Chapter 4 Interaction of Chemotherapy and Radiation
Historical Perspective
Radiosensitization and chemosensitization are each complex concepts that have many different interpretations and have been used to describe a variety of interactions.1,2 The combination of irradiation and chemotherapy for mutual or even simultaneous sensitization increases the intricacies of these interactions. For example, over 100 years ago radiation treatment and benzene systemic therapy were combined for leukemia treatment.3 However, probably the best historical model of chemotherapy and radiation therapy interaction is the use of 5-fluorouracil.
5-Fluorouracil
In the 1950s, the halogenated pyrimidine 5-fluorouracil (5-FU) was combined with external beam irradiation therapy (EBRT) after this class of drug was determined to have anticancer properties.4 In the past 50 years, 5-FU has been successfully combined with radiation to treat a variety of gastrointestinal cancers, as well as cervical cancer and head and neck cancer.5 The route of administration and scheduling of 5-FU doses have been reconfigured many times to reduce toxicity and maximize tumor control. What began as bolus delivery at the beginning and end of a fractionated radiation treatment course (Moertel regimen) has progressed to protracted venous infusion (PVI), and now to twice-daily doses of oral 5-FU analog formulations. These approaches have allowed for an increase in cumulative dose of the drug, decreased chemotherapy toxicity, and improved radiosensitization. 5-FU has proven to be a staple drug in the armamentarium of medical oncologists as well as a key radiosensitizer for the radiation oncologist.
Rationale
Limitations in Current Therapeutic Approach
Tumor Detection
If ionizing radiation were not toxic to normal tissues, tumor detection would be immaterial and radiotherapy could be delivered to the entire body much as chemotherapy is given. Obviously, this is not the case. Just as surgeons must identify tumor tissue and remove it with a scalpel, radiation oncologists must be able to identify tumor tissue so that they can precisely and accurately target it with radiation. Fortunately, advances in radiology have dramatically improved the ability to detect tumor location and extent. CT and MRI scanning provide excellent anatomic information, but when they are combined with biologic or functional imaging techniques such as positron emission tomography (PET) or single-photon emission computed tomography (SPECT), they are even more precise at differentiating tumor tissue from nontumor tissue. Emerging MRI sequences, including dynamic contrast-enhanced MRI or CT scanning, fast imaging employing steady-state acquisition (FIESTA), and ultrafast pulse sequence approaches, provide improved anatomic imaging for surgeons and radiation oncologists. Nevertheless, the resolution of current techniques (on the order of 5 mm for PET resolution6) and the high rate of false-negatives with small tumors still limit the ability to identify microscopic tumor extent and micrometastatic disease. Technologies currently being explored, such as PET/MRI, as well as novel radiopharmaceuticals may provide improvements in the near future.
Inherent and Acquired Resistance
Certain tumors have inherent radiation resistance pathways that manifest with high rates of local failure following irradiation. In some cases, such as pancreatic cancer, it is difficult to deliver adequate doses of radiation to the target because of the limitations in dose tolerance of surrounding bowel, kidney, and liver tissues. Other tumors have extremely high local failure rates despite dose escalation; for example, glioblastoma multiforme has local recurrence rates approaching 100%. Biologic factors within the tumor or tumor microenvironment also generate resistance. Figure 4-1 summarizes some of the major resistance pathways within tumors. Later in this chapter we will describe how chemotherapeutic agents can potentially mitigate these resistance pathways.
Increased Toxicity
In the original treatise by Steel and Peckham7 on combining chemotherapy and radiation therapy, it was assumed that each modality functioned independently in both beneficence and toxicity. However, concurrent chemoradiation therapy has shown increased toxicity, indicating some level of overlapping toxicity, chemosensitization by radiation, or radiosensitization by chemotherapeutic agents. Because chemoradiation is often used when tumors have wide anatomic extension (and thus surgery is precluded), the volume of normal tissue irradiated—and at risk for toxicity—is larger. In some cases, a patient has co-morbid conditions that prevent aggressive therapy.
