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Marvaso G, Jereczek-Fossa BA, Zaffaroni M, Vincini MG, Corrao G, Andratschke N, Balagamwala EH, Bedke J, Blanck O, Capitanio U, Correa RJM, De Meerleer G, Franzese C, Gaeta A, Gandini S, Garibaldi C, Gerszten PC, Gillessen S, Grubb WR, Guckenberger M, Hannan R, Jhaveri PM, Josipovic M, Kerkmeijer LGW, Lehrer EJ, Lindskog M, Louie AV, Nguyen QN, Ost P, Palma DA, Procopio G, Rossi M, Staehler M, Tree AC, Tsang YM, Van As N, Zaorsky NG, Zilli T, Pasquier D, Siva S. Delphi consensus on stereotactic ablative radiotherapy for oligometastatic and oligoprogressive renal cell carcinoma-a European Society for Radiotherapy and Oncology study endorsed by the European Association of Urology. Lancet Oncol 2024; 25:e193-e204. [PMID: 38697165 DOI: 10.1016/s1470-2045(24)00023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 05/04/2024]
Abstract
The purpose of this European Society for Radiotherapy and Oncology (ESTRO) project, endorsed by the European Association of Urology, is to explore expert opinion on the management of patients with oligometastatic and oligoprogressive renal cell carcinoma by means of stereotactic ablative radiotherapy (SABR) on extracranial metastases, with the aim of developing consensus recommendations for patient selection, treatment doses, and concurrent systemic therapy. A questionnaire on SABR in oligometastatic renal cell carcinoma was prepared by a core group and reviewed by a panel of ten prominent experts in the field. The Delphi consensus methodology was applied, sending three rounds of questionnaires to clinicians identified as key opinion leaders in the field. At the end of the third round, participants were able to find consensus on eight of the 37 questions. Specifically, panellists agreed to apply no restrictions regarding age (25 [100%) of 25) and primary renal cell carcinoma histology (23 [92%] of 25) for SABR candidates, on the upper threshold of three lesions to offer ablative treatment in patients with oligoprogression, and on the concomitant administration of immune checkpoint inhibitor. SABR was indicated as the treatment modality of choice for renal cell carcinoma bone oligometatasis (20 [80%] of 25) and for adrenal oligometastases 22 (88%). No consensus or major agreement was reached regarding the appropriate schedule, but the majority of the poll (54%-58%) retained the every-other-day schedule as the optimal choice for all the investigated sites. The current ESTRO Delphi consensus might provide useful direction for the application of SABR in oligometastatic renal cell carcinoma and highlight the key areas of ongoing debate, perhaps directing future research efforts to close knowledge gaps.
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Affiliation(s)
- Giulia Marvaso
- Division of Radiation Oncology, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Mattia Zaffaroni
- Division of Radiation Oncology, European Institute of Oncology, IRCCS, Milan, Italy.
| | - Maria Giulia Vincini
- Division of Radiation Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Giulia Corrao
- Division of Radiation Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ehsan H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jens Bedke
- Department of Urology and Transplantation surgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig Holstein, Kiel, Germany
| | - Umberto Capitanio
- IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Rohann J M Correa
- Department of Radiation Oncology, London Health Sciences Centre, London, ON, Canada
| | - Gert De Meerleer
- Department of Radiation Oncology, Leuven University Hospitals, Leuven, Belgium
| | - Ciro Franzese
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Aurora Gaeta
- Department of Experimental Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Sara Gandini
- Department of Experimental Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Cristina Garibaldi
- Unit of Radiation Research, European Institute of Oncology, IRCCS, Milan, Italy
| | - Peter C Gerszten
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - William R Grubb
- Department of Radiation Oncology, Augusta University Medical Center, Augusta, GA, USA
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Pavan M Jhaveri
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Mirjana Josipovic
- Section of Radiotherapy, Department of Oncology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Magnus Lindskog
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden; Department of Pelvic Cancer, Section of Genitourinary Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Quynh-Nhu Nguyen
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Piet Ost
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium and Department of Radiation Oncology, Iridium Network, Antwerp, Belgium
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, ON, Canada
| | - Giuseppe Procopio
- Dipartimento Di Oncologia Medica, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Maddalena Rossi
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Michael Staehler
- Interdisciplinary Centre on Renal Tumours, University of Munich, Munich, Germany
| | - Alison C Tree
- Department of Urology, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Yat Man Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nicholas Van As
- Department of Urology, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; The Institute of Cancer Research, London, UK
| | - Nicholas G Zaorsky
- University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, USA
| | - Thomas Zilli
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - David Pasquier
- Academic Department of Radiation Oncology, Centre O Lambret, Lille, France; University of Lille, Centrale Lille, CNRS, UMR 9189-CRIStAL, Lille, France
| | - Shankar Siva
- Peter MacCallum Cancer Centre, Department of Radiation Oncology, University of Melbourne, Parkville, VIC, Australia; Faculty of Medicine, University of Melbourne, Parkville, VIC, Australia
