SPECIAL SERIES: MATHEMATICAL ONCOLOGY
o iginal epo
Immunologic Consequences o Sequencing
Cance Radio he apy and Su ge y
Juan Ca los L´
opez Al onso, PhD
1
; Jan Poleszczuk, PhD
2
; Rachel Walke , PhD
3
; Sungjune Kim, MD, PhD
3
; Sha i Pilon-Thomas, PhD
3
;
Jose J. Conejo-Ga cia, MD, PhD
3
; Ha em Soliman, MD
3
; B ian Cze niecki, MD
3
; Louis B. Ha ison, MD
3
; and Heiko Ende ling, PhD
3
abs ac
PURPOSE Ea ly-s age cance s a e ou inely ea ed wi h su ge y ollowed by adio he apy (SR). Radio he apy
be o e su ge y (RS) has been widely igno ed o some cance s. We e alua e o e all su i al (OS) and disease-
ee su i al (DFS) wi h SR and RS o di e en cance ypes and simula e he plausibili y o RS- and SR-induced
an i umo immuni y con ibu ing o ou comes.
MATERIALS AND METHODS We analyzed a SEER da a se o ea ly-s age cance s ea ed wi h SR o RS. OS and
DFS we e calcula ed o cance s wi h su ficien numbe s o s a is ical powe (cance s o lung and b onchus,
esophagus, ec um, ce ix u e i, co pus u e i, and b eas ). We simula ed he immunologic consequences o SR,
RS, and adio he apy alone in a ma hema ical model o umo -immune in e ac ions.
RESULTS RS imp o ed OS o cance s wi h low 20-yea su i al a es (lung: haza d a io [HR], 0.88; P=.046)
and imp o ed DFS o cance s wi h highe su i al (b eas : HR = 0.64; P,.001). Fo ec al cance , wi h
in e media e 20-yea su i al, RS imp o ed bo h OS (HR = 0.89; P= .006) and DFS (HR = 0.86; P=.04).
Model simula ions sugges ed ha RS could inc ease OS by elimina ing cance o a b oade ange o model
pa ame e s and adio he apy-induced an i umo immuni y compa ed wi h SR o selec ed pa ame e
combina ions. This could c ea e an immune memo y ha may explain inc eased DFS a e RS o ce ain
cance s.
CONCLUSION S udy esul s sugges plausibili y ha adia ion o he bulk o he umo could induce a mo e obus
immune esponse and be e ha ness he syne gy o adio he apy and an i umo immuni y han pos su gical
adia ion o he umo bed. This explo a o y s udy p o ides mo i a ion o p ospec i e e alua ion o immune
ac i a ion o RS e sus SR in con olled clinical s udies.
Clin Cance In o m. © 2019 by Ame ican Socie y o Clinical Oncology
INTRODUCTION
Su ge y ollowed by adio he apy (SR) imp o es
loco egional con ol in nume ous locally ad anced
cance s,
1-3
making adio he apy a i al componen o
in en - o-cu e cance ea men .
4
Radio he apy ol-
lowed by su ge y (RS) e sus su ge y alone has
demons a ed imp o ed ou comes in bladde , ce -
ical, esophageal, ec al, and esec able panc ea ic
cance s. Clinical ials compa ing SR and RS ou -
comes a e sca ce and ha e been limi ed o a ew
cance ypes. One success ul example is ec al
ca cinoma,
5,6
whe e imp o ed local con ol a e RS
e sus SR (wi h o wi hou concu en chemo he apy)
was demons a ed and esul ed in a pa adigm shi
om SR o RS. Howe e , hese ials ha e ailed o
demons a e supe io o e all su i al (OS) a e RS.
Simila ly, in a p ospec i e ial o muscle-in asi e
bladde cance ,
7
no significan di e ence in 3-yea
s a is ics be ween RS and SR was ound. A sligh
inc ease in OS o pa ien s unde going RS compa ed
wi h SR was obse ed in so issue sa coma o he
limbs.
8
To da e, he ew published s udies compa ing adio-
he apy and su ge y sequencing seem inconclusi e. A
SEER analysis showed ha RS can be associa ed wi h
a significan ly highe isk o dea h in Siewe ype II
gas oesophageal junc ion cance when compa ed
wi h SR.
9
Howe e , o locally ad anced esophageal
cance , and squamous cell ca cinoma in pa icula ,
supe io i y o RS o e SR wi h concu en chemo-
he apy was demons a ed.
10
Re ospec i e analyses
ha e also shown supe io OS a e RS in s age III
non–small-lung cance
11
and in cT2 noninflamma o y
b eas cance wi h concu en chemo he apy.
12
The e a e also some indica ions ha RS can e-
duce he isk o local ecu ence in localized so
issue sa coma.
13
I is inc easingly app ecia ed ha adio he apy in-
c eases he mu a ional bu den and induces cell s ess
ASSOCIATED
CONTENT
Appendix
Da a Supplemen
Au ho a ilia ions
and suppo
in o ma ion (i
applicable) appea a
he end o his
a icle.
Accep ed on
No embe 27, 2018
and published a
ascopubs.o g/jou nal/
cci on Ap il 9, 2019:
DOI h ps://doi.o g/10.
