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Biomedical subjects

S M Bentzen

Publications and source records attributed to S M Bentzen.

At least 37 records · Page 2Linked to original sources

An evolutionary-game model of tumour-cell interactions: possible relevance to gene therapy.

Evolutionary games have been applied as simple mathematical models of populations where interactions between individuals control the dynamics. Recently, it has been proposed to use this type of model to describe the evolution of tumour cell populations with interactions between cells. We extent the analysis to allow for synergistic effects between cells. A mathematical model of a tumour cell population is presented in which population-level synergy is assumed to originate through the interaction of triplets of cells. A threshold of two cooperating cells is assumed to be required to produce a proliferative advantage. The mathematical behaviour of this model is explored. Even this simple synergism (minor clustering effect) is sufficient to generate qualitatively different cell-population dynamics from the models published previously. The most notable feature of the model is the existence of an unstable internal equilibrium separating two stable equilibria. Thus, cells of a malignant phenotype can exist in a stable polymorphism, but may be driven to extinction by relatively modest perturbations of their relative frequency. The proposed model has some features that may be of interest to biological interpretations of gene therapy. Two prototypical strategies for gene therapy are suggested, both of them leading to extinction of the malignant phenotype: one approach would be to reduce the relative proportion of the cooperating malignant cell type below a certain critical value. Another approach would be to increase the critical threshold value without reducing the relative frequency of cells of the malignant phenotype.

Algorithms↗

Relationship between DNA double-strand breaks, cell killing, and fibrosis studied in confluent skin fibroblasts derived from breast cancer patients.

PURPOSE: To investigate the relationship between DNA double-strand breaks (dsbs), cell killing, and fibrosis using skin fibroblasts derived from breast cancer patients who received postmastectomy radiotherapy. METHODS AND MATERIALS: Experiments were performed with 12 lines of normal skin fibroblasts derived from recurrence-free breast cancer patients. Cells were irradiated in confluence and cell survival was determined either after immediate or delayed (14 h) plating using a colony-forming assay. Dsbs were measured by constant-field gel electrophoresis. The "excess risk of fibrosis" was previously scored by Johansen et al. (IJRB 1994;66:407-412). RESULTS: The 12 cell lines showed a typical spectrum of radiosensitivity. The mean value of surviving fraction after 3.5 Gy (SF3.5) was 0.063 for immediate and 0.174 for delayed plating with a coefficient of variation (CV) of 44 and 39%, respectively. There was also a broad variation in the extent of recovery from potentially lethal damage (RPLD), which was not correlated with the immediate sensitivity. The number of initial dsbs as well as the half-times of dsb repair showed little variation, whereas there were considerable differences in the number of residual dsbs (CV = 29%). The number of residual dsbs after 100 Gy was correlated significantly only with SF3.5 after delayed (r2 = O.59; p = 0.006) but not after immediate plating (r2 = 0.21, p = 0.16). There was also no significant relationship between residual dsbs and the "excess risk of fibrosis" determined for the respective patients. CONCLUSION: It is shown that the number of residual dsbs measured in confluent human fibroblast lines can be used to predict the cellular radiosensitivity after delayed but not after immediate plating and also not to predict the excess risk of fibrosis of the respective breast cancer patients.

Breast Neoplasms↗

Clinical radiation doses for spinal cord: the 1998 international questionnaire.

BACKGROUND AND PURPOSE: Emmanuel van der Schueren gave a keynote lecture at the 1988 ASTRO annual conference pointing out that the spinal cord 'tolerance doses' then prescribed were probably unnecessarily cautious, resulting in probable underdosing of some tumours. This lecture was supported both by an international questionnaire which he and two of the present authors had conducted, and by animal experimental data. In 1997 he initiated a 10-year follow-up questionnaire, the results of which are summarised here. MATERIALS AND METHODS: The present report analyses the change in prescriptions from 1988 to 1998 and the variation in prescriptions among various regions of the World. RESULTS AND CONCLUSIONS: The main conclusion is that prescribed dose levels have increased significantly in this period. Large geographical variations still exist. Among responders who use a formula to correct for changed dose per fraction, 90% are now using the linear-quadratic model vs. 33% in 1988. The current status of clinically acceptable doses to spinal cord in 2-Gy fractions is discussed briefly. Further details from the responses to the 1998 questionnaire will be presented in another publication.

Dose Fractionation, Radiation↗

Clinical impact of dosimetry quality assurance programmes assessed by radiobiological modelling of data from the thermoluminescent dosimetry study of the European Organization for Research and Treatment of Cancer.