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Tan VS, Correa RJM, Warner A, Ali M, Muacevic A, Ponsky L, Ellis RJ, Lo SS, Onishi H, Swaminath A, Kwon YS, Morgan SC, Cury F, Teh BS, Mahadevan A, Kaplan ID, Chu W, Hannan R, Staehler M, Grubb W, Louie AV, Siva S. 5-Year Renal Function Outcomes after SABR for Primary Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium of the Kidney (IROCK). Int J Radiat Oncol Biol Phys 2023; 117:S84. [PMID: 37784588 DOI: 10.1016/j.ijrobp.2023.06.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Renal cell carcinoma (RCC) presents uncommonly in patients with a congenital solitary kidney or prior contralateral nephrectomy. The objective of this study was to compare renal function outcomes of stereotactic ablative body radiotherapy (SABR) in patients with solitary vs. bilateral kidneys. MATERIALS/METHODS Patients with primary RCC with ≥2 years of follow-up at 12 participating International Radiosurgery Consortium for Kidney (IROCK) institutions were included. Patients with upper tract urothelial carcinoma or metastatic disease were excluded. Renal function was measured by estimated glomerular filtration rate (eGFR). For patients where eGFR was not recorded, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used to estimate eGFR based on known creatinine. Baseline characteristics and renal function outcomes were compared between solitary vs. bilateral kidneys. Multivariable logistic regression was used to identify factors predictive of eGFR decline ≥ 15 mL/min and any eGFR increase evaluated at 1-year post-SABR. RESULTS One hundred and ninety patients with solitary (n = 56) or bilateral kidneys (n = 134) underwent SABR and were followed for a median of 5.0 years (IQR: 3.4-6.8). Pre-SABR eGFR (mean ± SD) was similar in patients with solitary (61.1 ± 23.2 mL/min) vs. bilateral kidneys (58.0 ± 22.3 mL/min, p = 0.324). Mean tumor size was 3.70 ± 1.40 cm in solitary and 4.35 ± 2.50 cm in bilateral kidneys (p = 0.026). After SABR, an initial compensatory increase in eGFR was observed in both cohorts (22.7% solitary and 17.7% bilateral at 1 year). This compensatory increase persisted in patients with bilateral but not a solitary kidney (10.3% vs. 0% at 3-years and 21.1% vs. 0% at 5-years, respectively). At 5-years post-SABR, eGFR decreased by -14.5 ± 7.6 in solitary and -13.3 ± 15.9 mL/min in bilateral kidneys (p = 0.665). At all timepoints assessed, there were no significant differences in eGFR decline between solitary vs. bilateral cohorts (all p > 0.05). There were also no significant differences in post-SABR end-stage renal disease (7.1% vs. 6.7%) or dialysis (3.6% vs. 3.7%) in solitary vs. bilateral, respectively. Multivariable analysis demonstrated that increasing tumor size (OR per 1 cm: 1.57; 95% CI: 1.14-2.16, p = 0.006) and baseline eGFR (OR per 10 mL/min: 1.30; 95% CI: 1.02-1.66, p = 0.034) was more likely to be associated with eGFR decline ≥ 15 mL/min. There was no significant association between solitary vs. bilateral kidney and eGFR decline (OR: 1.22; 95% CI: 0.45-3.34, p = 0.693). CONCLUSION There was no observed difference between renal function outcomes in patients with a solitary vs. bilateral kidneys. While larger tumor size may increase the risk of eGFR decline post-SABR, treatment of a solitary kidney does not appear to increase the risk of renal dysfunction long-term.
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Affiliation(s)
- V S Tan
- London Regional Cancer Program, London, ON, Canada
| | - R J M Correa
- London Regional Cancer Program, London, ON, Canada
| | - A Warner
- London Regional Cancer Program, London, ON, Canada
| | - M Ali
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - A Muacevic
- University of Munich Hospitals, Munich, Germany
| | - L Ponsky
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - S S Lo
- University of Washington School of Medicine, Seattle, WA
| | - H Onishi
- University of Yamanashi, Chuo, Japan
| | - A Swaminath
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Y S Kwon
- University of Texas Southwestern Medical Center, Dallas, TX
| | - S C Morgan
- The Ottawa Hospital Cancer Center, Ottawa, ON, Canada
| | - F Cury
- McGill University Health Centre, Montreal, QC, Canada
| | - B S Teh
- Houston Methodist Hospital, Houston, TX
| | - A Mahadevan
- NYU Langone Health Laura and Isaac Perlmutter Cancer Center, New York, NY
| | - I D Kaplan
- Beth Israel Deaconess Medical Center, Boston, MA
| | - W Chu
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - R Hannan
- University of Texas Southwestern Medical Center, Dallas, TX
| | - M Staehler
- University of Munich Hospitals, Munich, Germany
| | - W Grubb
- Augusta University, Augusta, GA
| | - A V Louie
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - S Siva
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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Correa RJM, Appu S, Siva S. Stereotactic Radiotherapy for Renal Cell Carcinoma: The Fallacy of (False) Positive Post-treatment Biopsy? Eur Urol 2023; 84:287-288. [PMID: 37032187 DOI: 10.1016/j.eururo.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 04/11/2023]
Affiliation(s)
- Rohann J M Correa
- Department of Oncology, London Health Sciences Centre and Western University, London, Canada
| | - Sree Appu
- Cabrini Department of Surgery, Monash University, Melbourne, Australia; Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Shankar Siva
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
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Barbour AB, Kirste S, Grosu AL, Siva S, Louie AV, Onishi H, Swaminath A, Teh BS, Psutka SP, Weg ES, Chen JJ, Zeng J, Gore JL, Hall E, Liao JJ, Correa RJM, Lo SS. The Judicious Use of Stereotactic Ablative Radiotherapy in the Primary Management of Localized Renal Cell Carcinoma. Cancers (Basel) 2023; 15:3672. [PMID: 37509333 PMCID: PMC10377531 DOI: 10.3390/cancers15143672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Localized renal cell carcinoma is primarily managed surgically, but this disease commonly presents in highly comorbid patients who are poor operative candidates. Less invasive techniques, such as cryoablation and radiofrequency ablation, are effective, but require percutaneous or laparoscopic access, while generally being limited to cT1a tumors without proximity to the renal pelvis or ureter. Active surveillance is another management option for small renal masses, but many patients desire treatment or are poor candidates for active surveillance. For poor surgical candidates, a growing body of evidence supports stereotactic ablative radiotherapy (SABR) as a safe and effective non-invasive treatment modality. For example, a recent multi-institution individual patient data meta-analysis of 190 patients managed with SABR estimated a 5.5% five-year cumulative incidence of local failure with one patient experiencing grade 4 toxicity, and no other grade ≥3 toxic events. Here, we discuss the recent developments in SABR for the management of localized renal cell carcinoma, highlighting key concepts of appropriate patient selection, treatment design, treatment delivery, and response assessment.
