In vitro radiation-induced apoptosis and early response to low-dose radiotherapy in non-Hodgkin's lymphomas

doi:10.1016/S0167-8140(97)00148-5

Radiotherapy and Oncology

Volume 46, Issue 2, February 1998, Pages 185-191

https://doi.org/10.1016/S0167-8140(97)00148-5 Get rights and content

Abstract

Purpose: Prospective investigation of spontaneous and in vitro radiation-induced apoptosis to predict early response to palliative radiotherapy in patients with non-Hodgkin's lymphomas.

Patients and methods: Fine-needle sampling was performed in 28 tumor sites (26 patients) and yielded adequate cell numbers in 27 cases. Apoptotic cells were counted by fluorescence microscopy immediately after sampling and after 24-h culture (spontaneous apoptosis) and 24 h after 2- and 10-Gy in vitro irradiation (radiation-induced apoptosis). Early response to low-dose in vivo radiotherapy (mostly 4 Gy in two fractions over 3 days) was evaluated 15 days after treatment.

Results: The tumor response rates at 15 days were 11 (39%) complete responses, nine (32%) responses of greater than 50% reduction in volume, six (21%) responses of less than 50% reduction in volume and two (7%) cases of no response. Tumors achieving complete or major response after in vivo irradiation had higher percentages of apoptotic cells after in vitro irradiation, while no significant differences in terms of spontaneous apoptosis were observed between responders and non-responders.

Conclusion: Spontaneous and in vitro radiation-induced apoptosis can be easily and quickly assessed on cells obtained by fine-needle sampling of non-Hodgkin's lymphoma lesions. The present results suggest that in vitro radiation-induced apoptosis could be used as a predictive assay of early response to low-dose in vivo irradiation in patients with non-Hodgkin's lymphomas.

Introduction

The efficacy of low-dose irradiation in low-grade non-Hodgkin's lymphomas was reported in the early years of radiotherapy. In the 1970s, this observation justified investigation of fractionated low-dose (1.5–2.0 Gy) total body irradiation (TBI) 2, 3, 7, 16. Several randomized studies 1, 9, 11showed that the results of this approach were similar to those of the chemotherapy regimens available at that time. This was confirmed by the recent update of an EORTC trial activated in 1982, which compared low-dose TBI and CHVmP chemotherapy, both followed by consolidation localized irradiation [15]. However, the development of new chemotherapy regimens and the introduction of interferon, combined with the inability to clearly identify subgroups of patients unequivocally benefiting from low-dose TBI, led to the relative abandonment of this technique in recent years. A possible increase in the secondary leukemia risk after low-dose TBI and chemotherapy for non-Hodgkin's lymphoma constitutes an additional concern [21].

In parallel, low-dose limited-field radiation therapy appeared to be an efficient palliative treatment in selected patients with advanced low-grade non-Hodgkin's lymphoma. In a previous study [8], 27 patients received palliative irradiation consisting of two fractions of 2 Gy limited to bulky lymph nodes. Ten complete regressions and 14 partial responses (≥50% reduction in size) were observed within a few days. These high response rates to unconventionally low doses of irradiation were confirmed by a recent publication from an independent group [20]. The particularly short delay in tumor response reported by Ganem et al. [8]contrasted with the natural history of a usually slowly progressive disease [10]. This delay suggested that a large amount of radiation-induced apoptosis may have occurred as a result of treatment. This hypothesis was supported by the well-known sensitivity to radiation-induced apoptosis of normal human lymphocytes [5]and murine lymphoma cells [18]and the kinetics of the apoptotic process (see review in Ref. [6]).

The present study was designed to prospectively investigate spontaneous and in vitro radiation-induced apoptosis in patients with non-Hodgkin's lymphomas. These patients often have involved lymph nodes or skin lesions that are readily accessible to fine-needle sampling. Radiation therapy, either exclusive or in combination with chemotherapy, is commonly indicated as curative or palliative treatment. A total dose of 36–40 Gy is usually administered with daily fraction sizes of 1.80 or 2.00 Gy. A demonstration that apoptosis sensitivity of lymphoma cells obtained by fine-needle sampling could be measured in vitro before treatment in vivo and correlated with response to therapeutic irradiation would allow early recognition of a subset of patients responsive to low doses of radiotherapy.

Section snippets

Inclusion

The criteria for inclusion in the study were biopsy-proven non-Hodgkin's lymphoma, the presence of involved lymph nodes or skin lesion accessible to fine-needle sampling (possibly guided by ultrasound or CT scan) and evaluable for response to treatment and an indication for low-dose limited-field irradiation. Previous chemotherapy or radiotherapy to other sites were allowed. All the patients gave their informed consent.

Apoptosis assessment

Fine-needle sampling was performed before local therapeutic irradiation to

Patients and treatment modalities

Twenty-six patients (17 (61%) females and 11 (39%) males) entered the study (Table 1). Seven patients had a previous history of malignant disease (three had breast cancers, one had breast cancer and rectal adenocarcinoma, one had prostate cancer, one had plasmocytoma and one had seminoma) and one patient had been followed for acromegaly. The mean age at the time of fine-needle sampling was 65 years (range 37–86 years) and the mean time since the initial diagnosis was 48 months (range 2–208).

Discussion

To our knowledge, the present study is the first published attempt to correlate radiation-induced apoptosis measured in vitro before treatment and response with radiotherapy delivered in vivo in humans. Patients with non-Hodgkin's lymphomas represent a convenient model as the disease often involves lymph nodes or subcutaneous masses that can be easily sampled and are readily accessible for treatment response assessment. No complications were observed after fine-needle sampling and the cell

Conclusion

Pretreatment measurements of spontaneous and in vitro radiation-induced apoptosis could be performed on cells obtained by 27 out of 28 fine-needle samplings in 26 patients with non-Hodgkin's lymphoma. The procedure is atraumatic and results are obtained in 24 h. Compared to minor responders to low-dose in vivo radiotherapy, major responders had higher levels of apoptotic cells after 2- and 10-Gy in vitro irradiation. It is suggested that this assay could be used for pretreatment identification

Acknowledgements

This study was supported in part by Electricité de France (Grant RB96.38) and the Ligue Nationale Contre le Cancer.

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