Transaction Management in Database Management System
Role of Radiation Therapy for Lung Cancer
1. Role of Radiation
Therapy for Lung Cancer
- Paradigm Shift
Zhongxing Liao, MD
Professor of Radiation Oncology
2. • Early stage NSCLC (SBRT)
• Surgically
unresectable/inoperable LA-
NSCLC (RTOG 617)
• Combined with Immunotherapy
Outline
3. • Used by its cytocidal power,
• RT biological effect-double
strand break in DNA (the
target) (Eric Hall, Radiobiology for the
Radiologist, 4th ed., page 8)
• RT Improve OS by:
– LC when tumor is localized
– LC to reduce DM
• Kill the immune system in TBI
Traditional Perception of Role of Radiation
in Cancer Treatment
30%, higher with
heavy particles
70%, main
mechanism
4. LC n=674 OS=24%
LP n=761 OS = 6%
P<0.001
MST:
18.6 mo. vs. 15.5 mo.
OverallSurvival(%)
Months
Machtay, ASTRO 05
Local Control and Survival
Radiation dose escalation without
increase toxicity
5. • Treatment of choice for non-
surgical candidate (LC >90%),
• Excellent alternative for surgical
candidate (Lancet 2015)
Early Stage NSCLC - SBRT
6. Trial n Dose FU LC % OS %
Kyoto 45 12 Gy x 4 32 mo 94 83/72 (3-yr)
Stanford 20 15-30 x 1 18 mo ---- -------
Scandinavian 57 15 Gy x 3 35 mo 92 (3-yr) 60 (3-yr)
Indiana 70 20-22 x 3 50 mo 88 (3y) 43 (3-yr)
RTOG 0236 55 20 Gy x 3 34 mo 97 56 (3-yr)
42 19-30 x 1 15 mo 68 37 (3-yr)
Heidelberg 62 15 Gy x 3 28 mo 88 57 (3-yr)
Tohoku 31 15 x 3, 7.5x8 32 mo 78/40 71 (3-yr)
VU Univ 206 20 x 3 ,12 x 5
7.5 x 8
12 mo 97 64 (2-yr)
Selected SBRT Prospective Reports
7. BED < 100 Gy BED > 100 Gy P-value
Local Tumor 43% 8% <0.01
Regional nodal
metastasis
21% 9% <0.05
Distant metastasis 26% 19% 0.3
Locoregional failure depends on BED
Onishi et al. 2007
Onishi et al., JTO 2007
8. Increasing Radiation Therapy Dose Is Associated With
Improved Survival in Patients Undergoing SBRT for Stage
I NSCLC
Koshy et al., Int J Radiation Oncol Biol Phys, Vol. 91, No. 2, pp. 344e350, 2015
Overall survival of T2 tumors treated with SBRT stratified by dose; low-dose cohort BED
<150 Gy; high-dose BED >150 Gy
9. SBRT – Curative Treatment for Early Stage
NSCLC – Operable Patients
Chang et al., Lancet Oncol. 2015
• BED: 112.5 -151.2Gy
– 50Gy/12.5 Gy/fx x 4
– 54Gy/18 Gy/fx x 3
– 60Gy/12Gy/fx x 5
• PTV=GTV+3mm
• GTV: 110-140% of
prescribe dose
• Volumetric
IGRT/Motion
management
10. • Surgically unresectable/inoperable
NSCLC (RTOG 617)
–Dose escalation in conventional
fractionation showed no OS benefit
–Adding Cetuximab in unselected
patient did not show OS benefit
• Prolonged OTT and Lymphocytes
During the Treatment
LA-NSCLC – Non Surgery
11. Intergroup Participation:
RTOG, NCCTG, CALGB
RTOG 0617
A Randomized Phase III Comparison of Standard-Dose (60 Gy)
Versus High-Dose (74 Gy) Conformal Radiotherapy with
Concurrent and Consolidation Carboplatin/Paclitaxel +/-
Cetuximab In Patients with Stage IIIA/IIIB Non-Small Cell
Lung Cancer
12. RTOG 0617 – OS
Bradley et al., Lancet Oncol 2015; 16: 187–99
13. RTOG 0617 – OS
• Cancer death similar
• More treatment related death at 74 Gy
• Higher Heart V5
• Non compliance to Chemotherapy
• Prolonged overall Treatment Time - OTT
Bradley et al., Lancet Oncol 2015; 16: 187–99
Cervical Cancer: TCP as a function of total
dose (left) and total treatment time (right).
