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McGarrigle JM, Long KR, Prezado Y. The FLASH effect-an evaluation of preclinical studies of ultra-high dose rate radiotherapy. Front Oncol 2024; 14:1340190. [PMID: 38711846 PMCID: PMC11071325 DOI: 10.3389/fonc.2024.1340190] [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: 11/17/2023] [Accepted: 03/20/2024] [Indexed: 05/08/2024] Open
Abstract
FLASH radiotherapy (FLASH-RT) is a novel radiotherapy approach based on the use of ultra-high dose radiation to treat malignant cells. Although tumours can be reduced or eradicated using radiotherapy, toxicities induced by radiation can compromise healthy tissues. The FLASH effect is the observation that treatment delivered at an ultra-high dose rate is able to reduce adverse toxicities present at conventional dose rates. While this novel technique may provide a turning point for clinical practice, the exact mechanisms underlying the causes or influences of the FLASH effect are not fully understood. The study presented here uses data collected from 41 experimental investigations (published before March 2024) of the FLASH effect. Searchable databases were constructed to contain the outcomes of the various experiments in addition to values of beam parameters that may have a bearing on the FLASH effect. An in-depth review of the impact of the key beam parameters on the results of the experiments was carried out. Correlations between parameter values and experimental outcomes were studied. Pulse Dose Rate had positive correlations with almost all end points, suggesting viability of FLASH-RT as a new modality of radiotherapy. The collective results of this systematic review study suggest that beam parameter qualities from both FLASH and conventional radiotherapy can be valuable for tissue sparing and effective tumour treatment.
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Affiliation(s)
| | - Kenneth Richard Long
- Department of Physics, Imperial College London, London, United Kingdom
- Science and Technology Facilities Council (STFC), Rutherford Appleton Laboratory, Oxford, United Kingdom
| | - Yolanda Prezado
- Institut Curie, Universite Paris-Saclay, Centre national de la recherche scientifique (CNRS) UMR3347, Inserm U1021, Signalisation radiobiologie et cancer, Orsay, France
- Universite Paris-Saclay, Centre national de la recherche scientifique (CNRS) UMR3347, Inserm U1021, Signalisation radiobiologie et cancer, Orsay, France
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2
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Giannini N, Gadducci G, Fuentes T, Gonnelli A, Di Martino F, Puccini P, Naso M, Pasqualetti F, Capaccioli S, Paiar F. Electron FLASH radiotherapy in vivo studies. A systematic review. Front Oncol 2024; 14:1373453. [PMID: 38655137 PMCID: PMC11035725 DOI: 10.3389/fonc.2024.1373453] [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: 01/20/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
FLASH-radiotherapy delivers a radiation beam a thousand times faster compared to conventional radiotherapy, reducing radiation damage in healthy tissues with an equivalent tumor response. Although not completely understood, this radiobiological phenomenon has been proved in several animal models with a spectrum of all kinds of particles currently used in contemporary radiotherapy, especially electrons. However, all the research teams have performed FLASH preclinical studies using industrial linear accelerator or LINAC commonly employed in conventional radiotherapy and modified for the delivery of ultra-high-dose-rate (UHDRs). Unfortunately, the delivering and measuring of UHDR beams have been proved not to be completely reliable with such devices. Concerns arise regarding the accuracy of beam monitoring and dosimetry systems. Additionally, this LINAC totally lacks an integrated and dedicated Treatment Planning System (TPS) able to evaluate the internal dose distribution in the case of in vivo experiments. Finally, these devices cannot modify dose-time parameters of the beam relevant to the flash effect, such as average dose rate; dose per pulse; and instantaneous dose rate. This aspect also precludes the exploration of the quantitative relationship with biological phenomena. The dependence on these parameters need to be further investigated. A promising advancement is represented by a new generation of electron LINAC that has successfully overcome some of these technological challenges. In this review, we aim to provide a comprehensive summary of the existing literature on in vivo experiments using electron FLASH radiotherapy and explore the promising clinical perspectives associated with this technology.
