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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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Koukourakis IM, Gkegka AG, Giatromanolaki A, Koukourakis MI. Neoplasia-related and treatment-induced lymphopenia: impact on the outcome of chemoradiotherapy in laryngeal cancer. Int J Radiat Biol 2024; 100:736-743. [PMID: 38394349 DOI: 10.1080/09553002.2024.2316608] [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: 06/29/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION The role of the immune system in the efficacy of radiotherapy (RT) has been well established. We examined the role of neoplasia-related and treatment-induced lymphopenia in the outcome of RT or chemoradiotherapy (CRT) in squamous cell laryngeal cancer. MATERIALS AND METHODS We retrospectively analyzed a series of 135 laryngeal carcinomas treated with radical or postoperative RT/CRT. Six lymphocyte-related variables were defined and examined: i. lymphocyte counts (LCs) before a brief course of induction chemotherapy, ii. pre-RT LCs, iii. post-RT LCs, iv. pre-RT neutrophil/lymphocyte ratio (N/L), v. pre-RT monocyte/lymphocyte ratio (M/L), and vi. pre-RT platelet/lymphocyte ratio (Pt/L). RESULTS RT and CRT resulted in a significant decrease of LCs at the end of therapy, and this was significantly more prominent in patients treated with radical intent and neck irradiation (median LC nadir 810/μl vs. 1250/μl; p = .0003). Induction chemotherapy did not intensify the lymphotoxic effect of RT. LCs lower than the 33rd percentile before RT (<1718/μl) and after RT (<720/μl) were significantly linked to poor locoregional progression-free survival (LRFS; p = .02 and p = .08, respectively) and disease-specific overall survival (OS; p = .02 and p = .03, respectively). This was also confirmed multivariate analysis (LRFS: p = .006/HR = 2.41 and p = .08/HR = 1.76, respectively; OS: p = .001/HR = 3.06 and p = .02/HR = 2.07, respectively). High pre-RT N/L, M/L, and Pt/L ratios were also of ominous prognostic relevance. CONCLUSIONS Both neoplasia-related and RT-induced lymphopenia define the outcome of RT in terms of locoregional failure, incidence of metastasis, and, finally, disease-specific survival of patients with laryngeal cancer. Restoration of pre-RT lymphopenia and protection of peripheral lymphocytes during RT emerge as critical issues that demand therapeutic interventions to maximize the efficacy of RT/CRT in patients with laryngeal cancer.
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Affiliation(s)
- Ioannis M Koukourakis
- Radiation Oncology Unit, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia G Gkegka
- Department of Pathology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Alexandra Giatromanolaki
- Department of Pathology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Michael I Koukourakis
- Department of Radiotherapy/Oncology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Laurent PA, Deutsch É. [Radiation-induced lymphopenia: Lymphocytes as a new organ at risk]. Cancer Radiother 2023; 27:511-518. [PMID: 37661506 DOI: 10.1016/j.canrad.2023.06.017] [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: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 09/05/2023]
Abstract
Taking the immune system into account in the fight against tumors has upset the cancer treatment paradigm in the 21st century. Combination treatment strategies associating radiotherapy with immunotherapy are being increasingly implemented in clinical practice. In this context, lymphocytes, whether lymphocytes infiltrating the tumour, circulating blood lymphocytes or lymphocytes residing within the lymph nodes, are key players in cellular and humoral anti-tumor immunity. The significant radiosensitivity of lymphocytes was demonstrated in the early 1990s. Along with the cells of the digestive mucosa, lymphocytes are thus among the most radiosensitive cell types in the body. Compared to the old practices of external radiotherapy, current intensity modulated treatments have allowed a considerable improvement in acute and late toxicity, at the cost of a significant increase in the volume irradiated at low doses. This is not without consequence on the incidence of radiation-induced lymphopenia, with prognostic implications for many tumor types. Thus, in order not to hinder the action of antitumor immunity and the efficacy of immunotherapy, it is essential to consider lymphocytes as a new organ at risk in its own right. In this development, based on current data from the literature, we will begin by justifying the necessary prevention of radiation-induced lymphopenia, before providing the tools currently known to apprehend lymphocytes as a new multicompartments. Finally, we will broaden the perspective by outlining ways to develop research in this area.