1200/CCI.18.00075
1
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as well as immunogenic cell dea h, he eby exposing
a weal h o p e iously hidden and de no o umo -associa ed
an igens, s ess p o eins, and dange -associa ed molecula
pa e ns o he immune sys em.
14-18
Tumo -infil a ing lym-
phocy e en ichmen a e adio he apy was p e iously
assessed in 40 pa ien s wi h ec al cance . The densi ies o
CD3
+
and CD8
+
T-lymphocy es significan ly inc eased om
p e adio he apy biopsy specimens o pos adio he apy
su gically esec ed specimens.
19
I is concei able ha
immune- ela ed benefi s o adia ion o he bulk umo
compa ed wi h adia ion o he pos su gical ca i y could be
gene al phenomena e en in ea ly-s age disease. He ein, we
e alua e OS and disease- ee su i al (DFS) ou come da a
o a ious cance s and p esen a quan i a i e amewo k o
simula e umo –immune sys em dynamics du ing he di -
e en ea men sequences, which u he suppo s he
plausibili y o inc eased an i umo immuni y wi h RS com-
pa ed wi h SR.
MATERIALS AND METHODS
SEER Analysis
We que ied he SEER da abase (No embe 2016 sub-
mission wi h addi ional ea men in o ma ion) o local-
ized cance s (no lymph node in ol emen and no
me as asis; N0M0) wi h a leas 100 cases o each o RS
and SR and a ailable in o ma ion abou po en ially con-
ounding co a ia es (Fig 1A). These included cance s o
he lung and b onchus, esophagus, ec um, ce ix u e i,
co pus u e i, and b eas . We selec ed pa ien s who e-
cei ed ei he RS o SR and censo ed he ollow-up pe iod
o 20 yea s. DFS was calcula ed as p e iously discussed.
19a
Haza d a ios (HRs) o DFS and OS adjus ed o age, sex,
yea o diagnosis, his ology, ype o su ge y, umo size, and
ea men sequencing (RS SR) we e calcula ed using
mul i a iable Cox p opo ional haza d models.
20
Modeling o Tumo –Immune Sys em Dynamics Du ing SR
and RS
Ma hema ical modeling o umo –immune sys em in-
e ac ions has a long his o y.
21,22
The es ablished
Kuzne so model cap u es fi s -o de p inciples un-
de lying he complex disease dynamics and has been
calib a ed agains expe imen al da a.
21
This model elies
on he ollowing main assump ions: umo s ollow logis ic
g ow h dynamics, whe e ini ially exponen ial g ow h
decele a es as he umo app oaches he issue-ca ying
capaci y; umo g ow h is modula ed by he cy o oxic
ac ion o immunocompe en e ec o T cells as pa o
specific adap i e immune esponses; cy o oxic e ec o
T cells a e ec ui ed in esponse o umo bu den ol-
lowing Michaelis-Men en dynamics; umo -infil a ing
e ec o T cells may ge exhaus ed by hei an i umo
ac i i y and unde go spon aneous dea h; and inna e
immuni y o base immune su eillance is ep esen ed as
a baseline p esence o e ec o T cells a any ime, e en in
he absence o umo cells.
We ex ended he Kuzne so model o explo e he po-
en ial benefi s and immunologic consequences o a-
dio he apy and su ge y sequencing, on he basis o
he ollowing addi ional assump ions: adio he apy kills
bo h cance and e ec o T cells
23,24
a di e en a es
de e mined by he adia ion dose and cell ype–specific
adiosensi i i y by some o ms o cell dea h, including
au ophagy, apop osis, nec osis, mi o ic ca as ophe,
and senescence; i adia ed umo cells may unde go
immunogenic cell dea h ha emi s immunos imula ing
signals and chemokines, esul ing in he ec ui -
men o inflamma o y immune cells o he umo mi-
c oen i onmen , including an igen-p esen ing cells
such as dend i ic cells and mac ophages, which in
u n ec ui and ac i a e cy o oxic e ec o T cells
15,25-28
;
he s eng h o adio he apy-induced an i umo e-
sponse, cha ac e ized by subsequen immune cell
infil a ion o he umo , is assumed o depend on
he numbe o umo cells killed by adio he apy;
and su gical esec ion is simula ed by ins an a-
neously dec easing bo h cance and e ec o cell
popula ions.