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Affiliation(s)
- Noemi Giannini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Giovanni Gadducci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Taiusha Fuentes
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Alessandra Gonnelli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Fabio Di Martino
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Unit of Medical Physics, Azienda Ospedaliero-Universitaria Pisana, Pisa, Tuscany, Italy
- National Institute of Nuclear Physics (INFN)-section of Pisa, Pisa, Tuscany, Italy
| | - Paola Puccini
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
| | - Monica Naso
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
| | - Francesco Pasqualetti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
| | - Simone Capaccioli
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Department of Physics, University of Pisa, Pisa, Tuscany, Italy
| | - Fabiola Paiar
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
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3
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Almeida A, Godfroid C, Leavitt RJ, Montay-Gruel P, Petit B, Romero J, Ollivier J, Meziani L, Sprengers K, Paisley R, Grilj V, Limoli CL, Romero P, Vozenin MC. Antitumor Effect by Either FLASH or Conventional Dose Rate Irradiation Involves Equivalent Immune Responses. Int J Radiat Oncol Biol Phys 2024; 118:1110-1122. [PMID: 37951550 PMCID: PMC11093276 DOI: 10.1016/j.ijrobp.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/05/2023] [Accepted: 10/14/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE The capability of ultrahigh dose rate FLASH radiation therapy to generate the FLASH effect has opened the possibility to enhance the therapeutic index of radiation therapy. The contribution of the immune response has frequently been hypothesized to account for a certain fraction of the antitumor efficacy and tumor kill of FLASH but has yet to be rigorously evaluated. METHODS AND MATERIALS To investigate the immune response as a potentially important mechanism of the antitumor effect of FLASH, various murine tumor models were grafted either subcutaneously or orthotopically into immunocompetent mice or in moderately and severely immunocompromised mice. Mice were locally irradiated with single dose (20 Gy) or hypofractionated regimens (3 × 8 or 2 × 6 Gy) using FLASH (≥2000 Gy/s) and conventional (CONV) dose rates (0.1 Gy/s), with/without anti-CTLA-4. Tumor growth was monitored over time and immune profiling performed. RESULTS FLASH and CONV 20 Gy were isoeffective in delaying tumor growth in immunocompetent and moderately immunodeficient hosts and increased tumor doubling time to >14 days versus >7 days in control animals. Similar observations were obtained with a hypofractionated scheme, regardless of the microenvironment (subcutaneous flank vs ortho lungs). Interestingly, in profoundly immunocompromised mice, 20 Gy FLASH retained antitumor activity and significantly increased tumor doubling time to >14 days versus >8 days in control animals, suggesting a possible antitumor mechanism independent of the immune response. Analysis of the tumor microenvironment showed similar immune profiles after both irradiation modalities with significant decrease of lymphoid cells by ∼40% and a corresponding increase of myeloid cells. In addition, FLASH and CONV did not increase transforming growth factor-β1 levels in tumors compared with unirradiated control animals. Furthermore, when a complete and long-lasting antitumor response was obtained (>140 days), both modalities of irradiation were able to generate a long-term immunologic memory response. CONCLUSIONS The present results clearly document that the tumor responses across multiple immunocompetent and immunodeficient mouse models are largely dose rate independent and simultaneously contradict a major role of the immune response in the antitumor efficacy of FLASH. Therefore, our study indicates that FLASH is as potent as CONV in modulating antitumor immune response and can be used as an immunomodulatory agent.
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Affiliation(s)
- Aymeric Almeida
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Céline Godfroid
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Department of Oncology UNIL CHUV, University of Lausanne, Épalinges, Switzerland
| | - Ron J Leavitt
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre Montay-Gruel
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Radiation Oncology Department, Iridium Netwerk, Wilrijk (Antwerp), Belgium; Antwerp Research in Radiation Oncology (AReRO), Centre for Oncological Research (CORE), University of Antwerp, Antwerp, Belgium
| | - Benoit Petit
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jackeline Romero
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jonathan Ollivier
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lydia Meziani
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kevin Sprengers
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Ryan Paisley
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Veljko Grilj
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Charles L Limoli
- Department of Radiation Oncology, University of California, Irvine, California
| | - Pedro Romero
- Department of Oncology UNIL CHUV, University of Lausanne, Épalinges, Switzerland
| | - Marie-Catherine Vozenin
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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4
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Borghini A, Labate L, Piccinini S, Panaino CMV, Andreassi MG, Gizzi LA. FLASH Radiotherapy: Expectations, Challenges, and Current Knowledge. Int J Mol Sci 2024; 25:2546. [PMID: 38473799 DOI: 10.3390/ijms25052546] [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: 11/18/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Major strides have been made in the development of FLASH radiotherapy (FLASH RT) in the last ten years, but there are still many obstacles to overcome for transfer to the clinic to become a reality. Although preclinical and first-in-human clinical evidence suggests that ultra-high dose rates (UHDRs) induce a sparing effect in normal tissue without modifying the therapeutic effect on the tumor, successful clinical translation of FLASH-RT depends on a better understanding of the biological mechanisms underpinning the sparing effect. Suitable in vitro studies are required to fully understand the radiobiological mechanisms associated with UHDRs. From a technical point of view, it is also crucial to develop optimal technologies in terms of beam irradiation parameters for producing FLASH conditions. This review provides an overview of the research progress of FLASH RT and discusses the potential challenges to be faced before its clinical application. We critically summarize the preclinical evidence and in vitro studies on DNA damage following UHDR irradiation. We also highlight the ongoing developments of technologies for delivering FLASH-compliant beams, with a focus on laser-driven plasma accelerators suitable for performing basic radiobiological research on the UHDR effects.