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Affiliation(s)
- P A Laurent
- Service de radiothérapie oncologique, Gustave-Roussy Cancer Campus, Villejuif, France; Inserm, U1030 Molecular Radiation Therapy and Therapeutic Innovation, Gustave-Roussy Cancer Campus, université Paris-Saclay, Villejuif, France
| | - É Deutsch
- Service de radiothérapie oncologique, Gustave-Roussy Cancer Campus, Villejuif, France; Inserm, U1030 Molecular Radiation Therapy and Therapeutic Innovation, Gustave-Roussy Cancer Campus, université Paris-Saclay, Villejuif, France.
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Paganetti H. A review on lymphocyte radiosensitivity and its impact on radiotherapy. Front Oncol 2023; 13:1201500. [PMID: 37601664 PMCID: PMC10435323 DOI: 10.3389/fonc.2023.1201500] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
It is well known that radiation therapy causes lymphopenia in patients and that this is correlated with a negative outcome. The mechanism is not well understood because radiation can have both immunostimulatory and immunosuppressive effects. How tumor dose conformation, dose fractionation, and selective lymph node irradiation in radiation therapy does affect lymphopenia and immune response is an active area of research. In addition, understanding the impact of radiation on the immune system is important for the design and interpretation of clinical trials combining radiation with immune checkpoint inhibitors, both in terms of radiation dose and treatment schedules. Although only a few percent of the total lymphocyte population are circulating, it has been speculated that their increased radiosensitivity may contribute to, or even be the primary cause of, lymphopenia. This review summarizes published data on lymphocyte radiosensitivity based on human, small animal, and in vitro studies. The data indicate differences in radiosensitivity among lymphocyte subpopulations that affect their relative contribution and thus the dynamics of the immune response. In general, B cells appear to be more radiosensitive than T cells and NK cells appear to be the most resistant. However, the reported dose-response data suggest that in the context of lymphopenia in patients, aspects other than cell death must also be considered. Not only absolute lymphocyte counts, but also lymphocyte diversity and activity are likely to be affected by radiation. Taken together, the reviewed data suggest that it is unlikely that radiation-induced cell death in lymphocytes is the sole factor in radiation-induced lymphopenia.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston MA, United States
- Harvard Medical School, Boston MA, United States
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Wang JJ, Shao H, Yan J, Jing M, Xu WJ, Sun HW, Zhou ZW, Zhang YJ. Neoadjuvant chemoradiotherapy induced lymphopenia in gastric cancer and associations with spleen dosimetry and survival outcomes. Clin Transl Radiat Oncol 2023; 40:100617. [PMID: 37008513 PMCID: PMC10060597 DOI: 10.1016/j.ctro.2023.100617] [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: 12/04/2022] [Revised: 02/05/2023] [Accepted: 03/17/2023] [Indexed: 04/04/2023] Open
Abstract
Background Few studies concentrate on spleen dosimetry of radiotherapy for gastric cancer (GC). Although there is no consensus on the spleen dose-volume threshold for lymphopenia, several studies indicated that the higher the spleen dose, the higher the risk of lymphopenia. This study aimed to identify the appropriate spleen dosimetric parameters for predicting grade 4 + lymphopenia in patients with locally advanced GC. Material and methods A total of 295 patients treated with nCRT and nChT from June 2013 to December 2021 at two major centers were included, of whom 220 were assigned to the training cohort and 75 to the external validation cohort. Results Grade 4 + lymphopenia was more common in the nCRT than in the nChT group (49.5% vs. 0, P < 0.001 in the training cohort; 25.0% vs. 0, P = 0.001 in the external validation cohort). Age ≥ 60 years (P = 0.006), lower pretreatment absolute lymphocyte count (P = 0.001), higher spleen volume (SPV) (P = 0.001), and higher V20 (P = 0.003) were significant risk factors of grade 4 + lymphopenia for patients treated with nCRT. Patients with grade 4 + lymphopenia had significantly worse PFS (P = 0.043) and showed a negative correlation trend with OS (P = 0.07). Limiting V20 to < 84.5% could decrease the incidence of grade 4 + lymphopenia by 35.7%. The predictive effectiveness of the multivariable model in the training and external validation cohorts was 0.880 and 0.737, respectively. Conclusion Grade 4 + lymphopenia during nCRT was more common than nChT, and was associated with a worse PFS in GC patients. Constraining the spleen V20 to < 84.5% may indirectly improve outcomes through lymphocyte preservation.
