Mechthild Krause

Exploring the role of cancer stem cells in radioresistance

Radiobiological research over the past decades has provided evidence that cancer stem cell content and the intrinsic radiosensitivity of cancer stem cells varies between tumours, thereby affecting their radiocurability. Translation of this knowledge into predictive tests for the clinic has so far been hampered by the lack of methods to discriminate between stem cells and non-stem cells. New technologies allow isolation of cells expressing specific surface markers that are differentially expressed in tumour cell subpopulations that are enriched for cancer stem cells. Combining these techniques with functional radiobiological assays holds the potential to elucidate the role of cancer stem cells in radioresistance in individual tumours, and to use this knowledge for the development of predictive markers for optimization of radiotherapy.

Radiation oncology in the era of precision medicine

Technological advances and clinical research over the past few decades have given radiation oncologists the capability to personalize treatments for accurate delivery of radiation dose based on clinical parameters and anatomical information. Eradication of gross and microscopic tumours with preservation of health-related quality of life can be achieved in many patients. Two major strategies, acting synergistically, will enable further widening of the therapeutic window of radiation oncology in the era of precision medicine: technology-driven improvement of treatment conformity, including advanced image guidance and particle therapy, and novel biological concepts for personalized treatment, including biomarker-guided prescription, combined treatment modalities and adaptation of treatment during its course.

ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer

BACKGROUND AND PURPOSE Delineation of clinical target volumes (CTVs) is a weak link in radiation therapy (RT), and large inter-observer variation is seen in breast cancer patients. Several guidelines have been proposed, but most result in larger CTVs than based on conventional simulator-based RT. The aim was to develop a delineation guideline obtained by consensus between a broad European group of radiation oncologists. MATERIAL AND METHODS During ESTRO teaching courses on breast cancer, teachers sought consensus on delineation of CTV through dialogue based on cases. One teacher delineated CTV on CT scans of 2 patients, followed by discussion and adaptation of the delineation. The consensus established between teachers was sent to other teams working in the same field, both locally and on a national level, for their input. This was followed by developing a broad consensus based on discussions. RESULTS Borders of the CTV encompassing a 5mm margin around the large veins, running through the regional lymph node levels were agreed, and for the breast/thoracic wall other vessels were pointed out to guide delineation, with comments on margins for patients with advanced breast cancer. CONCLUSION The ESTRO consensus on CTV for elective RT of breast cancer, endorsed by a broad base of the radiation oncology community, is presented to improve consistency.

Three-Dimensional Cell Growth Confers Radioresistance by Chromatin Density Modification

Cell shape and architecture are determined by cell-extracellular matrix interactions and have profound effects on cellular behavior, chromatin condensation, and tumor cell resistance to radiotherapy and chemotherapy. To evaluate the role of chromatin condensation for radiation cell survival, tumor cells grown in three-dimensional (3D) cell cultures as xenografts and monolayer cell cultures were compared. Here, we show that increased levels of heterochromatin in 3D cell cultures characterized by histone H3 deacetylation and induced heterochromatin protein 1alpha expression result in increased radiation survival and reduced numbers of DNA double strand breaks (DSB) and lethal chromosome aberrations. Intriguingly, euchromatin to heterochromatin-associated DSBs were equally distributed in irradiated 3D cell cultures and xenograft tumors, whereas irradiated monolayer cultures showed a 2:1 euchromatin to heterochromatin DSB distribution. Depletion of histone deacetylase (HDAC) 1/2/4 or application of the class I/II pharmacologic HDAC inhibitor LBH589 induced moderate or strong chromatin decondensation, respectively, which was translated into cell line-dependent radiosensitization and, in case of LBH589, into an increased number of DSBs. Neither growth conditions nor HDAC modifications significantly affected the radiation-induced phosphorylation of the important DNA repair protein ataxia telangiectasia mutated. Our data show an interrelation between cell morphology and cellular radiosensitivity essentially based on chromatin organization. Understanding the molecular mechanisms by which chromatin structure influences the processing of radiation-induced DNA lesions is of high relevance for normal tissue protection and optimization of cancer therapy.

