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Tawk B, Rein K, Schwager C, Knoll M, Wirkner U, Hörner-Rieber J, Liermann J, Kurth I, Balermpas P, Rödel C, Linge A, Löck S, Lohaus F, Tinhofer I, Krause M, Stuschke M, Grosu AL, Zips D, Combs SE, Belka C, Stenzinger A, Herold-Mende C, Baumann M, Schirmacher P, Debus J, Abdollahi A. DNA-Methylome-Based Tumor Hypoxia Classifier Identifies HPV-Negative Head and Neck Cancer Patients at Risk for Locoregional Recurrence after Primary Radiochemotherapy. Clin Cancer Res 2023; 29:3051-3064. [PMID: 37058257 PMCID: PMC10425733 DOI: 10.1158/1078-0432.ccr-22-3790] [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: 12/12/2022] [Revised: 02/16/2023] [Accepted: 04/11/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE Tumor hypoxia is a paradigmatic negative prognosticator of treatment resistance in head and neck squamous cell carcinoma (HNSCC). The lack of robust and reliable hypoxia classifiers limits the adaptation of stratified therapies. We hypothesized that the tumor DNA methylation landscape might indicate epigenetic reprogramming induced by chronic intratumoral hypoxia. EXPERIMENTAL DESIGN A DNA-methylome-based tumor hypoxia classifier (Hypoxia-M) was trained in the TCGA (The Cancer Genome Atlas)-HNSCC cohort based on matched assignments using gene expression-based signatures of hypoxia (Hypoxia-GES). Hypoxia-M was validated in a multicenter DKTK-ROG trial consisting of human papillomavirus (HPV)-negative patients with HNSCC treated with primary radiochemotherapy (RCHT). RESULTS Although hypoxia-GES failed to stratify patients in the DKTK-ROG, Hypoxia-M was independently prognostic for local recurrence (HR, 4.3; P = 0.001) and overall survival (HR, 2.34; P = 0.03) but not distant metastasis after RCHT in both cohorts. Hypoxia-M status was inversely associated with CD8 T-cell infiltration in both cohorts. Hypoxia-M was further prognostic in the TCGA-PanCancer cohort (HR, 1.83; P = 0.04), underscoring the breadth of this classifier for predicting tumor hypoxia status. CONCLUSIONS Our findings highlight an unexplored avenue for DNA methylation-based classifiers as biomarkers of tumoral hypoxia for identifying high-risk features in patients with HNSCC tumors. See related commentary by Heft Neal and Brenner, p. 2954.
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Affiliation(s)
- Bouchra Tawk
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Katrin Rein
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Schwager
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Maximilian Knoll
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ute Wirkner
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jakob Liermann
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ina Kurth
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Dresden, Germany
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Panagiotis Balermpas
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), partner site, Frankfurt, Germany
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Claus Rödel
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), partner site, Frankfurt, Germany
- Department of Radiotherapy and Oncology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Annett Linge
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Dresden, Germany
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz Association and Helmholtz-Zentrum Dresden – Rossendorf (HZDR), Dresden, Germany
| | - Steffen Löck
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Dresden, Germany
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fabian Lohaus
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Dresden, Germany
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz Association and Helmholtz-Zentrum Dresden – Rossendorf (HZDR), Dresden, Germany
| | - Ingeborg Tinhofer
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Berlin, Germany
- Department of Radiooncology and Radiotherapy, Charité University Hospital, Berlin, Germany
| | - Mechtild Krause
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Dresden, Germany
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz Association and Helmholtz-Zentrum Dresden – Rossendorf (HZDR), Dresden, Germany
| | - Martin Stuschke
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Essen, Germany
- Department of Radiotherapy, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Anca Ligia Grosu
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Freiburg, Germany
- Department of Radiation Oncology, University of Freiburg, Freiburg, Germany
| | - Daniel Zips
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Berlin, Germany
- Department of Radiooncology and Radiotherapy, Charité University Hospital, Berlin, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), partner site Tuebingen, Germany
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, Germany
| | - Stephanie E. Combs
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Munich, Germany
- Department of Radiation Oncology, Technische Universität München, Munich, Germany
| | - Claus Belka
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Munich, Germany
- Department of Radiation Oncology, University Hospital Ludwig-Maximilians-University of Munich, Munich, Germany
- Research Unit Radiation Cytogenetics, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany
| | - Albrecht Stenzinger
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christel Herold-Mende
- Division of Experimental Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Baumann
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany, and German Cancer Consortium (DKTK), partner site Dresden, Germany
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter Schirmacher
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Amir Abdollahi
- German Cancer Research Center (DKFZ), Heidelberg, Germany and German Cancer Consortium (DKTK), Core Center Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Bresser PL, Sathekge MM, Vorster M. PET/CT features of a novel gallium-68 labelled hypoxia seeking agent in patients diagnosed with tuberculosis: a proof-of-concept study. Nucl Med Commun 2022; 43:787-793. [PMID: 35506285 DOI: 10.1097/mnm.0000000000001580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Positron emission tomography/computed tomography (PET/CT) in infection and inflammation has yielded promising results across a range of radiopharmaceuticals. In particular, PET/CT imaging of tuberculosis (TB) allows for a better understanding of this complex disease by providing insights into molecular processes within the TB microenvironment. TB lesions are hypoxic with research primarily focussed on cellular processes occurring under hypoxic stress. With the development of hypoxia seeking PET/CT radiopharmaceuticals, that can be labelled in-house using a germanium-68/gallium-68 (68Ge/68Ga) generator, a proof-of-concept for imaging hypoxia in TB is presented. METHODS Ten patients diagnosed with TB underwent whole-body PET/CT imaging, 60-90 min after intravenous administration of 74-185 MBq (2-5 mCi) 68Ga-nitroimidazole. No oral or intravenous contrast was administered. Images were visually and semiquantitatively assessed for abnormal 68Ga-uptake in the lungs. RESULTS A total of 28 lesions demonstrating hypoxic uptake were identified. Low- to moderate-uptake was seen in nodules, areas of consolidation and cavitation as well as effusions. The mean standard uptake value (SUVmean) of the lesions was 0.47 (IQR, 0.32-0.82) and SUVmax was 0.71 (IQR, 0.41-1.11). The lesion to muscle ratio (median, 1.70; IQR, 1.15-2.31) was higher than both the left ventricular and the aorta lesion to blood ratios. CONCLUSION Moving towards the development of unique host-directed therapies (HDT), modulation of oxygen levels may improve therapeutic outcome by reprogramming TB lesions to overcome hypoxia. This proof-of-concept study suggests that hypoxia in TB lesions can be imaged and quantified using 68Ga-nitroimidazole PET/CT. Subsequently, hypoxic load can be estimated to inform personalised treatment plans of patients diagnosed with TB.