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Affiliation(s)
- Ji-jin Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, People’s Republic of China
| | - Han Shao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, People’s Republic of China
| | - Jin Yan
- Department of Radiation Oncology, Chongqing University Cancer Hospital, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing 400030, People’s Republic of China
| | - Ming Jing
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, People’s Republic of China
| | - Wen-jing Xu
- Department of Radiotherapy, Cancer Center, Guangdong Provincial People’s Hospital, Guangdong AcadCmy of Medical Sciences, Guangzhou 510080, People’s Republic of China
| | - Heng-wen Sun
- Department of Radiotherapy, Cancer Center, Guangdong Provincial People’s Hospital, Guangdong AcadCmy of Medical Sciences, Guangzhou 510080, People’s Republic of China
- Corresponding authors.
| | - Zhi-wei Zhou
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, People’s Republic of China
| | - Yu-jing Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, People’s Republic of China
- Corresponding authors.
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Rutenberg MS, Hoppe BS, Starr JS, Awad Z, Thomas M, Morris CG, Johnson P, Henderson RH, Jones JC, Gharia B, Bowers S, Wolfsen HC, Krishnan S, Ko SJ, Babiker HM, Nichols RC. Proton Therapy With Concurrent Chemotherapy for Thoracic Esophageal Cancer: Toxicity, Disease Control, and Survival Outcomes. Int J Part Ther 2022; 9:18-29. [PMID: 36721483 PMCID: PMC9875824 DOI: 10.14338/ijpt-22-00021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/26/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose When treating esophageal cancer with radiation therapy, it is critical to limit the dose to surrounding structures, such as the lung and/or heart, as much as possible. Proton radiation therapy allows a reduced radiation dose to both the heart and lungs, potentially reducing the risk of cardiopulmonary toxicity. Here, we report disease control, survival, and toxicity outcomes among patients with esophageal cancer treated with proton radiation therapy and concurrent chemotherapy (chemoradiation therapy; CRT) with or without surgery. Materials and Methods We enrolled 17 patients with thoracic esophageal carcinoma on a prospective registry between 2010 and 2021. Patients received proton therapy to a median dose of 50.4-GyRBE (range, 50.4-64.8) in 1.8-Gy fractions.Acute and late toxicities were graded per the Common Terminology Criteria for Adverse Events, version 4.0 (US National Cancer Institute, Bethesda, Maryland). In addition, disease control, patterns of failure, and survival outcomes were collected. Results Nine patients received preoperative CRT, and 8 received definitive CRT. Overall, 88% of patients had adenocarcinoma, and 12% had squamous cell carcinoma. With a median follow-up of 2.1 years (range, 0.5-9.4), the 3-year local progression-free, disease-free, and overall survival rates were 85%, 66%, and 55%, respectively. Two patients (1 with adenocarcinoma and 1 with squamous cell carcinoma) recurred at the primary site after refusing surgery after a complete clinical response to CRT. The most common acute nonhematologic and hematologic toxicities, respectively, were grades 1 to 3 esophagitis and grades 1 to 4 leukopenia, both affecting 82% of patients. No acute cardiopulmonary toxicities were observed in the absence of surgical resection. Reagarding surgical complications, 3 postoperative cardiopulmonary complications occurred as follows: 1 grade 1 pleural effusion, 1 grade 3 pleural effusion, and 1 grade 2 anastomotic leak. Two severe late CRT toxicities occurred: 1 grade 5 tracheoesophageal fistula and 1 grade 3 esophageal stenosis requiring a feeding tube. Conclusion Proton radiation therapy is a safe, effective treatment for esophageal cancer with increasing evidence supporting its role in reducing cardiopulmonary toxicity.