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Affiliation(s)
| | - Luca Labate
- Intense Laser Irradiation Laboratory (ILIL), CNR Istituto Nazionale di Ottica, 56124 Pisa, Italy
| | - Simona Piccinini
- Intense Laser Irradiation Laboratory (ILIL), CNR Istituto Nazionale di Ottica, 56124 Pisa, Italy
| | | | | | - Leonida Antonio Gizzi
- Intense Laser Irradiation Laboratory (ILIL), CNR Istituto Nazionale di Ottica, 56124 Pisa, Italy
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5
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Portier L, Daira P, Fourmaux B, Heinrich S, Becerra M, Fouillade C, Berthault N, Dutreix M, Londoño-Vallejo A, Verrelle P, Bernoud-Hubac N, Favaudon V. Differential Remodeling of the Oxylipin Pool After FLASH Versus Conventional Dose-Rate Irradiation In Vitro and In Vivo. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00281-5. [PMID: 38340776 DOI: 10.1016/j.ijrobp.2024.01.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/09/2024] [Accepted: 01/13/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE The products of lipid peroxidation have been implicated in human diseases and aging. This prompted us to investigate the response to conventional (CONV) versus FLASH irradiation of oxylipins, a family of bioactive lipid metabolites derived from omega-3 or omega-6 polyunsaturated fatty acids through oxygen-dependent non-enzymatic as well as dioxygenase-mediated free radical reactions. METHODS AND MATERIALS Ultrahigh performance liquid chromatography coupled to tandem mass spectrometry was used to quantify the expression of 37 oxylipins derived from eicosatetraenoic, eicosapentaenoic and docosahexaenoic acid in mouse lung and in normal or cancer cells exposed to either radiation modality under precise monitoring of the temperature and oxygenation. Among the 37 isomers assayed, 14-16 were present in high enough amount to enable quantitative analysis. The endpoints were the expression of oxylipins as a function of the dose of radiation, normoxia versus hypoxia, temperature and post-irradiation time. RESULTS In normal, normoxic cells at 37°C radiation elicited destruction and neosynthesis of oxylipins acting antagonistically on a background subject to rapid remodeling by oxygenases. Neosynthesis was observed in the CONV mode only, in such a way that the level of oxylipins at 5 minutes after FLASH irradiation was 20-50% lower than in non-irradiated and CONV-irradiated cells. Hypoxia mitigated the differential CONV versus FLASH response in some oxylipins. These patterns were not reproduced in tumor cells. Depression of specific oxylipins following FLASH irradiation was observed in mouse lung at 5 min following irradiation, with near complete recovery in 24 hours and further remodeling at one week and two months post-irradiation. CONCLUSIONS Down-regulation of oxylipins was a hallmark of FLASH irradiation specific of normal cells. Temperature effects suggest that this process occurs via diffusion-controlled, bimolecular recombination of a primary radical species upstream from peroxyl radical formation and evoke a major role of the membrane composition and fluidity in response to the FLASH modality.
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Affiliation(s)
- Lucie Portier
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | - Patricia Daira
- Univ Lyon, INSA Lyon, CNRS, LaMCoS, UMR 5259, Villeurbanne, France
| | | | - Sophie Heinrich
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | - Margaux Becerra
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | - Charles Fouillade
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | - Nathalie Berthault
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | - Marie Dutreix
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | - Arturo Londoño-Vallejo
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | - Pierre Verrelle
- Institut Curie, Hospital Section, Department of Radiotherapy-Oncology, 26 rue d'Ulm, 75248 Paris Cedex 05, France; Institut Curie, Research Division, Inserm U 1196-CNRS UMR 9187, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France
| | | | - Vincent Favaudon
- Institut Curie, Research Division, Inserm U 1021-CNRS UMR 3347, Paris-Saclay University, PSL Research University, Centre Universitaire CS 90030, Orsay, France.
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6
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Liljedahl E, Konradsson E, Linderfalk K, Gustafsson E, Petersson K, Ceberg C, Redebrandt HN. Comparable survival in rats with intracranial glioblastoma irradiated with single-fraction conventional radiotherapy or FLASH radiotherapy. Front Oncol 2024; 13:1309174. [PMID: 38322292 PMCID: PMC10845047 DOI: 10.3389/fonc.2023.1309174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 12/22/2023] [Indexed: 02/08/2024] Open
Abstract
Background Radiotherapy increases survival in patients with glioblastoma. However, the prescribed dose is limited by unwanted side effects on normal tissue. Previous experimental studies have shown that FLASH radiotherapy (FLASH-RT) can reduce these side effects. Still, it is important to establish an equal anti-tumor efficacy comparing FLASH-RT to conventional radiotherapy (CONV-RT). Methods Fully immunocompetent Fischer 344 rats with the GFP-positive NS1 intracranial glioblastoma model were irradiated with CONV-RT or FLASH-RT in one fraction of 20 Gy, 25 Gy or 30 Gy. Animals were monitored for survival and acute dermal side effects. The brains were harvested upon euthanasia and tumors were examined post mortem. Results Survival was significantly increased in animals irradiated with CONV-RT and FLASH-RT at 20 Gy and 25 Gy compared to control animals. The longest survival was reached in animals irradiated with FLASH-RT and CONV-RT at 25 Gy. Irradiation at 30 Gy did not lead to increased survival, despite smaller tumors. Tumor size correlated inversely with irradiation dose, both in animals treated with CONV-RT and FLASH-RT. Acute dermal side effects were mild, but only a small proportion of the animals were alive for evaluation of those side effects. Conclusion The dose response was similar for CONV-RT and FLASH-RT in the present model. Tumor size upon the time of euthanasia correlated inversely with the irradiation dose.