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Affiliation(s)
- Andrew B Barbour
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Simon Kirste
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, 79085 Freiburg, Germany
| | - Anca-Liga Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, 79085 Freiburg, Germany
| | - Shankar Siva
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Center, University of Melbourne, Parkville, VIC 3052, Australia
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Hiroshi Onishi
- Department of Radiology, School of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Anand Swaminath
- Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Bin S Teh
- Department of Radiation Oncology, Cancer Center and Research Institute, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Emily S Weg
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Jonathan J Chen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - John L Gore
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Evan Hall
- Department of Medical Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Rohann J M Correa
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
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Zayed S, Louie AV, Breadner DA, Palma DA, Correa RJM. Radiation and immune checkpoint inhibitors in the treatment of oligometastatic non-small-cell lung cancer: a practical review of rationale, recent data, and research questions. Ther Adv Med Oncol 2023; 15:17588359231183668. [PMID: 37435562 PMCID: PMC10331344 DOI: 10.1177/17588359231183668] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
The combined use of stereotactic ablative radiotherapy (SABR) and immune checkpoint inhibitors (ICIs) is an emerging treatment paradigm for oligometastatic non-small-cell lung cancer (NSCLC). Recent phase I and II trial data suggest that SABR to multiple metastases in addition to ICI use is safe and effective with promising progression-free survival and overall survival signals. There is great interest in capitalizing on combined immunomodulation from these two modalities for the treatment of oligometastatic NSCLC. Ongoing trials seek to validate the safety, efficacy, and preferred sequencing of SABR and ICI. This narrative review of the role of SABR when combined with ICI in oligometastatic NSCLC discusses the rationale for this bimodality treatment, summarizes recent clinical trial evidence, and proposes key principles of management based on the available evidence.
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Affiliation(s)
- Sondos Zayed
- Department of Radiation Oncology, London Health Sciences Centre, London, ON, Canada
| | - Alexander V. Louie
- Department of Radiation Oncology, Sunnybrook Hospital Odette Cancer Centre, Toronto, ON, Canada
| | - Daniel A. Breadner
- Department of Medical Oncology, London Health Sciences Centre, London, ON, Canada
| | - David A. Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, ON, Canada
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Siva S, Ali M, Correa RJM, Muacevic A, Ponsky L, Ellis RJ, Lo SS, Onishi H, Swaminath A, McLaughlin M, Morgan SC, Cury FL, Teh BS, Mahadevan A, Kaplan ID, Chu W, Grubb W, Hannan R, Staehler M, Warner A, Louie AV. 5-year outcomes after stereotactic ablative body radiotherapy for primary renal cell carcinoma: an individual patient data meta-analysis from IROCK (the International Radiosurgery Consortium of the Kidney). Lancet Oncol 2022; 23:1508-1516. [PMID: 36400098 DOI: 10.1016/s1470-2045(22)00656-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stereotactic ablative body radiotherapy (SABR) is a non-invasive treatment option for primary renal cell carcinoma, for which long-term data are awaited. The primary aim of this study was to report on long-term efficacy and safety of SABR for localised renal cell carcinoma. METHODS This study was an individual patient data meta-analysis, for which patients undergoing SABR for primary renal cell carcinoma across 12 institutions in five countries (Australia, Canada, Germany, Japan, and the USA) were eligible. Eligible patients had at least 2 years of follow-up, were aged 18 years or older, had any performance status, and had no previous local therapy. Patients with metastatic renal cell carcinoma or upper-tract urothelial carcinoma were excluded. SABR was delivered as a single or multiple fractions of greater than 5 Gy. The primary endpoint was investigator-assessed local failure per the Response Evaluation Criteria in Solid Tumours version 1.1, and was evaluated using cumulative incidence functions. FINDINGS 190 patients received SABR between March 23, 2007, and Sept 20, 2018. Single-fraction SABR was delivered in 81 (43%) patients and multifraction SABR was delivered in 109 (57%) patients. Median follow-up was 5·0 years (IQR 3·4-6·8). 139 (73%) patients were men, and 51 (27%) were women. Median age was 73·6 years (IQR 66·2-82·0). Median tumour diameter was 4·0 cm (IQR 2·8-4·9). 96 (75%) of 128 patients with available operability details were deemed inoperable by the referring urologist. 56 (29%) of 190 patients had a solitary kidney. Median baseline estimated glomerular filtration rate (eGFR) was 60·0 mL/min per 1·73 m2 (IQR 42·0-76·0) and decreased by 14·2 mL/min per 1·73 m2 (IQR 5·4-22·5) by 5 years post-SABR. Seven (4%) patients required dialysis post-SABR. The cumulative incidence of local failure at 5 years was 5·5% (95% CI 2·8-9·5) overall, with single-fraction SABR yielding fewer local failures than multifraction (Gray's p=0·020). There were no grade 3 toxic effects or treatment-related deaths. One (1%) patient developed an acute grade 4 duodenal ulcer and late grade 4 gastritis. INTERPRETATION SABR is effective and safe in the long term for patients with primary renal cell carcinoma. Single-fraction SABR might yield less local failure than multifraction, but further evidence from randomised trials is needed to elucidate optimal treatment schedules. These mature data lend further support for renal SABR as a treatment option for patients unwilling or unfit to undergo surgery. FUNDING None.