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Affiliation(s)
- Philippa L Bresser
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mike M Sathekge
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mariza Vorster
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Department of Nuclear Medicine, Inkosi Albert Luthuli Central Hospital, University of Kwazulu Natal, Durban, South Africa
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Bresser PL, Reed J, Sathekge MM, Vorster M. 68 Ga-nitroimidazole PET/CT imaging of hypoxia in tuberculosis: A case series. J Med Radiat Sci 2022; 69:518-524. [PMID: 35760568 DOI: 10.1002/jmrs.603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/02/2022] [Indexed: 12/19/2022] Open
Abstract
Tuberculosis (TB) lesions in humans have been proven to be severely hypoxic with hypoxia leading to latency and dormancy of disease. Dormant TB lesions become less susceptible to standard TB treatment regimens with varying responses to treatment but may have increased susceptibility to nitroimidazole drugs. This in turn implies that positron emission tomography / computed tomography (PET/CT) imaging with radiolabelled nitroimidazoles may identify patients who will benefit from treatment with antimicrobial agents that are active against anaerobic bacteria. This case series aims to highlight the hypoxic uptake and retention of a novel 68 Ga-labelled hypoxia-seeking agent in TB lesions at different time points during anti-TB therapy using PET/CT imaging. Patients with confirmed TB underwent whole-body PET/CT after administration of a 68 Ga-nitroimidazole derivative at baseline and follow-up. Images were analysed both qualitatively and semi-quantitatively. Hypoxic uptake and change in uptake over time were analysed using lesion-to-muscle ratio (LMR) and lesion-to-blood ratio (LBR). 68 Ga-nitroimidazole avid lesions were demonstrated most frequently in the upper lobes of the lung. Low-grade hypoxic uptake was visualised in areas of consolidation, cavitation, nodules and lymph nodes. From baseline to follow-up imaging, the LMR increased with persistent hypoxic load despite morphologic improvement. This case series highlights the dynamic hypoxic microenvironment in TB lesions. From these initial data, it appears that 68 Ga-nitroimidazole is a promising candidate for monitoring hypoxic load in patients diagnosed with TB. Such imaging could identify patients who would benefit from individualised therapy targeting other mechanisms in the TB microenvironment with the intention to predict or improve treatment response.
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Affiliation(s)
- Philippa L Bresser
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Janet Reed
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mariza Vorster
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Department of Nuclear Medicine, Inkosi Albert Luthuli Central Hospital, University of Kwazulu-Natal, Durban, South Africa
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Bresser PL, Vorster M, Sathekge MM. An overview of the developments and potential applications of 68Ga-labelled PET/CT hypoxia imaging. Ann Nucl Med 2021; 35:148-158. [PMID: 33400147 DOI: 10.1007/s12149-020-01563-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/01/2020] [Indexed: 12/19/2022]
Abstract
Non-invasive imaging of hypoxia plays a role in monitoring the body's adaptive response or the development of pathology under hypoxic conditions. Various techniques to image hypoxia have been investigated with a shift towards the use of molecular imaging using PET/CT. The role of hypoxia-specific radiopharmaceuticals such as radiolabelled nitroimidazoles is well documented particularly in the oncologic setting. With the increasing utilisation of in-house labelling with a PET benchtop generator, such as the 68Ge/68Ga generator, the use of 68Ga-labelled hypoxic radiopharmaceuticals in the clinical setting is developing. Since hypoxia plays a role in various pathologic states including infectious disease such as TB, there is a need to explore the potential application of 68Ga-labelled hypoxia seeking radiopharmaceuticals beyond oncology. The purpose of this review is to describe the developments of 68Ga-labelled hypoxic radiopharmaceuticals including the various chelators that have been investigated. Further, the role of hypoxia imaging in various pathologies is discussed with particular emphasis on the potential clinical applications of hypoxia PET/CT in TB.
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Affiliation(s)
- Philippa L Bresser
- Department of Radiography, Faculty of Health Sciences, School of Healthcare Sciences, University of Pretoria, HW Snyman Building North, Room 4-33, Bophelo Road, Gezina, Pretoria, 0002, South Africa. .,Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - Mariza Vorster
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Saksø M, Mortensen LS, Primdahl H, Johansen J, Kallehauge J, Hansen CR, Overgaard J. Influence of FAZA PET hypoxia and HPV-status for the outcome of head and neck squamous cell carcinoma (HNSCC) treated with radiotherapy: Long-term results from the DAHANCA 24 trial (NCT01017224). Radiother Oncol 2020; 151:126-133. [PMID: 32805273 DOI: 10.1016/j.radonc.2020.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/30/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Hypoxic tumor volumes can be visualized with 18F-FAZA PET/CT. In head and neck squamous cell carcinoma (HNSCC), hypoxia is important for the clinical outcome after primary radiotherapy (RT). The outcome is furthermore heavily influenced by the HPV/p16-positivity of oropharyngeal tumors (OPCp16+ tumors). The study purposes were (1) to report on locoregional failures within five years after primary RT in a prospective cohort stratified by both HPV/p16-status and PET hypoxia and (2) to characterize the failure site and the spatial association to PET hypoxia. MATERIAL AND METHODS From 2009 to 2011, 38 patients with non-metastatic SCC of the larynx, oro-, hypo- and nasopharynx completing primary RT were included in the prospective DAHANCA 24 trial (NCT01017224). Fifteen patients had OPCp16+ tumors. All were imaged with a static FAZA PET/CT prior to treatment. The hypoxia threshold was determined by a tumor-to-muscle ratio (TMR) of 1.6. Recurrences were documented histologically. Imaging of the recurrence was deformable fused with the pre-treatment FAZA PET/CT. The spatial information of recurrence- and hypoxic volumes were compared visually. RESULTS Sixteen patients had more hypoxic tumors (high tracer uptake, TMR ≥1.6) before treatment (42%). With a median follow-up of 7.8 years, nine locoregional recurrences were observed, of which seven were in patients with high-uptake tumors (44% and 9%, respectively, HR 5.8 [1.2-28.2]). The risk of locoregional recurrence was highest among patients with more hypoxic, non-OPCp16+ tumors (57% [21-94%]), with a risk difference of 45% [4-86%], when comparing to less hypoxic, non-OPCp16+ tumors. Eight patients had sufficient imaging of the recurrence for co-registration with the FAZA PET/CT. Six had hypoxic primary tumors, and in two, the recurrence was overlapping the baseline hypoxic subvolume. CONCLUSION HNSCC demonstrating a TMR ≥1.6 at baseline is significantly associated with treatment failure after primary RT. In addition to HPV/p16-status, FAZA PET/CT has potential for the selection of tumors requiring treatment intensification.