A novel poly(ADP-ribose) polymerase inhibitor, ABT-888, radiosensitizes malignant human cell lines under hypoxia

The chemo- and radioresponse of tumor cells can be determined by genetic factors (e.g., those that modify cell cycle arrest, DNA damage repair or cell death) and microenvironmental factors, such as hypoxia. Poly(ADP-ribose) polymerase (PARP) is a nuclear enzyme that rapidly recognizes and binds to DNA breaks to facilitate DNA strand break repair. Pre-clinical data suggest that PARP inhibitors (PARPi) may potentiate the effects of radiotherapy and chemotherapy. However, it is unclear as to whether PARPi are effective against hypoxic cells. We therefore tested the role for a novel PARPi, ABT-888, as a radiosensitizing agent under hypoxic conditions. Using human prostate (DU-145, 22RV1) and non-small cell lung (H1299) cancer cell lines, we observed that ABT-888 inhibited both recombinant PARP activity and intracellular PARP activity (86% to 92% decrease in all 3 cells lines following 2.5 microM treatment). ABT-888 was toxic to both oxic and hypoxic cells. When ABT-888 was combined with ionizing radiation (IR), clonogenic radiation survival was decreased by 40-50% under oxic conditions. Under acute hypoxia, ABT-888 radiosensitized malignant cells to a level similar to oxic radiosensitivity. To our knowledge, this is the first study to demonstrate that inhibition of PARP activity can sensitize hypoxic cancer cells and the combination of IR-PARPi has the potential to improve the therapeutic ratio of radiotherapy.

Cancer stem cells at the crossroads of current cancer therapy failures--radiation oncology perspective.

Despite continuous improvements in cancer management, locoregional recurrence or metastatic spread still occurs in a high proportion of patients after radiotherapy or combined treatments. One underlying reason might be a low efficacy of current treatments on eradication of cancer stem cells (CSCs). It has been recognised for a long time, that only the small subpopulation of CSCs can cause recurrences and that all CSCs need to be killed for permanent tumour cure. However, only recently novel technologies have allowed to enrich CSCs and to investigate their biology. An emerging experimental and clinical database provides first hints that cell populations accumulated by putative stem cell markers or tumours that highly express such markers may be more radioresistant than their marker-negative counterparts. Other data support a higher tolerance of CSCs to hypoxia and preferential location in specific microenvironmental niches. However, conflicting data, methodological problems of the assays and a generally small database on only few tumour types necessitate further large and well-designed prospective experimental and clinical investigations that specifically address this question to corroborate this hypothesis. If such investigations confirm biological differences between CSCs and non-CSCs, this would imply that novel treatment strategies need to be tested specifically for their effect on CSCs. Another implication is that also biomarkers for prediction of local tumour control after radiotherapy or combined treatments need to reflect the behaviour of CSCs and not of the bulk of all cancer cells. This review discusses the importance of CSCs for treatment failure and challenges occurring from the CSC concept for cancer diagnosis, treatment and prediction of outcome. It is concluded that CSC-based endpoints and biomarkers are eventually expected to considerably improve tumour cure rates in the clinics through individualised tailoring of treatment.

Cancer stem cells and radiotherapy

Purpose: The present work summarises the history and current status of research into the importance of cancer stem cells for radiobiological research and for clinical radiation oncology. An effort is made to differentiate clonogenicity from stemness of cancer cells. Conclusion: In radiooncology, cancer stem cells have been an important research field for five decades. Quantitative transplantation assays with evaluation of the take dose 50% (TD50) remain the gold standard to verify the stemness of the selected cells. New technologies allow sorting of tumour cells according to their surface marker expression and thereby selecting subpopulations that are enriched in cancer stem cells (e.g., CD133, CD44, CD29). While development of surface-marker-based assays is a highly important step in cancer-stem-cell research, to date there are still problems to be solved, e.g., the specifity of markers, adequate animal models, and optimised in vitro assays. Of special concern for radiobiology is that clonogenic in vitro assays do not necessarily measure stemness of cancer cells. This hampers investigations into the important question of whether cancer stem cells are more radioresistant than non-stem cells. The most extensive of the limited data on this topic relate to glioma stem cells identified by the surface marker CD133. These do not provide firm evidence for difference of radiosensitivity between stem and non stem cells. In spite of many problems to be solved, the combination of stem cell markers with radiobiological assays bears considerable promise for advancing translational research in radiation oncology.

EGF Receptor Inhibition Radiosensitizes NSCLC Cells by Inducing Senescence in Cells Sustaining DNA Double-Strand Breaks

The mechanisms by which inhibition of the epidermal growth factor receptor (EGFR) sensitizes non-small cell lung cancer (NSCLC) cells to ionizing radiation remain poorly understood. We set out to characterize the radiosensitizing effects of the tyrosine kinase inhibitor erlotinib and the monoclonal antibody cetuximab in NSCLC cells that contain wild-type p53. Unexpectedly, EGFR inhibition led to pronounced cellular senescence but not apoptosis of irradiated cells, both in vitro and in vivo. Senescence was completely dependent on wild-type p53 and associated with a reduction in cell number as well as impaired clonogenic radiation survival. Study of ten additional NSCLC cell lines revealed that senescence is a prominent mechanism of radiosensitization in 45% of cell lines and occurs not only in cells with wild-type p53 but also in cells with mutant p53, where it is associated with an induction of p16. Interestingly, senescence and radiosensitization were linked to an increase in residual radiation-induced DNA double-strand breaks irrespective of p53/p16 status. This effect of EGFR inhibition was at least partially mediated by disruption of the MEK-ERK pathway. Thus, our data indicate a common mechanism of radiosensitization by erlotinib or cetuximab across diverse genetic backgrounds. Our findings also suggest that assays that are able to capture the initial proliferative delay that is associated with senescence should be useful for screening large cell line panels to identify genomic biomarkers of EGFR inhibitor-mediated radiosensitization.