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Affiliation(s)
- Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.
| | - Muhammad Ali
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Rohann J M Correa
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Alexander Muacevic
- European Radiosurgery Center Munich, University of Munich Hospitals, Munich, Germany
| | - Lee Ponsky
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Anand Swaminath
- Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Mark McLaughlin
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Scott C Morgan
- Department of Radiology, Radiation Oncology and Medical Physics, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fabio L Cury
- Division of Radiation Oncology, Department of Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX, USA
| | - Anand Mahadevan
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Irving D Kaplan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - William Chu
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - William Grubb
- Department of Radiation Oncology, Augusta University, Augusta, GA, USA
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael Staehler
- Department of Urology, University of Munich Hospitals, Munich, Germany
| | - Andrew Warner
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Alexander V Louie
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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Correa RJM, Morton G, Loblaw A. Can a FLAME forge a stronger SABRe? Let's await the evidence for focal boost with Stereotactic Ablative Radiotherapy. Radiother Oncol 2022; 174:173-174. [PMID: 35817321 DOI: 10.1016/j.radonc.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Rohann J M Correa
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Department of Health Policy, Measurement and Evaluation, University of Toronto, Canada.
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Correa RJM, Loblaw A. Stereotactic Body Radiotherapy: Hitting Harder, Faster, and Smarter in High-Risk Prostate Cancer. Front Oncol 2022; 12:889132. [PMID: 35875062 PMCID: PMC9301671 DOI: 10.3389/fonc.2022.889132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Stereotactic body radiotherapy (SBRT) is a technologically sophisticated form of radiotherapy that holds significant potential to effectively treat high-risk prostate cancer (HRPC). Prostate SBRT has been the subject of intense investigation in the context of low- and intermediate-risk disease, but less so for HRPC. However, emerging data are demonstrating its potential to safely and efficiently delivery curative doses of radiotherapy, both to the prostate and elective lymph nodes. SBRT theoretically hits harder through radiobiological dose escalation facilitated by ultra-hypofractionation (UHRT), faster with only five treatment fractions, and smarter by using targeted, focal dose escalation to maximally ablate the dominant intraprostatic lesion (while maximally protecting normal tissues). To achieve this, advanced imaging modalities like magnetic resonance imaging and prostate specific membrane antigen positron emmission tomography (PSMA-PET) are leveraged in combination with cutting-edge radiotherapy planning and delivery technology. In this focused narrative review, we discuss key evidence and upcoming clinical trials evaluating SBRT for HRPC with a focus on dose escalation, elective nodal irradiation, and focal boost.
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Affiliation(s)
- Rohann J. M. Correa
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Canada
- *Correspondence: Andrew Loblaw,
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Correa RJM, Palma DA. Should stereotactic ablative body radiotherapy be the standard of care in oligometastatic cancer? Lancet Oncol 2021; 22:6-8. [PMID: 33387496 DOI: 10.1016/s1470-2045(20)30633-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Rohann J M Correa
- Division of Radiation Oncology, Department of Oncology, Western University, London Health Sciences Centre, London, ON N6A4L6, Canada
| | - David A Palma
- Division of Radiation Oncology, Department of Oncology, Western University, London Health Sciences Centre, London, ON N6A4L6, Canada.
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Siva S, Correa RJM, Warner A, Staehler M, Ellis RJ, Ponsky L, Kaplan ID, Mahadevan A, Chu W, Gandhidasan S, Swaminath A, Onishi H, Teh BS, Lo SS, Muacevic A, Louie AV. Stereotactic Ablative Radiotherapy for ≥T1b Primary Renal Cell Carcinoma: A Report From the International Radiosurgery Oncology Consortium for Kidney (IROCK). Int J Radiat Oncol Biol Phys 2020; 108:941-949. [PMID: 32562838 DOI: 10.1016/j.ijrobp.2020.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Patients with larger (T1b, >4 cm) renal cell carcinoma (RCC) not suitable for surgery have few treatment options because thermal ablation is less effective in this setting. We hypothesize that SABR represents an effective, safe, and nephron-sparing alternative for large RCC. METHODS AND MATERIALS Individual patient data from 9 institutions in Germany, Australia, USA, Canada, and Japan were pooled. Patients with T1a tumors, M1 disease, and/or upper tract urothelial carcinoma were excluded. Demographics, treatment, oncologic, and renal function outcomes were assessed using descriptive statistics. Kaplan-Meier estimates and univariable and multivariable Cox proportional hazards regression were generated for oncologic outcomes. RESULTS Ninety-five patients were included. Median follow-up was 2.7 years. Median age was 76 years, median tumor diameter was 4.9 cm, and 81.1% had Eastern Cooperative Oncology Group performance status of 0 to 1 (or Karnofsky performance status ≥70%). In patients for whom operability details were reported, 77.6% were defined as inoperable as determined by the referring urologist. Mean baseline estimated glomerular filtration rate (eGFR) was 57.2 mL/min (mild-to-moderate dysfunction), with 30% of the cohort having moderate-to-severe dysfunction (eGFR <45mL/min). After SABR, eGFR decreased by 7.9 mL/min. Three patients (3.2%) required dialysis. Thirty-eight patients (40%) had a grade 1 to 2 toxicity. No grade 3 to 5 toxicities were reported. Cancer-specific survival, overall survival, and progression-free survival were 96.1%, 83.7%, and 81.0% at 2 years and 91.4%, 69.2%, 64.9% at 4 years, respectively. Local, distant, and any failure at 4 years were 2.9%, 11.1%, and 12.1% (cumulative incidence function with death as competing event). On multivariable analysis, increasing tumor size was associated with inferior cancer-specific survival (hazard ratio per 1 cm increase: 1.30; P < .001). CONCLUSIONS SABR for larger RCC in this older, largely medically inoperable cohort, demonstrated efficacy and tolerability and had modest impact on renal function. SABR appears to be a viable treatment option in this patient population.
