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Pandya P, Vendetti FP, El-Ghoubaira J, Pathak S, Deppas JJ, Jones R, Columbus AV, Zhang Y, Ivanov D, Huang Z, MacDonald KM, Harding SM, Buj R, Aird KM, Beumer JH, Sobol RW, Bakkenist CJ. Deoxyuridine-rich cytoplasmic DNA antagonizes STING-dependent innate immune responses and sensitizes resistant tumors to anti-PD-L1 therapy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.04.588079. [PMID: 38883769 PMCID: PMC11178004 DOI: 10.1101/2024.04.04.588079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
DNA damage and cytoplasmic DNA induce type-1 interferon (IFN-1) and potentiate responses to immune checkpoint inhibitors. Our prior work found that inhibitors of the DNA damage response kinase ATR (ATRi) induce IFN-1 and deoxyuridine (dU) incorporation by DNA polymerases, akin to antimetabolites. Whether and how dU incorporation is required for ATRi-induced IFN-1 signaling is not known. Here, we show that ATRi-dependent IFN-1 responses require uracil DNA glycosylase (UNG)-initiated base excision repair and STING. Quantitative analyses of nine distinct nucleosides reveals that ATRi induce dU incorporation more rapidly in UNG wild-type than knockout cells, and that induction of IFN-1 is associated with futile cycles of repair. While ATRi induce similar numbers of micronuclei in UNG wild-type and knockout cells, dU containing micronuclei and cytoplasmic DNA are increased in knockout cells. Surprisingly, DNA fragments containing dU block STING-dependent induction of IFN-1, MHC-1, and PD-L1. Furthermore, UNG knockout sensitizes cells to IFN-γ in vitro , and potentiates responses to anti-PD-L1 in resistant tumors in vivo . These data demonstrate an unexpected and specific role for dU-rich DNA in suppressing STING-dependent IFN-1 responses, and show that UNG-deficient tumors have a heightened response to immune checkpoint inhibitors. STATEMENT OF SIGNIFICANCE Antimetabolites disrupt nucleotide pools and increase dU incorporation by DNA polymerases. We show that unrepaired dU potentiates responses to checkpoint inhibitors in mouse models of cancer. Patients with low tumor UNG may respond to antimetabolites combined with checkpoint inhibitors, and patients with high tumor UNG may respond to UNG inhibitors combined with checkpoint inhibitors.
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2
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Hardaker EL, Sanseviero E, Karmokar A, Taylor D, Milo M, Michaloglou C, Hughes A, Mai M, King M, Solanki A, Magiera L, Miragaia R, Kar G, Standifer N, Surace M, Gill S, Peter A, Talbot S, Tohumeken S, Fryer H, Mostafa A, Mulgrew K, Lam C, Hoffmann S, Sutton D, Carnevalli L, Calero-Nieto FJ, Jones GN, Pierce AJ, Wilson Z, Campbell D, Nyoni L, Martins CP, Baker T, Serrano de Almeida G, Ramlaoui Z, Bidar A, Phillips B, Boland J, Iyer S, Barrett JC, Loembé AB, Fuchs SY, Duvvuri U, Lou PJ, Nance MA, Gomez Roca CA, Cadogan E, Critichlow SE, Fawell S, Cobbold M, Dean E, Valge-Archer V, Lau A, Gabrilovich DI, Barry ST. The ATR inhibitor ceralasertib potentiates cancer checkpoint immunotherapy by regulating the tumor microenvironment. Nat Commun 2024; 15:1700. [PMID: 38402224 PMCID: PMC10894296 DOI: 10.1038/s41467-024-45996-4] [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: 07/10/2023] [Accepted: 02/09/2024] [Indexed: 02/26/2024] Open
Abstract
The Ataxia telangiectasia and Rad3-related (ATR) inhibitor ceralasertib in combination with the PD-L1 antibody durvalumab demonstrated encouraging clinical benefit in melanoma and lung cancer patients who progressed on immunotherapy. Here we show that modelling of intermittent ceralasertib treatment in mouse tumor models reveals CD8+ T-cell dependent antitumor activity, which is separate from the effects on tumor cells. Ceralasertib suppresses proliferating CD8+ T-cells on treatment which is rapidly reversed off-treatment. Ceralasertib causes up-regulation of type I interferon (IFNI) pathway in cancer patients and in tumor-bearing mice. IFNI is experimentally found to be a major mediator of antitumor activity of ceralasertib in combination with PD-L1 antibody. Improvement of T-cell function after ceralasertib treatment is linked to changes in myeloid cells in the tumor microenvironment. IFNI also promotes anti-proliferative effects of ceralasertib on tumor cells. Here, we report that broad immunomodulatory changes following intermittent ATR inhibition underpins the clinical therapeutic benefit and indicates its wider impact on antitumor immunity.