We deno ed he numbe o iable cance cells (o clo-
nogens) in an a bi a y umo olume as C( ), umo -
infil a ing ac i a ed immune e ec o T cells as E( ), and
i adia ed cance cells unde going immunogenic cell dea h
as D( ). The model was o mula ed as a sys em o o dina y
di e en ial equa ions gi en by dC/d = ( umo g ow h) −
(dea h o umo cells by e ec o T cells) −( adio he apy) −
(su gical esec ion), o
dC
d  C1−C+D
k−apEC −δτiTR ,d,C
−δτjTS ,C(1)
by dE/d = ( umo bu den–s imula ed e ec o T-cell e-
c ui men ) −(exhaus ion o e ec o T cells by hei an i-
umo ac ion) + (physiologic le el and decay o e ec o
T cells) + ( adio he apy-induced immunos imula ion) −
( adio he apy) −(su gical esec ion), o
dE
d  C
g+CE−a1−pEC +hEp−E+qD
−δτiTR ,d,E−δτjTS ,E(2)
and by dD/d = ( umo cell s e ilized by adio he apy) −
(lysis o umo cells s e ilized by adio he apy), o
dD
d δτiTR ,d,C−nD (3)
whe e he ime coo dina e on he sys em a iables was
omi ed o no a ional simplici y. δ(τ)is heDi acdel a
unc ion. Fo demons a ion pu poses, we chose p e iously
epo ed specific model pa ame e alues ha simula e
a g owing umo and associa ed e ec o cell dynamic in he
L´
opez Al onso e al
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absence o he apy (Table 1). Fo analysis, we changed model
pa ame e s ha may ep esen he pa ien -specific biology o
indi idual pa ien s, including di e en human leukocy e
an igen haplo ypes o inc eased mu a ional bu den
o di e en cance s ha may ansla e in o highe
immunogenici y.
The cy o oxic e ec o adio he apy on cance cells was
simula ed using he linea quad a ic (LQ) model ha is
A
Reco ds o pa ien s wi h cance o b eas , ce ix u e i, co pus
u e i, ec um, esophagus, o lung and b onchus
(N = 3,483,681)
Excluded in o al (n = 3,254,384)
(n = 583,418)
(n = 1,851,801)
(n = 708,477)
(n = 7)
(n = 1,028)
(n = 28,403)
(n = 5,273)
(n = 3,706)
(n = 72,271)
P io cance
Regional o dis an disease
Did no ecei e RT in adju an o
neoadju an se ing
Unknown age a diagnosis
Unknown ace
Incomple e da es
Missing da a on second p ima y
Unable o calcula e cance - ee su i al
Unknown/unde ined alue o ≥ 1 co a ia e
in mul i a iable analysis
B
5101520
Follow-Up (yea s)
Su i al (p obabili y)
0
0.25
0.50
0.75
1.00
B eas
Ce ix u e i
Co pus u e i
Rec um
Esophagus
203,151 124,384 59,965 19,284 5,380
2,769 1,461 738 252 81
11,940 5,709 2,652 1,068 355
8,136 4,316 1,767 480 129
795 249 107 31 3
2,506 752 251 61 15
No. a isk:
Lung and b onchus
Su ge y ollowed
by adia ion (SR)
B eas
Ce ix u e i
Co pus u e i
Rec um
Esophagus
Lung and b onchus
(n = 221,231)
(n = 201,631)
(n = 2,444)
(n = 11,745)
(n = 3,142)
(n = 189)
(n = 2,080)
B eas
Co pus u e i
Rec um
Lung and b onchus
Ce ix u e i
Esophagus
Radia ion ollowed
B eas
Ce ix u e i
Co pus u e i
Rec um
Esophagus
Lung and b onchus
(n = 8,066)
(n = 1,520)
(n = 325)
(n = 195)
(n = 4,994)
(n = 606)
(n = 426)
by su ge y (RS)
0.56
0.54
0.37
0.30
0.13
0.04
FIG 1. (A) SEER in-
clusion/exclusion. (B)
Kaplan-Meie 20-yea
su i al.
Sequencing Cance Radio he apy and Su ge y
JCO Clinical Cance In o ma ics 3
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widely used in clinical applica ions
32-34
o app oxima e he
dose-dependen su i ing ac ion SF(d) o i adia ed
cance cells by
SFde−ξ(αd+βd2)(4)
whe e d(Gy) is he adia ion dose and α(Gy
−1
) and β(Gy
−2
)
a e cell ype–specific adiosensi i i y pa ame e s. Com-
pelling e idence demons a es ha hypoxic (poo ly oxy-
gena ed) cance cells a e g ow h a es ed and es ima ed o
be app oxima ely h ee imes mo e esis an o adia ion
han no moxic cycling cells.
30,35
We se ξ=1o ξ= 1/3 o
espec i ely scale he adiosensi i i y o p oli e a i e and
quiescen cance cells as p e iously demons a ed.
30,36
We
se adiosensi i i y pa ame e s α=0.3Gy
−1
and β=0.03Gy
−2
as con en ionally assumed and es ima ed o a a ie y o
umo ypes.
29
The p obabili ies o su i ing 2 Gy adia-
ion we e SF (2 Gy) = 0.49 o p oli e a ing cance cells
(ξ= 1) and SF (2 Gy) = 0.79 o quiescen cance cells
(ξ=1/3).
E ec o T-cell adiosensi i i y was es ima ed on he basis
o expe imen al da a o adio he apy-induced apop osis
in lymphocy es ob ained om blood samples.
37
Apo-
p osis is conside ed one o he dominan cell dea h
p ocesses in esponse o adio he apy,
38
and co ela ion
be ween he in ensi y o apop osis in lymphocy es and
adia ion dose has been epo ed.
37,39
F om dose-
esponse cu es o e ec o CD8
+
T cells in i o a e
exposu e o acu e doses o 0 o 8 Gy,
37
we de i ed SF
E
(2 Gy) = 0.61.
