Influence of thoracic radiotherapy on exhaled nitric oxide levels in patients with lung cancer

Gasotransmitters in the tumor microenvironment: Impacts on cancer chemotherapy (Review)

Nitric oxide, carbon monoxide and hydrogen sulfide are three endogenous gasotransmitters that serve a role in regulating normal and pathological cellular activities. They can stimulate or inhibit cancer cell proliferation and invasion, as well as interfere with cancer cell responses to drug treatments. Understanding the molecular pathways governing the interactions between these gases and the tumor microenvironment can be utilized for the identification of a novel technique to disrupt cancer cell interactions and may contribute to the conception of effective and safe cancer therapy strategies. The present review discusses the effects of these gases in modulating the action of chemotherapies, as well as prospective pharmacological and therapeutic interfering approaches. A deeper knowledge of the mechanisms that underpin the cellular and pharmacological effects, as well as interactions, of each of the three gases could pave the way for therapeutic treatments and translational research.

Nitric oxide in occurrence, progress and therapy of lung Cancer: a systemic review and meta-analysis

Background

Nitric oxide (NO) plays an important role in lung cancer. However, the results of previous studies about NO in the occurrence, progress and therapy were not consistent. Therefore, we conducted a meta-analysis to evaluate the relationship between NO and lung cancer.

Method

We carried out comprehensive search in the databases, and collected related studies. The data of fraction of exhaled nitric oxide (FeNO) or blood NO in different populations (lung cancer patients and control subjects) and different time points (before therapy and after therapy) were extracted by two investigators. A random effect model was applied to analyze the differences of FeNO and blood NO in different populations and different time points. To further compare NO level of each subgroup with different pathological types and different stages, a network meta-analysis (NMA) was performed.

Results

Fifty studies including 2551 cases and 1691 controls were adopted in this meta-analysis. The FeNO (SMD 3.01, 95% CI 1.89–4.13, p < 0.00001) and blood NO (SMD 1.34, 95% CI 0.84–1.85, p < 0.00001) level in lung cancer patients was much higher than that in control subjects. NMA model indicated blood NO level in each cancer type except SCLC was higher than that in control patients. There was no significant difference of blood NO level among four kinds of lung cancer patients. Blood NO level in LCC patients (SUCRA = 83.5%) was the highest. Blood NO level in advanced stage but not early stage was higher than that in control subjects. Patients in advanced stage (SUCRA = 95.5%) had the highest blood NO level. No significant difference of FeNO (SMD -0.04, 95% CI -0.46-0.38, p > 0.05) and blood NO level (SMD -0.36, 95% CI -1.08-0.36, p > 0.05) was observed between pretreatment and posttreatment in all patients. However, FeNO level elevated (SMD 0.28, 95% CI 0.04–0.51, p = 0.02) and blood NO level decreased in NSCLC patients (SMD -0.95, 95% CI -1.89-0.00, p = 0.05) after therapy.

Conclusion

FeNO and blood NO level would contribute to diagnosis of lung cancer and evaluation of therapy effect, especially for NSCLC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08430-2.

Fractional exhaled nitric oxide as a potential biomarker for radiation pneumonitis in patients with non-small cell lung cancer: A pilot study

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Weekly FeNO during radiotherapy can be useful in predicting radiation pneumonitis.

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6 months of clinical follow-up is necessary to detect delayed radiation pneumonitis.

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Pulmonary function tests are not predictable for radiation pneumonitis.

Introduction

The aim of the study was to investigate repetitive fractional exhaled nitric oxide (FeNO) measurements during high-dose radiation therapy (HDRT) and to evaluate the use of FeNO to predict symptomatic radiation pneumonitis (RP) in patients being treated for non-small cell lung cancer (NSCLC).

Materials and methods

A total of 50 patients with NSCLC referred for HDRT were enrolled. FeNO was measured at baseline, weekly during HDRT, one month- and every third month after HDRT for a one-year follow-up period. The mean FeNO_{(visit 0-6)} was calculated using the arithmetic mean of the baseline and weekly measurements during HDRT. Patients with grade ≥ 2 of RP according to the Common Terminology Criteria for Adverse Events (CTCAE) were considered symptomatic.

Results

A total of 42 patients completed HDRT and weekly FeNO measurements. Grade ≥ 2 of RP was diagnosed in 24 (57%) patients. The mean FeNO_{(visit 0-6)} ± standard deviation in patients with and without RP was 15.0 ± 7.1 ppb (95%CI: 12.0–18.0) and 10.3 ± 3.4 ppb (95%CI: 8.6–11.9) respectively with significant differences between the groups (p = 0.0169, 95%CI: 2.3–2.6). The leave-one-out cross-validated cut-off value of the mean FeNO_{(visit 0-6)} ≥ 14.8 ppb was predictive of grade ≥ 2 RP with a specificity of 71% and a positive predictive value of 78%.