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Affiliation(s)
- Emma Liljedahl
- The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Elise Konradsson
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Karin Linderfalk
- The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Emma Gustafsson
- The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Kristoffer Petersson
- Department of Oncology, Medical Research Council Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
- Radiation Physics, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Crister Ceberg
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Henrietta Nittby Redebrandt
- The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
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7
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Almeida A, Togno M, Ballesteros-Zebadua P, Franco-Perez J, Geyer R, Schaefer R, Petit B, Grilj V, Meer D, Safai S, Lomax T, Weber DC, Bailat C, Psoroulas S, Vozenin MC. Dosimetric and biologic intercomparison between electron and proton FLASH beams. Radiother Oncol 2024; 190:109953. [PMID: 37839557 DOI: 10.1016/j.radonc.2023.109953] [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: 04/12/2023] [Revised: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND AND PURPOSE The FLASH effect has been validated in different preclinical experiments with electrons (eFLASH) and protons (pFLASH) operating at an average dose rate above 40 Gy/s. However, no systematic intercomparison of the FLASH effect produced by eFLASHvs. pFLASH has yet been performed and constitutes the aim of the present study. MATERIALS AND METHODS The electron eRT6/Oriatron/CHUV/5.5 MeV and proton Gantry1/PSI/170 MeV were used to deliver conventional (0.1 Gy/s eCONV and pCONV) and FLASH (≥110 Gy/s eFLASH and pFLASH) dose rates. Protons were delivered in transmission. Dosimetric and biologic intercomparisons were performed using previously validated dosimetric approaches and experimental murine models. RESULTS The difference between the average absorbed dose measured at Gantry 1 with PSI reference dosimeters and with CHUV/IRA dosimeters was -1.9 % (0.1 Gy/s) and + 2.5 % (110 Gy/s). The neurocognitive capacity of eFLASH and pFLASH irradiated mice was indistinguishable from the control, while both eCONV and pCONV irradiated cohorts showed cognitive decrements. Complete tumor response was obtained after an ablative dose of 20 Gy delivered with the two beams at CONV and FLASH dose rates. Tumor rejection upon rechallenge indicates that anti-tumor immunity was activated independently of the beam-type and the dose-rate. CONCLUSION Despite major differences in the temporal microstructure of proton and electron beams, this study shows that dosimetric standards can be established. Normal brain protection and tumor control were produced by the two beams. More specifically, normal brain protection was achieved when a single dose of 10 Gy was delivered in 90 ms or less, suggesting that the most important physical parameter driving the FLASH sparing effect might be the mean dose rate. In addition, a systemic anti-tumor immunological memory response was observed in mice exposed to high ablative dose of electron and proton delivered at CONV and FLASH dose rate.
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Affiliation(s)
- A Almeida
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M Togno
- Center for Proton Therapy, Paul Scherrer Institute, 5323, Villigen, Switzerland
| | - P Ballesteros-Zebadua
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Instituto Nacional de Neurología y Neurocirugía MVS, Mexico City, Mexico
| | - J Franco-Perez
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Instituto Nacional de Neurología y Neurocirugía MVS, Mexico City, Mexico
| | - R Geyer
- Department of Radiation Oncology, lnselspital, Bern University Hospital, University of Bern, Switzerland
| | - R Schaefer
- Center for Proton Therapy, Paul Scherrer Institute, 5323, Villigen, Switzerland
| | - B Petit
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - V Grilj
- Institute of Radiation Physics (IRA)/CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - D Meer
- Center for Proton Therapy, Paul Scherrer Institute, 5323, Villigen, Switzerland
| | - S Safai
- Center for Proton Therapy, Paul Scherrer Institute, 5323, Villigen, Switzerland
| | - T Lomax
- Center for Proton Therapy, Paul Scherrer Institute, 5323, Villigen, Switzerland
| | - D C Weber
- Center for Proton Therapy, Paul Scherrer Institute, 5323, Villigen, Switzerland; Department of Radiation Oncology, lnselspital, Bern University Hospital, University of Bern, Switzerland; Department of Radiation Oncology, University Hospital of Zurich, Switzerland
| | - C Bailat
- Institute of Radiation Physics (IRA)/CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - S Psoroulas
- Center for Proton Therapy, Paul Scherrer Institute, 5323, Villigen, Switzerland
| | - Marie-Catherine Vozenin
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Radiotherapy and Radiobiology sector, Radiation Therapy service, University hospital of Geneva, Geneva, Switzerland.