Radio he apy was simula ed wi h a o al dose o 50 Gy
deli e ed in 25 weekday ac ions o d= 2 Gy pe day. The
o al dose o 50 Gy was chosen o demons a ion pu poses
in line wi h he s anda d dose o b eas cance , he la ges
pa ien coho in he SEER da a. Ex ension o he analysis o
o he o al doses was s aigh o wa d and did no al e he
esul s o his s udy (Appendix Fig A1). A e logis ic umo
g ow h and he LQ model in Equa ion 4,
32,40
he ac ion o
cance cells (C) s e ilized by adio he apy wi h dose da
ime τ
i
was de e mined by he loss e m T
R
(τ
i
,d,C)in
Equa ion 1 gi en by
TRτi,d,C1−SFpdCτi1−Cτi+Dτi
k
+1−SFqdCτiCτi+Dτi
k
(5)
whe e he e ms C(τi)1−C(τi)+D(τi)
kand C(τi)C(τi)+D(τi)
ka e
he numbe o p oli e a ing and quiescen cance cells a
ime τ
i
such ha hei sum is equal o C(τ
i
). The adiobi-
ologic e ms 1 −SF
p
(d) and 1 −SF
q
(d) ep esen e-
spec i ely he ac ion o p oli e a ing and quiescen cance
cell s e ilized by adio he apy wi h dose dand de e mined
by he LQ model in Equa ion 4.
TABLE 1. O e iew o Model Pa ame e s and Values Used in Simula ions
Pa ame e Desc ip ion Value Uni Fi s Au ho
Tumo g ow h a e (1.0 - 4.0) ×10
−1
Day
−1
Poleszczuk
22
kTumo issue ca ying capaci y 5.32 ×10
8
Cells Poleszczuk
22
aT cell–cance cell in e ac ions cons an 0.14 ×10
−6
Day
−1
cells
−1
Poleszczuk
22
pP obabili y ha du ing T cell–cance cell
in e ac ions he la e is killed
9.98 ×10
−1
Dimensionless Poleszczuk
22
Magni ude o immune sys em s imula ion
by he p esence o cance cells
(1.0 - 3.0) ×10
−1
Day
−1
Poleszczuk
22
gImmune s imula ion damping coe ficien 0.16 ×10
6
Cells Poleszczuk
22
hE ec o cells decay a e 5.9 ×10
−1
Day
−1
Poleszczuk
22
E* Physiologic le el o e ec o cells 0.3 ×10
6
Cells Poleszczuk
22
αRadia ion sensi i i y pa ame e 0.3 Gy
−1
Gue e o
29
βRadia ion sensi i i y pa ame e 0.03 Gy
−2
Gue e o
29
ξCance cell adia ion esis ance 1 (p oli e a ing cells) Dimensionless Ende ling
30
1/3 (quiescen cells)
qRT-induced immunos imula ion (0.0 −6.5) ×10
−1
Day
−1
Assumed o demon-
s a ion pu pose
nLysis a e o umo cells killed by RT 6.9 ×10
−1
Day
−1
E imie
31
Abb e ia ion: RT, adio he apy.
L´
opez Al onso e al
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The loss e m T
R
(τ
i
,d,E) in Equa ion 2 simula es he killing
e ec s o adio he apy on e ec o T cells (E) a ime τ
i
and is
gi en by
TRτi,d,E1−SFEdEτi(6)
Su gical esec ion was simula ed by ins an aneously de-
c easing bo h cance and e ec o cell popula ions by 99%.
A he ime o su ge y τ
j
, emo al o cell popula ions was
inco po a ed in he model by he ollowing loss e ms
TSτj,CλCCτj(7)
TSτj,EλEEτj(8)
whe e su gical esec ion was simula ed wi h λ
C
=λ
E
= 0.99.
A e su gical esec ion, he dynamics o emaining cell
popula ions, i any, con inued o be go e ned by Equa ions
1 o 3. Model simula ions we e ini ialized wi h 10
6
iable
cance cells (o clonogens) and 10
5
e ec o T cells in an
a bi a y umo olume. Tumo –immune sys em in e ac ion
dynamics we e simula ed o di e en combina ions o
umo g ow h a e ( ) and ec ui men o e ec o T cells in
esponse o umo bu den ( ). Combina ions o pa ame e s
and ha yielded an inc ease o cance cells .10
8
we e
conside ed o ea men simula ions. No e ha his
numbe ep esen s iable cance cells in a umo ha may
ha e conside ably la ge adiog aphic olumes. Tumo
con ol (TC) was assumed i he numbe o iable cance
cells d opped below C( ) ,1. The ma hema ical model was
simula ed using Ma lab (www.ma hwo ks.com).
RESULTS
OS and DFS o RS and SR
Cance si es we e e alua ed o 20-yea OS (Fig 1B)and
DFS (Appendix Fig A2). A end o RS benefi e sus SR
became appa en when cance s we e so ed by hei
20-yea OS (DFS eg ession coe ficien , −0.69; P,.05;
OS eg ession coe ficien , +0.35; P,.05; Fig 2). Fo
cance s o he lung and b onchus (n = 2,506), RS yielded
significan lyimp o edOS(HR=0.88;P= .046; 20-yea
su i al, 6.2% 2.5%; Fig 2B). Al hough an OS benefi
was no obse ed in b eas cance (n = 203,151) wi h high
baseline 20-yea OS a es, RS yielded a significan im-
p o emen in DFS (HR = 0.64; P,.001; Fig 2A). In-
e es ingly, pa ien s wi h ec al cance (n = 8,136) wi h an
in e media e 20-yea su i al a e o 30% may benefi
om RS, wi h bo h inc eased OS (HR = 0.89; P= .006)
and DFS (HR = 0.86; P= .04). C ucially, RS was no ound
o be significan ly in e io o SR in any o he mul i a iable
Cox p opo ional model analyses (Da a Supplemen ).