Therapeutic Index
A metric is necessary to determine the efficacy of a therapy relative to its toxicity, so that newer approaches can be compared. This metric, known as the therapeutic index (or therapeutic ratio), is the ratio of the probability of tumor control to the probability of normal tissue toxicity. Typically, the ratio is calculated based on the 50% control rate of tumor tissue versus the 50% rate of normal tissue toxicity. These sigmoid-shaped curves determine estimated efficacy versus toxicity of treatment (Fig. 4-2). The therapeutic index is the “holy grail” of cancer therapy, and it takes careful treatment planning to achieve maximal tumor cell destruction while also sparing normal tissue in hopes of preserving function. There are a host of technologic factors that affect the therapeutic ratio, one in particular is the ability to correctly identify tumor tissue and normal tissue. Use of PET, MRI, and SPECT imaging, as described earlier, allows radiation oncologists to better differentiate target tissue from other tissues. The ability to precisely deliver radiation through techniques such as intensity-modulated radiation therapy (IMRT), stereotactic procedures, and proton therapy permits radiation oncologists to avoid normal tissue while targeting tumor tissue. Increasingly accurate delivery of radiation via image guidance (IGRT) enables smaller margin expansions, thus limiting the size of the dose that reaches normal tissue. However, because of the anatomic location of some tumors, there are still technological limits as to what can be accomplished with radiation alone. Additional improvements are likely to rely on the interaction of systemic agents with technologically advanced radiation delivery methods.
General Strategies to Improve the Therapeutic Index
In 1979, Steel and Peckham7 defined four potential ways that combined modality therapy might be used to improve the therapeutic index: (1) independent toxicity, (2) normal tissue protection, (3) spatial cooperation, and (4) enhanced tumor response. As discussed later, the first theoretical concept may not function as originally intended. However, the latter three concepts are relevant for modern strategies of combining drugs with radiation. Recent innovative concepts of biologic cooperation and temporal modulation that expand on Steel and Peckham’s “exploitable mechanisms in combined radiotherapy-chemotherapy”7 are having an impact on current investigative strategies for improving the therapeutic index.
Normal Tissue Protection
Only a few clinically relevant, therapeutic agents have been identified as promoting normal tissue protection without protecting tumors. There has been limited success with the free-radical scavenging agent amifostine (WR-2721). The drug appears to be selectively taken up by normal tissue relative to tumor tissue, where it is converted into the active thiol metabolite WR-1065.8 Although amifostine has been shown to protect against xerostomia in head and neck cancer treatment (Table 4-1) and to limit renal toxicity from cisplatin, several clinical trials have failed to show an advantage of amifostine use. Undoubtedly, clinical trials will continue to investigate novel radioprotectors that have the potential to affect the therapeutic ratio.
Mechanism | Example | Notes |
---|---|---|
Normal tissue protection | Amifostine in head and neck cancer | Reduces xerostomia rates from RT alone |
Spatial cooperation | Early-stage breast cancer with adjuvant CT PCI in SCLC |
RT provides locoregional control for breast cancer but no impact on DM SCLC CT does not effectively cross BBB → RT can effectively treat the brain |
Biologic cooperation | Targeted therapies inhibit prosurvival/proliferation pathways within tumors | Kinase-targeted agents, including tyrosine kinase inhibitors such as dasatinib and sunitinib, as well as monoclonal antibodies such as cetuximab and bevacizumab; mTOR inhibitors |
Temporal modulation | Drugs that affect tumor response between fractions, namely, targeting repair, repopulation, reoxygenation, and redistribution | This is essentially a composite of several of the other mechanisms but requires concomitant, rather than sequential, delivery of the drug |
Increased DNA damage | Drugs that incorporate into DNA | 5-FU and platinum are classic examples |
Inhibition of DNA repair | DNA intercalators and nucleoside analogs can disrupt repair and enhance radiation cytotoxicity | Alkylators, antimetabolites, platinum, and topoisomerase inhibitors are a few examples |
Cell cycle effects | Most chemotherapeutics are cell cycle specific (except alkylators) Cell cycle arrest in radiosensitive phases (microtubule-targeting agents at M phase) Elimination of radioresistant cells (S phase) |
Taxanes, epothilones, 5-FU, gemcitabine, topoisomerase inhibitors are good examples |
Targeting repopulation | Conceivably, any systemic agent that has at least cytostatic properties can prevent repopulation | Molecularly targeted agents as well as chemotherapeutics (particularly antimetabolites) can function this way |
Hypoxia targeting | Mitomycin C and tirapazamine selectively targeting hypoxic cells Tumor shrinkage by CT decreases interstitial pressure and improves oxygenation |
Taxanes and other chemotherapeutics that can produce tumor shrinkage are indirect means (given as induction therapy), whereas mitomycin C and tirapazamine are directly affecting hypoxic cells |
Tumor microenvironment targeting | Anti-angiogenesis promotes vascular renormalization | Bevacizumab in glioma |
BBB, blood-brain barrier; CT, chemotherapy; DM, distant metastases; 5-FU, 5-fluorouracil; PCI, prophylactic cranial irradiation; RT, radiation therapy; SCLC, small cell lung carcinoma.