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Affiliation(s)
- Shankar Siva
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | - Rohann J M Correa
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | | | - Rodney J Ellis
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Lee Ponsky
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - William Chu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Senthilkumar Gandhidasan
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Anand Swaminath
- Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, Texas
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | | | - Alexander V Louie
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Correa RJM, Louie AV, Zaorsky NG, Lehrer EJ, Ellis R, Ponsky L, Kaplan I, Mahadevan A, Chu W, Swaminath A, Hannan R, Onishi H, Teh BS, Muacevic A, Lo SS, Staehler M, Siva S. Reply to Francesco Montorsi, Alessandro Larcher, and Umberto Capitanio's Letter to the Editor re: Rohann J.M. Correa, Alexander V. Louie, Nicholas G. Zaorsky, et al. The Emerging Role of Stereotactic Ablative Radiotherapy for Primary Renal Cell Carcinoma: A Systematic Review and Meta-Analysis. Eur Urol Focus. 2019 Jun 24. pii: S2405-4569(19)30157-9. https://doi.org/10.1016/j.euf.2019.06.002. [Epub ahead of print]. Eur Urol Focus 2019; 7:404-405. [PMID: 31679868 DOI: 10.1016/j.euf.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rohann J M Correa
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rodney Ellis
- University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Lee Ponsky
- University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Irving Kaplan
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - William Chu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Anand Swaminath
- Department of Radiation Oncology, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Raquibul Hannan
- Department of Radiation Oncology, Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX, USA
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Shankar Siva
- Division of Radiation Oncology & Cancer Imaging, Peter MacCallum Cancer Centre, and University of Melbourne, Melbourne, Australia.
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Palma DA, Olson R, Harrow S, Correa RJM, Schneiders F, Haasbeek CJA, Rodrigues GB, Lock M, Yaremko BP, Bauman GS, Ahmad B, Schellenberg D, Liu M, Gaede S, Laba J, Mulroy L, Senthi S, Louie AV, Swaminath A, Chalmers A, Warner A, Slotman BJ, de Gruijl TD, Allan A, Senan S. Stereotactic ablative radiotherapy for the comprehensive treatment of 4-10 oligometastatic tumors (SABR-COMET-10): study protocol for a randomized phase III trial. BMC Cancer 2019; 19:816. [PMID: 31426760 PMCID: PMC6699121 DOI: 10.1186/s12885-019-5977-6] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 07/24/2019] [Indexed: 12/19/2022] Open
Abstract
Background Stereotactic ablative radiotherapy (SABR) has emerged as a new treatment option for patients with oligometastatic disease. SABR delivers precise, high-dose, hypofractionated radiotherapy, and achieves excellent rates of local control for primary tumors or metastases. A recent randomized phase II trial evaluated SABR in a group of patients with a small burden of oligometastatic disease (mostly with 1–3 metastatic lesions), and found that SABR was associated with benefits in progression-free survival and overall survival. The goal of this phase III trial is to assess the impact of SABR in patients with 4–10 metastatic cancer lesions. Methods One hundred and fifty-nine patients will be randomized in a 1:2 ratio between the control arm (consisting of standard of care palliative-intent treatments), and the SABR arm (consisting of standard of care treatment + SABR to all sites of known disease). Randomization will be stratified by two factors: histology (Group 1: prostate, breast, or renal; Group 2: all others), and type of pre-specified systemic therapy (Group 1: immunotherapy/targeted; Group 2: cytotoxic; Group 3: observation). SABR is to be completed within 2 weeks, allowing for rapid initiation of systemic therapy. Recommended SABR doses are 20 Gy in 1 fraction, 30 Gy in 3 fractions, or 35 Gy in 5 fractions, chosen to minimize risks of toxicity. The primary endpoint is overall survival, and secondary endpoints include progression-free survival, time to development of new metastatic lesions, quality of life, and toxicity. Translational endpoints include assessment of circulating tumor cells, cell-free DNA, and tumor tissue as prognostic and predictive markers, including assessment of immunological predictors of response and long-term survival. Discussion This study will provide an assessment of the impact of SABR on clinical outcomes and quality of life, to determine if long-term survival can be achieved for selected patients with 4–10 oligometastatic lesions. Trial registration Clinicaltrials.gov identifier: NCT03721341. Date of registration: October 26, 2018. Electronic supplementary material The online version of this article (10.1186/s12885-019-5977-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David A Palma
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada.