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8
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Böhlen TT, Germond JF, Petersson K, Ozsahin EM, Herrera FG, Bailat C, Bochud F, Bourhis J, Moeckli R, Adrian G. Effect of Conventional and Ultrahigh Dose Rate FLASH Irradiations on Preclinical Tumor Models: A Systematic Analysis. Int J Radiat Oncol Biol Phys 2023; 117:1007-1017. [PMID: 37276928 DOI: 10.1016/j.ijrobp.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/19/2023] [Accepted: 05/26/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE Compared with conventional dose rate irradiation (CONV), ultrahigh dose rate irradiation (UHDR) has shown superior normal tissue sparing. However, a clinically relevant widening of the therapeutic window by UHDR, termed "FLASH effect," also depends on the tumor toxicity obtained by UHDR. Based on a combined analysis of published literature, the current study examined the hypothesis of tumor isoefficacy for UHDR versus CONV and aimed to identify potential knowledge gaps to inspire future in vivo studies. METHODS AND MATERIALS A systematic literature search identified publications assessing in vivo tumor responses comparing UHDR and CONV. Qualitative and quantitative analyses were performed, including combined analyses of tumor growth and survival data. RESULTS We identified 66 data sets from 15 publications that compared UHDR and CONV for tumor efficacy. The median number of animals per group was 9 (range 3-15) and the median follow-up period was 30.5 days (range 11-230) after the first irradiation. Tumor growth assays were the predominant model used. Combined statistical analyses of tumor growth and survival data are consistent with UHDR isoefficacy compared with CONV. Only 1 study determined tumor-controlling dose (TCD50) and reported statistically nonsignificant differences. CONCLUSIONS The combined quantitative analyses of tumor responses support the assumption of UHDR isoefficacy compared with CONV. However, the comparisons are primarily based on heterogeneous tumor growth assays with limited numbers of animals and short follow-up, and most studies do not assess long-term tumor control probability. Therefore, the assays may be insensitive in resolving smaller response differences, such as responses of radioresistant tumor subclones. Hence, tumor cure experiments, including additional TCD50 experiments, are needed to confirm the assumption of isoeffectiveness in curative settings.
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Affiliation(s)
- Till Tobias Böhlen
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean-François Germond
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Kristoffer Petersson
- Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital, Lund, Sweden; MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Esat Mahmut Ozsahin
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Fernanda G Herrera
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Claude Bailat
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - François Bochud
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Raphaël Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.
| | - Gabriel Adrian
- Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital, Lund, Sweden; Division of Oncology and Pathology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
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9
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Duval KEA, Aulwes E, Zhang R, Rahman M, Ashraf MR, Sloop A, Sunnerberg J, Williams BB, Cao X, Bruza P, Kheirollah A, Tavakkoli A, Jarvis LA, Schaner PE, Swartz HM, Gladstone DJ, Pogue BW, Hoopes PJ. Comparison of Tumor Control and Skin Damage in a Mouse Model after Ultra-High Dose Rate Irradiation and Conventional Irradiation. Radiat Res 2023; 200:223-231. [PMID: 37590482 PMCID: PMC10551764 DOI: 10.1667/rade-23-00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/07/2023] [Indexed: 08/19/2023]
Abstract
Recent studies suggest ultra-high dose rate radiation treatment (UHDR-RT) reduces normal tissue damage compared to conventional radiation treatment (CONV-RT) at the same dose. In this study, we compared first, the kinetics and degree of skin damage in wild-type C57BL/6 mice, and second, tumor treatment efficacy in GL261 and B16F10 dermal tumor models, at the same UHDR-RT and CONV-RT doses. Flank skin of wild-type mice received UHDR-RT or CONV-RT at 25 Gy and 30 Gy. Normal skin damage was tracked by clinical observation to determine the time to moist desquamation, an endpoint which was verified by histopathology. Tumors were inoculated on the right flank of the mice, then received UHDR-RT or CONV-RT at 1 × 11 Gy, 1 × 15, 1 × 25, 3 × 6 and 3 × 8 Gy, and time to tumor tripling volume was determined. Tumors also received 1 × 11, 1 × 15, 3 × 6 and 3 × 8 Gy doses for assessment of CD8+/CD4+ tumor infiltrate and genetic expression 96 h postirradiation. All irradiations of the mouse tumor or flank skin were performed with megavoltage electron beams (10 MeV, 270 Gy/s for UHDR-RT and 9 MeV, 0.12 Gy/s for CONV-RT) delivered via a clinical linear accelerator. Tumor control was statistically equal for similar doses of UHDR-RT and CONV-RT in B16F10 and GL261 murine tumors. There were variable qualitative differences in genetic expression of immune and cell damage-associated pathways between UHDR and CONV irradiated B16F10 tumors. Compared to CONV-RT, UHDR-RT resulted in an increased latent period to skin desquamation after a single 25 Gy dose (7 days longer). Time to moist skin desquamation did not significantly differ between UHDR-RT and CONV-RT after a 30 Gy dose. The histomorphological characteristics of skin damage were similar for UHDR-RT and CONV-RT. These studies demonstrated similar tumor control responses for equivalent single and fractionated radiation doses, with variable difference in expression of tumor progression and immune related gene pathways. There was a modest UHDR-RT skin sparing effect after a 1 × 25 Gy dose but not after a 1 × 30 Gy dose.