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Affiliation(s)
- Mette Saksø
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
| | | | - Hanne Primdahl
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | | | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
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Radioresistant tumours: From identification to targeting. Cancer Radiother 2020; 24:699-705. [PMID: 32753241 DOI: 10.1016/j.canrad.2020.05.005] [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: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
From surviving fraction to tumour curability, definitions of tumour radioresistance may vary depending on the view angle. Yet, mechanisms of radioresistance have been identified and involve tumour-specific oncogenic signalling pathways, tumour metabolism and proliferation, tumour microenvironment/hypoxia, genomics. Correlations between tumour biology (histology) and imaging allow theragnostic approaches that use non-invasive biological imaging using tracer functionalization of tumour pathway biomarkers, imaging of hypoxia, etc. Modelling dose prescription function based on their tumour radio-resistant factor enhancement ratio, related to metabolism, proliferation, hypoxia is an area of investigation. Yet, the delivery of dose painting by numbers/voxel-based radiotherapy with low lineal energy transfer particles may be limited by the degree of modulation complexity needed to achieve the doses needed to counteract radioresistance. Higher lineal energy transfer particles or combinations of different particles, or combinations with drugs and devices such as done with radioenhancing nanoparticles may be promising.
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Socarrás Fernández JA, Mönnich D, Leibfarth S, Welz S, Zwanenburg A, Leger S, Löck S, Pfannenberg C, La Fougère C, Reischl G, Baumann M, Zips D, Thorwarth D. Comparison of patient stratification by computed tomography radiomics and hypoxia positron emission tomography in head-and-neck cancer radiotherapy. Phys Imaging Radiat Oncol 2020; 15:52-59. [PMID: 33043157 PMCID: PMC7536307 DOI: 10.1016/j.phro.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Hypoxia Positron-Emission-Tomography (PET) as well as Computed Tomography (CT) radiomics have been shown to be prognostic for radiotherapy outcome. Here, we investigate the stratification potential of CT-radiomics in head and neck cancer (HNC) patients and test if CT-radiomics is a surrogate predictor for hypoxia as identified by PET. MATERIALS AND METHODS Two independent cohorts of HNC patients were used for model development and validation, HN1 (n = 149) and HN2 (n = 47). The training set HN1 consisted of native planning CT data whereas for the validation cohort HN2 also hypoxia PET/CT data was acquired using [18F]-Fluoromisonidazole (FMISO). Machine learning algorithms including feature engineering and classifier selection were trained for two-year loco-regional control (LRC) to create optimal CT-radiomics signatures.Secondly, a pre-defined [18F]FMISO-PET tumour-to-muscle-ratio (TMRpeak ≥ 1.6) was used for LRC prediction. Comparison between risk groups identified by CT-radiomics or [18F]FMISO-PET was performed using area-under-the-curve (AUC) and Kaplan-Meier analysis including log-rank test. RESULTS The best performing CT-radiomics signature included two features with nearest-neighbour classification (AUC = 0.76 ± 0.09), whereas AUC was 0.59 for external validation. In contrast, [18F]FMISO TMRpeak reached an AUC of 0.66 in HN2. Kaplan-Meier analysis of the independent validation cohort HN2 did not confirm the prognostic value of CT-radiomics (p = 0.18), whereas for [18F]FMISO-PET significant differences were observed (p = 0.02). CONCLUSIONS No direct correlation of patient stratification using [18F]FMISO-PET or CT-radiomics was found in this study. Risk groups identified by CT-radiomics or hypoxia PET showed only poor overlap. Direct assessment of tumour hypoxia using PET seems to be more powerful to stratify HNC patients.
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Affiliation(s)
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Sara Leibfarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Germany
| | - Alex Zwanenburg
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Leger
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Steffen Löck
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Christina Pfannenberg
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Germany
| | - Michael Baumann
- OncoRay National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- German Cancer Research Center DKFZ, Heidelberg, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University of Tübingen, Germany
- German Cancer Consortium (DKTK), partner Site Tübingen, Tübingen, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
- German Cancer Consortium (DKTK), partner Site Tübingen, Tübingen, Germany
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8
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Kazmierska J, Cholewinski W, Piotrowski T, Sowinska A, Bak B, Cegła P, Malicki J. Assessment of tumour hypoxia, proliferation and glucose metabolism in head and neck cancer before and during treatment. Br J Radiol 2020; 93:20180781. [PMID: 31860336 DOI: 10.1259/bjr.20180781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The aim of the study was to assess the feasibility of multitracer positron emission tomography (PET) imaging before and during chemoradiation and to evaluate the predictive value of image-based factors for outcome in locally advanced head and neck cancers treated with chemoradiation. METHODS In the week prior to the treatment [18F]-2-flu-2-deoxy-D-glucose (FDG), [18F]-3'-flu-3'deoxythymidine (FLT) and [18F]-flumisonidazole (FMISO) imaging was performed. FLT scans were repeated at 14 and 28 Gy and FMISO at 36 Gy. Overall survival, disease-free survival and local control were correlated with subvolume parameters, and with tumour-to-muscle ratio for FMISO. For every tracer, total metabolic tumour volume was calculated. RESULTS 33 patients were included. No correlation was found between pre-treatment maximum standardised uptake value for FDG, FLT, FMISO and outcomes. Tumour volume measured on initial CT scans and initial FLT volume correlated with disease-free survivall (p = 0.007 and 0.04 respectively). FDG and FLT metabolic tumour volumes correlated significantly with local control (p = 0.005 and 0.02 respectively). In multivariate Cox analysis only individual initial TMRmax correlated with overall survival. CONCLUSION PET/CT imaging is a promising tool. However, various aspects of image analysis need further clinical validation in larger multicentre study employing uniform imaging protocol and standardisation, especially for hypoxia tracer. ADVANCES IN KNOWLEDGE Monitoring of biological features of the tumour using multitracer PET modality seems to be a feasible option in daily clinical practice.Evaluation of hypoxic subvolumes is more patient dependent; thus, exploration of individual parameters of hypoxia is needed. tumour-to-muscle ratio seems to be the most promising so far.