Loss of LC with prolonged OTT due to cancer
cell repopulation.
Huang et al., Int J Radiation Oncol Biol Phys, Vol. 84, No. 2,
pp. 478e484, 2012
14. BED for Different Regimens
BED = nd {1+[d/(α/β)}
BED[(α/β) =10]:
- Conventional Fractionation
72 Gy: 60 Gy in 30 Fx
84 Gy: 70 Gy in 35 Fx
88.8Gy: 74 Gy in 37Fx
- Hypofractionation/SBRT
96 Gy: 60 Gy in 10 Fx
106 Gy: 48 Gy in 4 Fx (Japan Oncology Group)
112.5 Gy: 50 Gy in 4 Fx (MD Anderson, PTV)
119 Gy: 70 Gy in 10 Fx (MD Anderson, GTV)
151.2 Gy: 54 Gy in 3 Fx (RTOG, STAR Trial)
180 Gy: 60 Gy in 3 Fx (RTOG, 80% Isodose)
Chang
17. Combining Radiotherapy and Cancer
Immunotherapy: A Paradigm Shift
• Tumor response to RT need T-Cells
• RT induces immunogeneic cell death
• Adaptive and innate immune response
could convert the irradiated cancer into
an in situ vaccine that elicits tumor-
specific T cells.
• Abscopal effect (ie, a tumor response
in a metastasis outside RT field, after
treatment of another tumor site)
• Preclinical and clinical evidence
Formenti et al., J Natl Cancer Inst;2013;105:256–265
20. PD-L1 in tumor cells induced with IR
TUBO tumor cells SQ
Deng L et al., JCI 2014
21. Anti-PD-L1 enhance anti-tumor effect with IR
that is CD8+ T cell mediated
Tumor rechallenge experiment Abscopal Effect experiment
Deng L et al., JCI 2014
22. Waterfall plot: unirradiated tumor measurements in a phase I trial combining radiation and ipilimumab
Recapitulation of experiment in mice: resistance to RT and anti-CTLA4 (C4) therapy due to T-cell exhaustion and PD-L1
increases
Radiation and dual checkpoint blockade activate
non-redundant immune mechanisms in cancer
- Twyman-Saint Victor C et al., Nature. 2015 Apr 16;520(7547):373-7
23. Conclusions: Radiation, anti-
CTLA4, and anti PD-1/PD-L1
therapy play distinct
complementary roles
– Anti-CTLA4 promotes T cell
expansion
– Radiation shapes the TCR
repertoire of expanded
peripheral clones
– Anti-PD-1/PD-L1 reverses T-
cell exhaustion
Radiation and dual checkpoint blockade activate
non-redundant immune mechanisms in cancer
- Twyman-Saint Victor C et al., Nature. 2015 Apr 16;520(7547):373-7
24. Original Article: Brief Report
Immunologic Correlates of the Abscopal Effect in a
Patient with Melanoma
Michael A. Postow, M.D., Margaret K. Callahan, M.D., Ph.D., Christopher A.
Barker, M.D., Yoshiya Yamada, M.D., Jianda Yuan, M.D., Ph.D., Shigehisa
Kitano, M.D., Ph.D., Zhenyu Mu, M.D., Teresa Rasalan, B.S., Matthew Adamow, B.S.,
Erika Ritter, B.S., Christine Sedrak, B.S., Achim A. Jungbluth, M.D., Ramon
Chua, B.S., Arvin S. Yang, M.D., Ph.D., Ruth-Ann Roman, R.N., Samuel Rosner,
Brenna Benson, James P. Allison, Ph.D., Alexander M. Lesokhin, M.D., Sacha
Gnjatic, Ph.D., and Jedd D. Wolchok, M.D., Ph.D.