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Affiliation(s)
| | | | | | - Devon Taylor
- Oncology R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Marta Milo
- Oncology R&D, AstraZeneca, Cambridge, UK
| | | | | | - Mimi Mai
- Oncology R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | | | | | | | | | - Gozde Kar
- Oncology R&D, AstraZeneca, Cambridge, UK
| | - Nathan Standifer
- Oncology R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
- Tempest Therapeutics, Brisbane, CA, USA
| | | | - Shaan Gill
- Oncology R&D, AstraZeneca, Cambridge, UK
| | | | | | | | | | - Ali Mostafa
- Oncology R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Kathy Mulgrew
- Oncology R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | | | | | - Daniel Sutton
- Imaging and Data Analytics, AstraZeneca, Cambridge, UK
| | | | | | | | - Andrew J Pierce
- Oncology R&D, AstraZeneca, Cambridge, UK
- Crescendo Biologics Limited, Cambridge, UK
| | | | | | | | | | | | | | | | - Abdel Bidar
- CPSS, Imaging, AstraZeneca, Gothenburg, Sweden
| | - Benjamin Phillips
- Data Sciences & Quantitative Biology, Discovery Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Joseph Boland
- Oncology R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Sonia Iyer
- Oncology R&D, AstraZeneca, Boston, MA, USA
| | | | | | - Serge Y Fuchs
- Department of Biomedical Sciences, School of Veterinary Medicine University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Umamaheswar Duvvuri
- UPMC Department of Otolaryngology and UPMC Hillman Cancer Center, 200 Lothrop St. Suite 500, Pittsburg, PA, 15213, USA
| | - Pei-Jen Lou
- National Taiwan University Hospital, No. 7, Chung Shan S. Rd. (Zhongshan S. Rd.), Zhongzheng Dist., Taipei City, 10002, Taiwan
| | - Melonie A Nance
- VA Pittsburgh Healthcare System, University Drive C, Pittsburg, PA, 15240, USA
| | - Carlos Alberto Gomez Roca
- Institut Claudius Regaud-Cancer Comprehensive Center, 1 Avenue Irene Joliot-Curie, IUCT-O, Toulouse, 31059 Cedex 9, France
| | | | | | | | - Mark Cobbold
- Oncology R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Emma Dean
- Oncology R&D, AstraZeneca, Cambridge, UK
| | | | - Alan Lau
- Oncology R&D, AstraZeneca, Cambridge, UK
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3
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Zhang Q, Jiang L, Wang W, Huber AK, Valvo VM, Jungles KM, Holcomb EA, Pearson AN, The S, Wang Z, Parsels LA, Parsels JD, Wahl DR, Rao A, Sahai V, Lawrence TS, Green MD, Morgan MA. Potentiating the radiation-induced type I interferon antitumoral immune response by ATM inhibition in pancreatic cancer. JCI Insight 2024; 9:e168824. [PMID: 38376927 PMCID: PMC11063931 DOI: 10.1172/jci.insight.168824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/14/2024] [Indexed: 02/21/2024] Open
Abstract
Radiotherapy induces a type I interferon-mediated (T1IFN-mediated) antitumoral immune response that we hypothesized could be potentiated by a first-in-class ataxia telangiectasia mutated (ATM) inhibitor, leading to enhanced innate immune signaling, T1IFN expression, and sensitization to immunotherapy in pancreatic cancer. We evaluated the effects of AZD1390 or a structurally related compound, AZD0156, on innate immune signaling and found that both inhibitors enhanced radiation-induced T1IFN expression via the POLIII/RIG-I/MAVS pathway. In immunocompetent syngeneic mouse models of pancreatic cancer, ATM inhibitor enhanced radiation-induced antitumoral immune responses and sensitized tumors to anti-PD-L1, producing immunogenic memory and durable tumor control. Therapeutic responses were associated with increased intratumoral CD8+ T cell frequency and effector function. Tumor control was dependent on CD8+ T cells, as therapeutic efficacy was blunted in CD8+ T cell-depleted mice. Adaptive immune responses to combination therapy provided systemic control of contralateral tumors outside of the radiation field. Taken together, we show that a clinical candidate ATM inhibitor enhances radiation-induced T1IFN, leading to both innate and subsequent adaptive antitumoral immune responses and sensitization of otherwise resistant pancreatic cancer to immunotherapy.