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Affiliation(s)
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jason S. Starr
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Ziad Awad
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Perry Johnson
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Jeremy C. Jones
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Bharatsinh Gharia
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Steven Bowers
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Herbert C. Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Stephen J. Ko
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Hani M. Babiker
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Romaine C. Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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El Houat Y, Massard C, Quillien V, de Crevoisier R, Castelli J. Meta-analysis and Critical Review: Association Between Radio-induced Lymphopenia and Overall Survival in Solid Cancers. Adv Radiat Oncol 2022; 8:101038. [PMID: 36561078 PMCID: PMC9763695 DOI: 10.1016/j.adro.2022.101038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Immune system modulation, with the use of immune checkpoint inhibitors, has drastically changed the field of oncology. Strong preclinical data indicate that radiation therapy (RT) may enhance the response rate to such drugs via in situ vaccination, although these data do not consider immune radiotoxicity. This meta-analysis investigates whether radio-induced lymphopenia (RIL) is associated with overall survival (OS). Methods and Materials A systematic literature search and quantitative analysis were planned, conducted, and reported per the Preferred Reporting Items for Systematic Reviews and Meta-analyses and Quality of Reporting of Meta-analyses checklists. The literature from January 1990 to March 2021 was searched to identify clinical studies with OS data in patients treated with RT and presenting with lymphopenia. A random-effect model was employed for the meta-analysis. Heterogeneity was assessed using the I2 statistic. Publication bias was estimated using a P-curve analysis. Results A total of 56 studies with 13 223 patients and 11 types of cancers were selected. The mean follow-up time was 35.9 months. Over a third of patients had RIL (37.25%). After removing outlying studies (n = 14), the between-study heterogeneity variance was estimated at t2 = 0.018 (P = .01) with an I2 value of 36.0% (95% confidence interval, 6%-56%). The results showed that RIL was significantly associated with worse OS (hazard ratio: 1.70; 95% confidence interval, 1.55-1.86; P < .01; 95% prediction interval, 1.27-2.26). A subgroup analysis was performed based on the type of primary tumor, and a difference between the subgroups was found (P < .01). Based on the P-curve analysis, a significant evidential value was found, and no significant publication bias was identified among the studies. Conclusions RIL is a significant prognostic factor for mortality in virtually all solid cancers. Pooled-effect estimates indicate a significantly reduced risk of death in patients without RIL. Tailoring RT regimens to spare the immune system and updating dosimetric constraints for new organs at risk, such as major blood vessels, organs with rich blood supplies, bones, and all lymph node areas, may improve prognoses.
