Hypoxia-related radiotherapy resistance in tumours: treatment efficacy investigation in an eco-evolutionary perspective

In the study of therapeutic strategies for the treatment of cancer, eco-evolutionary dynamics are of particular interest, since characteristics of the tumour population, interaction with the environment and effects of the treatment, influence the geometric and epigenetic characterization of the tumour with direct consequences on the efficacy of the therapy and possible relapses. In particular, when considering radiotherapy, oxygen concentration plays a central role both in determining the effectiveness of the treatment and the selective pressure due to hypoxia. We propose a mathematical model, settled in the framework of epigenetically-structured population dynamics and formulated in terms of systems of coupled non-linear integro-differential equations, that aims to catch these phenomena and to provide a predictive tool for the tumour mass evolution and therapeutic effects. The outcomes of the simulations show how the model is able to explain the impact of environmental selection and therapies on the evolution of the mass, motivating observed dynamics such as relapses and therapeutic failures. Furthermore it offers a first hint for the development of therapies which can be adapted to overcome problems of resistance and relapses

A simple mathematical model of cyclic hypoxia and hypofractionated radiotherapy

There is now substantial evidence that the population of cells that experience fluctuating oxygen levels ("cyclic" hypoxia) are more radioresistant than chronically hypoxic ones and hence, this population likely determines radiotherapy (RT) response, in particular for hypofractionated RT, where reoxygenation may not be as prominent. A considerable effort has been devoted to examining the impact of hypoxia on hypofractionated RT; however, much less attention has been paid to cyclic hypoxia specifically and the role its kinetics may play in determining the efficacy of these treatments. Here, a simple model of cyclic hypoxia and fractionation effects was worked out to quantify this. Cancer clonogen survival was estimated using the linear quadratic model, modified to account for oxygen enhancement effects. An analytic approximation for oxygen transport away from a random network of capillaries with fluctuating oxygen levels was used to model inter-fraction tissue oxygen kinetics. Using relevant literature parameter values, inter-fraction fluctuations in oxygenation were found to result in an added 1-2 logs of clonogen survival fraction in going from five fractions to one for the same nominal biologically effective dose (i.e., excluding the effects of oxygen levels on radiosensitivity). Although significant, the loss of cell-killing with increasing hypofractionation is not nearly as large as previous estimates based on the assumption of complete reoxygenation between fractions. Most ultra-hypofractionated regimens currently in place offer sufficiently high doses to counter this loss of cell killing, although care should be taken in implementing single-fraction regimens

Impact of SBRT fractionation in hypoxia dose painting - Accounting for heterogeneous and dynamic tumor oxygenation

Purpose Tumor hypoxia, often found in nonsmall cell lung cancer (NSCLC), implies an increased resistance to radiotherapy. Pretreatment assessment of tumor oxygenation is, therefore, warranted in these patients, as functional imaging of hypoxia could be used as a basis for dose painting. This study aimed at investigating the feasibility of using a method for calculating the dose required in hypoxic subvolumes segmented on F-18-HX4 positron emission tomography (PET) imaging of NSCLC. Methods Positron emission tomography imaging data based on the hypoxia tracer F-18-HX4 of 19 NSCLC patients were included in the study. Normalized tracer uptake was converted to oxygen partial pressure (pO(2)) and hypoxic target volumes (HTVs) were segmented using a threshold of 10 mmHg. Uniform doses required to overcome the hypoxic resistance in the target volumes were calculated based on a previously proposed method taking into account the effect of interfraction reoxygenation, for fractionation schedules ranging from extremely hypofractionated stereotactic body radiotherapy (SBRT) to conventionally fractionated radiotherapy. Results Gross target volumes ranged between 6.2 and 859.6 cm(3), and the hypoxic fraction <10 mmHg between 1.2% and 72.4%. The calculated doses for overcoming the resistance of cells in the HTVs were comparable to those currently prescribed in clinical practice as well as those previously tested in feasibility studies on dose escalation in NSCLC. Depending on the size of the HTV and the distribution of pO(2), HTV doses were calculated as 43.6-48.4 Gy for a three-fraction schedule, 51.7-57.6 Gy for five fractions, and 59.5-66.4 Gy for eight fractions. For patients in whom the HTV pO(2) distribution was more favorable, a lower dose was required despite a bigger volume. Tumor control probability was lower for single-fraction schedules, while higher levels of tumor control probability were found for schedules employing several fractions. Conclusions The method to account for heterogeneous and dynamic hypoxia in target volume segmentation and dose prescription based on F-18-HX4-PET imaging appears feasible in NSCLC patients. The distribution of oxygen partial pressure within HTV could impact the required prescribed dose more than the size of the volume

