symptom scales were evaluated, and two outcome measures were defined as worsening in ≥2 (WS2) or ≥3 (WS3) scales, respectively. The weekly ID and clinical risk factors were tested in multivariable logistic regression analysis. Results In REQUITE, WS2 was seen in 28% and WS3 in 16% of patients. The median weekly ID was 13.1 L·Gy/week [interquartile (IQ) range 10.2-19.3]. The weekly ID, diabetes, the use of intensity-modulated radiotherapy, and the dose per fraction were significantly associated with WS2 [AUC (area under the receiver operating characteristics curve) =0.59; 95% CI 0.55-0.63] and WS3 (AUC=0.60; 95% CI 0.55-0.64). The prevalence of WS2 (15.3%) and WS3 (6.1%) was lower in DUE-01, but the median weekly ID was higher (15.8 L·Gy/week; IQ range 13.2-19.3). The model for WS2 was validated with reduced discrimination (AUC=0.52 95% CI 0.47-0.61), The AUC for WS3 was 0.58. Conclusion Increasing the weekly ID and the dose per fraction lead to the worsening of fatigue and functional outcomes in patients with localized PCa treated with EBRT.
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Affiliation(s)
- Nuradh Joseph
- Department of Clinical Oncology, District General Hambantota, Hambantota, Sri Lanka
- Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Maharagama, Sri Lanka
| | - Alessandro Cicchetti
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Hambantota, Italy
| | - Alan McWilliam
- Department of Medical Physics, University of Manchester, Manchester, United Kingdom
| | - Adam Webb
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Petra Seibold
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Claudio Fiorino
- Department of Medical Physics, San Raffaele Scientific Institute - IRCCS, Milan, Italy
| | - Cesare Cozzarini
- Department of Radiation Oncology, San Raffaele Scientific Institute - IRCCS, Milan, Italy
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Renée Bultijnck
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Valérie Fonteyne
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Christopher J. Talbot
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Paul R. Symonds
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Kerstie Johnson
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Tim Rattay
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Maarten Lambrecht
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Rebecca M. Elliott
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Elena Sperk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Carsten Herskind
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marlon Veldwijk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Barbara Avuzzi
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tommaso Giandini
- Department of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Hambantota, Italy
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - David Azria
- Department of Radiation Oncology, University Federation of Radiation Oncology, Montpellier Cancer Institute, Univ Montpellier MUSE, Grant INCa_Inserm_DGOS_12553, Inserm U1194, Montpellier, France
| | | | - Marie Charissoux
- University Federation of Radiation Oncology of Mediterranean Occitanie, ICM Montpellier, Univ Montpellier, Montpellier, France
| | - Ana Vega
- Fundación Pública Galega de Medicina Xenómica, Grupo de Medicina Xenómica (USC), Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Biomedical Network on Rare Diseases (CIBERER), Madrid, Spain
| | - Miguel E. Aguado-Barrera
- Fundación Pública Galega de Medicina Xenómica, Grupo de Medicina Xenómica (USC), Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Gómez-Caamaño
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Pierfrancesco Franco
- Department of Radiation Oncology, Ospedale Regionale U. Parini-AUSL Valle d’Aosta, Aosta, Italy
| | - Elisabetta Garibaldi
- Department of Radiation Oncology, Istituto di Candiolo - Fondazione del Piemonte per l’Oncologia IRCCS, Candiolo, Italy
| | | | - Cinzia Iotti
- Department of Radiation Oncology, Azienda USL – IRCCS di Reggio Emilia, Emilia-Romagna, Italy
| | | | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharine M. L. West
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Hambantota, Italy
| | - Ananya Choudhury
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, and The Christie NHS Foundation Trust, Manchester, United Kingdom
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5
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D’Auria F, Statuto T, Rago L, Montagna A, Castaldo G, Schirò I, Zeccola A, Virgilio T, Bianchino G, Traficante A, Sgambato A, Fusco V, Valvano L, Calice G. Modulation of Peripheral Immune Cell Subpopulations After RapidArc/Moderate Hypofractionated Radiotherapy for Localized Prostate Cancer: Findings and Comparison With 3D Conformal/Conventional Fractionation Treatment. Front Oncol 2022; 12:829812. [PMID: 35719968 PMCID: PMC9198604 DOI: 10.3389/fonc.2022.829812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy (RT) is an important therapeutic option in patients with localized prostate cancer (PC). Unfortunately, radiation treatment causes a decrease in peripheral lymphocytes and, consequently, influences the patients' immune status. Our aim was to study changes in peripheral blood immune cell subpopulations after RT and during 6 months' follow-up in 2 groups of PC patients irradiated with different techniques and dose fractions with curative intent. We also investigated the presence of correlation between immune cell modulation and genitourinary or gastrointestinal toxicity. We enrolled 44 patients treated with curative RT (RapidArc/hypofractionation regimen or 3D conformal/conventional fractionation) for localized PC. Total white blood cell (WBC), absolute lymphocyte counts (ALCs), and peripheral immune cell subpopulations were analyzed at baseline, at the end of RT, and 3 and 6 months after the end of RT. WBC and ALC greatly decreased at the end of RT with a trend to recover at 6 months' follow-up in the hypofractionation group but not in the conventional one. Furthermore, B, total T, T CD4+, T CD8+, and NK cell values dropped significantly in both groups at the end of RT, with a minor decrease detectable in the hypofractionation group for B, total T, and T CD4+ lymphocytes with respect to the other technique/fractionation group. Double-negative T (DNT), double-positive T (DPT), and NKT cells significantly decreased at the end of RT with a slight tendency to recover values during follow-up, particularly in the hypofractionation group. No correlation with genitourinary or gastrointestinal toxicity was found. In this study, we showed, for the first time, the effects of RapidArc/moderate hypofractionation RT on immune cell subsets in patients treated for localized PC. Due to the growing interest in minority T-cell subpopulations for immunotherapy, we also reported longitudinal monitoring of the effects of RT on DNT, DPT, and NKT, which was never studied before. Our preliminary data highlight the importance of considering the effects of different RT techniques/fractionation regimens on peripheral immune cells, in the era of RT and immunotherapy combination.