Spatial Cooperation
The concept of spatial cooperation implies that chemotherapy and radiation therapy are independent “players,” with chemotherapy acting systemically (i.e., targeting micrometastatic disease) and radiation therapy acting locoregionally. Because these therapies function independently, it could be assumed that a full dose of each would be required to achieve the desired outcome. If the chemotherapy drug and irradiation did function completely independently, then concurrent administration should be possible with nonoverlapping toxicities. It is unclear whether a completely independent action can actually be achieved with the chemotherapeutics currently used with radiation treatment. Some in-field toxicities do occur, suggesting some level of localized radiation sensitization. Therefore, sequential therapy is probably the best means to exploit spatial cooperation. There are many clinical examples supporting this approach, such as adjuvant chemotherapy followed by irradiation for breast cancer, consolidative irradiation for bulky disease in lymphoma, and prophylactic cranial irradiation in small cell lung cancer (see Table 4-1).
Biologic Cooperation
The term biologic cooperation is a more recent concept9 that involves independent targeting of subpopulations of cells within the tumor itself (see Table 4-1). Although similar to the concept of spatial cooperation, biologic cooperation implies that some portion of the actual radiation target (i.e., in-field) is resistant to radiation and that this portion becomes the target of the drug given concomitantly. The most prominent example of an agent used in biologic cooperation is the hypoxic cell cytotoxin, tirapazamine. Hypoxia is a known condition of radiation resistance; tirapazamine targets the hypoxic subpopulations of cells because it is most potent in anoxic conditions. Tirapazamine is discussed in more detail later in this chapter.
Temporal Modulation
The four Rs of classical radiobiology, reoxygenation, repair, redistribution, and repopulation,10 refer to factors that are particularly important for fractionated radiation therapy. For example, antiproliferative therapies could prevent accelerated repopulation between fractions that might not be detectable using single-fraction assays in vitro. Conversely, although the DNA damage repair blockade may enhance radiation sensitivity in a tumor, if DNA repair is also inhibited in normal tissue, outcomes may be worse in fractionated therapy.9 Depending on which factors are most prominent in normal and tumor cells, the therapeutic index can be shifted in either a beneficial or a detrimental direction. Therefore temporal modulation implies therapeutics that optimize the four Rs between fractionated radiation treatments9 (see Table 4-1).
Potential Biologic Mechanisms of Drug-Radiation Interactions
The many potential mechanisms by which a drug may affect radiation efficacy are summarized in Table 4-1. The classic definition of a radiosensitizer had an enhancement of DNA damage as the critical factor. However, with increased understanding of cancer cell biology, it is apparent that targets other than DNA damage can enhance radiation efficacy. Therefore a more broadly defined “radiation enhancer” can affect several potential mechanisms to increase the effect of radiation.
Cell Cycle Effects
The G2/M phase has been identified as the most radiation-sensitive phase of the cell cycle and the S phase as the most radiation-resistant phase.11,12 In addition, many cytotoxic chemotherapeutic agents are cell cycle specific. Therefore agents that can maintain cells in radiation-sensitive phases or eliminate those cells in radiation-resistant phases will cooperate with radiation for enhanced efficacy. Although this is clearly seen in preclinical settings, there is much less direct evidence for this phenomenon in clinical data. Nevertheless, taxanes, nucleoside analogs, and modified pyrimidines appear to work in this manner.13–16
Hypoxia and Tumor Microenvironment
Hypoxia is one of the most potent factors of radiation protection known. Radiation relies on the production of oxygen free radicals, and hypoxic tissue is two to three times less sensitive to radiation than nonhypoxic tissue.17 There are four general chemotherapeutic approaches to mitigate hypoxia and enhance radiation efficacy:
Cell Death Pathway Effects
All of the above potential mechanisms of drug-radiation interaction display their efficacy through the consequences of cytotoxicity. However, recently it has become clear that there are several ways in which cytotoxicity is manifest. The Nomenclature Committee on Cell Death (NCCD)’s 2005 classification system,25 based purely on morphologic criteria, defined four modes of cell death: (type 1) apoptosis; (type 2) autophagy; (type 3) necrosis, or oncosis; and (type 4) mitotic catastrophe. Although these are distinct forms of cell death, the stimuli and processes involved are interrelated. There is also evidence that ionizing radiation can manifest its cytotoxicity by each type of cell death. As the understanding of the cell death pathways improves, novel therapeutics targeting each type could enhance radiation efficacy. The cell death mechanisms are briefly described below.