N Engl J Med
Volume 366(10):925-931
March 8, 2012
25. • A patient with metastatic melanoma with slowly progressive disease while receiving
ipilimumab underwent radiotherapy for a pleural-based metastasis.
• Tumor lesions in nonirradiated sites began to disappear, and titers of antibody against a
tumor-associated antigen increased.
Postow MA et al. N Engl J Med 2012;366:925-931
N Engl J Med, Volume 366(10):925-931 March 8, 2012
26. NY-ESO-1 Expression and Antibody
Response to Ipilimumab and
Radiotherapy.
Postow MA et al. N Engl J Med 2012;366:925-931
Flow Cytometry of
Peripheral-Blood
Mononuclear Cells
N Engl J Med, Volume 366(10):925-931 March 8, 2012
27. Preclinical data in local RT combined with
Immnunotherapy
Formenti et al., J Natl Cancer Inst;2013;105:256–265
28. Path Forward: 3 steps
1) Autologous T cell therapy with
XRT for NSCLC
– Current trial, safe and easy,
POC
2) Generate unique radiation
induced antigens
- Sequence TCR of novel XRT
induced antibodies
• These can be expanded out for
autologous therapy
• Can generate XRT specific
CAR T
3) Engineered T cells + anti-PD1
– Currently running these experiments
in the lab
– Currently running multiple IND trials
and of anti PD1/CTLA4 and XRT
Welsh, Cortez, Seyedin, Hahn et al CCR 2014
29. DOD Clinical Exploration Grant – Jim Welsh
Phase I study to assess safety of combining
autologous T cell transfer plus concurrent
chemoradiation therapy for patients with stage 3
non-small cell lung cancer
30.
31. A Phase III, Randomized, Double-blind, Placebo-controlled, Multicenter,
International Study of MEDI4736* as Sequential Therapy in Patients with Locally
Advanced, Unresectable NSCLC (Stage III) Who Have Not Progressed Following
Definitive, Platinum-based, Concurrent Chemoradiation Therapy (PACIFIC)
Primary Study Objective(s):
Primary Objective:
Efficacy of MEDI4736 vs placebo in terms of OS and
PFS
Secondary Objectives:
OS24, ORR, DoR, APF12, APF18, PFS2 and DSR
Safety and tolerability
PK
Immunogenicity
Symptoms/HRQOL – EORTC QLQ-C30 v3 and LC13
*MEDI4736: Fully human monoclonal Ab that inhibits PD-L1 binding to PD1 and CD80
32. • Phase II Trial, 2 stage design
– Primary Objective: Safety of MPDL3280A added to
carboplatin-paclitaxel chemoradiation for
unresectable non-small cell lung cancer
– Secondary Objectives:
• 6 month, 1 year and median PFS time (historical
benchmark from RTOG 0617: 6 mos 75%, 1 yr 50%)
• PD-L1 IHC staining on pretreatment tumor biopsy and
correlation to 1-year Progress Free Survival (PFS)
• Overall Survival (OS)
• Incidence of ≥Grade 3 radiation pneumonitis
• Blood based immunologic correlates to PFS
• Tissue based immunologic correlates to PFS
2014-0722: DETERRED: PD-L1 BlockadE To ERadicate
Lung Cancer using Carboplatin, Paclitaxle, and Radiation
combinEd with MPDL3280A
33. Trials of Abscopal Effect of SBRT
on Stage IV patients – Jim Welsh
• 2013-0882 Phase I/II
ipilimumab + XRT:
– Phase I completed, no MTD
reached
– Phase II accruing
• 2014-1020 Phase I/II MK-
3475 + XRT in NSCLC:
– Phase I accruing soon
34. Background-NSCLC treatment with
nivolumab
• 272 squamous cell
NSCLC treated with
nivolumab (3mg/kg q2
wks) versus docetaxel
• Docetaxel median OS:
6 mo, PFS: 2.8 mo
• Nivolumab median OS:
9.2 mo, PFS: 3.5 mo*
(FDA approved dose)
35. Baseline, 1 month, every 3 months
-Brain MRI
-Neurocognitive testing
C1
WBRT/SRS
C2
2wk
C3
6wk
C4
10wk
C6
12wk
C7
14wk
C8
16wk
C3
4wk
C3
8wkNivolumab 3mg/kg
Part A:
At starting dose
DLT
Assessment
C1
C1
WBRT/SRS
C2 3wk
C2 3wk
C3 6wk C4 9wk