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Affiliation(s)
- Fiorella D’Auria
- Laboratory of Clinical Pathology, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Teodora Statuto
- Laboratory of Clinical Research and Advanced Diagnostics, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Luciana Rago
- Radiotherapy Unit, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Antonietta Montagna
- Radiotherapy Unit, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Giovanni Castaldo
- Radiotherapy Unit, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Irene Schirò
- Radiotherapy Unit, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Anna Zeccola
- Radiotherapy Unit, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Teresa Virgilio
- Radiotherapy Unit, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Gabriella Bianchino
- Laboratory of Clinical Pathology, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Antonio Traficante
- Laboratory of Clinical Pathology, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Alessandro Sgambato
- Scientific Direction, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Vincenzo Fusco
- Radiotherapy Unit, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Luciana Valvano
- Laboratory of Clinical Research and Advanced Diagnostics, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Giovanni Calice
- Laboratory of Preclinical and Translational Research, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
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Danckaert W, Spaas M, Vandecasteele K, De Wagter C, Ost P. Impact of radiotherapy parameters on the risk of lymphopenia in urological tumors: a systematic review of the literature. Radiother Oncol 2022; 170:64-69. [DOI: 10.1016/j.radonc.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
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7
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Bastiani I, McMahon SJ, Turner P, Redmond KM, McGarry CK, Cole A, O'Sullivan JM, Prise KM, Ainsbury L, Anderson R. Dose estimation after a mixed field exposure: Radium-223 and intensity modulated radiotherapy. Nucl Med Biol 2021; 106-107:10-20. [PMID: 34968973 DOI: 10.1016/j.nucmedbio.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 11/04/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Radium-223 dichloride ([223Ra]RaCl2), a radiopharmaceutical that delivers α-particles to regions of bone metastatic disease, has been proven to improve overall survival of men with metastatic castration resistant prostate cancer (mCRPC). mCRPC patients enrolled on the ADRRAD clinical trial are treated with a mixed field exposure comprising radium-223 (223Ra) and intensity modulated radiotherapy (IMRT). While absorbed dose estimation is an important step in the characterisation of wider systemic radiation risks in nuclear medicine, uncertainties remain for novel radiopharmaceuticals such as 223Ra. METHODS 24-Colour karyotyping was used to quantify the spectrum of chromosome aberrations in peripheral blood lymphocytes of ADRRAD patients at incremental times during their treatment. Dicentric equivalent frequencies were used in standard models for estimation of absorbed blood dose. To account for the mixed field nature of the treatment, existing models were used to determine the ratio of the component radiation types. Additionally, a new approach (M-FISHLET), based on the ratio of cells containing damage consistent with high-LET exposure (complex chromosomal exchanges) and low-LET exposure (simple exchanges), was used as a pseudo ratio for 223Ra:IMRT dose. RESULTS Total IMRT estimated doses delivered to the blood after completion of mixed radiotherapy (after 37 IMRT fractions and two [223Ra]RaCl2 injections) were in the range of 1.167 ± 0.092 and 2.148 ± 0.096 Gy (dose range across all models applied). By the last treatment cycle analysed in this study (four [223Ra]RaCl2 injections), the total absorbed 223Ra dose to the blood was estimated to be between 0.024 ± 0.027 and 0.665 ± 0.080 Gy, depending on the model used. Differences between the models were observed, with the observed dose variance coming from inter-model as opposed to inter-patient differences. The M-FISHLET model potentially overestimates the 223Ra absorbed blood dose by accounting for further PBL exposure in the vicinity of metastatic sites. CONCLUSIONS The models presented provide initial estimations of cumulative dose received during incremental IMRT fractions and [223Ra]RaCl2 injections, which will enable improved understanding of the doses received by individual patients. While the M-FISHLET method builds on a well-established technique for external exposures, further consideration is needed to evaluate this method and its use in assessing non-targeted exposure by 223Ra after its localization at bone metastatic sites.