Apoptosis
Apoptosis is the most clearly defined and studied mechanism of cell death. This “programmed cell death” involves characteristic morphologic changes, including chromatin condensation (nuclear pyknosis) and nuclear fragmentation (karyorrhexis). Apoptotic bodies ultimately form, and the cell is removed through phagocytosis without generation of an inflammatory response. Apoptosis can occur with or without caspase activation26,27 and does not require DNA fragmentation,25 though this is a classic hallmark. Apoptosis is considered the major mechanism for chemotherapy-induced cell death. As a mechanism for radiation-induced cytotoxicity, apoptosis occurs readily in “liquid tumors” as opposed to most solid tumors, where apoptosis is a minor component of cell death. As such, drugs targeting the apoptosis pathway may enhance radiation cytotoxicity in solid tumors.
Autophagy
Whereas apoptosis is a clear self-destructive mechanism for a cell, the role of autophagy in cell death is more controversial. Autophagy, literally meaning “self-eating,” can provide a protective mechanism for a cell during times of stress (such as nutrient deprivation) because it allows recycling of cellular building blocks through controlled breakdown of cytoplasmic components. However, autophagic cell death does occur; it differs from apoptosis mainly because of the lack of chromatin condensation.25
Necrosis
Type 3 cell death, or necrosis, is a mechanism in which a cell swells (oncosis) until the plasma membrane ruptures and the cell contents are released, resulting in a local inflammatory response.25 The best example of this type of cell death is ischemic injury. Large, single-fraction radiation or radio-ablative doses can produce this type of cell death (e.g., stereotactic radiosurgery of brain lesions).
Analyzing Drug-Radiation Interactions
Several methodologies for determining the interaction between a drug and radiation have been detailed in the literature. Several definitions for possible interactions have also been described. The concept of radiosensitization originated many years ago, and classic radiosensitization has been defined as an increased amount of radiation-induced cell death that results from exposure to a second agent, after correction for the cytotoxicity of the agent. Clonogenic survival assay, which measures all forms of cell death as well as prolonged or irreversible cell cycle arrest, is the most encompassing method of measuring radiation cytotoxicity in vitro (Figure 4-3). Survival curves are generated by plating known quantities of cells, treating them with various doses of radiation and/or drug, and plotting the surviving fraction of colonies formed in a semilogarithmic fashion. Normalization is performed by dividing the surviving fraction for treated groups by the plating efficiency, which is defined as the surviving fraction of the untreated cells. Modification in radiosensitization, therefore, is demonstrated in clonogenic survival curve data in which a downward or leftward shift of the normalized surviving fraction implies a radiosensitizing interaction and an upward or rightward shift implies a radioprotective interaction. Although survival curves can show interaction between chemotherapy and irradiation, a better description of radiation modulation is necessary because neither chemotherapy nor radiation cytotoxicity typically follows a linear relationship.
One of the early attempts at providing a more descriptive system was by Tyrell.28 His system may be a better starting point for describing various interactions among therapies:
These terms seem to have been supplanted by the “additivity” descriptors, including supra-additive, additive, and infra-additive. Once again, the classic paper by Steel and Peckham7 describes the construction of an “envelope of additivity” for evaluating the interaction of two treatments using isobologram analysis. This envelope of additivity is constructed from cytotoxicity data by calculating a mode 1 curve that assumes that both agents have completely independent mechanisms of action as well as a mode 2 curve that assumes that the two agents have exactly the same mechanism of action (see Expert Consult website for isobologram construction detail). When combination therapy data points are plotted on the isobologram, they may fall between mode 1 and mode 2 (additive interaction; within the envelope), above mode 1 (infra-additive interaction), or below mode 2 (supra-additive, or synergistic, interaction). An idealized isobologram is shown in Figure 4-4, and a step-by-step method for constructing an isobologram is included on the Expert Consult website.