The European Organization for Research and Treatment of Cancer (EORTC) Radiotherapy Group initiated its mailed thermoluminescence dosimetry (TLD) programme in 1986. The aim of the present study was to evaluate the clinical relevance of variations in beam output detected in the period 1993 to 1996. A total of 140 beam outputs were checked (26 for cobalt-60 units and 114 for linear accelerators) in 35 centres. Clinical dose-response data for tumour control and normal tissue morbidity were used to assess the variation in clinical outcome resulting from variability in beam output. For 75 checked beams with nominal accelerating potentials (n. a.p.) of 6 MV or less the mean ratio, +/- standard deviation (S.D.) of measured to stated output was 1.004+/-0.020. For 65 beams with n. a.p. of 8 MV or more, the ratio was 1.009+/-0.021. Even with this relatively high level of precision, broad distributions of estimated tumour control or normal tissue morbidity were found. In the 10% of the beams with the most pronounced underdosage, the loss in tumour control probability was estimated at 7-8 percentage points. Likewise, in the 10% of the beams with the most pronounced overdosage, the increase in mild/moderate morbidity was 19-22 percentage points. For severe morbidity the same beams raised the estimated incidence of severe complications from 5% to 9-10%. An estimation of the loss of uncomplicated cure probability was about 1% for both high and low energy beams. Sequential mailings considerably improved the uniformity of clinical outcome. We conclude that small deviations in beam output may lead to clinically important variations in outcome. Substantial reductions in the variation between measured and stated output can be achieved by sequential mailings. Mailed TLD checks should be an integral part of a continuously ongoing quality assurance activity in radiotherapy.

Dose-Response Relationship, Radiation↗

National audit of the management and outcome of carcinoma of the cervix treated with radiotherapy in 1993.

The aim of the study was to investigate the UK prevalence of late, severe side-effects associated with radical radiotherapy for cancer of the cervix and try to identify associated factors. All patients treated for cancer of the cervix with radical radiotherapy in 1993 were identified and retrospective case notes studied to determine mortality and severe complications occurring following treatment. Of the 55 radiotherapy departments in the UK that were treating gynaecological malignancy in 1993, 53 participated in the study. There were 1558 patients with carcinoma of the cervix receiving radical radiotherapy as part of their treatment regimen in 1993, whose patterns of treatment were assessed. The main outcome measures were the development of late severe complications as defined by the Franco-Italian Glossary and mortality. Of the patients receiving surgery and radiotherapy, 58.5% underwent Wertheim's procedure. The crude rate of late severe complications in all patients with cervical cancer treated with radical radiotherapy in 1993 was 6.1% (actuarial rate 8%) at 5 years, and only four of the 91 patients who developed complications died as a result of their morbidity. There was no significant correlation of stage, centre size, surgery or radiotherapeutic approach with late morbidity in univariate analysis. The overall survival at 5 years was 47% and was lower than that of the European data from FIGO's 1990-92 cohort, for all stages. Increasing FIGO stage was the only factor significantly associated with mortality. The absence of variables that were significantly associated with late complications may well be related to the relatively low event rate compared to the sample size. Differences in surgical treatment prior to radiotherapy and radiation technique may be confounding the comparison of outcomes. The relatively poor survival for locally advanced disease and the difficulty with which these data were collated indicates that national prospective data collection is urgently required to monitor performance and hence derive best practice.

Adult↗

Time course of radiological lung density changes after postmastectomy radiotherapy.

The purpose of this study was to quantify the time course of radiological lung changes in patients after postmastectomy radiotherapy assessed from routine follow-up chest x-rays. Radiological density changes in the apex of the irradiated lung were quantified by a recent lung densitometry assay. Lung changes were expressed as the so-called Relative change in Equivalent Absorber Thickness (REAT). The clinical series comprised 329 patients treated with postmastectomy radiotherapy between 1978 and 1982. Of these patients 100 were treated with chemotherapy (CTX or CMF) and 41 were given tamoxifen as an additional adjuvant treatment; 290 patients (88.2%) had pretreatment x-rays and at least one x-ray after completion of radiotherapy and these were included in the study. A total of 2,209 chest x-rays was taken during follow-up, and among these 1921 x-rays (86.9%) were judged to be assessable. Late changes were defined as changes occurring more than a year after radiotherapy. A total of 280 patients had at least one chest x-ray taken more than one year after radiotherapy and these were evaluable with respect to late changes. There were 1,390 follow-up x-rays in these patients and 207 patients (73.9%) had three or more follow-up x-rays. Linear regression of REAT vs. observation time was used to identify three patterns of time changes: progressive, regressive, and stable. The results were as follows. Two phases of lung changes were observed. The early phase peaks around 6 months and the density changes may subsequently resolve, completely or in part. In most cases (173 patients or 84%), the lung density changes reached a stable level 12 months after irradiation. Yet, in 16 patients (7.7%) the lung changes progressed for five or more years. Regression of the density changes was seen in 18 patients (8.7%), and in some cases there were signs that this apparent regression was caused by contraction of the fibrotic tissue. We conclude that two phases of lung response can be distinguished and can be graded according to severity using this assay. Early lung changes reach a maximum around 6 months after RT. Late reactions reach a plateau in most patients after one year, but progress in some cases for five or more years.