Combination of EGFR/HER2 Tyrosine Kinase Inhibition by BIBW 2992 and BIBW 2669 with Irradiation in FaDu Human Squamous Cell Carcinoma

Purpose:To investigate the effect of the dual EGFR/HER2 (ErbB2) tyrosine kinase inhibitors BIBW 2992 and BIBW 2669 on proliferation and clonogenic cell survival of FaDu human squamous cell carcinoma in vitro, and on tumor growth after single-dose irradiation in nude mice.Material and Methods:Cell proliferation, cell-cycle distribution and clonogenic cell survival after irradiation were assayed with and without BIBW 2992 or BIBW 2669 (3, 30, and 300 nM) in vitro. Tumor volume and tumor growth delay (GDV2) were determined in tumors growing in NMRI (nu/nu) nude mice, treated with (a) BIBW 2992 (20 mg kg–1 body weight orally), BIBW 2669 (3–4 mg kg–1 body weight orally) or carrier until a final tumor diameter of 15 mm, or, (b) 3 days before a 20-Gy single-dose irradiation or, (c) after a 20-Gy single-dose irradiation until reaching the final tumor diameter.Results:BIBW 2992 and BIBW 2669 significantly increased the doubling time of FaDu cells in vitro. A marked dose-dependent antiproliferative effect with blockade of the cells in G0/G1-phase of the cell cycle was found. Incubation with BIBW 2669 or BIBW 2992 for 3 days marginally increased radiosensitivity of FaDu cells in vitro. For BIBW 2992, this effect was statistically significant (p = 0.006). Daily oral application of BIBW 2669 or BIBW 2992 in mice bearing unirradiated FaDu tumors showed a marked antiproliferative effect with a significant prolongation of tumor growth delay (p < 0.0001). After drug application for 3 days, followed by 20-Gy single-dose irradiation, a slight effect of both drugs on tumor growth delay was seen. For BIBW 2669, this effect was statistically significant (p = 0.007). However, this effect disappeared when tumor volumes were normalized to the time point of irradiation suggesting that both drugs showed no or only a slight radiosensitizing effect in vivo. Daily application of BIBW 2669 or BIBW 2992 after a single-dose irradiation showed a clear inhibition of tumor growth with a significantly longer tumor growth delay after drug treatment compared to control tumors (p < 0.002). Enhancement ratios were smaller for irradiated than for unirradiated tumors, suggesting an additive effect for combinations with radiotherapy. In all treatment arms, the effects of BIBW 2669 were not significantly different from BIBW 2992.Conclusion:BIBW 2669 and BIBW 2992 showed a clear antiproliferative effect in vitro, whereas radiosensitization was only marginal. The present data are the first to show an effect of combined irradiation and dual EGFR/ErbB2 inhibition on tumor growth delay in vivo. Further preclinical investigations using fractionated irradiation schedules and local tumor control as experimental endpoint are needed to evaluate a possible curative potential for the combination treatment.Ziel:In der vorliegenden Arbeit wurde die Wirkung der neuen dualen EGFR/HER2-Tyrosinkinaseinhibitoren BIBW 2992 und BIBW 2669 auf die Zellproliferation und das klonogene Zellüberleben in der humanen Plattenepithelkarzinomlinie FaDu in vitro sowie auf das Tumorwachstum und die Tumorwachstumsverzögerung nach Einzeldosisbestrahlung in vivo untersucht.Material und Methodik:Zellproliferation, Zellzyklusverteilung und klonogenes Zellüberleben nach Bestrahlung wurden mit und ohne BIBW 2992 oder BIBW 2669 (3, 30 und 300 nM) in vitro untersucht. In NMRI-(nu/nu-)Nacktmäusen wurden Tumorvolumen und Tumorwachstumsverzögerung (GDV2) nach a) alleiniger Applikation von BIBW 2992 (20 mg kg–1 KG oral), BIBW 2669 (3–4 mg kg–1 KG oral) oder Kontrollsubstanz bis zur Tumorendgröße von 15 mm, b) 3-tägiger Substanzapplikation und folgender 20-Gy-Einzeldosisbestrahlung und c) 20-Gy-Einzeldosisbestrahlung bis zur Tumorendgröße bestimmt.Ergebnisse:BIBW 2992 und BIBW 2669 führten zu einer signifikanten Verlängerung der Verdopplungszeit von FaDu-Zellen in vitro (Abbildung 1, Tabelle 1). Der ausgeprägte dosisabhängige antiproliferative Effekt ging mit einem G0/G1-Block einher (Abbildungen 1 und 2). Die Inkubation mit BIBW 2669 und BIBW 2992 führte zu einer geringen Erhöhung der Strahlenempfindlichkeit von FaDu-Zellen in vitro (Abbildung 3). Dieser Effekt war für BIBW 2992 statistisch signifikant (p = 0,006). Die tägliche orale Applikation von BIBW 2669 oder BIBW 2992 führte bei unbestrahlten Tumoren in vivo zu einem deutlichen proliferationshemmenden Effekt (Abbildung 4) mit signifikanter Verlängerung der Tumorwachstumsverzögerung (p < 0,0001; Abbildung 6, Tabelle 2). Eine 3-tägige Substanzapplikation und anschließende 20-Gy-Einzeldosisbestrahlung zeigten einen geringen Effekt auf die Tumorwachstumsverzögerung. Für BIBW 2669 war dieser Effekt signifikant (p = 0,007). Der Effekt verschwand, wenn die Tumorvolumina zum Zeitpunkt der Bestrahlung normiert wurden (Abbildung 5). Für beide Substanzen konnte somit kein oder nur ein geringer strahlensensitivierender Effekt in vivo nachgewiesen werden. Eine Einzeldosisbestrahlung mit 20 Gy und anschließender Substanzapplikation bis zur Tumorendgröße führte zusätzlich zum Effekt der Bestrahlung zu einem deutlichen proliferationshemmenden Effekt mit signifikanter Verlängerung der Tumorwachstumsverzögerung im Vergleich zu Kontrolltumoren (p < 0,002). Die Verstärkungsratios waren bei bestrahlten Tumoren geringer als bei unbestrahlten Tumoren, was auf einen additiven Effekt der Substanzen schließen lässt. In allen Behandlungsarmen konnte zwischen BIBW 2669 und BIBW 2992 kein signifikanter Unterschied gefunden werden.Schlussfolgerung:BIBW 2669 und BIBW 2992 zeigten einen deutlichen antiproliferativen Effekt in vitro bei nur geringer Strahlensensitivierung. Die vorliegenden Daten haben erstmals die Wirkung einer kombinierten Bestrahlung und dualen EGFR/ ErbB2-Inhibition auf die Verzögerung des Tumorwachstums in vivo gezeigt. Weitere präklinische Untersuchungen mit einem fraktionierten Bestrahlungsschema und lokaler Tumorkontrolle als Endpunkt sind nötig, um ein mögliches kuratives Potential von BIBW 2669 oder BIBW 2992 in Kombination mit Strahlentherapie zu untersuchen.