C6
11wk
C7
15wk
C8
17wk
C3 6wk C4 12wk
Nivolumab 3mg/kg
Ipilimumab 1mg/kg
Part B
At starting dose
DLT
Assessment
Phase I/II trial of Nivolumab and Ipilimumab with radiation for the
treatment of intracranial metastases from non-small cell lung
cancer
36. Role of RT in Lung Cancer Treatment –
beyond DNA double strand breaks
• Early Stage: SBRT Curative treatment,
• Dose escalation with Conventional Fractionation had no
OS benefit (RTOG 617)
• RT and cancer immunotherapy:
– RT induced tumor response mediated by T cells
– RT induced Abscopal effect
– Radiation, anti-CTLA4, and anti PD-1/PD-L1 therapy play distinct
complementary roles
• BED >100 Gy needed for eliminating the cancer on site or
induce the immune response
• RT dose, fractionation, sequence with immunotherapy to
be defined
However, higher dose RT in the range of BED 72-90 Gy, below BED 100 Gy did not show any difference in OS, if anything, the higher dose was associated with worse OS compared with the standard dose 60 Gy.
However, higher dose RT in the range of BED 72-90 Gy, below BED 100 Gy did not show any difference in OS, if anything, the higher dose was associated with worse OS compared with the standard dose 60 Gy.
n = number of fractions, D = dose/fraction, and nD = total dose.
Prescription doses incompletely describe the actual delivered doses, which also depend strongly on how the dose is prescribed (to the isocenter or isodose volume), the degree of dose heterogeneity, whether tissue heterogeneity corrections are used, and the type of dose calculation algorithm
A role of T cells in the tumor response to ionizing radiation was first suggested in 1979 in experiments demonstrating reduced therapeutic efficacy in irradiated mice that lacked a normal T-cell repertoire (18). However, the relationship between radiation-induced tumor cell death and priming of antitumor T-cell responses was only recently elucidated. Several research milestones preceded this step. First, it was demonstrated that cell death is an efficient process to transfer antigens from tumor cells to DCs and that DCs are required to activate tumor-specific T cells (19,20). Moreover, during the past 5 years, a functional redefinition of cell death, based on its effects on immune cells (ie, tolerance or activation) has emerged. Molecular signals required to achieve an “immunogenic cell death” have been established (21,22). To date, they include: 1) cell surface translocation of calreticulin (an endoplasmic reticulum resident protein); 2) extracellular release of high-mobility group protein B1 (HMGB1, a nonhistone nuclear protein), and 3) release of ATP (the primary unit of cellular energy transfer) (23–26). Current evidence indicates that ionizing radiation and some, but not all, commonly used chemotherapy agents successfully induce each of these steps and culminate in immunogenic cell death. Additional or alternative signals and pathways remain an area of active investigation (22). Successful induction of immunogenic cell death also depends on characteristics intrinsic to tumor cells (27) and is modulated by the host’s genetic polymorphism in genes that encode key receptors. For instance, data suggest that patients carrying a Toll-like receptor 4 loss-of-function allele that cannot bind to HMGB1 have a worse outcome after chemotherapy and radiation (23). Likewise, expression of a loss-of-function allele of the purinergic receptor for ATP P2X (7) has been associated with poorer prognosis after treatment (25).