Conclusions

The mean FeNO_{(visit 0-6)} in patients with symptomatic RP after HDRT for NSCLC was significantly higher than in patients without RP and may serve as a potential biomarker for RP.

Treatment with the nitric oxide synthase inhibitor L-NAME provides a survival advantage in a mouse model of Kras mutation-positive, non-small cell lung cancer

Oncogenic mutations in the gene KRAS are commonly detected in non-small cell lung cancer (NSCLC). This disease is inherently difficult to treat, and combinations involving platinum-based drugs remain the therapeutic mainstay. In terms of novel, pharmacologically actionable targets, nitric oxide synthases (NOS) have been implicated in the etiology of KRAS-driven cancers, including lung cancer, and small molecular weight NOS inhibitors have been developed for the treatment of other diseases. Thus, we evaluated the anti-neoplastic activity of the oral NOS inhibitor L-NAME in a randomized preclinical trial using a genetically engineered mouse model of Kras and p53 mutation-positive NSCLC. We report here that L-NAME decreased lung tumor growth in vivo, as assessed by sequential radiological imaging, and provided a survival advantage, perhaps the most difficult clinical parameter to improve upon. Moreover, L-NAME enhanced the therapeutic benefit afforded by carboplatin chemotherapy, provided it was administered as maintenance therapy after carboplatin. Collectively, these results support the clinical evaluation of L-NAME for the treatment of KRAS mutation-positive NSCLC.

Measurement of exhaled nitric oxide and serum surfactant protein D levels for monitoring radiation pneumonitis following thoracic radiotherapy

The present study aimed to examine the role of exhaled nitric oxide (eNO) and serum surfactant protein D (SP-D) level in the determination of radiation pneumonitis (RP) after thoracic radiotherapy (RT). The study included 34 treatments for 33 patients, including 16 three-dimensional conformal and 18 stereotactic body RT treatments. eNO levels were measured prior to RT, immediately subsequent to RT, every week during the RT course and at 1, 3, 6, 9 and 12 months following the treatment. The therapy reduced the eNO from 24.3±12.8 ppb prior to RT to 19.0±10.4 ppb immediately subsequent to RT (P=0.04). A total of 5 patients (14%) developed symptomatic RP of grade 2 or higher 3–5 months later, and exhibited an eNO elevation of 2.1±0.68-fold the minimum value, whereas the RP- group exhibited 1.4±0.6-fold elevation (P=0.02). The sensitivity of a cut-off of a 1.4-fold increase in the eNO ratio at the onset of RP was 100%; however, the specificity was 52%, and no predictive alterations to eNO levels were observed prior to the onset of RP. RT was associated with an elevated serum SP-D level at 3–6 months after RT. There was a statistically significant difference in the initial serum SP-D level between RP+ and RP- patients. In conclusion, obtaining the eNO ratio was a useful RP monitoring tool but did not predict RP occurrence in the present setting, whereas serum SP-D level may be a potential predictor for the detection of RP risk.

Can exhaled NO fraction predict radiotherapy-induced lung toxicity in lung cancer patients?

Background

A large increase in nitric oxide fraction (FeNO) after radiotherapy (RT) for lung cancer may predict RT-induced lung toxicity.

Methods

In this study, we assessed the relationships between FeNO variations and respiratory symptoms, CT scan changes or dose volume histogram (DVH) parameters after RT. We measured FeNO before RT, 4, 5, 6, 10 weeks, 4 and 7.5 months after RT in 65 lung cancer patients.

Results

Eleven lung cancer patients (17%) complained of significant respiratory symptoms and 21 (31%) had radiation pneumonitis images in >1/3 of the irradiated lung after RT. Thirteen patients (20%) showed increases in FeNO >10 ppb. The sensitivity and specificity of a >10 ppb FeNO increase for the diagnosis of RT-associated respiratory symptoms were 18% and 83%, respectively. There was no correlation between DVH parameters or CT scan changes after RT and FeNO variations. Three patients (5%) showed intriguingly strong (2 or 3-fold, up to 55 ppb) and sustained increases in FeNO at 4 and 5 weeks, followed by significant respiratory symptoms and/or radiation-pneumonitis images.

Conclusion

Serial FeNO measurements during RT had a low ability to identify lung cancer patients who developed symptoms or images of radiation pneumonitis. However, three patients presented with a particular pattern which deserves to be investigated.