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Affiliation(s)
- Isabella Bastiani
- Centre for Health Effects of Radiological and Chemical Agents, College of Health, Medicine and Life Sciences, Brunel University London, Kingston Lane, Uxbridge, London UB8 3PH, United Kingdom of Great Britain and Northern Ireland.
| | - Stephen J McMahon
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast BT9 7AE, United Kingdom of Great Britain and Northern Ireland.
| | - Philip Turner
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast BT9 7AE, United Kingdom of Great Britain and Northern Ireland; Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, United Kingdom of Great Britain and Northern Ireland.
| | - Kelly M Redmond
- Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, United Kingdom of Great Britain and Northern Ireland.
| | - Conor K McGarry
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast BT9 7AE, United Kingdom of Great Britain and Northern Ireland; Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, United Kingdom of Great Britain and Northern Ireland.
| | - Aidan Cole
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast BT9 7AE, United Kingdom of Great Britain and Northern Ireland; Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, United Kingdom of Great Britain and Northern Ireland.
| | - Joe M O'Sullivan
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast BT9 7AE, United Kingdom of Great Britain and Northern Ireland; Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, United Kingdom of Great Britain and Northern Ireland.
| | - Kevin M Prise
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast BT9 7AE, United Kingdom of Great Britain and Northern Ireland.
| | - Liz Ainsbury
- Centre for Radiation, Chemical & Environmental Hazards, Public Health England, Didcot OX11 0RQ, United Kingdom of Great Britain and Northern Ireland.
| | - Rhona Anderson
- Centre for Health Effects of Radiological and Chemical Agents, College of Health, Medicine and Life Sciences, Brunel University London, Kingston Lane, Uxbridge, London UB8 3PH, United Kingdom of Great Britain and Northern Ireland.
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8
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Zwicker F, Swartman B, Huber PE, Herfarth K, Debus J, Hauswald H. Lack of Relevant Haemogram Changes During Percutaneous Radiotherapy of Localised Prostate Cancer. In Vivo 2021; 34:1555-1563. [PMID: 32354962 DOI: 10.21873/invivo.11945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM In percutaneous radiotherapy dose-distribution and volumetric-load of normal tissue varies in different radiation-techniques. Haematotoxicity may lead to deficiencies of the immune and blood system or to secondary malignancies. Therefore, regular blood-counts are carried out during fractionated radiotherapy. The aim was to investigate patient haemogram courses during radiotherapy of localised prostate-cancer treated with different radiation-techniques (n=3). PATIENTS AND METHODS In this prospective study, blood count changes were examined during fractionated radiotherapy (3D-conformal-RT/step-and-shoot-IMRT/helical-IMRT) on the prostate-region in localised prostate-cancer cases (n=50). RESULTS The whole patient group displayed a small but significant reduction in leukocytes. This reduction was higher in the two IMRT groups compared to the 3D-group but without any case of leukopenia. Haemoglobin- or thrombocyte-levels did not significantly change. CONCLUSION Regardless of the delivery mode used, localised fractionated irradiation of prostate region did not cause any clinically relevant haemogram changes in this study. These findings question the necessity of regular blood counts during fractionated radiotherapy of the prostate region for patients without any risk factors.
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Affiliation(s)
- Felix Zwicker
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany .,Clinical Cooperation Unit Molecular Radiation Oncology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Benedict Swartman
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter E Huber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Radiation Oncology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Radiation Oncology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Henrik Hauswald
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
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9
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Luo HC, Fu ZC, Wang XP, Cai LJ, Wang FM, Yin Q, Lin G, Chen ZH, Liao SG. Treating the primary in low burden metastatic prostate cancer: Where do we stand? Medicine (Baltimore) 2020; 99:e23715. [PMID: 33371121 PMCID: PMC7748322 DOI: 10.1097/md.0000000000023715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/16/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022] Open
Abstract
ABSTRACT On the basis of endocrine therapy for patients with low burden metastatic prostate cancer (LBMP), the clinical efficacy and quality of life were compared between prostate-only directed radiotherapy (PODT) and prostate and metastasis radiotherapy (PMRT).From November 2009 to November 2015, total 91 patients newly diagnosed with LBMP were retrospectively analyzed, of which 52 patients received PODT and 39 patients received PMRT. The biochemical failure free interval (IBF), prostate specific survival (PCSS), and overall survival (OS) time were compared between the 2 groups, and expanded prostate cancer index composite (EPIC) scale was used to evaluate the difference in quality of life between the 2 groups.The median IBF of the PODT group was 31 months, which was significantly lower than the 39 months of the PMRT group (P < .05); the 5-year OS and PCSS were 58.9%, 65.3% in PODT group, and 58.9%, 71.79% in PMRT group, respectively. There was no significant between the 2 groups (P > .05); the side effects of acute radiotherapy in PMRT group were significantly higher than PODT group (P < .05), especially in bone marrow suppression and gastrointestinal reactions; The scores of urinary system function and intestinal system function in PMRT group were significantly higher than PODT group at the end of radiotherapy, 3 months after radiotherapy, and 6 months after radiotherapy (P < .05). The score of sexual function in PMRT group was significantly lower than that in PODT group after radiotherapy (P < .05), and higher than that in PORT group at other follow-up time points (P < .05). The hormone function was decreased at each follow-up time point in 2 groups, and there was no significant difference between the 2 groups (P > .05).Patients with LBMP receiving PMRT can improve IBF, but cannot increase PCSS and OS, and increase the incidence of acute radiation injury.