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Affiliation(s)
- Joanna Kazmierska
- Electroradiology Department, University of Medical Sciences, Poznan, Poland.,Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland
| | - Witold Cholewinski
- Electroradiology Department, University of Medical Sciences, Poznan, Poland.,Department of Nuclear Medicine, Greater Poland Cancer Centre, Poznan, Poland
| | - Tomasz Piotrowski
- Electroradiology Department, University of Medical Sciences, Poznan, Poland.,Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
| | - Anna Sowinska
- Department of Computer Science and Statistics, University of Medical Sciences, Poznan, Poland
| | - Bartosz Bak
- Electroradiology Department, University of Medical Sciences, Poznan, Poland.,Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland
| | - Paulina Cegła
- Department of Nuclear Medicine, Greater Poland Cancer Centre, Poznan, Poland
| | - Julian Malicki
- Electroradiology Department, University of Medical Sciences, Poznan, Poland.,Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
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9
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Textural features of hypoxia PET predict survival in head and neck cancer during chemoradiotherapy. Eur J Nucl Med Mol Imaging 2019; 47:1056-1064. [PMID: 31773233 DOI: 10.1007/s00259-019-04609-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/07/2019] [Indexed: 01/24/2023]
Abstract
PURPOSE The aim of this study was to investigate whether textural features of tumour hypoxia, assessed with serial [18F]fluoromisonidazole (FMISO)-PET, were able to predict clinical outcome in patients with head and neck squamous cell carcinoma (HNSCC, T1-4, N+, M0) during chemoradiotherapy (CRT). METHODS In a preliminary evaluation of a prospective trial, tumour hypoxia was evaluated in 29 patients via serial FMISO-PET before and during CRT. All patients received an initial [18F]fluorodeoxyglucose (FDG)-PET before CRT, and tumour regions were defined on this FDG-PET. The first-order metrics tumour-to-background ratio (TBRmean, TBRmax, TBRpeak), coefficient of variation, total lesion uptake and integral non-uniformity were calculated for all scans. Further, 3 second-order (textural) features from two grey-level matrices were calculated, as well as differential non-uniformity (udiff). Prognostic value was examined by median split for group separation (GS) in Kaplan-Meier estimates and correlated with overall survival (OS), quantified via log-rank tests (p ≤ 0.05) and group-relative hazard ratios (HR). RESULTS Within a median follow-up of 29.6 months (95% CI: 16.8-48.0 months), no first-order metrics predicted OS with a significant GS (all p > 0.05) on any FMISO-PET scan. Only udiff before and in week 2 during CRT (p = 0.03, HR = 10.8 and p = 0.05, HR = 5.2) and non-uniformity from grey-level run length matrix in week 2 separated prognostic groups (p = 0.05, HR = 5.3); lower values were correlated with better OS. Further, the decrease in udiff from before CRT to week 2 was correlated with better OS (p = 0.04, HR = 9.4). FDG-PET before CRT did not predict outcome in any measure. CONCLUSIONS Textural features on FMISO-PET scans before CRT, in week 2 and, to a limited degree, the change of features during CRT, were able to identify head and neck squamous cell carcinoma patients with better OS, suggesting that a higher homogeneity of the degree of hypoxia in tumours could correlate with a better outcome after CRT.
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10
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Thorwarth D, Welz S, Mönnich D, Pfannenberg C, Nikolaou K, Reimold M, La Fougère C, Reischl G, Mauz PS, Paulsen F, Alber M, Belka C, Zips D. Prospective Evaluation of a Tumor Control Probability Model Based on Dynamic 18F-FMISO PET for Head and Neck Cancer Radiotherapy. J Nucl Med 2019; 60:1698-1704. [PMID: 31076504 DOI: 10.2967/jnumed.119.227744] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022] Open
Abstract
Our purpose was to evaluate an imaging parameter-response relationship between the extent of tumor hypoxia quantified by dynamic 18F-fluoromisonidazole (18F-FMISO) PET/CT and the risk of relapse after radiotherapy in patients with head and neck cancer. Methods: Before a prospective cohort of 25 head and neck cancer patients started radiotherapy, they were examined with dynamic 18F-FMISO PET/CT 0-240 min after tracer injection. 18F-FMISO image parameters, including a hypoxia metric, M FMISO , derived from pharmacokinetic modeling of dynamic 18F-FMISO and maximum tumor-to-muscle ratio (TMRmax) at 4 h after injection, gross tumor volume (GTV), relative hypoxic volume based on M FMISO , and a logistic regression model combining GTV and TMRmax, were assessed and compared with a previous training cohort (n = 15). Dynamic 18F-FMISO was used to validate a tumor control probability model based on M FMISO The prognostic potential with respect to local control of all potential parameters was validated using the concordance index for univariate Cox regression models determined from the training cohort, in addition to Kaplan-Meier analysis including the log-rank test. Results: The tumor control probability model was confirmed, indicating that dynamic 18F-FMISO allows stratification of patients into different risk groups according to radiotherapy outcome. In this study, M FMISO was the only parameter that was confirmed as prognostic in the independent validation cohort (concordance index, 0.71; P = 0.004). All other investigated parameters, such as TMRmax, GTV, relative hypoxic volume, and the combination of GTV and TMRmax, were not able to stratify patient groups according to outcome in this validation cohort (P = not statistically significant). Conclusion: In this study, the relationship between M FMISO and the risk of relapse was prospectively validated. The data support further evaluation and external validation of dynamic 18F-FMISO PET/CT as a promising method for patient stratification and hypoxia-based radiotherapy personalization, including dose painting.