Elevation in exhaled nitric oxide predicts for radiation pneumonitis

PURPOSE

Radiation pneumonitis is a major toxicity after thoracic radiotherapy (RT), with no method available to accurately predict the individual risk. This was a prospective study to evaluate exhaled nitric oxide as a predictive biomarker for radiation pneumonitis in esophageal cancer patients.

PATIENTS AND METHODS

A total of 34 patients prescribed neoadjuvant chemoradiotherapy for esophageal cancer were enrolled in the present trial. Each patient underwent respiratory surveys and exhaled nitric oxide (NO) measurements before, at the end of, and 1 to 2 months after completing RT. Pneumonitis toxicity was scored using the Common Terminology Criteria for Adverse Events, version 4.0. The demographics, dosimetric factors, and exhaled NO levels were evaluated for correlation with symptomatic patients (scores ≥ 2).

RESULTS

Of the 34 patients, 28 were evaluable. All had received 50.4 Gy RT with concurrent chemotherapy. The pneumonitis toxicity score was Grade 3 for 1, Grade 2 for 3, Grade 1 for 7, and Grade 0 for 17. The dosimetric factors were not predictive of symptoms. The mean exhaled NO level measured before, at completion, and at restaging was 17.3 ± 8.5 (range, 5.5-36.7), 16.0 ± 14.2 (range, 5.8-67.7), and 14.7 ± 6.2 (range, 5.5-28.0) parts per billion, respectively. The ratio of exhaled NO at the end of RT vs. before treatment was 3.4 (range, 1.7-6.7) for the symptomatic and 0.8 (range, 0.3-1.3) for the asymptomatic (p = .0017) patients. The elevation in exhaled NO preceded the peak symptoms by 33 days (range, 21-50). The interval to peak symptoms was inversely related to the exhaled NO elevation.

CONCLUSIONS

Elevations in exhaled NO at the end of RT was found to predict for radiation pneumonitis symptoms.

Exhaled nitric oxide predicts radiation pneumonitis in esophageal and lung cancer patients receiving thoracic radiation

BACKGROUND AND PURPOSE

Radiation pneumonitis is a significant toxicity following thoracic radiotherapy with no method to predict individual risk.

MATERIALS AND METHODS

Sixty-five patients receiving thoracic radiation for lung or esophageal cancer were enrolled in a phase II study. Each patient received respiratory surveys and exhaled nitric oxide measurements before, on the last day of, and 30-60 days after completing radiotherapy (RT). Pneumonitis toxicity was scored using the common terminology criteria for adverse events, version 4.0. The demographics, dosimetric factors, and nitric oxide ratio (NOR) of end RT/pre-RT were evaluated for correlation with symptomatic patients (Grade ≥ 2).

RESULTS

Fifty patients completed the trial. The pneumonitis toxicity score was: Grade 3 for 1 patient, Grade 2 for 6 patients, Grade 1 for 18 patients, and Grade 0 for 25 patients. Dosimetric factors were not predictive of symptoms. The NOR was 3.0 ± 1.8 (range 1.47-6.73) for the symptomatic and 0.78 ± 0.29 (range 0.33-1.37) for the asymptomatic patients (p=0.006). A threshold NOR of 1.4 separated symptomatic and asymptomatic patients (p<0.001). The average error was 4%.

CONCLUSIONS

Elevation in eNO on the last day of radiotherapy predicted subsequent symptomatic radiation pneumonitis weeks to months after treatment.

Exhaled nitric oxide in a Taiwanese population: age and lung function as predicting factors

BACKGROUND/PURPOSE

The fractional concentration of exhaled nitric oxide (FE(NO)) has been reported to be elevated in asthma and many other lung diseases. The present study investigated reference values and determinants of FE(NO) in a Taiwanese non-smoking, healthy adult population.

METHODS

We used a chemiluminescence analyzer according to American Thoracic Society/European Respiratory Society recommendations to measure FE(NO) values in 356 adults who received a health check-up and a detailed respiratory questionnaire at Taichung Veterans General Hospital, Taiwan. Among the volunteers, 249 fulfilled our definition of healthy adults: no history of smoking or physician-diagnosed asthma; no recent upper airway infection; no chronic respiratory symptoms; and no allergic rhinitis and urticaria.

RESULTS

Among the 249 non-smoking and non-asthmatic adults, the mean (5th to 95th percentile reference range) FE(NO) was 27.9 (12.5-58.0) parts per billion. In multivariate regression analyses, age and lung function (forced vital capacity or forced expiratory volume in 1 second) were associated positively with FE(NO) values. Sex, height, weight, and ambient NO values were not associated significantly with FE(NO) values.