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Affiliation(s)
| | | | | | | | - Feng-Mei Wang
- Department of Gynaecology and Obstetrics, The 900th Hospital of Joint Logistics Force (Xiamen Dongfang Hospital), Fuzhou
| | - Qin Yin
- Department of Oncology, Longyan People's Hospital, Longyan
| | - Guishan Lin
- Department of Radiation Oncology, Fujian Province's Hospital, Fujian
| | | | - Shao-Guang Liao
- Department of Oncology, Taizhou First People's Hospital (Huangyan Hospital, Wenzhou Medical University), Taizhou, Zhejiang, China
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10
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Lv Y, Song M, Tian X, Yv X, Liang N, Zhang J. Impact of radiotherapy on circulating lymphocyte subsets in patients with esophageal cancer. Medicine (Baltimore) 2020; 99:e20993. [PMID: 32898991 PMCID: PMC7478455 DOI: 10.1097/md.0000000000020993] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Radiotherapy (RT) can affect the immune function of patients with cancer. The purpose of this study was to investigate the effect of RT on lymphocyte and its subsets in patients with esophageal cancer (EC).All patients received RT with a mean dose of 5369 cGy (gray). Blood parameters were measured in 31 patients on 3 occasions (before, at the end of radiotherapy, and at 3 months follow-up). The whole blood count and lymphocyte subsets were measured and correlated with short time efficiency and radiation dose parameters.White blood count (WBC) and lymphocyte count (ALC) were greatly decreased at the end of radiotherapy, and the percentages of CD3+, CD3+CD8+ T cells were significantly increased, on the other hand, a decrease in the CD4/CD8 ratio was observed. The percentages of CD3-CD16/56+NK cells and CD19+ B cell were decreased at the end of RT compared with prior RT. The percentages of CD3+ T cells before RT and the WBC and ALC count after RT can be used as prognostic indicators for survival. The PTV dose can cause significant changes in lymphocytes count after RT. CD3+T cells after RT were significantly correlated with mean heart dose and heart V50.Our study identified that RT causes changes in lymphocyte subsets, and these changes may indicate differences in immune function between individuals. Radiotherapy plan should be designed to minimize normal tissue dose to reduce the impact on WBC and lymphocytes.
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Affiliation(s)
- Yajuan Lv
- Shandong Provincial Qianfoshan Hospital, Shandong University
| | - Meijuan Song
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
| | - Xiufang Tian
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
| | - Xinshuang Yv
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
| | - Ning Liang
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
| | - Jiandong Zhang
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
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11
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Zhi X, Jiang K, Shen Y, Su X, Wang K, Ma Y, Zhou L. Peripheral blood cell count ratios are predictive biomarkers of clinical response and prognosis for non-surgical esophageal squamous cell carcinoma patients treated with radiotherapy. J Clin Lab Anal 2020; 34:e23468. [PMID: 32681567 PMCID: PMC7595892 DOI: 10.1002/jcla.23468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 05/25/2020] [Accepted: 06/18/2020] [Indexed: 12/24/2022] Open
Abstract
Background Peripheral blood cell count ratios, including the neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and lymphocyte‐to‐monocyte ratio (LMR), have been reported to be prognostic factors in many malignancies as markers of inflammation and immune status. The aim of this study was to determine whether NLR, PLR, or LMR can be clinical response and prognostic biomarkers of non‐surgical esophageal squamous cell carcinoma (ESCC) patients treated with radiotherapy. Methods 193 non‐surgical ESCC patients who underwent radiotherapy were retrospectively analyzed. The peripheral blood cell count ratios were obtained before, during (weekly) and at the end of the treatment. Then, we compared the subsequent results with the corresponding pretreatment values and computed the rates of change, which were defined as cNLR, cPLR, and cLMR. Univariate and multivariate Cox regression analyses were used for overall survival (OS). Ordinal logistic regression was used to analyze the clinical response. Results In multivariate analysis, cNLR at week 4(P = .026) and week 5(P = .025) during radiotherapy were significantly associated with OS, along with BMI, tumor stage, tumor length, tumor location, and grade of adverse events. Besides, BMI, tumor stage, tumor length, adverse event grade, cNLR at week 4(P = .044) and week 5(P = .013), and cPLR at week 4(P = .034) and week 5(P = .015) were significantly associated with the clinical response in the multivariate logistic regression analysis. Conclusions The cNLR at weeks 4 and 5 was negatively correlated with the OS and clinical response of non‐surgical ESCC patients treated with radiotherapy. The elevated cPLR at weeks 4 and 5 was only related to poor clinical response.