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Affiliation(s)
- Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany .,German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Christina Pfannenberg
- Diagnostic and Interventional Radiology, Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Diagnostic and Interventional Radiology, Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Matthias Reimold
- Department of Nuclear Medicine, University of Tübingen, Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, University of Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Markus Alber
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany.,Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany; and
| | - Claus Belka
- German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, LMU Munich, München, Germany
| | - Daniel Zips
- German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
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11
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Stieb S, Eleftheriou A, Warnock G, Guckenberger M, Riesterer O. Longitudinal PET imaging of tumor hypoxia during the course of radiotherapy. Eur J Nucl Med Mol Imaging 2018; 45:2201-2217. [PMID: 30128659 DOI: 10.1007/s00259-018-4116-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022]
Abstract
Hypoxia results from an imbalance between oxygen supply and consumption. It is a common phenomenon in solid malignant tumors such as head and neck cancer. As hypoxic cells are more resistant to therapy, tumor hypoxia is an indicator for poor prognosis. Several techniques have been developed to measure tissue oxygenation. These are the Eppendorf O2 polarographic needle electrode, immunohistochemical analysis of endogenous (e.g., hypoxia-inducible factor-1α (HIF-1a)) and exogenous markers (e.g., pimonidazole) as well as imaging methods such as functional magnetic resonance imaging (e.g., blood oxygen level dependent (BOLD) imaging, T1-weighted imaging) and hypoxia positron emission tomography (PET). Among the imaging modalities, only PET is sufficiently validated to detect hypoxia for clinical use. Hypoxia PET tracers include 18F-fluoromisonidazole (FMISO), the most commonly used hypoxic marker, 18F-flouroazomycin arabinoside (FAZA), 18Ffluoroerythronitroimidazole (FETNIM), 18F-2-nitroimidazolpentafluoropropylacetamide (EF5) and 18F-flortanidazole (HX4). As technical development provides the opportunity to increase the radiation dose to subregions of the tumor, such as hypoxic areas, it has to be ensured that these regions are stable not only from imaging to treatment but also through the course of radiotherapy. The aim of this review is therefore to characterize the behavior of tumor hypoxia during radiotherapy for the whole tumor and for subregions by using hypoxia PET tracers, with focus on head and neck cancer patients.
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Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,Institute of Diagnostic and Interventional Radiology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Afroditi Eleftheriou
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Geoffrey Warnock
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Department of Nuclear Medicine, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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12
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Yasui H, Kawai T, Matsumoto S, Saito K, Devasahayam N, Mitchell JB, Camphausen K, Inanami O, Krishna MC. Quantitative imaging of pO 2 in orthotopic murine gliomas: hypoxia correlates with resistance to radiation. Free Radic Res 2018; 51:861-871. [PMID: 29076398 DOI: 10.1080/10715762.2017.1388506] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hypoxia is considered one of the microenvironmental factors associated with the malignant nature of glioblastoma. Thus, evaluating intratumoural distribution of hypoxia would be useful for therapeutic planning as well as assessment of its effectiveness during the therapy. Electron paramagnetic resonance imaging (EPRI) is an imaging technique which can generate quantitative maps of oxygen in vivo using the exogenous paramagnetic compound, triarylmethyl and monitoring its line broadening caused by oxygen. In this study, the feasibility of EPRI for assessment of oxygen distribution in the glioblastoma using orthotopic U87 and U251 xenograft model is examined. Heterogeneous distribution of pO2 between 0 and 50 mmHg was observed throughout the tumours except for the normal brain tissue. U251 glioblastoma was more likely to exhibit hypoxia than U87 for comparable tumour size (median pO2; 29.7 and 18.2 mmHg, p = .028, in U87 and U251, respectively). The area with pO2 under 10 mmHg on the EPR oximetry (HF10) showed a good correlation with pimonidazole staining among tumours with evaluated size. In subcutaneous xenograft model, irradiation was relatively less effective for U251 compared with U87. In conclusion, EPRI is a feasible method to evaluate oxygen distribution in the brain tumour.