| | - Robert Olson
- Department of Radiation Oncology, British Columbia Cancer, Centre for the North, Prince George, BC, Canada
| | | | - Rohann J M Correa
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Famke Schneiders
- Department of Radiation Oncology, Amsterdam UMC Vrije Universiteit Amsterdam Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Cornelis J A Haasbeek
- Department of Radiation Oncology, Amsterdam UMC Vrije Universiteit Amsterdam Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - George B Rodrigues
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Michael Lock
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Brian P Yaremko
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Glenn S Bauman
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Belal Ahmad
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Devin Schellenberg
- Department of Radiation Oncology, British Columbia Cancer, Centre for the North, Prince George, BC, Canada
| | - Mitchell Liu
- Department of Radiation Oncology, British Columbia Cancer, Centre for the North, Prince George, BC, Canada
| | - Stewart Gaede
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Joanna Laba
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Liam Mulroy
- Nova Scotia Cancer Centre, Halifax, NS, Canada
| | | | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Cancer Centre, Toronto, Canada
| | | | - Anthony Chalmers
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Andrew Warner
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam UMC Vrije Universiteit Amsterdam Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tanja D de Gruijl
- Department of Radiation Oncology, Amsterdam UMC Vrije Universiteit Amsterdam Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Alison Allan
- Department of Oncology Western University, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6A4L6, Canada
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC Vrije Universiteit Amsterdam Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands
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13
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Correa RJM, Ahmad B, Warner A, Johnson C, MacKenzie MJ, Pautler SE, Bauman GS, Rodrigues GB, Louie AV. A prospective phase I dose-escalation trial of stereotactic ablative radiotherapy (SABR) as an alternative to cytoreductive nephrectomy for inoperable patients with metastatic renal cell carcinoma. Radiat Oncol 2018; 13:47. [PMID: 29558966 PMCID: PMC5859400 DOI: 10.1186/s13014-018-0992-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 03/06/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Cytoreductive nephrectomy is thought to improve survival in metastatic renal cell carcinoma (mRCC). As many patients are ineligible for major surgery, we hypothesized that SABR could be a safe alternative. METHODS In this dose-escalation trial, inoperable mRCC patients underwent SABR targeting the entire affected kidney. Toxicity (CTCAE v3.0), quality of life (QoL), renal function, and tumour response (RECIST v1.0) were assessed. RESULTS Twelve patients of mostly intermediate (67%) or poor (25%) International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic class, median KPS of 70%, and median tumour size of 8.7 cm (range: 4.8-13.8) were enrolled in successive dose cohorts of 25 (n = 3), 30 (n = 6), and 35 Gy (n = 3) in 5 fractions. SABR was well tolerated with 3 grade 3 events: fatigue (2) and bone pain (1). QoL decreased for physical well-being (p = 0.016), but remained unchanged in other domains. SABR achieved a median tumour size reduction of - 17.3% (range: + 5.3 to - 54.4) at 5.3 months. All patients progressed systemically and median OS was 6.7 months. Crude median follow-up was 5.8 months. CONCLUSIONS In non-operable mRCC patients, renal-ablative SABR to 35 Gy in 5 fractions yielded acceptable toxicity, renal function preservation, and stable QoL. SABR merits further prospective investigation as an alternative to cytoreductive nephrectomy. TRIAL REGISTRATION ClinicalTrials.gov NCT02264548. Registered July 22 2014 - Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT02264548.
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Affiliation(s)
- Rohann J M Correa
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Belal Ahmad
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Craig Johnson
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Mary J MacKenzie
- Department of Medical Oncology, London Regional Cancer Program, London, Canada
| | - Stephen E Pautler
- Division of Urology, Western University, London, Canada.,Division of Surgical Oncology, Western University, London, Canada
| | - Glenn S Bauman
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - George B Rodrigues
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada. .,Department of Epidemiology and Biostatistics, Western University, London, Canada.
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Peart T, Ramos Valdes Y, Correa RJM, Fazio E, Bertrand M, McGee J, Préfontaine M, Sugimoto A, DiMattia GE, Shepherd TG. Intact LKB1 activity is required for survival of dormant ovarian cancer spheroids. Oncotarget 2016; 6:22424-38. [PMID: 26068970 PMCID: PMC4673173 DOI: 10.18632/oncotarget.4211] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 05/23/2015] [Indexed: 12/12/2022] Open
Abstract
Metastatic epithelial ovarian cancer (EOC) cells can form multicellular spheroids while in suspension and disperse directly throughout the peritoneum to seed secondary lesions. There is growing evidence that EOC spheroids are key mediators of metastasis, and they use specific intracellular signalling pathways to control cancer cell growth and metabolism for increased survival. Our laboratory discovered that AKT signalling is reduced during spheroid formation leading to cellular quiescence and autophagy, and these may be defining features of tumour cell dormancy. To further define the phenotype of EOC spheroids, we have initiated studies of the Liver kinase B1 (LKB1)-5′-AMP-activated protein kinase (AMPK) pathway as a master controller of the metabolic stress response. We demonstrate that activity of AMPK and its upstream kinase LKB1 are increased in quiescent EOC spheroids as compared with proliferating adherent EOC cells. We also show elevated AMPK activity in spheroids isolated directly from patient ascites. Functional studies reveal that treatment with the AMP mimetic AICAR or allosteric AMPK activator A-769662 led to a cytostatic response in proliferative adherent ovarian cancer cells, but they fail to elicit an effect in spheroids. Targeted knockdown of STK11 by RNAi to reduce LKB1 expression led to reduced viability and increased sensitivity to carboplatin treatment in spheroids only, a phenomenon which was AMPK-independent. Thus, our results demonstrate a direct impact of altered LKB1-AMPK signalling function in EOC. In addition, this is the first evidence in cancer cells demonstrating a pro-survival function for LKB1, a kinase traditionally thought to act as a tumour suppressor.