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Venkatesulu B, Giridhar P, Pujari L, Chou B, Lee JH, Block AM, Upadhyay R, Welsh JS, Harkenrider MM, Krishnan S, Verma V, En Hsieh C, Pradhan S, Small W, Solanki AA. Lymphocyte sparing normal tissue effects in the clinic (LymphoTEC): A systematic review of dose constraint considerations to mitigate radiation-related lymphopenia in the era of immunotherapy. Radiother Oncol 2022; 177:81-94. [PMID: 36334694 DOI: 10.1016/j.radonc.2022.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/07/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Radiation-related lymphopenia has been associated with suboptimal tumor control rates leading to inferior survival outcomes. To date, no standardized dose constraints are available to limit radiation dose to resident and circulating lymphocyte populations. We undertook this systemic review of the literature to provide a synopsis of the dosimetric predictors of radiation-related lymphopenia in solid malignancies. METHODOLOGY A systematic literature review of PubMed (National Institutes of Health), Cochrane Central (Cochrane collaboration), and Google Scholar was conducted with the following keywords: "radiation", "lymphopenia", "cancer", "dosimetric predictors" with an inclusion deadline of May 31, 2022. Studies that met prespecified inclusion criteria were designated either Good, Fair, or Poor Quality based on the Newcastle-Ottawa quality assessment. The dosimetric parameters derived from Good Quality studies were tabulated as LymphoTEC dose constraints. Dosimetric parameters derived from Fair and Poor-quality studies were grouped as optional. RESULTS An initial systematic search of the literature yielded 1,632 articles. After screening, a total of 48 studies met inclusion criteria and were divided into the following categories: central nervous system (CNS, 6), thoracic (11), gastrointestinal (26), gynecologic (2), head and neck, breast, and genitourinary (one each) cancers. Lung mean dose, heart mean dose, brain V25, spleen mean dose, estimated dose to immune cells, and bone marrow V10 were among the strongest predictors for severe lymphopenia related to radiotherapy. CONCLUSION Optimizing the delivery of radiation therapy to limit dose to lymphocyte-rich structures may curb the negative oncologic impact of lymphocyte depletion. The dose constraints described herein may be considered for prospective validation and future use in clinical trials to limit risk of radiation-related lymphopenia and possibly improve cancer-associated outcomes.
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Affiliation(s)
- BhanuPrasad Venkatesulu
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA.
| | | | - Lincoln Pujari
- Department of Radiation Oncology, Tata memorial center, Varanasi, India
| | - Brian Chou
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Jae Han Lee
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Alec M Block
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - James S Welsh
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
| | - Matthew M Harkenrider
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Verma
- Department of Radiation Oncology, MD Anderson cancer center, Houston, Texas, USA
| | - Cheng En Hsieh
- Department of Radiation Oncology, Institute for Radiological Research, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taoyuan City, Taiwan; Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston and The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Satyajit Pradhan
- Department of Radiation Oncology, Tata memorial center, Varanasi, India
| | - William Small
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA
| | - Abhishek A Solanki
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA; Edward Hines Veteran affairs hospital, Chicago, IL, USA
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Yu H, Chen F, Lam KO, Yang L, Wang Y, Jin JY, EI Helali A, Kong FM(S. Potential Determinants for Radiation-Induced Lymphopenia in Patients With Breast Cancer Using Interpretable Machine Learning Approach. Front Immunol 2022; 13:768811. [PMID: 35799797 PMCID: PMC9253393 DOI: 10.3389/fimmu.2022.768811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Radiation-induced lymphopenia is known for its survival significance in patients with breast cancer treated with radiation therapy. This study aimed to evaluate the impact of radiotherapy on lymphocytes by applying machine learning strategies. We used Extreme Gradient Boosting (XGboost) to predict the event of lymphopenia (grade≥1) and conduced an independent validation. Then, we induced feature attribution analysis (Shapley additive explanation, SHAP) in explaining the XGboost models to explore the directional contribution of each feature to lymphopenia. Finally, we implemented the proof-of-concept clinical validation. The results showed that the XGboost models had rigorous generalization performances (accuracies 0.764 and ROC-AUC 0.841, respectively) in the independent cohort. The baseline lymphocyte counts are the most protective feature (SHAP = 5.226, direction of SHAP = -0.964). Baseline platelets and monocytes also played important protective roles. The usage of taxane only chemotherapy was less risk on lymphopenia than the combination of anthracycline and taxane. By the contribution analysis of dose, we identified that firstly lymphocytes were sensitive to a radiation dose less than 4Gy; secondly the irradiation volume was more important in promoting lymphopenia than the irradiation dose; thirdly the irradiation dose promoted the event of lymphopenia when the irradiation volume was fixed. Overall, our findings paved the way to clarifying the radiation dose volume effect. To avoid radiation-induced lymphopenia, irradiation volume should be kept to a minimum during the planning process, as long as the target coverage is not compromised.