Adult↗

Morbidity related to axillary irradiation in the treatment of breast cancer.

Some of the most debilitating morbidity after surgery and radiotherapy for breast cancer is related to treatment of the axilla. This includes persistent arm lymphoedema, impaired shoulder mobility and brachial plexopathy. Considerable research efforts have been carried out on the radiation pathogenesis and the clinical radiobiology of these clinical endpoints, which has enabled their severity and incidence to be minimized. It is clear that the radiation dose-response relationships for these late endpoints are very steep. In other words, even small changes in the exact dose fractionation and physical dose distribution can cause major changes in toxicity. In particular, in many treatment schedules dose fractions larger than 2 Gy have been used without a sufficient reduction in total dose to avoid increased late effects. This is important, as much of the available literature reports side effects after suboptimal dose-fractionation schedules and inferior radiotherapy techniques. Such reports are not representative of what can be achieved using modern radiotherapy. An interesting parallelism to the problems encountered in reviewing historical experience is found in the British breast litigation, the current status of which is presented in this article. Furthermore, morbidity after radiotherapy is strongly influenced by concomitant surgery and/or chemotherapy, and this should be allowed for when designing the overall treatment. Apart from other therapeutic modalities, it has been suggested that other exogenous factors have an influence on the risk of radiotherapy-related morbidity. However, patients' age and, in the case of lymphoedema, also obesity are the only factors that have been established with some certainty. Routine adjustment of radiotherapy dose in these cases is not recommended. Two current developments may strengthen the role of radiotherapy in the treatment of breast cancer. Sentinel node biopsy may allow nodal staging without major surgical excision of axillary nodes and this opens the possibility for a more optimal combination of radiotherapy and surgery in the management of the axilla. With more cancers now being detected by systematic screening programmes, this will also increase the possibilities for conservative management, which in most cases involves radiotherapy. In conclusion, the improved understanding of the clinical radiobiology of late sequelae after radiotherapy allows treatment schedules and techniques to be devised that are therapeutically effective while maintaining a minimal risk of serious, late morbidity.

Axilla↗

Fibroblast differentiation in subcutaneous fibrosis after postmastectomy radiotherapy.

In order to acquire a better understanding of the mechanism of radiation-induced fibrosis, we studied the differentiation of normal skin fibroblasts cultured from breast cancer radiotherapy patients with different risk of fibrosis. The differentiation state of fibroblasts was characterized in clonal cultures using established cytomorphological criteria. Collagen synthesis was determined by 3H-proline incorporation into pepsin-resistant protein. Radiation-induced inactivation of fibroblasts was paralleled by an increase in terminally differentiated fibrocytes, demonstrating that premature terminal differentiation is an important response to irradiation of fibroblasts from radiotherapy patients. Surviving colony-forming fibroblasts showed a change in differentiation with an increase in the ratio L:E of progenitor fibroblasts in late (L) compared to early (E) differentiation states. Furthermore, increased collagen production was observed after irradiation. The results provide evidence supporting a role of terminal fibroblast differentiation in radiation-induced fibrosis and imply that the progenitor population surviving radiotherapy might be more prone to terminal differentiation than before radiotherapy.

Breast Neoplasms↗

Quantitative clinical radiobiology of early and late lung reactions.