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Affiliation(s)
- Teresa Peart
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Yudith Ramos Valdes
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada
| | - Rohann J M Correa
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Biochemistry, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Elena Fazio
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Monique Bertrand
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Oncology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Jacob McGee
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Michel Préfontaine
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Akira Sugimoto
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Oncology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Gabriel E DiMattia
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Biochemistry, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Oncology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Trevor G Shepherd
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.,Department of Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Oncology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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15
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Correa RJM. Found in translation: a medical student's reflection on the emotional realities of translational cancer research. Curr Oncol 2015; 22:e412-3. [PMID: 26628890 DOI: 10.3747/co.22.2561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The packed snow yielded its familiar crunch with every step I took. Behind me, the winter daylight faded as darkness crept through the cloudless sky. With each step forward, the brick walls of the cancer centre loomed larger ahead. This was my destination for the evening. Despite my fatigue after a day of classes and clinical sessions, I believed these hours—and many more like them—were justified, for they were spent in pursuit of worthwhile scientific goals and were ultimately in service to patients [...]
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Affiliation(s)
- R J M Correa
- Schulich School of Medicine and Dentistry, Western University, London, ON
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16
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Correa RJM, Valdes YR, Shepherd TG, DiMattia GE. Beclin-1 expression is retained in high-grade serous ovarian cancer yet is not essential for autophagy induction in vitro. J Ovarian Res 2015; 8:52. [PMID: 26239434 PMCID: PMC4524172 DOI: 10.1186/s13048-015-0182-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/27/2015] [Indexed: 12/22/2022] Open
Abstract
Background Autophagy is a conserved cellular self-digestion mechanism that can either suppress or promote cancer in a context-dependent manner. In ovarian cancer, prevalent mono-allelic deletion of BECN1 (a canonical autophagy-inducer) suggests that autophagy is impaired to promote carcinogenesis and that Beclin-1 is a haploinsufficient tumor suppressor. Nonetheless, autophagy is known to be readily inducible in ovarian cancer cells. We sought to clarify whether Beclin-1 expression is in fact disrupted in ovarian cancer and whether this impacts autophagy regulation. Methods BECN1 expression levels were assessed using The Cancer Genome Atlas (TCGA) datasets from 398 ovarian high-grade serous cystadenocarcinomas (HGSC) and protein immunoblot data from HGSC samples obtained at our institution. Knockdown of BECN1 and other autophagy-related gene expression was achieved using siRNA in established human ovarian cancer cell lines (CaOV3, OVCAR8, SKOV3, and HeyA8) and a novel early-passage, ascites-derived cell line (iOvCa147-E2). LC3 immunoblot, autophagic flux assays, transmission electron microscopy and fluorescence microscopy were used to assess autophagy. Results We observed prevalent mono-allelic BECN1 gene deletion (76 %) in TCGA tumors, yet demonstrate for the first time that Beclin-1 protein expression remains relatively unaltered in these and additional samples generated at our institution. Surprisingly, efficient siRNA-mediated Beclin-1 knockdown did not attenuate autophagy induction, whereas knockdown of other autophagy-related genes blocked the process. Beclin-1 knockdown instead decreased cell viability without inducing apoptosis. Conclusions Taken together, these data demonstrate that despite its sustained expression, Beclin-1 is dispensable for autophagy induction in ovarian tumor cells in vitro, yet may be retained to promote cell viability by a mechanism independent of autophagy or apoptosis regulation. Overall, this work makes novel observations about tumor expression of Beclin-1 and challenges the accepted understanding of its role in regulating autophagy in ovarian cancer. Electronic supplementary material The online version of this article (doi:10.1186/s13048-015-0182-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rohann J M Correa
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada. .,Department of Biochemistry, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.
| | - Yudith Ramos Valdes
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada.
| | - Trevor G Shepherd
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada. .,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada. .,Department of Oncology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada. .,Department of Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.
| | - Gabriel E DiMattia
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, Canada. .,Department of Biochemistry, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada. .,Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada. .,Department of Oncology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada. .,London Regional Cancer Program, 790 Commissioners Road East, Room A4-919A, London, Ontario, Canada, N6A 4 L6.
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17
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Correa RJM, Valdes YR, Peart TM, Fazio EN, Bertrand M, McGee J, Préfontaine M, Sugimoto A, DiMattia GE, Shepherd TG. Combination of AKT inhibition with autophagy blockade effectively reduces ascites-derived ovarian cancer cell viability. Carcinogenesis 2014; 35:1951-61. [PMID: 24562574 DOI: 10.1093/carcin/bgu049] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Recent genomics analysis of the high-grade serous subtype of epithelial ovarian cancer (EOC) show aberrations in the phosphatidylinositol 3-kinase (PI3K)/AKT pathway that result in upregulated signaling activity. Thus, the PI3K/AKT pathway represents a potential therapeutic target for aggressive high-grade EOC. We previously demonstrated that treatment of malignant ascites-derived primary human EOC cells and ovarian cancer cell lines with the allosteric AKT inhibitor Akti-1/2 induces a dormancy-like cytostatic response but does not reduce cell viability. In this report, we show that allosteric AKT inhibition in these cells induces cytoprotective autophagy. Inhibition of autophagy using chloroquine (CQ) alone or in combination with Akti-1/2 leads to a significant decrease in viable cell number. In fact, Akti-1/2 sensitizes EOC cells to CQ-induced cell death by exhibiting markedly reduced EC50 values in combination-treated cells compared with CQ alone. In addition, we evaluated the effects of the novel specific and potent autophagy inhibitor-1 (Spautin-1) and demonstrate that Spautin-1 inhibits autophagy in a Beclin-1-independent manner in primary EOC cells and cell lines. Multicellular EOC spheroids are highly sensitive to Akti-1/2 and CQ/Spautin-1 cotreatments, but resistant to each agent alone. Indeed, combination index analysis revealed strong synergy between Akti-1/2 and Spautin-1 when both agents were used to affect cell viability; Akti-1/2 and CQ cotreatment also displayed synergy in most samples. Taken together, we propose that combination AKT inhibition and autophagy blockade would prove efficacious to reduce residual EOC cells for supplying ovarian cancer recurrence.