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Affiliation(s)
- Qiang Zhang
- Department of Radiation Oncology and
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Weiwei Wang
- Department of Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | | | - Kassidy M. Jungles
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Stephanie The
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | | | | | | | - Daniel R. Wahl
- Department of Radiation Oncology and
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Arvind Rao
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Vaibhav Sahai
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Division of Hematology and Oncology, Department of Internal Medicine, and
| | - Theodore S. Lawrence
- Department of Radiation Oncology and
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael D. Green
- Department of Radiation Oncology and
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Meredith A. Morgan
- Department of Radiation Oncology and
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
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4
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Sugitani N, Mason HR, Campfield BT, Piganelli JD. An orally available cancer drug AZD6738 prevents type 1 diabetes. Front Immunol 2023; 14:1290058. [PMID: 38164129 PMCID: PMC10757955 DOI: 10.3389/fimmu.2023.1290058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Type 1 diabetes (T1D) affects three million Americans, with 80 new people diagnosed each day. T1D is currently uncurable and there is an urgent need to develop additional drug candidates to achieve the prevention of T1D. We propose AZD6738 (ATRi), an orally available drug currently in phases I and II of clinical trials for various cancers, as a novel candidate to prevent T1D. Based on previously reported findings of ATRi inducing cell death in rapidly proliferating T cells, we hypothesized that this drug would specifically affect self-antigen activated diabetogenic T cells. These cells, if left unchecked, could otherwise lead to the destruction of pancreatic β cells, contributing to the development of T1D. This work demonstrates that increasing the duration of ATRi treatment provides extended protection against T1D onset. Remarkably, 5-week ATRi treatment prevented T1D in a robust adoptive transfer mouse model. Furthermore, the splenocytes of animals that received 5-week ATRi treatment did not transfer immune-mediated diabetes, while the splenocytes from control animal transferred the disease in 10 days. This work shows that ATRi prevents T1D by specifically inducing cell death in self-antigen activated, highly proliferative diabetogenic T cells through the induction of DNA damage, resulting in the inhibition of IFNγ production and proliferation. These findings support the consideration of repurposing ATRi for T1D prevention.
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Affiliation(s)
- Norie Sugitani
- Division of Pediatric Surgery, Department of Surgery, Pittsburgh, PA, United States
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Pittsburgh, PA, United States
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Hannah R. Mason
- Division of Pediatric Surgery, Department of Surgery, Pittsburgh, PA, United States
| | - Brian T. Campfield
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Pittsburgh, PA, United States
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Jon D. Piganelli
- Division of Pediatric Surgery, Department of Surgery, Pittsburgh, PA, United States
- Department of Endocrinology, Indiana University, Pittsburgh, PA, United States
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5
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Menolfi D, Lee BJ, Zhang H, Jiang W, Bowen NE, Wang Y, Zhao J, Holmes A, Gershik S, Rabadan R, Kim B, Zha S. ATR kinase supports normal proliferation in the early S phase by preventing replication resource exhaustion. Nat Commun 2023; 14:3618. [PMID: 37336885 DOI: 10.1038/s41467-023-39332-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 06/08/2023] [Indexed: 06/21/2023] Open
Abstract
The ATR kinase, which coordinates cellular responses to DNA replication stress, is also essential for the proliferation of normal unstressed cells. Although its role in the replication stress response is well defined, the mechanisms by which ATR supports normal cell proliferation remain elusive. Here, we show that ATR is dispensable for the viability of G0-arrested naïve B cells. However, upon cytokine-induced proliferation, Atr-deficient B cells initiate DNA replication efficiently, but by mid-S phase they display dNTP depletion, fork stalling, and replication failure. Nonetheless, productive DNA replication and dNTP levels can be restored in Atr-deficient cells by suppressing origin firing, such as partial inhibition of CDC7 and CDK1 kinase activities. Together, these findings indicate that ATR supports the proliferation of normal unstressed cells by tempering the pace of origin firing during the early S phase to avoid exhaustion of dNTPs and importantly also other replication factors.