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Affiliation(s)
- Xiaohui Zhi
- Department of Radiation Oncology, the Affiliated Huai'an Hospital of Xuzhou Medical University, the Second People's Hospital of Huai'an, Huai'an, China
| | - Kan Jiang
- Department of Radiation Oncology, the Affiliated Huai'an Hospital of Xuzhou Medical University, the Second People's Hospital of Huai'an, Huai'an, China
| | - Yue Shen
- Department of Radiation Oncology, the Affiliated Huai'an Hospital of Xuzhou Medical University, the Second People's Hospital of Huai'an, Huai'an, China.,Shandong Provincial Key Laboratory of Radiation Oncology, Cancer Research Center, Shandong Academy of Medical Sciences, Shandong Cancer Hospital affiliated to Shandong University, Jinan, China
| | - Xinyu Su
- Department of Radiation Oncology, the Affiliated Huai'an Hospital of Xuzhou Medical University, the Second People's Hospital of Huai'an, Huai'an, China
| | - Ke Wang
- Department of Radiation Oncology, the Affiliated Huai'an Hospital of Xuzhou Medical University, the Second People's Hospital of Huai'an, Huai'an, China
| | - Yuanyuan Ma
- Department of Radiation Oncology, the Affiliated Huai'an Hospital of Xuzhou Medical University, the Second People's Hospital of Huai'an, Huai'an, China
| | - Liqing Zhou
- Department of Radiation Oncology, the Affiliated Huai'an Hospital of Xuzhou Medical University, the Second People's Hospital of Huai'an, Huai'an, China
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12
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Sanguineti G, Giannarelli D, Petrongari MG, Arcangeli S, Sangiovanni A, Saracino B, Farneti A, Faiella A, Conte M, Arcangeli G. Leukotoxicity after moderately Hypofractionated radiotherapy versus conventionally fractionated dose escalated radiotherapy for localized prostate Cancer: a secondary analysis from a randomized study. Radiat Oncol 2019; 14:23. [PMID: 30700317 PMCID: PMC6352380 DOI: 10.1186/s13014-019-1223-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/20/2019] [Indexed: 11/29/2022] Open
Abstract
Background To compare WBC counts during treatment of localized prostate cancer with either conventionally fractionated (CF) or moderately hypofractionated (HYPO) radiotherapy. Methods Weekly blood test results were extracted from the charts of patients treated within a phase III study comparing HYPO to CF. In order to compare WBC counts at the same nominal dose in both arms and thus to tease out the effect of fractionation, for each recorded WBC value the corresponding cumulative total dose was extracted as well. WBC counts were binned according to percentiles of the delivered dose and three dose levels were identified at median doses of 16, 34.1 and 52 Gy, respectively. A General Linear Model based on mixed design Analysis Of Variance (ANOVA) was used to test variation of WBC counts between the two treatment arms. Results Out of 168 randomized patients, 140 (83.3%) had at least one observation for each one of the selected dose levels and were included in the analysis. Mean counts were lower in the CF than the HYPO arm at all selected dose levels, reaching a statistically significant difference at dose level #3 (5397/mm3 vs 6038/mm3 for CF and HYPO, respectively, p = 0.004). The GLM model confirms that the impact of dose on WBC counts is significantly lower in the HYPO arm over the CF one (Greenhouse-Geisser test, p = 0.04). Interestingly, while WBC counts tend to drop throughout all dose levels in the CF arm, this is the case only in the earlier part of treatment in the HYPO arm. Conclusion This secondary analysis of a phase III study shows that dose fractionation is correlated to WBC drop during treatment of localized prostate cancer, favoring HYPO over CF. Electronic supplementary material The online version of this article (10.1186/s13014-019-1223-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Diana Giannarelli
- Biostatistical Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maria Grazia Petrongari
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Stefano Arcangeli
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Angelo Sangiovanni
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Biancamaria Saracino
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Alessia Farneti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Adriana Faiella
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Mario Conte
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Giorgio Arcangeli
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
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13
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D’Auria F, Valvano L, Rago L, Statuto T, Calice G, D’Arena G, Fusco V, Musto P. Monoclonal B-cell lymphocytosis and prostate cancer: incidence and effects of radiotherapy. J Investig Med 2019; 67:779-782. [DOI: 10.1136/jim-2018-000902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2018] [Indexed: 11/03/2022]
Abstract
Monoclonal B-cells lymphocytosis (MBL) is a benign condition that may precede chronic lymphocytic leukemia (CLL), not rarely present in peripheral blood of healthy elderly people, among which there is also a male prevalence. Though CLL has been associated with various types of solid tumors, including prostate cancer (PC), no data exist about the relationship between PC and MBL. We studied the frequency of CLL-like MBL clones in a group of 48 patients affected by PC and followed them during and after whole-pelvis radiotherapy (WPRT) treatment. We found four MBL clones (8.3%), two of which (4.2%) had a B-cell clonal count >1000 cells/µL (‘clinical MBL’). A single case (1.8%) of ‘low-count’ MBL occurred in a control group of 54 healthy males. Notably, normal B-lymphocytes were consistently affected by WPRT, while MBL clones were less radiosensitive. Our results suggest a possible association between ‘clinical’ MBL and PC and show a different impact of the radiation on monoclonal respect to normal B-cells, which could also imply a greater risk of clonal transformation.
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14
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Bahtiyar N, Onaran İ, Aydemir B, Baykara O, Toplan S, Agaoglu FY, Akyolcu MC. Monitoring of platelet function parameters and microRNA expression levels in patients with prostate cancer treated with volumetric modulated arc radiotherapy. Oncol Lett 2018; 16:4745-4753. [PMID: 30250541 DOI: 10.3892/ol.2018.9167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/16/2017] [Indexed: 12/24/2022] Open
Abstract
Radiotherapy (RT) may result in platelet activation and thrombosis development. To the best of our knowledge, the potential effect of volumetric-modulated arc therapy (VMAT), a novel radiotherapy technique, on platelet function and microRNA (miRNA/miR) expression has not been previously investigated. The present study aimed to determine the effect of VMAT on the alterations in platelet function parameters and miRNA expression levels. A total of 25 patients with prostate cancer and 25 healthy subjects were included in the present study. Blood samples were collected from the patient group on the day prior to RT (pre-RT), the day RT was completed (post-RT day 0), and 40 days following the end of therapy (post-RT day 40). Platelet count, mean platelet volume (MPV) value, platelet aggregation, plasma P-selectin, thrombospondin-1, platelet factor 4, plasma miR-223 and miR-126 expression levels were measured. A significant decrease in platelet count in the post-RT day 0 group was measured in comparison with the pre-RT and the post-RT day 40 groups. Pre-RT MPV values were higher than those of the post-RT day 0 and the post-RT day 40 groups. No significant differences were observed in the levels of platelet activation markers or miR-223 and miR-126 expression levels between the RT groups. Although RT may result in a reduction in platelet and MPV counts, the results of the present study indicate that platelet activation markers are not affected by VMAT. Therefore, it is possible that no platelet activation occurs during VMAT, owing to the conformal dose distributions, improved target volume coverage and the sparing of normal tissues from undesired radiation.