CD8+ tumour-infiltrating lymphocytes in relation to HPV status and clinical outcome in patients with head and neck cancer after postoperative chemoradiotherapy: A multicentre study of the German cancer consortium radiation oncology group (DKTK-ROG)

We examined the prognostic value of tumour‐infiltrating lymphocytes (TILs) in patients with squamous cell carcinoma of the head and neck (SCCHN) after surgery and postoperative cisplatin‐based chemoradiotherapy. FFPE‐tissue originating from the surgery of 161 patients treated in 8 DKTK partner sites was immunohistochemically stained for CD3 and CD8. Their expression was correlated with clinicopathological characteristics as well as overall survival (OS), local progression‐free survival (LPFS) and distant metastases free‐survival (DMFS), also in the context of the HPV16‐DNA/p16 status. After a median follow‐up of 48 months (range: 4100 months), OS at 4 years was 46.5% for the entire cohort. In multivariate analysis, high CD8 expression was confirmed as an independent prognostic parameter for OS (p = 0.002), LPFS (p = 0.004) and DMFS (p = 0.006), while CD3 expression lacked significance. In multivariate analysis HPV16 DNA positivity was associated with improved OS (p = 0.025) and LPFS (p = 0.013) and p16‐positive patients showed improved DMFS (p = 0.008). Interestingly, high CD8 expression was a prognostic parameter for the clinical outcome in both HPV16 DNA‐positive and HPV16 DNA‐negative patients. Similar findings were observed in the multivariate analysis for the combined HPV16 DNA/p16 status. Altogether, CD8+ TILs constitute an independent prognostic marker in SCCHN patients treated with adjuvant chemoradiotherapy. These data indicate that CD8‐positive TILs have antitumour activity and could be used for treatment stratification. Further validation of the prognostic value of CD8+ TILs as a biomarker and its role in the immune response in SCCHN patients after adjuvant chemoradiotherapy is warranted and will be performed in the prospective DKTK‐ROG study.