The following is a step-by-step procedure for calculating isobolograms using Steel and Peckham’s method7,29 (see Fig. 4-WO1).
Step 1. The investigator must choose to make the assessments at one level of cytotoxicity (e.g., construct an isobologram that represents the interaction of the agents for a cumulative cytotoxicity of 50%, 10%, or 1%). The example in Figure 4-3 depicts the chosen level of cytotoxicity as horizontal line Z: 1% cytotoxicity (0.01 surviving fraction) in this case.
Step 2. Plots are made of dose-response data for both agents. In Figure 4-WO1, the dose-response data for the two agents are represented by curves A and B.
Step 3. The extreme points of the envelope of additivity are determined. Initially, a separate cartesian graph is created. The y-axis represents the dose of agent B and the x-axis the dose of agent A. The first extreme point of the envelope is placed on the y-axis at the dose of agent B alone that causes a specific level of cytotoxicity, as determined by the dose-response curve of agent B, at the intersection of line Z (Fig. 4-WO1). The second extreme point of the envelope is placed on the x-axis, at the dose of agent A alone that results in the level of cytotoxicity at the intersection of the dose-response curve with line Z (Fig. 4-WO1).
Median Dose-Effect Principle
A mathematical modeling system that has gained fairly widespread use for interactions of cytotoxic agents is the median effect principle of Chou and Talalay.29,30,31 This system was derived from Michaelis-Menten equations and basic mass-action law considerations and has been useful for describing competitive enzyme interactions and interactions of cytotoxic agents. The primary relationship of the median effect principle is described by the following equation: fa/fu = (D/Dm)m, in which D is dose, fa is the fraction affected, fu is the fraction unaffected, Dm is the dose required to produce the median effect (50%), and m is a Hill-type coefficient used to describe the sigmoid nature of the curve. For first-order Michaelis-Menten kinetics, m = 1.
The general equation is y = mx + b.
A plot of log[(1/SF) – 1] on the y-axis and log(D) on the x-axis results in a line with a slope of m and a y-intercept of mlog(Dm). The survival curves for the individual agents and for the combination treatment (the individual agents given together in some fashion) can be fitted to the equation for a line by linear regression. If the interaction of two agents is assessed, three lines (i.e., median effect plots) are produced: one for each agent and one for the combination treatment. A graph of the median effect plots for mock individual agents A and B and for the combination of A and B is shown in Figure 4-5. For the combination treatment, D is the sum of the doses of the two agents given concomitantly; it is helpful to perform the experiments with the two agents given together in a fixed ratio of doses (e.g., 1 : 2). By using various total doses (i.e., the sum), with the agents given in the same ratio, it is possible to determine the contribution of the individual agents to the combination treatment in a later calculation.
This concept can be visualized in Figure 4-5. For instance, in the case of log[(1/SF) – 1] = 0, where SF is surviving fraction, the corresponding log(D), D indicating the sum of the doses of the two agents, can be calculated from the median effect plot for the combination treatment. An example of an actual combination treatment that has been assessed in this manner is radiation followed by a 24-hour exposure to etoposide.29 In this example, a set of experiments was performed with the dose ratio fixed as 32 Gy to 1 µg/mL of etoposide. In this example, the dose D that resulted in log[(1/SF) – 1] equaling a given value was a combination of radiation and etoposide given in the ratio of 32 : 1. The radiation and etoposide components could be discerned, from the median effect plot of the combination treatment, by dividing the resulting dose into the appropriate components based on the ratio of delivery of the two agents.
Definitions used in the median effect principle include the following:
For a mutually nonexclusive interaction,
in which
CI represents the doses of the agents required for a given effect when they are given together, divided by the doses required when the agents are given alone; in this way, CI less than 1 represents a synergistic interaction. A diagram of a CI plot for various levels of surviving fraction is shown in Figure 4-5.