Immunodeficiency abrogates the antitumor effect of RT. (A) WT C57BL/6 or nude mice (n = 10) were injected with 2 × 106 B16 melanoma cells and treated 7 days later with 20 Gy. The radiation group in WT but not in nude mice showed significantly smaller tumor size (**P = .002 at day 10 after RT). (B) WT or nude mice (n = 8-12) were injected with 2 × 105 B16-SIY and treated 10 days later with 25 Gy. The radiation group showed significantly smaller tumor size (***P < .001 on day 12 after RT). A similar trend of the inhibition was also detected with single 20 Gy. A total of 60% WT mice were cured, whereas 100% nude mice die with 20 Gy. (C) Tumor growth curve and (D) survival for WT mice injected with 105 B16 and treated on day 14 with 15 Gy given on days 0, 1, and 2 after RT. A total of 200 μg/mouse anti-CD8 antibody was administered on days 0, 4, and 8 after RT (n = 5-9 per group). After RT plus depletion of CD8, the size of tumor increased significantly from RT alone (**P = .007 at day 14). Survival increased after RT (***P < .001), but with CD8 depletion survival was significantly reduced: *P < .05; **P < .01; ***P < .001. Similar experiments were repeated 3 times (A-D).
Chemotherapy diminishes the effect of radiation-mediated eradication of metastases and T-cell priming. (A) A total of 2 × 105 B16-CCR7 cells were subcutaneously injected; and on days 14, 15, and 16, mice received 15 Gy. On days 7 and 14 after RT, 200 mg/kg dacarbazine (also for human melanoma) was administered intraperitoneally. The radiation group showed a significantly smaller tumor size (***P < .001 at day 13 after RT). Additional dacarbazine after RT led to significant regrowth (**P < .007 at day 26 after RT, *P = .015 day 32 after RT; n = 3-5). (B) Tumor growth curve: 105 4T1 tumor cells were injected; and on days 15, 16, and 17, mice received 15 Gy. On days 7 and 14 after RT, 20 mg/kg paclitaxel was administered intraperitoneally. The radiation group showed significantly smaller tumor size (**P = .008 at day 23; n = 4-9 per group). (C) Metastasis assay: 105 4T1 tumor cells were subcutaneously injected; and on days 12, 13, and 14, Balb/c mice received local RT of 15 Gy. The tumors were removed on day 21. On days 7 and 12 after RT, 20 mg/kg paclitaxel was administered intraperitoneally No colonies were detected after radiation, whereas addition of chemotherapy completely eliminated the effect of radiation (n = 4 or 5 per group). (D) A total of 5 × 105 B16-SIY melanoma cells were injected subcutaneously. On day 17, mice were transferred with 2 × 106 CFSE-labeled 2C cells and locally RT with 20 Gy. A total of 200 mg/kg dacarbazine intraperitoneally was given 2 days after adoptive transfer. DLN and spleen were harvested on day 21 for analysis. (E) A total of 5 × 105 B16-SIY melanoma cells were injected subcutaneously. Mice received local tumor RT of 20 Gy once or 5 Gy × 4. Single-treatment 200 μg/mouse of anti-CD8 antibody was administered on days 0, 4, 8, and 12 after RT. Repeated treatment of radiation showed significant regrowth of tumor mass (*P = .03 at day 25; n = 4-6). (F) A total of 8 × 106 human lung tumor A549 cells were subcutaneously injected into B6/Rag−/− mice; and 4 weeks later, the mice were adoptively transferred with 2 × 106 LN cells from OT-I transgenic mice. Three days later, mice received 20 Gy of local RT. RT (P = .48) or T cells (P = .3) alone showed no significant differences from the no treatment group, whereas the radiation + T-cell group showed significantly smaller tumor size (*P = .018 at day 60). Similar experiments were repeated at least twice (A-F).