CONCLUSION

Age and lung function were predictors of FE(NO) in this population, and these factors should be considered for clinical applications of FE(NO) measurements.

Bronchoalveolar lavage findings of radiation induced lung damage in rats

Radiation induced lung damage is a main dose limiting factor when irradiating the thorax. Although Bronchoalveolar lavage (BAL) is a valuable tool for studying the mechanisms in pulmonary disorders, there are only a few studies about the BAL findings of radiation-induced lung damage. We evaluate the BAL findings for the evaluation of radiation-induced lung damage. Sprague-Dawley rats received 20 Gy of radiation to the right lung and control group were sham irradiated. BAL was performed for the right and left lungs separately 3, 7, 14, 28, and 56 days after radiation. The cells in the BAL fluid were counted and the concentrations of protein, NO, and TGF-beta in the BAL fluid were measured. Lung tissues were removed after BAL and stained with hematoxylin-eosin (H-E) and trichrome. From 2 weeks, histological findings showed definite lung damage. The protein level and TGF-beta in BAL fluid from the irradiated lung peaked at 4 and 8 weeks, respectively, after radiation. Total cell count in BAL fluid from both sides of lungs was increased from 2 weeks and continued to increase at 8 weeks after irradiation. NO in BAL fluid from both sides of lungs peaked at 4 weeks after irradiation. The protein level and TGF-beta were increased in BAL fluid from irradiated lungs. However, alveolar cells and NO increased in BAL fluid from both irradiated and non-irradiated lungs. BAL is a valuable tool for the evaluation of radiation induced lung damage.

Acetaldehyde and hexanaldehyde from cultured white cells

BACKGROUND

Noninvasive detection of innate immune function such as the accumulation of neutrophils remains a challenge in many areas of clinical medicine. We hypothesized that granulocytes could generate volatile organic compounds.

METHODS

To begin to test this, we developed a bioreactor and analytical GC-MS system to accurately identify and quantify gases in trace concentrations (parts per billion) emitted solely from cell/media culture. A human promyelocytic leukemia cell line, HL60, frequently used to assess neutrophil function, was grown in serum-free medium.

RESULTS

HL60 cells released acetaldehyde and hexanaldehyde in a time-dependent manner. The mean +/- SD concentration of acetaldehyde in the headspace above the cultured cells following 4-, 24- and 48-h incubation was 157 +/- 13 ppbv, 490 +/- 99 ppbv, 698 +/- 87 ppbv. For hexanaldehyde these values were 1 +/- 0.3 ppbv, 8 +/- 2 ppbv, and 11 +/- 2 ppbv. In addition, our experimental system permitted us to identify confounding trace gas contaminants such as styrene.

CONCLUSION

This study demonstrates that human immune cells known to mimic the function of innate immune cells, like neutrophils, produce volatile gases that can be measured in vitro in trace amounts.

Radiation pneumonitis and pulmonary fibrosis in non-small-cell lung cancer: pulmonary function, prediction, and prevention

Although radiotherapy improves locoregional control and survival in patients with non-small-cell lung cancer, radiation pneumonitis is a common treatment-related toxicity. Many pulmonary function tests are not significantly altered by pulmonary toxicity of irradiation, but reductions in D(L(CO)), the diffusing capacity of carbon monoxide, are more commonly associated with pneumonitis. Several patient-specific factors (e.g. age, smoking history, tumor location, performance score, gender) and treatment-specific factors (e.g. chemotherapy regimen and dose) have been proposed as potential predictors of the risk of radiation pneumonitis, but these have not been consistently demonstrated across different studies. The risk of radiation pneumonitis also seems to increase as the cumulative dose of radiation to normal lung tissue increases, as measured by dose-volume histograms. However, controversy persists about which dosimetric parameter optimally predicts the risk of radiation pneumonitis, and whether the volume of lung or the dose of radiation is more important. Radiation oncologists ought to consider these dosimetric factors when designing radiation treatment plans for all patients who receive thoracic radiotherapy. Newer radiotherapy techniques and technologies may reduce the exposure of normal lung to irradiation. Several medications have also been evaluated for their ability to reduce radiation pneumonitis in animals and humans, including corticosteroids, amifostine, ACE inhibitors or angiotensin II type 1 receptor blockers, pentoxifylline, melatonin, carvedilol, and manganese superoxide dismutase-plasmid/liposome. Additional research is warranted to determine the efficacy of these medications and identify nonpharmacologic strategies to predict and prevent radiation pneumonitis.