Analysis o p opensi y sco e–ma ched coho s is shown in
Appendix Figu e A3.
E ec s o T ea men O de Negligible Wi hou Simula ed
Radio he apy-Induced Immuni y
The e ec i eness o adio he apy in elimina ing cance may
esul om a combina ion o he le hal e ec o adio he apy
and s imula ion o an i umo immuni y. We fi s simula ed
ea men s wi hou addi ional adio he apy-induced im-
muni y (q= 0 day
−1
in Equa ion 2). Simula ions o SR and
RS yielded simila ou comes, wi h umo con ol (TC) being
dependen on umo g ow h a e and p e ea men umo
size. In e es ingly, adio he apy alone could no elimina e
Lung and
b onchus Rec um
HR = 0.86
P = .04
B eas
HR = 0.64
P < .001
Co pus u e i
Esophagus
Ce ix u e i
0.5
0.6
0.7
0.8
0.9
1.0
1.1
1.2
1.3
1.4
1.5
0 102030405060
20-Yea OS (%)
DFS HR (neoadju an adju an RT)
A
HRDFS = –0.69* DFS20y + 1.08†
20-Yea OS (%)
Lung and
b onchus
HR = 0.88
P = .046
Rec um
HR = 0.89
P = .006
B eas
Co pus u e i
Esophagus
Ce ix u e i
0.5
0.6
0.7
0.8
0.9
1.0
1.1
1.2
1.3
1.4
1.5
0 102030405060
OS HR (neoadju an adju an RT)
B
HROS = 0.35* OS20y + 0.84†
FIG 2. Haza d a ios (HRs; wi h 95% CIs, P alues, and linea leas squa es eg ession lines weigh ed by he in e ses o si e-specific CIs) o (A)
disease- ee su i al (DFS) and (B) o e all su i al (OS) a e p eope a i e (neoadju an ) RT (RS) compa ed wi h pos ope a i e (adju an ) RT (SR). HRs
we e adjus ed o age, sex, yea o diagnosis, his ology, ype o su ge y, ype o applied adia ion, and umo size. Equa ion desc ibes he end line, and
coe ficien s we e es ed o significan di e ence om 0 using es . (*) P,.05. (†)P,.001. RT, adio he apy
Sequencing Cance Radio he apy and Su ge y
JCO Clinical Cance In o ma ics 5
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umo s wi h as ew as 10
7
p e ea men iable cance cells
(Fig 3).
RS Imp o es Ou comes Wi h
Radio he apy-Induced Immuni y
Because adio he apy-induced cy o oxici y alone was un-
likely o e adica e all cance cells wi h he chosen adio-
sensi i i y pa ame e s, bu adio he apy o en s e ilized
la ge umo s wi h p esumably .10
7
iable cance cells,
clinically obse ed comple e umo e adica ion may de-
pend on he s eng h o adio he apy-induced an i umo
immuni y ac i a ion (q, day
−1
in Equa ion 2). The e ficacy o
adio he apy alone and RS bu no SR inc eased wi h in-
c eased adio he apy-induced immuni y (q=0.25 o
0.65 day
−1
). In addi ion, o s ong adio he apy-induced
an i umo immuni y, adio he apy alone esul ed in be e
ou comes han SR. RS yielded TC o mo e model pa-
ame e combina ions han adio he apy alone and SR
(Fig 4). Fo SR, inc eased adio he apy-induced immu-
nos imula ion had no no able impac on ou comes, be-
cause a majo i y o umo cells we e emo ed p ei adia ion,
and adio he apy-induced an i umo immuni y was no
su ficien ly achie ed. The benefi o adio he apyalone
and RS o e SR was independen o he o al numbe o
adia ion ac ions (Appendix Fig A1) and insensi i e o
changes in o he model pa ame e s (Appendix Figs A4
o A6).