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Affiliation(s)
- Hao Yu
- Institute of Biomedical and Health Engineering, Chinese Academy of Sciences Shenzhen Institutes of Advanced Technology, Shenzhen, China
| | - Fang Chen
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ka-On Lam
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Li Yang
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yang Wang
- Biomedical Engineering, Shenzhen Polytechnic, Shenzhen, China
| | - Jian-Yue Jin
- University Hospitals/Cleverland Medical Center, Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, United States
| | - Aya EI Helali
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Feng-Ming (Spring) Kong
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- *Correspondence: Feng-Ming (Spring) Kong,
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10
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Ho YC, Lai YC, Lin HY, Ko MH, Wang SH, Yang SJ, Lin PJ, Chou TW, Hung LC, Huang CC, Chang TH, Lin JB, Lin JC. Low cardiac dose and neutrophil-to-lymphocyte ratio predict overall survival in inoperable esophageal squamous cell cancer patients after chemoradiotherapy. Sci Rep 2021; 11:6644. [PMID: 33758232 PMCID: PMC7988072 DOI: 10.1038/s41598-021-86019-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/09/2021] [Indexed: 12/25/2022] Open
Abstract
We aimed to determine the prognostic significance of cardiac dose and hematological immunity parameters in esophageal cancer patients after concurrent chemoradiotherapy (CCRT). During 2010-2015, we identified 101 newly diagnosed esophageal squamous cell cancer patients who had completed definitive CCRT. Patients' clinical, dosimetric, and hematological data, including absolute neutrophil count, absolute lymphocyte count, and neutrophil-to-lymphocyte ratio (NLR), at baseline, during, and post-CCRT were analyzed. Cox proportional hazards were calculated to identify potential risk factors for overall survival (OS). Median OS was 13 months (95% confidence interval [CI]: 10.38-15.63). Univariate analysis revealed that male sex, poor performance status, advanced nodal stage, higher percentage of heart receiving 10 Gy (heart V10), and higher NLR (baseline and follow-up) were significantly associated with worse OS. In multivariate analysis, performance status (ECOG 0 & 1 vs. 2; hazard ratio [HR] 3.12, 95% CI 1.30-7.48), heart V10 (> 84% vs. ≤ 84%; HR 2.24, 95% CI 1.26-3.95), baseline NLR (> 3.56 vs. ≤ 3.56; HR 2.36, 95% CI 1.39-4.00), and follow-up NLR (> 7.4 vs. ≤ 7.4; HR 1.95, 95% CI 1.12-3.41) correlated with worse OS. Volume of low cardiac dose and NLR (baseline and follow-up) were associated with worse patient survival.
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Affiliation(s)
- Yu-Chieh Ho
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Yuan-Chun Lai
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.,Department of Medical Imaging Radiological Science, Central Taiwan University of Science and Technology, Taichung, 406, Taiwan
| | - Hsuan-Yu Lin
- Division of Hematology/Oncology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Ming-Hui Ko
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Sheng-Hung Wang
- Department of Radiation Oncology, Lukang Christian Hospital, Changhua Christian Medical Foundation, Lukang, 505, Taiwan
| | - Shan-Jun Yang
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Po-Ju Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Tsai-Wei Chou
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Li-Chung Hung
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Chia-Chun Huang
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Tung-Hao Chang
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.,Department of Medical Imaging Radiological Science, Central Taiwan University of Science and Technology, Taichung, 406, Taiwan.,Department of Medical Imaging and Radiological Technology, Yuanpei University of Science and Technology, Hsinchu, 300, Taiwan
| | - Jhen-Bin Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.