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Affiliation(s)
- Nurten Bahtiyar
- Department of Biophysics, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul 34098, Turkey
| | - İlhan Onaran
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul 34098, Turkey
| | - Birsen Aydemir
- Department of Biophysics, Faculty of Medicine, Sakarya University, Sakarya 54050, Turkey
| | - Onur Baykara
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul 34098, Turkey
| | - Selmin Toplan
- Department of Biophysics, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul 34098, Turkey
| | - Fulya Yaman Agaoglu
- Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul 34098, Turkey
| | - Mehmet Can Akyolcu
- Department of Biophysics, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul 34098, Turkey
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15
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Kamali K, Ashrafi M, Shadpour P, Ameli M, Khayyamfar A, Abolhasani M, Azizpoor A. The role of blood neutrophil count and the neutrophil-to-lymphocyte ratio as a predictive factor for prostate biopsy results. Urologia 2018; 85:158-162. [PMID: 29633657 DOI: 10.1177/0391560318766822] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND: It is apparent that prostate cancer has harmful effects on the erythrocytes, leucocytes, and platelets. In addition, it has been suggested that the toxic granules in neutrophils lead to inflammation in the cancerous tissues besides the activation of monocytes, so in this study we aimed to evaluate the blood neutrophil count besides the neutrophil-to-lymphocyte ratio as a predictive factor for prostate biopsy results and their relationship with prostate cancer grade in patients undergoing biopsy of the prostate. METHODS: For all men with irritative lower urinary tract symptoms visiting Hasheminezhad Hospital from January to July 2015, in case of having a suspicious digital rectal examination or aged above 40 years, prostate-specific antigen was requested and in case of abnormal results, they underwent prostate biopsy. In order to examine the study hypothesis, the blood neutrophil count and the neutrophil-to-lymphocyte ratio were measured and compared with the abnormal prostate-specific antigen results and suspicious digital rectal examination. RESULTS: Among the 500 referred samples for biopsy, 352 (70.4%) had a negative biopsy result, while it was positive in the other 148 (29.6). The mean neutrophil count showed no statistical difference regarding the biopsy results (p = 0.381). When measuring the neutrophil-to-lymphocyte ratio again with biopsy results, no statistically significant difference was obtained based on the biopsy results (p = 0.112). CONCLUSION: Neutrophil count and neutrophil-to-lymphocyte ratio cannot be predictive factors for positive prostate cancer biopsy.
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Affiliation(s)
- Koosha Kamali
- 1 Department of Urology, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mojtaba Ashrafi
- 2 Department of Urology, Zabol University of Medical Sciences, Zabol, Iran
| | - Pejman Shadpour
- 3 Hasheminejad Kidney Center (HKC), Urology Hospital Management Research Center (HMRC), Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mojtaba Ameli
- 4 Department of Surgery, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Amirmahdi Khayyamfar
- 5 Student research committee, Faculty of medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Maryam Abolhasani
- 6 Oncopathology Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Amin Azizpoor
- 7 Health Information Technology, Tehran University of Medical Sciences, Tehran, Iran
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16
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Yang ZR, Zhao N, Meng J, Shi ZL, Li BX, Wu XW, Li P, Zhang Q, Wei XB, Fu S. Peripheral lymphocyte subset variation predicts prostate cancer carbon ion radiotherapy outcomes. Oncotarget 2018; 7:26422-35. [PMID: 27029063 PMCID: PMC5041989 DOI: 10.18632/oncotarget.8389] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/29/2016] [Indexed: 11/25/2022] Open
Abstract
The immune system plays a complementary role in the cytotoxic activity of radiotherapy. Here, we examined changes in immune cell subsets after heavy ion therapy for prostate cancer. The lymphocyte counts were compared with acute radiotherapy-related toxicity, defined according to the Common Terminology Criteria for Adverse Events, and short-term local efficacy, defined based on prostate-specific antigen concentrations. Confirmed prostate cancer patients who had not received previous radiotherapy were administered carbon ion radiotherapy (CIR) in daily fractions of 2.74 GyE with a total dose of 63-66 GyE. Lymphocyte subset counts were investigated before, during and after radiotherapy, and at a 1 month follow-up. Most notable among our findings, the CD4/CD8 ratio and CD19+ cell counts were consistently higher in patients with a complete response (CR) or partial response (PR) to CIR than in those classified in the stable disease (SD) group (P<0.05 for both). But CD3+ and CD8+ cell counts were lower in the CR and PR groups than in the SD group. These results indicate that variations in peripheral lymphocyte subpopulations are predictive of outcome after CIR for prostate cancer.