RS Induces S onge An i umo Immuni y Than SR
A e su ge y, adia ion is deli e ed wi h he in en o
e adica e esidual cance cells o mic oscopic umo s in he
umo bed beyond he su gical ma gins. Compa ed wi h
SR RSRT alone
TC by ea men PD
1.0 × 107
1.0 × 108
P e ea men Viable Cance Cells C
( )
A
B
108
106
104
102
100
No. o Cells
–17 0 34 68 102
Time (days)
(RT)
108
106
104
102
100
No. o Cells
–20 –10 0 10 20 30
Time (days)
(SR)
108
106
104
102
100
No. o Cells
–20 –10 0 10 20 30
Time (days)
(RS)
(day–1)
(day–1) (day–1)
(day–1) (day–1)
(day–1) (day–1)
0.3
0.2
0.1
0.3
0.2
0.1
0.1 0.2 0.3 0.4
0.3
0.2
0.1
0.3
0.2
0.1
TC PD
(day–1) (day–1)
(day–1) (day–1) (day–1)
0.1 0.2 0.3 0.4
0.3
0.2
0.1
0.3
0.2
0.1
0.1 0.2 0.3 0.4
0.1 0.2 0.3 0.4 0.1 0.2 0.3 0.4 0.1 0.2 0.3 0.4
RTViable cance cells C( ) E ec o cells E( )
FIG 3. (A) Model-p edic ed ea men ou comes o adio he apy (RT) alone, RT a e su gical esec ion (SR), and RT be o e su gical esec ion (RS) wi hou
RT-induced immuni y (ie, q= 0.0 day
−1
in Equa ion 2) in a coho o i ual pa ien s wi h di e en combina ions o p e ea men umo size, umo g ow h a e
( ), and immune ec ui men a e ( ) in esponse o umo bu den. Radia ion is deli e ed o a o al dose o 50 Gy in 25 daily ac ions a 2 Gy pe day, 5 days pe
week. Tumo con ol (TC) by ea men (blue) and p og essi e disease (PD; ed) e e o umo e adica ion and escape a e ea men , espec i ely. (B) Time
e olu ion o umo and e ec o T cells co esponding o he loca ion ma ked by s a s in panel A.
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SR RSRT alone
TC by ea men PD
2.5 × 10–1
4.5 × 10–1
RT-Induced Immunos imula ion q (day
–1)
A
B
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
108
106
104
102
100
No. o Cells
–27 0 27 54 81 108
Time (days)
(RT)
–27 0 27 54 81 108
Time (days)
(SR)
–27 –14 0 14 27
Time (days)
(RS)
–27 –14 0 14 27
Time (days)
(RT)
–27 0 27 54 81 108
Time (days)
(SR)
–27 –14 0 14 27
Time (days)
(RS)
–17 0 17 34 6851
Time (days)
(RT)
–170 17345168
Time (days)
(SR)
–17 0 17 34
Time (days)
(RS)
(day–1)
(day–1) (day–1) (day–1)
(day–1) (day–1) (day–1)
(day–1) (day–1) (day–1)
0.3
0.2
0.1
0.3
0.2
0.1
0.1 0.2 0.3 0.4
6.5 × 10–1
0.3
0.2
0.1
0.3
0.2
0.1
TC
PD
(day–1)
0.1 0.2 0.3 0.4
0.3
0.2
0.1
0.3
0.2
0.1
(day–1)
0.1 0.2 0.3 0.4
(day–1)
0.1 0.2 0.3 0.4
(day–1)
0.1 0.2 0.3 0.4
(day–1)
0.1 0.2 0.3 0.4
RT
E ec o cells E( )
Viable cance cells C( )
(day–1)
0.3
0.2
0.1
0.1 0.2 0.3 0.4
0.3
0.2
0.1
(day–1)
0.1 0.2 0.3 0.4
0.3
0.2
0.1
(day–1)
0.1 0.2 0.3 0.4
Sequencing Cance Radio he apy and Su ge y
JCO Clinical Cance In o ma ics 7
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RS, SR implied a significan ly smalle numbe o cance
cells o adio he apy-induced immune ac i a ion. The
in eg al o he e m qD in Equa ion 2 simula ed he numbe
o e ec o cells ec ui ed o he umo . Simula ion analysis
confi med ha he s eng h o umo -specific immuni y
induced by RS was significan ly highe han ha induced by
SR (Figs 5A and 5B). This may con ibu e o bo h inc eased
OS a es and inc eased an i umo immuni y, which may
su eil me as a ic deposi s ou side he i adia ion field
(abscopal esponse) o inc ease DFS (compa e wi h Fig 2).
Radio he apy-Induced Immuni y Sugges s Plausibili y o
RS Dose De-escala ion
No mal issue oxici y emained a limi ing ac o in adio-
he apy, wi h acu e and la e oxici ies la gely being a ib-
u able o o al adia ion dose and dose pe ac ion. Model
simula ions sugges ed ha o high a es o adio he apy-
induced immuni y, RS wi h 2 Gy pe ac ion may be e-
duced o as low as hal he numbe o RS ac ions o
ou comes compa able o he ull cou se o SR (12- ac ion
RS 25- ac ion SR; Fig 5C). Lowe immunogenici y may
equi e .13 ac ions bu po en ially p o ides TC p oba-
bili y wi h ewe ac ions han SR. Fo high a es o
adio he apy-induced immuni y, adio he apy alone may
be a po en ial al e na i e o SR, wi h compa able TC a es
(Fig 5D).
DISCUSSION
Accumula ing e idence suppo s he no ion ha
adio he apy-induced an i umo immuni y, especially when
p omo ed wi h concu en immuno he apy, could esul in
long- e m memo y
41,42
and may yield obus sys emic im-
mune esponses agains me as a ic ese oi s ou side
he i adia ion field, a phenomenon e med he abscopal
e ec .
43-45
Radio he apy may no longe be conside ed
a pu ely cy o oxic ea men ; a he , i has biologic p op-
e ies o ans o m he umo in o an in si u accine.