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Affiliation(s)
- Demis Menolfi
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Brian J Lee
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Hanwen Zhang
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Wenxia Jiang
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Nicole E Bowen
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Yunyue Wang
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Junfei Zhao
- Program for Mathematical Genomics, Department of Systems Biology, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Antony Holmes
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Steven Gershik
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Raul Rabadan
- Program for Mathematical Genomics, Department of Systems Biology, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA
| | - Baek Kim
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Shan Zha
- Institute for Cancer Genetics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA.
- Department of Pathology and Cell Biology, Herbert Irvine Comprehensive Cancer Center, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA.
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA.
- Department of Immunology and Microbiology, Vagelos College for Physicians and Surgeons, Columbia University, New York City, NY, 10032, USA.
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6
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Menolfi D, Lee BJ, Zhang H, Jiang W, Bowen NE, Wang Y, Zhao J, Holmes A, Gershik S, Rabadan R, Kim B, Zha S. ATR kinase supports normal proliferation in the early S phase by preventing replication resource exhaustion. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.26.542515. [PMID: 37292881 PMCID: PMC10246007 DOI: 10.1101/2023.05.26.542515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The ATR kinase, which coordinates cellular responses to DNA replication stress, is also essential for the proliferation of normal unstressed cells. Although its role in the replication stress response is well defined, the mechanisms by which ATR supports normal cell proliferation remain elusive. Here, we show that ATR is dispensable for the viability of G0-arrested naïve B cells. However, upon cytokine-induced proliferation, Atr-deficient B cells initiate DNA replication efficiently in early S phase, but by mid-S phase they display dNTP depletion, fork stalling, and replication failure. Nonetheless, productive DNA replication can be restored in Atr-deficient cells by pathways that suppress origin firing, such as downregulation of CDC7 and CDK1 kinase activities. Together, these findings indicate that ATR supports the proliferation of normal unstressed cells by tempering the pace of origin firing during the early S phase to avoid exhaustion of dNTPs and other replication factors.
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7
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Vendetti FP, Pandya P, Clump DA, Schamus-Haynes S, Tavakoli M, diMayorca M, Islam NM, Chang J, Delgoffe GM, Beumer JH, Bakkenist CJ. The schedule of ATR inhibitor AZD6738 can potentiate or abolish antitumor immune responses to radiotherapy. JCI Insight 2023; 8:e165615. [PMID: 36810257 PMCID: PMC9977511 DOI: 10.1172/jci.insight.165615] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/05/2023] [Indexed: 02/23/2023] Open
Abstract
Inhibitors of the DNA damage signaling kinase ATR increase tumor cell killing by chemotherapies that target DNA replication forks but also kill rapidly proliferating immune cells including activated T cells. Nevertheless, ATR inhibitor (ATRi) and radiotherapy (RT) can be combined to generate CD8+ T cell-dependent antitumor responses in mouse models. To determine the optimal schedule of ATRi and RT, we determined the impact of short-course versus prolonged daily treatment with AZD6738 (ATRi) on responses to RT (days 1-2). Short-course ATRi (days 1-3) plus RT caused expansion of tumor antigen-specific, effector CD8+ T cells in the tumor-draining lymph node (DLN) at 1 week after RT. This was preceded by acute decreases in proliferating tumor-infiltrating and peripheral T cells and a rapid proliferative rebound after ATRi cessation, increased inflammatory signaling (IFN-β, chemokines, particularly CXCL10) in tumors, and an accumulation of inflammatory cells in the DLN. In contrast, prolonged ATRi (days 1-9) prevented the expansion of tumor antigen-specific, effector CD8+ T cells in the DLN, and entirely abolished the therapeutic benefit of short-course ATRi with RT and anti-PD-L1. Our data argue that ATRi cessation is essential to allow CD8+ T cell responses to both RT and immune checkpoint inhibitors.
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Affiliation(s)
- Frank P. Vendetti
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pinakin Pandya
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David A. Clump
- Department of Radiation Oncology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Sandra Schamus-Haynes
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Meysam Tavakoli
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maria diMayorca
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Naveed M. Islam
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jina Chang
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Greg M. Delgoffe
- Department of Immunology and
- Department of Medicine, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jan H. Beumer
- Department of Medicine, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Hematology-Oncology, Department of Medicine, and
| | - Christopher J. Bakkenist
- Department of Radiation Oncology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Medicine, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pharmacology and Chemical Biology, UPMC Hillman Cancer Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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