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Affiliation(s)
- Kayla E. A. Duval
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Ethan Aulwes
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Rongxiao Zhang
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mahbubur Rahman
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - M. Ramish Ashraf
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Austin Sloop
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Jacob Sunnerberg
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Benjamin B. Williams
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Xu Cao
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Petr Bruza
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | | | - Armin Tavakkoli
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Lesley A. Jarvis
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Philip E. Schaner
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Harold M. Swartz
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - David J. Gladstone
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Brian W. Pogue
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
| | - P. Jack Hoopes
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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10
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Almeida A, Togno M, Ballesteros-Zebadua P, Franco-Perez J, Geyer R, Schaefer R, Petit B, Grilj V, Meer D, Safai S, Lomax T, Weber DC, Bailat C, Psoroulas S, Vozenin MC. Dosimetric and biologic intercomparison between electron and proton FLASH beams. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.20.537497. [PMID: 37131769 PMCID: PMC10153243 DOI: 10.1101/2023.04.20.537497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background and purpose The FLASH effect has been validated in different preclinical experiments with electrons (eFLASH) and protons (pFLASH) operating at a mean dose rate above 40 Gy/s. However, no systematic intercomparison of the FLASH effect produced by e vs. pFLASH has yet been performed and constitutes the aim of the present study. Materials and methods The electron eRT6/Oriatron/CHUV/5.5 MeV and proton Gantry1/PSI/170 MeV were used to deliver conventional (0.1 Gy/s eCONV and pCONV) and FLASH (≥100 Gy/s eFLASH and pFLASH) irradiation. Protons were delivered in transmission. Dosimetric and biologic intercomparisons were performed with previously validated models. Results Doses measured at Gantry1 were in agreement (± 2.5%) with reference dosimeters calibrated at CHUV/IRA. The neurocognitive capacity of e and pFLASH irradiated mice was indistinguishable from the control while both e and pCONV irradiated cohorts showed cognitive decrements. Complete tumor response was obtained with the two beams and was similar between e and pFLASH vs. e and pCONV. Tumor rejection was similar indicating that T-cell memory response is beam-type and dose-rate independent. Conclusion Despite major differences in the temporal microstructure, this study shows that dosimetric standards can be established. The sparing of brain function and tumor control produced by the two beams were similar, suggesting that the most important physical parameter driving the FLASH effect is the overall time of exposure which should be in the range of hundreds of milliseconds for WBI in mice. In addition, we observed that immunological memory response is similar between electron and proton beams and is independent off the dose rate.
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Affiliation(s)
- A Almeida
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M Togno
- Center for Proton Therapy, Paul Scherrer Institute, 5323 Villigen PSI, Switzerland
| | - P Ballesteros-Zebadua
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Instituto Nacional de Neurología y Neurocirugía MVS, Mexico City, Mexico
| | - J Franco-Perez
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Instituto Nacional de Neurología y Neurocirugía MVS, Mexico City, Mexico
| | - R Geyer
- Department of Radiation Oncology, lnselspital, Bern University Hospital, University of Bern, Switzerland
| | - R Schaefer
- Center for Proton Therapy, Paul Scherrer Institute, 5323 Villigen PSI, Switzerland
| | - B Petit
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - V Grilj
- Institute of Radiation Physics (IRA)/CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - D Meer
- Center for Proton Therapy, Paul Scherrer Institute, 5323 Villigen PSI, Switzerland
| | - S Safai
- Center for Proton Therapy, Paul Scherrer Institute, 5323 Villigen PSI, Switzerland
| | - T Lomax
- Center for Proton Therapy, Paul Scherrer Institute, 5323 Villigen PSI, Switzerland
| | - D C Weber
- Center for Proton Therapy, Paul Scherrer Institute, 5323 Villigen PSI, Switzerland
- Department of Radiation Oncology, lnselspital, Bern University Hospital, University of Bern, Switzerland
- Department of Radiation Oncology, University Hospital of Zurich, Switzerland
| | - C Bailat
- Institute of Radiation Physics (IRA)/CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - S Psoroulas
- Center for Proton Therapy, Paul Scherrer Institute, 5323 Villigen PSI, Switzerland
| | - M C Vozenin
- Laboratory of Radiation Oncology/Radiation Oncology Service/Department of Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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11