46
The
clinical p omise o he complex bu p omising immune-
adia ion syne gy is eflec ed in .100 ac i e clinical ials
es ing he combina ion o adio he apy wi h immuno-
he apy, mos ly o me as a ic cance .
47
A obus immune
esponse a e ocal i adia ion may equi e a su ficien ly
la ge popula ion o cance cells o ac i a e immune cells in
numbe s la ge enough o dissemina e sys ema ically and
es ablish an immunologic memo y. The he ein p esen ed
model simula ions sugges a posi i e co ela ion be ween
adio he apy-induced an i umo immuni y and umo size a
ime o i adia ion and may explain he poo e local ou comes
achie ed wi h SR compa ed wi h RS. A e su gical esec ion
wi h clean ma gins, adio he apy will, a bes , ac upon
mic oscopic umo clus e s in he umo bed, which may be
insu ficien o elici a obus immune esponse.
Fo cance s wi h poo OS a es e en when de ec ed ea ly
(cance s o lung and b onchus, esophagus, ec um), RS
may inc ease OS compa ed wi h SR because o addi ional
cy o oxici y esul ing om he inc eased immune ac i a ion.
Fo umo s wi h highe OS a es (b eas , ec um), benefi s
o RS can be seen in DFS, a guably because o highe
an i umo immuni y ha may also ac sys emically agains
umo s ou side he i adia ion field and u u e disease.
22
Fo
some umo s, no significan ou come benefi s we e ob-
se able o ei he sequencing o adio he apy and su ge y.
Howe e , ends owa d inc eased OS o cance s wi h low
su i al a es ( eg ession coe ficien , −0.65; P,.05) as
well as inc eased DFS o cance s wi h high su i al a es
( eg ession coe ficien , 0.35; P,.05) we e no ed.
One inhe en limi a ion o SEER da a analysis is composed
o he po en ially con ounding ac o s ha a e no eco ded,
including pa ien selec ion c i e ia. Pa ien s eligible o RS
may be disp opo ionally ea ed in clinical ials and hus
could ep esen a subs an ially di e en popula ion han
pa ien s unde going SR. Mo eo e , RS may be p e e en-
ially pe o med by academic, high- olume cen e s ha
o en p o ide be e ou comes in gene al. To add ess he
issue o unbalanced a ms, we pe o med mul i a ia e Cox
p opo ional haza ds model analysis a e p ep ocessing
he da a wi h p opensi y sco e ma ching on he basis o all
conside ed co a ia es.
48
These da a a e compa able o he
esul s ob ained o he whole coho s (Appendix Fig A3).
Di e en ma hema ical models ha e been p oposed o
simula e umo –immune sys em in e ac ions
21,22,49-59
and
he syne gis ic e ec s o adio he apy wi h he immune
sys em and immuno he apy.
22,60-63
To demons a e im-
munologic consequences o sequencing adio he apy and
su ge y, we ex ended he es ablished Kuzne so model and
i s pa ame e iza ion as p e iously discussed.
21,22
Model
simula ions e ealed ha obse able clinical esponses
may be pa ame e dependen , and as such, he model
needs o be igo ously calib a ed o indi idual cance s
be o e defini e conclusions can be d awn.
Taken oge he , he s a is ical analysis o his o ical ou come
da a and he ma hema ical model combine o u he add o
he g owing in e es in unde s anding he biologic and
immunologic consequences o adio he apy. This s udy
FIG 4. (A) Model-p edic ed ea men ou comes o adio he apy (RT) alone, RT a e su gical esec ion (SR), and RT be o e su gical esec ion (RS) o umo s
o 10
8
iable cance cells p e ea men and inc easing s eng h o RT-induced immunos imula ion (q, day
−1
in Equa ion 2) in a coho o i ual pa ien s wi h
di e en combina ions o umo g ow h a e ( ) and immune ec ui men a e ( ) in esponse o umo bu den. Radia ion is deli e ed o a o al dose o 50 Gy in
25 daily ac ions a 2 Gy pe day, 5 days pe week. Tumo con ol (TC) by ea men (blue) and p og essi e disease (PD; ed) e e o umo e adica ion and
escape a e ea men , espec i ely. (B) Time e olu ion o umo and e ec o T cells co esponding o he loca ions ma ked by diamonds, iangles, and s a s
in panel A.
L´
opez Al onso e al
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p o ides a ionale and mo i a ion o addi ional in-
es iga ing and unde s anding he e ec s o adio he apy
on he immune sys em o pa ien s wi h cance o guide
app op ia e p ospec i e alida ion o adio he apy and
su ge y sequencing. This should include immune panels
on longi udinal blood d aws du ing adio he apy as well as
analysis o immune infil a ion in p ei adia ion biopsies and
su gically esec ed issues.
AFFILIATIONS
1
B aunschweig In eg a ed Cen e o Sys ems Biology, Helmhol z Cen e
o In ec ion Resea ch, B aunschweig, Ge many
2
Nalecz Ins i u e o Biocybe ne ics and Biomedical Enginee ing, Polish
Academy o Sciences, Wa saw, Poland
3
In eg a ed Ma hema ical Oncology, H. Lee Mo fi Cance Cen e and
Resea ch Ins i u e, Tampa, FL
CORRESPONDING AUTHOR
Heiko Ende ling, PhD, Depa men o In eg a ed Ma hema ical Oncology,
H. Lee Mo fi Cance Cen e and Resea ch Ins i u e, 12902 Magnolia
D i e, SRB 4, Tampa, FL 33612; e-mail: heiko.ende ling@mo fi .o g.