Radiobiologically derived biphasic fractionation schemes to overcome the effects of tumour hypoxia

OBJECTIVE: As a fractionated course of radiotherapy proceeds tumour shrinkage leads to resolution of hypoxia and the initiation of accelerated proliferation of radioresistant cancer cells with better repair capacity. We hypothesise that, in tumours with significant hypoxia, improved tumour control could be achieved with biphasic fractionation schedules that either use acceleration after 3–4 weeks of conventional radiotherapy or deliver a higher proportional dose towards the end of a course of treatment. We conducted a modelling study based on the concept of biological effective dose (BED) comparing such novel regimens with conventional fractionation. METHODS: The comparator conventional fractionation schedule 70 Gy in 35 fractions delivered over 7 weeks was tested against the following novel regimens, both of which were designed to be isoeffective in terms of late normal tissue toxicity. 40 Gy in 20 fractions over 4 weeks followed by 22.32 Gy in 6 consecutive daily fractions (delayed acceleration) 30.4 Gy in 27 fractions over 4 weeks followed by 40 Gy in 15 fractions over 3 weeks (temporal dose redistribution) The delayed acceleration regimen is exactly identical to that of the comparator schedule over the first 28 days and the BED gains with the novel schedule are achieved during the second phase of treatment when reoxygenation is complete. For the temporal redistribution regimen, it was assumed that the reoxygenation fraction progressively increases during the first 4 weeks of treatment and an iterative approach was used to calculate the final tumour BED for varying hypoxic fractions. RESULTS: Novel fractionation with delayed acceleration or temporal fractionation results in tumour BED gains equivalent to 3.5–8 Gy when delivered in 2 Gy fractions. CONCLUSION: In hypoxic tumours, novel fractionation strategies result in significantly higher tumour BED in comparison to conventional fractionation. ADVANCES IN KNOWLEDGE: We demonstrate that novel biphasic fractionation regimens could overcome the effects of tumour hypoxia resulting in biological dose escalation

Evaluation by Monte Carlo Simulation of Doses Distribution in Tumors with Hypoxia

Radiotherapy is one of the most useful modalities applied for tumor treatments, which use ionization radiation to eradicate the tumor, in major cases. Cells with normal oxygenation are more sensitive to the effects of ionizing radiation than those with hypoxic conditions, because O2 molecules react rapidly with free radicals, produced by irradiation, originating highly reactive radicals. Thus, the different concentrations of hypoxia in tumors can modulate the response of the irradiation through the radioresistance they present and consequently the success of the treatment. This chapter deals with the dose distributions in cranial tumors with different concentrations of hypoxia through a code based on Monte Carlo simulation

Multiscale modelling of tumour growth and therapy: the influence of vessel normalisation on chemotherapy

Following the poor clinical results of antiangiogenic drugs, particularly when applied in isolation, tumour biologists and clinicians are now turning to combinations of therapies in order to obtain better results. One of these involves vessel normalisation strategies. In this paper, we investigate the effects on tumour growth of combinations of antiangiogenic and standard cytotoxic drugs, taking into account vessel normalisation. An existing multiscale framework is extended to include new elements such as tumour-induced vessel dematuration. Detailed simulations of our multiscale framework allow us to suggest one possible mechanism for the observed vessel normalisation-induced improvement in the efficacy of cytotoxic drugs: vessel dematuration produces extensive regions occupied by quiescent (oxygen-starved) cells which the cytotoxic drug fails to kill. Vessel normalisation reduces the size of these regions, thereby allowing the chemotherapeutic agent to act on a greater number of cells