PURPOSE: To quantify the response of human lung to a course of fractionated radiotherapy based on a literature review of published clinical data. MATERIALS AND METHODS: Quantitative clinical radiobiology is concerned with the estimation of parameters that describe the clinical outcome of radiotherapy as a function of patient and treatment characteristics. Here, parameters describing the steepness of the dose-response curve, the response to a change in dose per fraction and to a change in overall treatment time for early and late lung injury are compiled based on published clinical studies. RESULTS: Two phases of lung injury are seen, radiation pneumonitis and lung fibrosis. The first signs of early lung changes are seen almost immediately after irradiation. This reaction peaks after 5 to 6 months, and settles partially before 9-10 months. Around that time, the late changes become manifest and these are stable in most cases. There is an important distinction between lung injury and radiotherapy-related morbidity, as even severe changes in a small volume may not give rise to any clinical symptoms. Many assays have been developed for lung damage, and these highlight various clinical and biological aspects of lung damage. Here, the literature on steepness of dose-response curves and fractionation sensitivity is reviewed and quantified by the alpha/beta ratio of the linear-quadratic model for both radiation pneumonitis and lung fibrosis. For the early phase a significant time factor exists. Current best estimates for these radiobiological parameters are derived. Other external factors affecting these estimates are briefly discussed. CONCLUSIONS: Quantitative estimates of radiobiological characteristics of human lung are available for the pneumonitis phase where the fractionation sensitivity is in the same range as for most late-responding normal tissues. Short intensive schedules may also bear an added risk for pneumonitis as the dose recovered per day is around 0.5 Gy. For the later phase of lung fibrosis, the estimates are fewer and generally less precise. It is clear though, that the alpha/beta ratio is low, possibly 2-3 Gy. No time factor has been demonstrated for the late reaction. Due to the considerable physiological reserve capacity in the normal human lung, the relationship between damage and morbidity depends strongly on the lung volume affected. It therefore seems likely that for small volumes irradiated to high doses, the dose-limiting complications may not be due to restriction of lung function, but rather to haemorrhage and formation of fistulae.

Animals↗

Time-course of the hazard of murine nephropathy induced by total-body irradiation.

PURPOSE: We investigated the form of the hazard function for total-body irradiation (TBI) induced nephropathy in mice during 1.5 years of follow-up. MATERIAL AND METHODS: The material was collected from our previously published data. Following single-dose or fractionated irradiation and bone marrow transplantation (BMT) the mice were tested regularly for kidney damage using the CrEDTA residual activity, percentage haematocrit and blood urea nitrogen endpoints. The hazard rate was studied in the pooled data of 172 mice for all three endpoints, while fractionation sensitivity was estimated from the direct analysis, which was performed using the CrEDTA residual activity endpoint and the actual follow-up data in individual mice. RESULTS: The hazard rate of kidney damage following TBI and BMT showed a biphasic pattern that is most evident with the CrEDTA residual activity endpoint, with a reduced risk of renal failure around week 36 after TBI. Assessment of kidney function in individual animals showed evidence of recovery from radiation damage around week 36 after TBI. An analysis of fractionation sensitivity showed that the first wave was characterized by an alpha/beta ratio of 8.4Gy (95% CI: 4.0-14.3Gy), while the alpha/beta ratio for the second wave was estimated at 6.1 Gy (95% CI: 3.3 9.8 Gy). CONCLUSIONS: The biphasic nature of the hazard function reported here may be a unique feature of TBI-induced renal damage. Differentiation between the two phases in terms of their alpha/beta ratio was not possible. The biological basis of this observation remains to be clarified. The reported high alpha/beta ratio of kidney damage in the TBI situation may have important clinical implications.

Animals↗

Selection of active drugs for ovarian cancer based on CA-125 and standard response rates in phase II trials.

PURPOSE: To determine whether precise definitions of response based on serial CA-125 levels can predict the activity of drugs in phase II trials for ovarian cancer as accurately as standard criteria. PATIENTS AND METHODS: Fourteen different drugs for relapsed ovarian cancer were analyzed in 25 treatment groups in 19 clinical trials. Response rates were estimated in 1,457 assessable patients according to standard criteria and in 1,092 assessable patients according to CA-125. For each drug trial, the observed response rates acted as the input data for an evaluation of how the two criteria would perform in a hypothetical Gehan two-stage phase II trial, accepting a target drug efficacy rate of 20% and a rejection error of 5%. RESULTS: CA-125 and clinical response criteria were concordant in 20 of the 25 groups, with less than 5% chance of rejecting the drug in nine groups and greater than 5% in 11 groups. In four groups, the drug had less than 5% chance of being rejected by CA-125 but greater than 5% chance of being rejected by standard criteria. The difference in the classification of drugs by the standard and CA-125 response criteria was not statistically significant (P =.38, McNemar's test). CA-125 response rates were slightly higher than standard response rates by a factor of 1.11. CONCLUSION: Definitions based on a 50% or 75% decrease of CA-125 levels accurately predicted which drugs in phase II trials for relapsed ovarian cancer were active and justified further investigation.

Antineoplastic Agents↗

Carcinoma of the cervix and the use of hyperbaric oxygen with radiotherapy: a report of a randomised controlled trial.