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Affiliation(s)
- Hironobu Yasui
- a Central Institute of Isotope Science, Hokkaido University , Sapporo , Japan
| | - Tatsuya Kawai
- b Radiation Oncology Branch , Center for Cancer Research, National Cancer Institute, National Health Institutes , Bethesda , MD , USA
| | - Shingo Matsumoto
- c Division of Bioengineering and Bioinformatics , Graduate School of Information Science and Technology, Hokkaido University , Sapporo , Japan
| | - Keita Saito
- d Radiation Biology Branch , Center for Cancer Research, National Cancer Institute, National Health Institutes , Bethesda , MD , USA
| | - Nallathamby Devasahayam
- d Radiation Biology Branch , Center for Cancer Research, National Cancer Institute, National Health Institutes , Bethesda , MD , USA
| | - James B Mitchell
- d Radiation Biology Branch , Center for Cancer Research, National Cancer Institute, National Health Institutes , Bethesda , MD , USA
| | - Kevin Camphausen
- b Radiation Oncology Branch , Center for Cancer Research, National Cancer Institute, National Health Institutes , Bethesda , MD , USA
| | - Osamu Inanami
- e Laboratory of Radiation Biology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine , Hokkaido University , Sapporo , Japan
| | - Murali C Krishna
- d Radiation Biology Branch , Center for Cancer Research, National Cancer Institute, National Health Institutes , Bethesda , MD , USA
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13
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Grau C, Høyer M, Poulsen PR, Muren LP, Korreman SS, Tanderup K, Lindegaard JC, Alsner J, Overgaard J. Rethink radiotherapy - BIGART 2017. Acta Oncol 2017; 56:1341-1352. [PMID: 29148908 DOI: 10.1080/0284186x.2017.1371326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ludvig Paul Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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14
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Mönnich D, Thorwarth D, Leibfarth S, Pfannenberg C, Reischl G, Mauz PS, Nikolaou K, la Fougère C, Zips D, Welz S. Overlap of highly FDG-avid and FMISO hypoxic tumor subvolumes in patients with head and neck cancer. Acta Oncol 2017; 56:1577-1582. [PMID: 28849721 DOI: 10.1080/0284186x.2017.1363910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND PET imaging may be used to personalize radiotherapy (RT) by identifying radioresistant tumor subvolumes for RT dose escalation. Using the tracers [18F]-fluorodeoxyglucose (FDG) and [18F]-fluoromisonidazole (FMISO), different aspects of tumor biology can be visualized. FDG depicts various biological aspects, e.g., proliferation, glycolysis and hypoxia, while FMISO is more hypoxia specific. In this study, we analyzed size and overlap of volumes based on the two markers for head-and-neck cancer patients (HNSCC). MATERIAL AND METHODS Twenty five HNSCC patients underwent a CT scan, as well as FDG and dynamic FMISO PET/CT prior to definitive radio-chemotherapy in a prospective FMISO dose escalation study. Three PET-based subvolumes of the primary tumor (GTVprim) were segmented: a highly FDG-avid volume VFDG, a hypoxic volume on the static FMISO image acquired four hours post tracer injection (VH) and a retention/perfusion volume (VM) using pharmacokinetic modeling of dynamic FMISO data. Absolute volumes, overlaps and distances to agreement (DTA) were evaluated. RESULTS Sizes of PET-based volumes and the GTVprim are significantly different (GTVprim>VFDG>VH >VM; p < .05). VH is covered by VFDG or DTAs are small (mean coverage 74.4%, mean DTA 1.4 mm). Coverage of VM is less pronounced. With respect to VFDG and VH, the mean coverage is 48.7% and 43.1% and the mean DTA is 5.3 mm and 6.3 mm, respectively. For two patients, DTAs were larger than 2 cm. CONCLUSIONS Hypoxic subvolumes from static PET imaging are typically covered by or in close proximity to highly FDG-avid subvolumes. Therefore, dose escalation to FDG positive subvolumes should cover the static hypoxic subvolumes in most patients, with the disadvantage of larger volumes, resulting in a higher risk of dose-limiting toxicity. Coverage of subvolumes from dynamic FMISO PET is less pronounced. Further studies are needed to explore the relevance of mismatches in functional imaging.
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Affiliation(s)
- David Mönnich
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniela Thorwarth
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sara Leibfarth
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christina Pfannenberg
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gerald Reischl
- Department of Diagnostic and Interventional Radiology, Preclinical Imaging and Radiopharmacy, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christian la Fougère
- Department of Radiology, Nuclear Medicine, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Daniel Zips
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
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15
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Boeke S, Thorwarth D, Mönnich D, Pfannenberg C, Reischl G, La Fougère C, Nikolaou K, Mauz PS, Paulsen F, Zips D, Welz S. Geometric analysis of loco-regional recurrences in relation to pre-treatment hypoxia in patients with head and neck cancer. Acta Oncol 2017; 56:1571-1576. [PMID: 28891398 DOI: 10.1080/0284186x.2017.1372626] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION A previous pattern-of-failure study has suggested that up to 50% of the loco-regional failures (LRF) in head and neck squamous cell carcinoma (HNSCC) occur outside the initial hypoxic volume determined by [18F]-fluoromisonidazole-PET ([18F]-FMISO-PET). The aim of the present analysis was to correlate spatial patterns of failure with respect to the pretherapeutic dynamic [18F]-FMISO-PET/CT in HNSCC after radiochemotherapy (RCT). MATERIAL AND METHODS Within a running phase 2 trial using [18F]-FMISO-PET imaging prior to RCT in HNSCC patients (n = 54), we have observed so far 11 LRF with a minimum follow-up of 12 months. For nine patients, LRF imaging (CT or [18F]-FDG-PET/CT) for pattern-of-failure analysis was available. Analysis included the static 4-h hypoxic subvolume (VH) as well as a M-parameter volume (VM), which is derived from modeling of dynamic PET. Deformable image registration of the CT scan with the recurrent tumor to the pre-treatment [18F]-FMISO-PET/CT and the planning CT was done to quantify the hypoxic subvolumes compared to the recurrent tumor volume. Moreover, a point-of-origin analysis was performed. RESULTS A total of five local, two regional and two loco-regional recurrences were detected. After deformable image registration of the CT scan with the recurrent tumor to the pre-treatment [18F]-FMISO-PET/CT and the planning CT, a significant overlap of the recurrence volume with [18F]-FMISO-positive subvolumes in the initial gross tumor volume (GTV) was observed. Median overlap of 40.2%, range 9.4-100.0%, for VH and 49.0%, range 4.4-96.4%, for VM was calculated. The point-of-origin analysis showed median distances of 0.0 mm, range 0.0-11.3 mm to VH and 8.6 mm, range 0.0-15.5 mm to VM, respectively. CONCLUSIONS Our data suggest that loco-regional recurrences after RCT originate from the initial GTV (primary tumor and/or lymph node metastases) containing hypoxic subvolumes, which supports the concept of hypoxia imaging-based dose escalation.