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Storozynsky QT, Agopsowicz KC, Noyce RS, Bukhari AB, Han X, Snyder N, Umer BA, Gamper AM, Godbout R, Evans DH, Hitt MM. Radiation combined with oncolytic vaccinia virus provides pronounced antitumor efficacy and induces immune protection in an aggressive glioblastoma model. Cancer Lett 2023; 562:216169. [PMID: 37061120 DOI: 10.1016/j.canlet.2023.216169] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/26/2023] [Accepted: 04/05/2023] [Indexed: 04/17/2023]
Abstract
Glioblastoma (GB) is a malignant and immune-suppressed brain cancer that remains incurable despite the current standard of care. Radiotherapy is a mainstay of GB treatment, however invasive cancer cells outside the irradiated field and radioresistance preclude complete eradication of GB cells. Oncolytic virus therapy harnesses tumor-selective viruses to spread through and destroy tumors while stimulating antitumor immune responses, and thus has potential for use following radiotherapy. We demonstrate that oncolytic ΔF4LΔJ2R vaccinia virus (VACV) replicates in and induces cytotoxicity of irradiated brain tumor initiating cells in vitro. Importantly, a single 10 Gy dose of radiation combined with ΔF4LΔJ2R VACV produced considerably superior anticancer effects relative to either monotherapy when treating immune-competent orthotopic CT2A-luc mouse models-significantly extending survival and curing the majority of mice. Mice cured by the combination displayed significantly increased survival relative to naïve age-matched controls following intracranial tumor challenge, with some complete rejections. Further, the combination therapy was associated with an increased ratio of CD8+ effector T cells to regulatory T cells compared to either monotherapy. This study validates the use of radiation with an oncolytic ΔF4LΔJ2R VACV to improve treatment of this malignant brain cancer.
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Affiliation(s)
- Quinn T Storozynsky
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB, Canada; Cancer Research Institute of Northern Alberta (CRINA), University of Alberta, Edmonton, AB, Canada
| | | | - Ryan S Noyce
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada; Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB, Canada
| | - Amirali B Bukhari
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Cancer Research Institute of Northern Alberta (CRINA), University of Alberta, Edmonton, AB, Canada
| | - Xuefei Han
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Natalie Snyder
- Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Brittany A Umer
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada; Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB, Canada
| | - Armin M Gamper
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Cancer Research Institute of Northern Alberta (CRINA), University of Alberta, Edmonton, AB, Canada
| | - Roseline Godbout
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Cancer Research Institute of Northern Alberta (CRINA), University of Alberta, Edmonton, AB, Canada
| | - David H Evans
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada; Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB, Canada
| | - Mary M Hitt
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB, Canada; Cancer Research Institute of Northern Alberta (CRINA), University of Alberta, Edmonton, AB, Canada.
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12
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Liljedahl E, Konradsson E, Gustafsson E, Jonsson KF, Olofsson JK, Osther K, Ceberg C, Redebrandt HN. Combined anti-C1-INH and radiotherapy against glioblastoma. BMC Cancer 2023; 23:106. [PMID: 36717781 PMCID: PMC9887755 DOI: 10.1186/s12885-023-10583-1] [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: 10/10/2022] [Accepted: 01/25/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A more effective immune response against glioblastoma is needed in order to achieve better tumor control. Radiotherapy can induce anti-tumor mediated immune reactions, in addition to its dose response effects. The complement system can function as a bridge between innate and adaptive immune responses. Combining radiotherapy and complement activating therapy is theoretically interesting. METHODS Radiotherapy at 8 Gy × 2 was combined with treatment against C1-inhibitor (C1-INH), a potent inhibitor of activation of the classical pathway of the complement system. Anti-C1-INH was delivered as intratumoral injections. Fully immunocompetent Fischer 344 rats with NS1 glioblastoma tumors were treated. Survival was monitored as primary outcome. Models with either intracranial or subcutaneous tumors were evaluated separately. RESULTS In the intracranial setting, irradiation could prolong survival, but there was no additional survival gain as a result of anti-C1-INH treatment. In animals with subcutaneous tumors, combined radio-immunotherapy with anti-C1-INH and irradiation at 8 Gy × 2 significantly prolonged survival compared to control animals, whereas irradiation or anti-C1-INH treatment as single therapies did not lead to significantly increased survival compared to control animals. CONCLUSIONS Anti-C1-INH treatment could improve the efficacy of irradiation delivered at sub-therapeutic doses and delay tumor growth in the subcutaneous tumor microenvironment. In the intracranial setting, the doses of anti-C1-INH were not enough to achieve any survival effect in the present setting.