Figure 1 Results of Diagnostic and Radiotherapy Simulation Imaging throughout the Disease Course. Axial CT images are shown, corresponding to the timeline showing therapy and disease status. White arrows indicate the paraspinal mass, red circles indicate the right hilar lymphadenopathy and spleen, and black arrows indicate an incidental hepatic hemangioma. Panel A (top) represents the status before treatment with ipilimumab. Panel B shows enlargement of the paraspinal mass (top), stable right hilar lymphadenopathy (middle), and new splenic lesions (bottom). Panel C shows images 1 month after radiotherapy, when the response to radiotherapy had not yet occurred, with apparent continued worsening disease at all three sites. Several months after radiotherapy, the targeted paraspinal mass showed a response (Panel D, top). Furthermore, disease response outside of the radiation field was seen with decreased right hilar lymphadenopathy (middle) and resolution of splenic lesions (bottom). The response was durable, as shown in Panel E. Panel F shows the CT simulation image for radiotherapy planning, with the target volume (indicated in purple) encompassing the right paraspinal metastatic mass. The isodose lines represent total doses of 2850 cGy (pink), 2000 cGy (orange), 1000 cGy (green), and 200 cGy (blue). Disease regression was confirmed by means of three-dimensional volumetric assessment (Table 2 in the Supplementary Appendix).
Figure 2 NY-ESO-1 Expression and Antibody Response to Ipilimumab and Radiotherapy. Immunohistochemical analysis of NY-ESO-1 expression in the pulmonary metastatic melanoma nodule is shown with the use of monoclonal antibody E978 (Panel A, with the inset showing a portion of the image magnified by a factor of 4) and polymerase-chain-reaction (PCR) assay (Panel B). For the PCR results, p53 was used as a reference standard, and the positive tumor specimen in lane 2 is the NY-ESO-1–positive melanoma cell line SK-Mel-37. Titers of antibody against the whole NY-ESO-1 protein and the N-terminal portion (amino acids [aa] 1–68) rose as the disease progressed and ipilimumab therapy was administered and diminished with the disease response after radiotherapy (Panels C and D). After radiotherapy, there was an increase by a factor of more than 30 in the titer of antibodies against an epitope or epitopes within the central portion of NY-ESO-1 (aa 71–130), which corresponded to the period of disease resolution (Panel E). Seroconversion to an epitope or epitopes in the C-terminal portion of NY-ESO-1 (aa 119–180) occurred with disease progression before radiotherapy (Panel F). Panels C through F show the means from an average of nine independent determinations, and the I bars indicate standard deviations. Reciprocal antibody titers of more than 100 are considered to be significant.
Figure 3 Results of Flow Cytometry of Peripheral-Blood Mononuclear Cells. Panel A shows that levels of CD4+ ICOShigh cells increased during ipilimumab induction but decreased before radiotherapy; after radiotherapy, there was a second increase in the levels. Panel B shows an increase in HLA-DR expression on monocytes, expressed as mean fluorescence intensity (MFI), after radiotherapy. Panel C shows a decline in levels of myeloid-derived suppressor cells (MDSCs) (CD14+ HLA-DRlow)9 after radiotherapy. Data in Panel A are a representative sample from two independent determinations; data in Panels B and C are the means from two determinations. I bars indicate standard deviations.
Schematic diagram outlining the antitumor activity and abscopal effect in combining checkpoint inhibitors with radiation-induced immuneresponse. Radiation induces DNA damage and tumor cell death by promoting tumor cell expression of Fas and MHC class I; dying tumor cells release ATP, tumor antigens, and danger signals such as HMGB1 and calreticulin. Radiation also increases tumor cell expression of PD-L1, secretion of TGFb, and suppression of CD4þ Tregs. Tumor antigens captured by antigen-presenting cells (APC) are processed and presented on MHC class I molecules in the draining lymph node to tumor antigen–specific T cells in conjunction with co-stimulation to promote activation and proliferation. CTLA-4 can bind B7-1 to down regulate T-cell activation. Activated CTLs leave the lymph node, follow inflammatory chemokines, and migrate to tumor sites. PD-L1 and PD-1 can interact to suppress CTL activation; various a-CTLA-4, a-PD-L1, and a-PD-1 mAbs have been developed and used successfully in cancer immunotherapies. CTL antitumor activity includes secretion of IFNg and TNF, suppression of MDSCs, expression of perforin and granzyme, and activation of Fas ligand–mediated tumor cell apoptosis.