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Affiliation(s)
- Rohann J M Correa
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Biochemistry and
| | - Yudith Ramos Valdes
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada
| | - Teresa M Peart
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Anatomy and Cell Biology, University of Western Ontario, London, Ontario, N6A 5C1, Canada
| | - Elena N Fazio
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada
| | - Monique Bertrand
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Obstetrics and Gynaecology, University of Western Ontario, London, Ontario, N6A 5W9, Canada and
| | - Jacob McGee
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Obstetrics and Gynaecology, University of Western Ontario, London, Ontario, N6A 5W9, Canada and
| | - Michel Préfontaine
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Obstetrics and Gynaecology, University of Western Ontario, London, Ontario, N6A 5W9, Canada and
| | - Akira Sugimoto
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Obstetrics and Gynaecology, University of Western Ontario, London, Ontario, N6A 5W9, Canada and
| | - Gabriel E DiMattia
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Biochemistry and Department of Obstetrics and Gynaecology, University of Western Ontario, London, Ontario, N6A 5W9, Canada and Department of Oncology, University of Western Ontario, London, Ontario, N6A 4L6, Canada
| | - Trevor G Shepherd
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, London, Ontario, N6A 4L6, Canada, Department of Anatomy and Cell Biology, University of Western Ontario, London, Ontario, N6A 5C1, Canada, Department of Obstetrics and Gynaecology, University of Western Ontario, London, Ontario, N6A 5W9, Canada and Department of Oncology, University of Western Ontario, London, Ontario, N6A 4L6, Canada
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18
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Peart TM, Correa RJM, Valdes YR, Dimattia GE, Shepherd TG. BMP signalling controls the malignant potential of ascites-derived human epithelial ovarian cancer spheroids via AKT kinase activation. Clin Exp Metastasis 2012; 29:293-313. [PMID: 22249415 DOI: 10.1007/s10585-011-9451-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 12/28/2011] [Indexed: 11/29/2022]
Abstract
Epithelial ovarian cancer (EOC) cells have the ability to form multi-cellular aggregates in malignant ascites which dramatically alters cell signalling, survival, and metastatic potential. Herein, we demonstrate that patient ascites-derived EOC cells down-regulate endogenous bone morphogenetic protein (BMP) signalling by decreasing BMP ligand expression when grown in suspension culture to form spheroids. Enforced BMP signalling in these cells via constitutively-active BMP type I ALK3(QD) receptor expression causes the formation of smaller, more loosely-aggregated spheroids. Additionally, ALK3(QD)-expressing spheroids have an increased rate of adhesion and dispersion upon reattachment to substratum. Inhibition of endogenous BMP signalling using recombinant Noggin or small molecule inhibitor LDN-193189, on the other hand, opposed these phenotypic changes. To identify potential targets that impact the phenotype of EOC spheroids due to activated BMP signalling, we performed genome-wide expression analyses using Affymetrix arrays. Using the online Connectivity Map resource, the BMP signalling gene expression signature revealed that the AKT pathway is induced by activated BMP signalling in EOC cells; this finding was further validated by phospho-AKT immuno-blotting. In fact, treatment of EOC spheroids with an AKT inhibitor, Akti-1/2, reduced BMP-stimulated cell dispersion during reattachment as compared to controls. Thus, we have identified AKT as being one important downstream component of activated BMP signalling on EOC spheroid pathobiology, which may have important implications on the metastatic potential of this malignancy.
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Affiliation(s)
- Teresa M Peart
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, 790 Commissioners Road East, Room A4-836, London, ON N6A 4L6, Canada
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Correa RJM, Peart T, Valdes YR, DiMattia GE, Shepherd TG. Modulation of AKT activity is associated with reversible dormancy in ascites-derived epithelial ovarian cancer spheroids. Carcinogenesis 2011; 33:49-58. [PMID: 22045027 DOI: 10.1093/carcin/bgr241] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Epithelial ovarian cancer (EOC) metastasis is a direct contributor to high recurrence and low survival for patients with this disease. Metastasis in EOC occurs by cell exfoliation from the primary tumor into the fluid-filled peritoneal cavity, persistence of these cells as non-adherent multicellular aggregates or spheroids and reattachment of spheroids to form secondary lesions. We have recovered native spheroids from ascites fluid and demonstrated that EOC cells within these structures exhibit reduced proliferation, yet regain the capacity to attach and reinitiate cell division. To model this process in vitro for further investigation, primary EOC cells from patient peritoneal fluid were cultured under non-adherent conditions. Here we show that these cells naturally form spheroids resembling those observed in ascites. Spheroids exhibit reduced cell proliferation and a protein expression pattern consistent with cellular quiescence: specifically, decreased phospho-AKT and p45/SKP2 with a concomitant increase in p130/RBL2 and p27(Kip1). However, when spheroids are seeded to an adherent surface, reattachment occurs rapidly and is followed by reinitiation of AKT-dependent cell proliferation. These results were strikingly consistent among numerous clinical specimens and were corroborated in the EOC cell line OVCAR3. Therefore, our data reveal that EOC cells become quiescent when forming spheroids, but reactivate proliferative mechanisms upon attachment to a permissive substratum. Overall, this work utilizes a novel in vitro model of EOC metastasis that employs primary human EOC cells and introduces the important concept of reversible dormancy in EOC pathogenesis.
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Affiliation(s)
- Rohann J M Correa
- Translational Ovarian Cancer Research Program, London Regional Cancer Program, 790 Commissioners Road East, London, Ontario, Canada
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