BACKGROUND AND PURPOSE: A randomised controlled trial of hyperbaric oxygen in the radiotherapy of Stage IIb and III carcinoma of cervix was performed between 1971 and 1980. Apart from an abstract giving an interim report in 1977, results have not been published. MATERIAL AND METHODS: In a four arm study, 335 patients were randomised to treatment in 10 or 28 fractions, in hyperbaric oxygen or in air. Data is available concerning 327 cases and this has been analysed. RESULTS: There was no advantage in tumour control shown with the use of hyperbaric oxygen. There was evidence for an increase in late radiation morbidity when treatment was given in hyperbaric oxygen rather than in air and when, using 10 fractions, a total dose of 45 rather than 40 Gy was achieved. For late intestinal morbidity, the fractionation sensitivity (alpha/beta ratio) was calculated to be 4.3 Gy and the steepness of the dose response curve (gamma50) to be 2.6. CONCLUSIONS: Hyperbaric oxygen gave no benefit in the treatment of patients with stage IIb and III carcinoma of the cervix treated with radiotherapy using two fractionation regimes. Important data regarding late radiation morbidity has been revealed.

Adult↗

Repair halftimes estimated from observations of treatment-related morbidity after CHART or conventional radiotherapy in head and neck cancer.

BACKGROUND AND PURPOSE: The CHART (Continuous Hyperfractionated Accelerated Radiotherapy) head and neck cancer fractionation schedule delivered 54 Gy in 36 fractions on 12 consecutive days and this was compared in a randomised controlled trial with conventional fractionation delivering 66 Gy in 33 fractions over 6-7 weeks. Patients receiving CHART experienced statistically significantly less treatment-related morbidity after 6 months than patients receiving conventional fractionation. However, this improved tolerance was much less than anticipated from existing knowledge of dose-fractionation effects on late-responding normal tissues. Here, the experience from the CHART study is analysed and repair halftimes for three types of late treatment-related morbidity of human tissues are estimated. PATIENTS AND METHODS: The CHART trial was open for patient accrual from March 1990 to April 1995 and a total of 918 patients in 11 participating centres were randomised. All patients were followed at regular intervals for a minimum of 5 years or until the time of death. At each follow-up, a number of treatment-related morbidity items were evaluated and scored prospectively. Data for three late endpoints are analysed here: laryngeal oedema, skin telangiectasia and subcutaneous fibrosis. Differences in the incidence of these endpoints in the two trial arms were quantified by means of the ratio of hazard rates in a Cox proportional hazards model. Monte Carlo sampling was performed from distributions of fractionation sensitivity (quantified by the alpha/beta-ratio) and steepness of the dose-response curve (quantified by the normalised dose-response gradient, gamma50) with means and standard deviations derived from the literature. Each pair of values were used to convert a Monte Carlo sampled estimate of the difference in biological effect into an estimate of the repair halftime. From the distribution of 1000 Monte Carlo samples, the mean repair halftime and its 95% confidence interval were estimated. RESULTS: The estimated repair halftimes, with 95% confidence intervals in parentheses, were 4.9 h (3.2, 6.4) for laryngeal oedema, 3.8 h (2.5, 4.6) for skin telangiectasia and 4.4 h (3.8, 4.9) for subcutaneous fibrosis. Calculations show that these repair halftimes are consistent with the observations from two published randomised controlled trials of altered fractionation in head and neck cancer, the EORTC 22791 and 22851 trials. CONCLUSIONS: These long repair halftimes for late effects in human normal tissues have to be considered in order to gain the full benefit from fractionation schedules employing multiple fractions per day.

Carcinoma, Squamous Cell↗

Use of tumour markers in monitoring the course of ovarian cancer.

BACKGROUND: There is a need to delineate how the best available serum marker for ovarian cancer, CA 125 should be used in monitoring the treatment of individual patients, and in clinical trials. PATIENTS AND METHODS: The situations where measurement of CA 125 could alter the management of individual patients during therapy and at relapse were critically analysed. Precise definitions for response according to CA 125 were first developed and tested on 989 patients receiving first line therapy and have since been tested on over 2000 patients in phase 2 trials. Precise definitions for progression were developed from 71 patients during and on 255 patients both during and after initial chemotherapy. RESULTS: In individual patient management, progression on initial chemotherapy can be demonstrated by serial rise in CA 125 suggesting the need for a change in therapy. A confirmed doubling of CA 125 from the upper limit of normal during follow up accurately predicts relapse. This endpoint needs prospective testing for use in clinical trials. Precise definitions of response based on a 50% or 75% fall in CA 125 levels accurately predicts whether a cytotoxic agent is active against ovarian cancer. CONCLUSION: Precise definitions of response based on CA 125 should be used in phase 2 trials of new cytotoxic drugs.

Antineoplastic Combined Chemotherapy Protocols↗