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Affiliation(s)
- Simon Boeke
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Daniela Thorwarth
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Mönnich
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christina Pfannenberg
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, Division of Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christian La Fougère
- Department of Nuclear Medicine, Division of Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
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16
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Thorwarth D, Wack LJ, Mönnich D. Hypoxia PET imaging techniques: data acquisition and analysis. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0250-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Puri T, Greenhalgh TA, Wilson JM, Franklin J, Wang LM, Strauss V, Cunningham C, Partridge M, Maughan T. [ 18F]Fluoromisonidazole PET in rectal cancer. EJNMMI Res 2017; 7:78. [PMID: 28933018 PMCID: PMC5607050 DOI: 10.1186/s13550-017-0324-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/29/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is an increasing interest in developing predictive biomarkers of tissue hypoxia using functional imaging for personalised radiotherapy in patients with rectal cancer that are considered for neoadjuvant chemoradiotherapy (CRT). The study explores [18F]fluoromisonidazole ([18F]FMISO) positron emission tomography (PET) scans for predicting clinical response in rectal cancer patients receiving neoadjuvant CRT. METHODS Patients with biopsy-proven rectal adenocarcinoma were imaged at 0-45 min, 2 and 4 h, at baseline and after 8-10 fractions of CRT (week 2). The first 6 patients did not receive an enema (the non-enema group) and the last 4 patients received an enema before PET-CT scan (the enema group). [18F]FMISO production failed on 2 occasions. Static PET images at 4 h were analysed using tumour-to-muscle (T:M) SUVmax and tumour-to-blood (T:B) SUVmax. The 0-45 min dynamic PET scans were analysed using Casciari model to report hypoxia and perfusion. Akaike information criteria (AIC) were used to compare data fittings for different pharmacokinetic models. Pathological tumour regression grade was scored using American Joint Committee on Cancer (AJCC) 7.0. Shapiro-Wilk test was used to evaluate the normality of the data. RESULTS Five out of eleven (5/11) patients were classed as good responders (AJCC 0/1 or good clinical response) and 6/11 as poor responders (AJCC 2/3 or poor clinical response). The median T:M SUVmax was 2.14 (IQR 0.58) at baseline and 1.30 (IQR 0.19) at week 2, and the corresponding median tumour hypoxia volume was 1.08 (IQR 1.31) cm3 and 0 (IQR 0.15) cm3, respectively. The median T:B SUVmax was 2.46 (IQR 1.50) at baseline and 1.61 (IQR 0.14) at week 2, and the corresponding median tumour hypoxia volume was 5.68 (IQR 5.86) cm3 and 0.76 (IQR 0.78) cm3, respectively. For 0-45 min tumour modelling, the median hypoxia was 0.92 (IQR 0.41) min-1 at baseline and 0.70 (IQR 0.10) min-1 at week 2. The median perfusion was 4.10 (IQR 1.71) ml g-1 min-1 at baseline and 2.48 (IQR 3.62) ml g-1 min-1 at week 2. In 9/11 patients with both PET scans, tumour perfusion decreased in non-responders and increased in responders except in one patient. None of the changes in other PET parameters showed any clear trend with clinical outcome. CONCLUSIONS This pilot study with small number of datasets revealed significant challenges in delivery and interpretation of [18F]FMISO PET scans of rectal cancer. There are two principal problems namely spill-in from non-tumour tracer activity from rectal and bladder contents. Emphasis should be made on reducing spill-in effects from the bladder to improve data quality. This preliminary study has shown fundamental difficulties in the interpretation of [18F]FMISO PET scans for rectal cancer, limiting its clinical applicability.
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Affiliation(s)
- Tanuj Puri
- CRUK/MRC Oxford Institute of Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Tessa A. Greenhalgh
- CRUK/MRC Oxford Institute of Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford, OX3 7DQ UK
| | - James M. Wilson
- CRUK/MRC Oxford Institute of Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Jamie Franklin
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lia Mun Wang
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Present address: Department of Laboratory Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, Singapore
| | - Victoria Strauss
- Centre for Statistics in Medicine, Oxford Clinical Trial Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Chris Cunningham
- Department of Colorectal Surgery, Cancer Centre, Churchill Hospital, Oxford, University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mike Partridge
- CRUK/MRC Oxford Institute of Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Tim Maughan
- CRUK/MRC Oxford Institute of Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford, OX3 7DQ UK
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Nishikawa Y, Yasuda K, Okamoto S, Ito YM, Onimaru R, Shiga T, Tsuchiya K, Watanabe S, Takeuchi W, Kuge Y, Peng H, Tamaki N, Shirato H. Local relapse of nasopharyngeal cancer and Voxel-based analysis of FMISO uptake using PET with semiconductor detectors. Radiat Oncol 2017; 12:148. [PMID: 28877734 PMCID: PMC5586018 DOI: 10.1186/s13014-017-0886-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 09/01/2017] [Indexed: 12/02/2022] Open
Abstract
Background Hypoxic cancer cells are thought to be radioresistant and could impact local recurrence after radiotherapy (RT). One of the major hypoxic imaging modalities is [18F]fluoromisonidazole positron emission tomography (FMISO-PET). High FMISO uptake before RT could indicate radioresistant sites and might be associated with future local recurrence. The predictive value of FMISO-PET for intra-tumoral recurrence regions was evaluated using high-resolution semiconductor detectors in patients with nasopharyngeal carcinoma after intensity-modulated radiotherapy (IMRT). Methods Nine patients with local recurrence and 12 patients without local recurrence for more than 3 years were included in this study. These patients received homogeneous and standard doses of radiation to the primary tumor irrespective of FMISO uptake. The FMISO-PET image before RT was examined via a voxel-based analysis, which focused on the relationship between the degree of FMISO uptake and recurrence region. Results In the pretreatment FMISO-PET images, the tumor-to-muscle ratio (TMR) of FMISO in the voxels of the tumor recurrence region was significantly higher than that of the non-recurrence region (p < 0.0001). In the recurrent patient group, a TMR value of 1.37 (95% CI: 1.36–1.39) corresponded to a recurrence rate of 30%, the odds ratio was 5.18 (4.87–5.51), and the area under the curve (AUC) of the receiver operating characteristic curve was 0.613. In all 21 patients, a TMR value of 2.42 (2.36–2.49) corresponded to an estimated recurrence rate of 30%, and the AUC was only 0.591. Conclusions The uptake of FMISO in the recurrent region was significantly higher than that in the non-recurrent region. However, the predictive value of FMISO-PET before IMRT is not sufficient for up-front dose escalation for the intra-tumoral high-uptake region of FMISO. Because of the higher mean TMR of the recurrence region, a new hypoxic imaging method is needed to improve the sensitivity and specificity for hypoxia. Electronic supplementary material The online version of this article doi: (10.1186/s13014-017-0886-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yukiko Nishikawa
- Department of Radiation Medicine, Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Koichi Yasuda
- Department of Radiation Medicine, Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan. .,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education, Sapporo, Japan.