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Affiliation(s)
- Zhang-Ru Yang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.,Department of Radiation Oncology, Shanghai Sixth People's Hospital of Jiao Tong University, Shanghai, China
| | - Ning Zhao
- Department of Radiation Oncology, Shanghai Sixth People's Hospital of Jiao Tong University, Shanghai, China
| | - Jin Meng
- Department of Radiation Oncology, Shanghai Sixth People's Hospital of Jiao Tong University, Shanghai, China
| | - Ze-Liang Shi
- Department of Radiation Oncology, Shanghai Sixth People's Hospital of Jiao Tong University, Shanghai, China
| | - Bing-Xin Li
- Department of Radiation Oncology, Shanghai Sixth People's Hospital of Jiao Tong University, Shanghai, China
| | - Xian-Wei Wu
- Radiation Oncology Center, Fudan University Shanghai Cancer Center (FUSCC), Shanghai Proton and Heavy Ion Center (SPHIC), Shanghai, China
| | - Ping Li
- Radiation Oncology Center, Fudan University Shanghai Cancer Center (FUSCC), Shanghai Proton and Heavy Ion Center (SPHIC), Shanghai, China
| | - Qing Zhang
- Radiation Oncology Center, Fudan University Shanghai Cancer Center (FUSCC), Shanghai Proton and Heavy Ion Center (SPHIC), Shanghai, China
| | - Xun-Bin Wei
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Shen Fu
- Department of Radiation Oncology, Shanghai Sixth People's Hospital of Jiao Tong University, Shanghai, China.,Radiation Oncology Center, Fudan University Shanghai Cancer Center (FUSCC), Shanghai Proton and Heavy Ion Center (SPHIC), Shanghai, China
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Zhao Q, Xu X, Yue J, Zhu K, Feng R, Jiang S, Qi Z, Wang R. Minimum absolute lymphocyte counts during radiation are associated with a worse prognosis in patients with unresectable hepatocellular carcinoma. Therap Adv Gastroenterol 2017; 10:231-241. [PMID: 28203281 PMCID: PMC5298483 DOI: 10.1177/1756283x16685557] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Peripheral blood lymphocytes play an important role in antitumour immunity. We examined the relationship between the minimum absolute lymphocyte counts (Min ALCs) during radiotherapy (RT) and clinical outcomes in patients with hepatocellular carcinoma (HCC). METHODS Data from a total of 69 HCC patients who had received RT were retrospectively analysed. Peripheral blood lymphocytes were measured before RT, weekly during RT and after RT. Regression and mixed-effect models were used to assess the relationships with and potential predictors of overall survival (OS). Receiver-operating characteristic (ROC) curve analysis was used to define optimal cut-off points of continuous variables for outcomes. RESULTS The median follow up was 30 months (range, 4-68 months). The median survival time (MST), 1-year OS rate and 2-year OS rate of the whole group were 25 months, 51% and 39%, respectively. The average circulating lymphocyte counts declined during RT (1493.19 versus 503.48 cells/µl, p < 0.001). A lower Min ALC was associated with worse OS (p = 0.001), with a cut-off value of 450 cells/µl (sensitivity and specificity, 50% and 70.6%, respectively). The MSTs, 1-year OS rates and 2-year OS rates were 15 months versus 47 months, 27% versus 78% and 4% versus 71% for patients with relatively lower (⩽450 cells/µl) and higher Min ALCs (>450 cells/µl), respectively (p < 0.001). After adjusting for potential confounders, multivariate Cox regression analysis demonstrated that Min ALC independently predicted patients' OS (HR, 0.32; 95% CI, 0.15-0.69). CONCLUSIONS Lower Min ALCs during RT may act as a worse prognostic factor for HCC after RT.
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Affiliation(s)
- Qianqian Zhao
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong Province, People’s Republic of China Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong Province, People’s Republic of China
| | - Xiaoqing Xu
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong Province, People’s Republic of China
| | - Jinbo Yue
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong Province, People’s Republic of China
| | - Kunli Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong Province, People’s Republic of China
| | - Rui Feng
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong Province, People’s Republic of China
| | - Shumei Jiang
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong Province, People’s Republic of China
| | - Zhonghua Qi
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong Province, People’s Republic of China Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong Province, People’s Republic of China
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18
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Feng L, Chen MK, Lukkahatai N, Hsiao CP, Kaushal A, Sechrest L, Saligan LN. Clinical Predictors of Fatigue in Men With Non-Metastatic Prostate Cancer Receiving External Beam Radiation Therapy. Clin J Oncol Nurs 2017; 19:744-50. [PMID: 26583638 DOI: 10.1188/15.cjon.744-750] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fatigue is one of the most distressing symptoms experienced by people with cancer receiving radiation therapy. OBJECTIVES The goal of this study is to evaluate clinical predictors of worsening fatigue during external beam radiation therapy (EBRT) in men with non-metastatic prostate cancer. METHODS Thirty-five men with non-metastatic prostate cancer scheduled for EBRT were followed at baseline, midpoint, and completion of EBRT. The Functional Assessment of Cancer Therapy-Fatigue scale was administered. Demographic and clinical data were obtained by chart review. Paired t-tests, correlations, general linear models, and logistic regressions were used to determine associations between fatigue scores and clinical data. FINDINGS Red blood cells, hemoglobin, and hematocrit levels were highly intercorrelated and, therefore, were grouped as one composite variable termed heme. Heme levels at baseline and androgen-deprivation therapy (ADT) were significantly correlated with worsening of fatigue symptoms from baseline to midpoint and endpoint. ADT alone did not have a significant correlation with fatigue, but it indirectly affected fatigue levels by influencing heme markers as treatment progressed. These findings provide evidence that hematologic markers and the use of ADT assist in predicting radiation therapy-related fatigue and guide symptom management.