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Affiliation(s)
- Emma Liljedahl
- grid.4514.40000 0001 0930 2361The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, BMC D10, 221 84 Lund, Sweden
| | - Elise Konradsson
- grid.4514.40000 0001 0930 2361Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Emma Gustafsson
- grid.4514.40000 0001 0930 2361The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, BMC D10, 221 84 Lund, Sweden
| | - Karolina Förnvik Jonsson
- grid.4514.40000 0001 0930 2361The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, BMC D10, 221 84 Lund, Sweden
| | - Jill K. Olofsson
- grid.5254.60000 0001 0674 042XDepartment for Geosciences and Natural Resource Management, University of Copenhagen, Copenhagen, Denmark
| | - Kurt Osther
- grid.4514.40000 0001 0930 2361The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, BMC D10, 221 84 Lund, Sweden
| | - Crister Ceberg
- grid.4514.40000 0001 0930 2361Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Henrietta Nittby Redebrandt
- grid.4514.40000 0001 0930 2361The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences, Lund University, BMC D10, 221 84 Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
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13
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Vozenin MC, Bourhis J, Durante M. Towards clinical translation of FLASH radiotherapy. Nat Rev Clin Oncol 2022; 19:791-803. [DOI: 10.1038/s41571-022-00697-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2022] [Indexed: 11/09/2022]
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14
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Hageman E, Che PP, Dahele M, Slotman BJ, Sminia P. Radiobiological Aspects of FLASH Radiotherapy. Biomolecules 2022; 12:biom12101376. [PMID: 36291585 PMCID: PMC9599153 DOI: 10.3390/biom12101376] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Radiotherapy (RT) is one of the primary treatment modalities for cancer patients. The clinical use of RT requires a balance to be struck between tumor effect and the risk of toxicity. Sparing normal tissue is the cornerstone of reducing toxicity. Advances in physical targeting and dose-shaping technology have helped to achieve this. FLASH RT is a promising, novel treatment technique that seeks to exploit a potential normal tissue-sparing effect of ultra-high dose rate irradiation. A significant body of in vitro and in vivo data has highlighted a decrease in acute and late radiation toxicities, while preserving the radiation effect in tumor cells. The underlying biological mechanisms of FLASH RT, however, remain unclear. Three main mechanisms have been hypothesized to account for this differential FLASH RT effect between the tumor and healthy tissue: the oxygen depletion, the DNA damage, and the immune-mediated hypothesis. These hypotheses and molecular mechanisms have been evaluated both in vitro and in vivo. Furthermore, the effect of ultra-high dose rate radiation with extremely short delivery times on the dynamic tumor microenvironment involving circulating blood cells and immune cells in humans is essentially unknown. Therefore, while there is great interest in FLASH RT as a means of targeting tumors with the promise of an increased therapeutic ratio, evidence of a generalized FLASH effect in humans and data to show that FLASH in humans is safe and at least effective against tumors as standard photon RT is currently lacking. FLASH RT needs further preclinical investigation and well-designed in-human studies before it can be introduced into clinical practice.
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Affiliation(s)
- Eline Hageman
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Radiation Oncology, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, 1081 HV Amsterdam, The Netherlands
| | - Pei-Pei Che
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Radiation Oncology, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, 1081 HV Amsterdam, The Netherlands
| | - Max Dahele
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Radiation Oncology, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Ben J. Slotman
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Radiation Oncology, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Peter Sminia
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Radiation Oncology, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, 1081 HV Amsterdam, The Netherlands
- Correspondence:
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15
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Lin B, Huang D, Gao F, Yang Y, Wu D, Zhang Y, Feng G, Dai T, Du X. Mechanisms of FLASH effect. Front Oncol 2022; 12:995612. [PMID: 36212435 PMCID: PMC9537695 DOI: 10.3389/fonc.2022.995612] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
FLASH radiotherapy (FLASH-RT) is a novel radiotherapy technology defined as ultra-high dose rate (≥ 40 Gy/s) radiotherapy. The biological effects of FLASH-RT include two aspects: first, compared with conventional dose rate radiotherapy, FLASH-RT can reduce radiation-induced damage in healthy tissue, and second, FLASH-RT can retain antitumor effectiveness. Current research shows that mechanisms of the biological effects of FLASH-RT are related to oxygen. However, due to the short time of FLASH-RT, evidences related to the mechanisms are indirect, and the exact mechanisms of the biological effects of FLASH-RT are not completely clear and some are even contradictory. This review focuses on the mechanisms of the biological effects of FLASH-RT and proposes future research directions.
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Affiliation(s)
- Binwei Lin
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Dan Huang
- Department of Radiology Mianyang Central Hospital, Mianyang, China
| | - Feng Gao
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Yiwei Yang
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Dai Wu
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Yu Zhang
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Gang Feng
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Tangzhi Dai
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Xiaobo Du
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
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