| | - Shozo Okamoto
- Department of Nuclear Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Graduate School of Medicine, Sapporo, Japan
| | - Rikiya Onimaru
- Department of Radiation Medicine, Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Tohru Shiga
- Department of Nuclear Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Kazuhiko Tsuchiya
- Department of Radiation Medicine, Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Shiro Watanabe
- Department of Nuclear Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Wataru Takeuchi
- Research & Development Group, Hitachi, Ltd., Kokubunji, Tokyo, Japan
| | - Yuji Kuge
- Central Institute of Isotope Science, Hokkaido University, Sapporo, Japan
| | - Hao Peng
- Stanford University, Stanford, CA, USA
| | - Nagara Tamaki
- Department of Nuclear Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Hiroki Shirato
- Department of Radiation Medicine, Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan.,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education, Sapporo, Japan
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Welz S, Mönnich D, Pfannenberg C, Nikolaou K, Reimold M, La Fougère C, Reischl G, Mauz PS, Paulsen F, Alber M, Belka C, Zips D, Thorwarth D. Prognostic value of dynamic hypoxia PET in head and neck cancer: Results from a planned interim analysis of a randomized phase II hypoxia-image guided dose escalation trial. Radiother Oncol 2017; 124:526-532. [PMID: 28434798 DOI: 10.1016/j.radonc.2017.04.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/27/2017] [Accepted: 04/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE To prospectively assess the prognostic value of tumour hypoxia determined by dynamic [18F]Fluoromisonidazole (dynFMISO) PET/CT, and to evaluate both feasibility and toxicity in patients with locally advanced squamous cell carcinomas of the head and neck (LASCCHN) treated with dynFMISO image-guided dose escalation (DE) using dose-painting by contours. PATIENTS AND METHODS We present a planned interim analysis of a randomized phase II trial. N=25 patients with LASCCHN received baseline dynFMISO PET/CT to derive hypoxic volumes (HV). Patients with tumour hypoxia were randomized into standard radiochemotherapy (stdRT) (70Gy/35 fractions) or DE (77Gy/35 fractions) to the HV. Patients with non-hypoxic tumours were treated with stdRT. Loco-regional control (LRC) in hypoxic patients randomized to stdRT was compared to non-hypoxic patients. Feasibility and toxicity were analysed for patients in the DE arm and compared to stdRT. RESULTS With a mean follow-up of 27months, LRC in hypoxic patients receiving stdRT (n=10) was significantly worse compared to the non-hypoxic group (n=5) (2y-LRC 44.4% versus 100%, p=0.048). The respective LRC for the DE group (n=10) was 70.0%. Treatment compliance as well as acute and late toxicity did not show significant differences between the DE and the standard dose arms. CONCLUSION Tumour hypoxia determined by baseline dynFMISO PET/CT is associated with a high risk of local failure in patients with LASCCHN. First data suggest that DE to HV is feasible without excess toxicity.
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Affiliation(s)
- Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Christina Pfannenberg
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Mathias Reimold
- Department of Nuclear Medicine, University of Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, University of Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University of Tübingen, Germany
| | - Markus Alber
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany; Department of Radiation Oncology, University of Heidelberg, Germany
| | - Claus Belka
- Department of Radiation Oncology, University of Tübingen, Germany; Department of Radiation Oncology, LMU Munich, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University of Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Colliez F, Gallez B, Jordan BF. Assessing Tumor Oxygenation for Predicting Outcome in Radiation Oncology: A Review of Studies Correlating Tumor Hypoxic Status and Outcome in the Preclinical and Clinical Settings. Front Oncol 2017; 7:10. [PMID: 28180110 PMCID: PMC5263142 DOI: 10.3389/fonc.2017.00010] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/10/2017] [Indexed: 12/30/2022] Open
Abstract
Tumor hypoxia is recognized as a limiting factor for the efficacy of radiotherapy, because it enhances tumor radioresistance. It is strongly suggested that assessing tumor oxygenation could help to predict the outcome of cancer patients undergoing radiation therapy. Strategies have also been developed to alleviate tumor hypoxia in order to radiosensitize tumors. In addition, oxygen mapping is critically needed for intensity modulated radiation therapy (IMRT), in which the most hypoxic regions require higher radiation doses and the most oxygenated regions require lower radiation doses. However, the assessment of tumor oxygenation is not yet included in day-to-day clinical practice. This is due to the lack of a method for the quantitative and non-invasive mapping of tumor oxygenation. To fully integrate tumor hypoxia parameters into effective improvements of the individually tailored radiation therapy protocols in cancer patients, methods allowing non-invasively repeated, safe, and robust mapping of changes in tissue oxygenation are required. In this review, non-invasive methods dedicated to assessing tumor oxygenation with the ultimate goal of predicting outcome in radiation oncology are presented, including positron emission tomography used with nitroimidazole tracers, magnetic resonance methods using endogenous contrasts (R1 and R2*-based methods), and electron paramagnetic resonance oximetry; the goal is to highlight results of studies establishing correlations between tumor hypoxic status and patients’ outcome in the preclinical and clinical settings.
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Affiliation(s)
- Florence Colliez
- Biomedical Magnetic Resonance Group, Louvain Drug Research Institute, Université Catholique de Louvain , Brussels , Belgium
| | - Bernard Gallez
- Biomedical Magnetic Resonance Group, Louvain Drug Research Institute, Université Catholique de Louvain , Brussels , Belgium
| | - Bénédicte F Jordan
- Biomedical Magnetic Resonance Group, Louvain Drug Research Institute, Université Catholique de Louvain , Brussels , Belgium
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Grau C, Overgaard J, Høyer M, Tanderup K, Lindegaard JC, Muren LP. Biology-guided adaptive radiotherapy (BiGART) is progressing towards clinical reality. Acta Oncol 2015; 54:1245-50. [PMID: 26390238 DOI: 10.3109/0284186x.2015.1076992] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Cai Grau
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Jens Overgaard
- b Department of Experimental Clinical Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Morten Høyer
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Kari Tanderup
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
- c Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
| | | | - Ludvig Paul Muren
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
- c Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
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