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Affiliation(s)
- Li Feng
- National Institute of Nursing Research in the National Institutes of Health
| | | | | | | | | | | | - Leorey N Saligan
- National Institute of Nursing Research in the National Institutes of Health
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19
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Schoenhals JE, Skrepnik T, Selek U, Cortez MA, Li A, Welsh JW. Optimizing Radiotherapy with Immunotherapeutic Approaches. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 995:53-71. [PMID: 28321812 DOI: 10.1007/978-3-319-53156-4_3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Several factors must be considered to successfully integrate immunotherapy with radiation into clinical practice. One such factor is that concepts arising from preclinical work must be tested in combination with radiation in preclinical models to better understand how combination therapy will work in patients; examples include checkpoint inhibitors, tumor growth factor-beta (TGF-β) inhibitors, and natural killer (NK) cell therapy. Also, many radiation fields and fractionation schedules typically used in radiation therapy had been standardized before the introduction of advanced techniques for radiation planning and delivery that account for changes in tumor size, location, and motion during treatment, as well as uncertainties introduced by variations in patient setup between treatment fractions. As a result, radiation therapy may involve the use of large treatment volumes, often encompassing nodal regions that may not be irradiated with more conformal techniques. Traditional forms of radiation in particular pose challenges for combination trials with immunotherapy. This chapter explores these issues in more detail and provides insights as to how radiation therapy can be optimized to combine with immunotherapy.
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Affiliation(s)
- Jonathan E Schoenhals
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tijana Skrepnik
- Department of Radiation Oncology, University of Arizona, Tucson, AZ, USA
| | - Ugur Selek
- Department of Radiation Oncology, Koc University, Istanbul, Turkey
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Anderson Central (Y2.5316), 1515 Holcombe Blvd., Unit 0097, Houston, TX, 77030, USA
| | - Maria A Cortez
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ailin Li
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - James W Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Anderson Central (Y2.5316), 1515 Holcombe Blvd., Unit 0097, Houston, TX, 77030, USA.
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20
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Pinkawa M, Ribbing C, Djukic V, Klotz J, Holy R, Eble MJ. Early hematologic changes during prostate cancer radiotherapy predictive for late urinary and bowel toxicity. Strahlenther Onkol 2015; 191:771-7. [PMID: 26009493 DOI: 10.1007/s00066-015-0841-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 04/09/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND The primary objective of the study was to identify early hematologic changes predictive for radiotherapy (RT)-associated genitourinary and gastrointestinal toxicity. METHODS In a group of 91 prostate cancer patients presenting for primary (n = 51) or postoperative (n = 40) curative RT, blood samples (blood count, acute phase proteins, and cytokines) were analyzed before (T1), three times during (T2-T4), and 6-8 weeks after (T5) radiotherapy. Before RT (baseline), on the last day (acute toxicity), a median of 2 months and 16 months (late toxicity) after RT, patients responded to a validated questionnaire (Expanded Prostate Cancer Index Composite). Acute score changes > 20 points and late changes > 10 points were considered clinically relevant. RESULTS Radiotherapy resulted in significant changes of hematologic parameters, with the largest effect on lymphocytes (mean decrease of 31-45 %) and significant dependence on target volume. C-reactive protein (CRP) elevation > 5 mg/l and hemoglobin level decrease ≥ 5 G/1 at T2 were found to be independently predictive for acute urinary toxicity (p < 0.01, respectively). CRP elevation was predominantly detected in primary prostate RT (p = 0.02). Early lymphocyte level elevation ≥ 0.3G/l at T2 was protective against late urinary and bowel toxicity (p = 0.02, respectively). Other significant predictive factors for late bowel toxicity were decreasing hemoglobin levels (cut-off ≥ 5 G/l) at T2 (p = 0.04); changes of TNF-α (tumor necrosis factor; p = 0.03) and ferritin levels (p = 0.02) at T5. All patients with late bowel toxicity had interleukin (IL)-6 levels < 1.5 ng/l at T2 (63 % without; p = 0.01). CONCLUSION Early hematologic changes during prostate cancer radiotherapy are predictive for late urinary and bowel toxicity.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany.
| | - Carolina Ribbing
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany
| | - Victoria Djukic
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany
| | - Jens Klotz
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany
| | - Richard Holy
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany
| | - Michael J Eble
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany
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21
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Lawrence YR, Dicker AP. Radiation therapy and the immune system: learning to live together. Future Oncol 2014; 10:777-80. [PMID: 24799058 DOI: 10.2217/fon.14.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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