| | - Jin-Ching Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, 500, Taiwan.,Division of Translation Research, Research Department, Changhua Christian Hospital, Changhua, 500, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, 112, Taiwan
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11
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Wang JL, Ma R, Kong W, Zhao R, Wang YY. Lymphopenia in Esophageal Cancer: What Have We Learned? Front Oncol 2021; 11:625963. [PMID: 33791213 PMCID: PMC8006429 DOI: 10.3389/fonc.2021.625963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/01/2021] [Indexed: 02/03/2023] Open
Abstract
Lymphopenia caused by disease or treatment is frequent in patients with cancer, which seriously affects the prognosis of these patients. Immune checkpoint inhibitors (ICIs) have garnered attention as one of the most promising strategies for the treatment of esophageal cancer (EC). The status of the immune system, such as, the lymphocyte count, is now considered to be an important biomarker for ICI treatments. Recognition of the significant impact of the lymphocyte count on the survival of patients with EC in the era of immunotherapy has revived interest in understanding the causes of lymphopenia and in developing strategies to predict, prevent and eliminate the adverse effect of lymphopenia. Here, we review what we have learned about lymphopenia in EC, including the prognostic and predictive value of lymphopenia in patients with EC, the predictors of lymphopenia, and the strategies to ameliorate the effect of lymphopenia in patients with EC.
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Affiliation(s)
- Jia-Lin Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Rong Ma
- Graduate School, Ningxia Medical University, Yinchuan, China
| | - Wei Kong
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Ren Zhao
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
| | - Yan-Yang Wang
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.,Cancer Institute, Ningxia Medical University, Yinchuan, China
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12
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Xu H, Lin M, Hu Y, Zhang L, Li Q, Zhu J, Wang S, Xi M. Lymphopenia During Definitive Chemoradiotherapy in Esophageal Squamous Cell Carcinoma: Association with Dosimetric Parameters and Patient Outcomes. Oncologist 2020; 26:e425-e434. [PMID: 32960471 DOI: 10.1002/onco.13533] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 08/26/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The objective of this study was to investigate the relationship between clinical characteristics, as well as dosimetric parameters, and the risk of treatment-related lymphopenia in esophageal squamous cell carcinoma (ESCC) treated with definitive chemoradiotherapy (CRT). MATERIALS AND METHODS Clinical characteristics and dosimetric parameters were collected from 436 patients with ESCC who received definitive CRT from 2010 through 2017. Absolute lymphocyte counts (ALCs) were obtained before, during, and 1 month after CRT. Grade 4 (G4) lymphopenia was defined as ALC <0.2 × 109 /L during CRT. Logistic regression analysis was used to evaluate the effect of each factor on predicting G4 lymphopenia. The relationship between lymphopenia and overall survival (OS) was examined, and a nomogram was developed to predict OS. RESULTS G4 lymphopenia was observed in 103 patients (23.6%) during CRT. Multivariate analysis indicated that planning target volume (PTV), lung V10 , heart V10 , performance status, and pretreatment lymphopenia were significant risk factors for G4 lymphopenia. Patients with G4 lymphopenia had significantly worse survival than those without. Based on multivariate analysis, clinical TNM stage, radiotherapy modality, pretreatment ALC, and G4 lymphopenia were predictive of OS and were incorporated into the nomogram, yielding a concordance index of 0.71. CONCLUSIONS G4 lymphopenia during definitive CRT was associated with larger PTVs, higher lung V10 and heart V10 , and worse survival. IMPLICATIONS FOR PRACTICE The purpose of this study was to investigate the relationship between clinical characteristics, as well as dosimetric parameters, and the risk of treatment-related lymphopenia in 436 patients with esophageal squamous cell carcinoma who received definitive chemoradiotherapy. Grade 4 (G4) lymphopenia was observed in 23.6% of patients during radiotherapy. G4 lymphopenia was associated with larger planning target volumes, higher lung V10 and heart V10 , and worse survival. Then, a nomogram was built based on multivariate analysis, yielding excellent performance to predict overall survival. Prospective studies are needed to investigate potential approaches for mitigating severe lymphopenia, which may ultimately convert into survival benefits.
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Affiliation(s)
- Hui Xu
- Department of Head and Neck Oncology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, People's Republic of China
| | - Maosheng Lin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yingying Hu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Department of Nuclear Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Li Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Qiaoqiao Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jinhan Zhu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Shi Wang
- Department of Engineering Physics, Tsinghua University, Beijing, People's Republic of China
| | - Mian Xi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Departments of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
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