Chemotherapy and Radiation Therapy and Combinations of Cytotoxic Agents
General Concepts
From the Bench to the Clinic
Occasionally, the process of quantifying interactions of chemotherapy and irradiation has frustrated clinicians attempting to interpret in vitro and in vivo laboratory information, as exemplified by Charles Moertel (quoted by Tannock32) in his keynote speech at the first International Conference on Combined-Modality Therapy in 1978:
This was not meant as disrespect for the radiobiology community but to point out that, at that time, the laboratory models were potentially quite different from the clinical setting. Because it has been difficult to extrapolate from laboratory results to clinical results, many clinicians have used combination treatments on a trial-and-error basis. However, the reverse order of study has occasionally been fruitful, and efficacious combinations of treatments demonstrated in clinical studies have inspired laboratory investigations that revealed interesting molecular bases of interaction.29,30 Translational research ideally occurs with a concept that arises from laboratory findings and subsequently is shown to have clinical efficacy. However, preclinical model systems have not always allowed investigators to take findings from the laboratory to the clinic, as indicated by the quotation of Moertel and by many of the early hypoxic cell sensitizer studies.
Therapeutic Benefits
Tannock32 mentioned another problem with translating findings from the laboratory to the clinical setting, emphasizing that investigators must not merely explore combinations of therapeutic agents to find synergistic interactions but must also find interactions that will produce a therapeutic benefit (e.g., provide greater cytotoxicity in tumor cells than in normal cells). To categorize potentially exploitable differences, Tannock32 described three main categories of biologic diversity between tumor cells and normal cells: tumor cells may display genetic instability compared with normal tissues; tumor cells and normal cells may be different with respect to cellular proliferation or proliferation that occurs after treatment; and environmental factors such as oxygenation and pH may affect tumor cells and normal cells differently. As findings are translated from the laboratory to the clinical setting, it is important to consider the effects of the host mechanisms on these three areas.
Chemotherapeutic Classes
In this section, several classes of systemic agents will be presented, followed by a brief review of clinical data describing combination treatment of these agents with radiation. There are a host of chemotherapeutic classes that are used in patients that will undergo radiation treatment. Although not all of these agents are used concurrently with radiation, it is helpful to understand their predominant mechanisms of action. Below is a brief description of several of the major classes of chemotherapeutics with some information regarding possible means of interaction with radiation. In addition, Figure 4-6 summarizes the cell cycle phase specificity of these agents.
Figure 4-6 Diagram of the cell cycle with the cell cycle phase dependence of various chemotherapeutics.
Antimetabolites
The origin of antimetabolite chemotherapy dates back to the 1940s, when aminopterin was used to treat pediatric leukemia.33 Since then, a large number of antimetabolite chemotherapeutics have been developed with tremendous success. The targets for these drugs include folate metabolism and nucleoside analogs. The major antimetabolites are presented below.
Fluoropyrimidines: Fluorouracil, Fluorodeoxyuridine, Capecitabine
The fluoropyrimidines, as the name implies, are halogenated pyrimidines that function as antifolates by inhibiting thymidylate synthesis. As mentioned previously in historical perspectives, 5-FU is one of the most established drugs used in combination with radiation. It has been used in both a bolus infusion as well as a continuous venous infusion when combined with radiation and appears to target the radioresistant cells in S phase.16 The two delivery methods have some differences in terms of side effect profile, but both seem to have good efficacy. In a phase III rectal cancer postoperative adjuvant chemoradiation trial, concurrent continuous infusion of 5-FU during external beam radiation therapy (EBRT) was more effective than the bolus delivery.34 Moreover, data show that 5-FU plasma levels and intracellular metabolite levels are rather short-lived,35 also suggesting a need for continuous administration of the drug for it to be effective with radiation. Because of this, oral formulations have been developed, most notably capecitabine, a fluoropyrimidine carbamate prodrug of 5-FU, which must be converted through the action of thymidine phosphorylase. In addition to the improved patient comfort of taking an oral medication rather than having an infusion pump, another potential advantage of capecitabine in combination with radiation is that it appears that radiation increases thymidine phosphorylase levels in tumors, allowing potential bioaccumulation of active metabolite within irradiated tumor.36,37
Gemcitabine
Gemcitabine is an analog of deoxycytidine that specifically functions during the S phase by preventing dNTP production. There is both preclinical and clinical evidence demonstrating dramatic radiation-sensitizing properties to combined gemcitabine and radiation.38,39–41