EQUAL CONTRIBUTION
J.C.L.A. and J.P. con ibu ed equally o his wo k.
SUPPORT
Suppo ed in pa by Ins i u ional Resea ch G an No. 14-189-19 om
he Ame ican Cance Socie y (H.E.), by he Ge man Fede al Minis y o
Educa ion and Resea ch unding o he eMED p ojec SYSIMIT (G an
No. 01ZX1308D; J.C.L.A.), and by he Helmhol z Associa ion o Ge man
Resea ch Cen e s Ini ia i e and Ne wo king Fund o he p ojec on
educed complexi y models (G an No. ZT-I-0010; J.C.L.A.).
AUTHOR CONTRIBUTIONS
Concep ion and design: Juan Ca los L´
opez Al onso, Jan Poleszczuk, Sha i
Pilon-Thomas, B ian Cze niecki, Louis B. Ha ison, Heiko Ende ling
Financial suppo : Juan Ca los L´
opez Al onso, Heiko Ende ling
Collec ion and assembly o da a: Jan Poleszczuk, B ian Cze niecki
1.0
0.8
0.6
0.4
0.2
0.0
1.0
0.8
0.6
0.4
0.2
0.0
Pa ame e Space
Con olled (%)
Pa ame e Space
Con olled (%)
1 5 10 15 20 2515 10
No. o T ea men F ac ions No. o T ea men F ac ions
15 20 25
CD
SR 2 Gy × 25
ac ions
q(day–1)
4.5 × 10–1
2.5 × 10–1
6.5 × 10–1
SR 2 Gy × 25
ac ions
TC by ea men
(SR)
0.1 0.2 0.3 0.4
0.3
0.2
0.1
0.3
0.2
0.1
ATC by ea men
(RS)
(day–1)
(day–1)
(day–1)
(day–1)
0.1 0.2 0.3 0.4
3 × 107
1 × 107
3 × 106
1 × 106
No. o E ec o
Cells
B
FIG 5. Compa ison o immune ec ui men and ea men ou comes o umo s o 10
8
iable cance cells p e ea men wi h umo g ow h a e ( )
be ween 0.1 and 0.4 day
−1
and immune ec ui men a e ( ) in esponse o umo bu den be ween 0.1 and 0.3 day
−1
. (A) Rec ui men o e ec o
T cells o he umo bed as a esul o adio he apy (RT) –induced immune esponses by su ge y ollowed by RT (SR). (B) Rec ui men o e ec o
T cells o he umo bed as a esul o RT-induced immune esponses by RT ollowed by su ge y (RS). Rec ui men o e ec o T cells a e bo h SR and
RS is es ima ed by he in eg al o he e m qD in Equa ion 2, wi h q= 4.5 ×10
−1
day
−1
. A ows poin o he pa ame e combina ions ha yield umo
con ol (TC) by SR and RS (c. . Fig 4A). (C) P opo ion o pa ame e space con olled o SR (25 daily ac ions a 2 Gy pe day, 5 days pe week; blue
line) compa ed wi h RS wi h g adually inc easing numbe o ac iona ions. (D) P opo ion o pa ame e space con olled o SR (25 daily ac ions a
2 Gy pe day, 5 days pe week; blue line) compa ed wi h RT alone wi h inc easing numbe o ac iona ions. Pa ame e s a e 0.1 ≤ ≤0.4 day
−1
and
0.1 ≤ ≤0.3 day
−1
. Di e en s eng hs o RT-induced immunos imula ion a e colo coded (q, day
−1
in Equa ion 2).
Sequencing Cance Radio he apy and Su ge y
JCO Clinical Cance In o ma ics 9
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SR RSRT alone
Su i ing F ac ion o E ec o Cells a 2 Gy (SF
2
)
0.410.610.81
TC by ea men PD
(day
–1
)
0.1 0.2 0.3 0.4
TC
PD
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
(day
–1
)
0.1 0.2 0.3 0.4
(day
–1
)
0.3
0.2
0.1
FIG A6. Model-p edic ed ea men ou comes o adio he apy (RT) alone, RT a e su gical esec ion (SR), and RT be o e su gical esec ion (RS) o umo s o
10
8
iable cance cells p e ea men and inc easing su i ing ac ions o e ec o cells a 2 Gy (SF
2
) in a coho o i ual pa ien s wi h di e en combina ions o
umo g ow h a e ( ) and immune ec ui men a e ( ) in esponse o umo bu den. Radia ion is deli e ed o a o al dose o 50 Gy in 25 daily ac ions a 2 Gy
pe day, 5 days pe week. Tumo con ol (TC) by ea men (blue) and p og essi e disease (PD; ed) e e o umo e adica ion and escape a e ea men ,
espec i ely. Fo all simula ions, we se RT-induced an i umo immuni y o q= 4.5 ×10
−1
day
−1
.
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opez Al onso e al
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