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The concurrent chemoradiation paradigm general principles

Tanguy Y Seiwert*, Joseph K Salama and Everett E Vokes S U M M A RY
During the past 20 years, the advent of neoadjuvant, primary, and adjuvant concurrent chemoradiotherapy has improved cancer care dramatically. Significant contributions have been made by technological improvements in radiotherapy, as well as by the introduction of novel chemotherapy agents and dosing schedules. This article will review the rationale for the use of concurrent chemoradiotherapy for treating malignancies. The molecular basis and mechanisms of action of combining classic cytotoxic agents (e.g. platinum-containing drugs, taxanes, etc.) and novel agents (e.g. tirapazamine, EGFR inhibitors and other targeted agents) with radiotherapy will be examined. This article is part one of two articles. In the subsequent article, the general principles outlined here will be applied to head and neck cancer, in which the impact of concurrent chemoradiotherapy is particularly evident.
KEYWORDS chemoradiation, cytotoxic, radiation, resistance, synergistic

INTRODUCTION

Three clinical rationales support the use of chemotherapy delivered concurrently with radiation. First, concomitant chemoradiotherapy can be used with organ-preserving intent, resulting in improved cosmesis and function compared with surgical resection with or without adjuvant treatment. Second, chemotherapy can act as a radiosensitizer, improving the probability of local control and, in some cases, survival, by aiding the destruction of radioresistant clones (Table 1). Third, chemotherapy given as part of concurrent chemoradiation may act systemically and potentially eradicate distant micrometastases.
CLINICAL APPLICATIONDISEASE ENTITIES

REVIEW CRITERIA The information for this Review was compiled using the PubMed and MEDLINE databases for articles published until 15 June 2006. Electronic earlyrelease publications were also included. Only articles published in English were considered. The search terms used included chemoradiotherapy or chemoradiation in association with the following search terms: reviews, radiosensitizer, concurrent, mechanism, molecular, cell cycle, cytotoxic chemotherapy, hypoxia, targeted therapies, radioresistance, cisplatin, tirapazamine, carboplatin, oxaliplatin, 5-FU, gemcitabine, capecitabine, pemetrexed, paclitaxel, mitomycin C, hydroxyurea, temozolomide, amifostine, palifermin, EGFR, Met, STAT 1, and VEGF. Full articles were obtained and references were checked for additional material when appropriate. References were chosen based on the best clinical or laboratory evidence, especially if the work had been corroborated by published work from other centers. Priority was given to studies in high impact factor journals when available.

TY Seiwert is a fellow in the Department of Medicine, University of Chicago Cancer Research Center, JK Salama is an instructor in the Department of Radiation and Cellular Oncology, Pritzker School of Medicine, The University of Chicago, and EE Vokes is the John E Ultmann Professor of Medicine and Radiation and Cellular Oncology, and Director of the Hematology/Oncology Section in the Department of Medicine, Pritzker School of Medicine, The University of Chicago, IL, USA.
Correspondence
*University of Chicago, 5841 South Maryland Avenue, MC 2115, Chicago, IL 606371470, USA tseiwert@medicine.bsd.uchicago.edu
Received 20 March 2006 Accepted 18 September 2006
www.nature.com/clinicalpractice doi:10.1038/ncponc0714

Currently, concomitant chemoradiotherapy is widely used in the treatment of solid tumors. In almost all malignancies in which locoregional control is necessary, concurrent chemoradiotherapy is either an established treatment modality or is actively being investigated. The optimum schedules, synergistic combination of agents, and integration of targeted therapies are also areas of active investigation. Chemoradiotherapy combinations for individual diseases with their specific indications and limitations are beyond the scope of this article; however, an overview of the most common uses is shown in Table 1. In the next issue of this journal, the application of chemoradiotherapy in head and neck cancer will be detailed, exemplifying some of the principles outlined here.
THEORETICAL FRAMEWORK FOR THERAPYTHE STEEL PARADIGM

In 1979, Steel and Peckham introduced a theoretical framework to describe the interaction of cytotoxic chemotherapy and radiotherapy.1 The term spatial cooperation is used to describe the scenario whereby radiotherapy acts locoregionally, and chemotherapy acts against distant micrometastases, without interaction between

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Table 1 Overview of disease entities and indications in which concurrent chemoradiotherapy is used.a
Disease entity Indication and treatment Commonly used agents Benefit

Upper aerodigestive tract cancers Head and neck cancer Non-small-cell lung cancer Small-cell lung cancer Esophageal cancer Locally advanced HNC primary or adjuvant treatment Stage IIIB, nonoperable nonmetastatic disease Limited stage disease Locally advanced disease Cisplatin, 5-FU, FHX, cetuximab Cisplatin, carboplatin/ paclitaxel, cisplatin/etoposide Cisplatin/etoposide Cisplatin/5-FU Improved organ preservation and survival compared with radiation alone Curative approach in poor surgical candidates or IIIB disease Curative in ~20% of patients Survival benefit, increased cure rates, organ preservation

Gastrointestinal malignancies Rectal cancer Anal cancer Gastric cancer Pancreatic cancer Cholangiocarcinoma Neoadjuvant Mainstay of curative treatment Adjuvant Adjuvant, unresectable locoregionally advanced tumors Adjuvant, unresectable locoregionally advanced tumors 5-FU 5-FU, MMC Cisplatin, 5-FU 5-FU 5-FU Improved sphincter preservation, decrease in local and distal failures Improved organ preservation Some data indicate a survival benefit Improved locoregional control, possibly a survival benefit Some data indicate a survival benefit

Gynecological and genitourinary cancers Cervical cancer Bladder cancer Other cancers Glioblastoma Sarcoma Adjuvant Neoadjuvant Temozolomide Doxorubicin Survival benefit Downstaging, improved organ preservation Primary modality Primary modality Cisplatin, 5-FU, hydroxyurea Cisplatin Improved local and distal control, organ preservation Improved local control

aThis is a limited overview, and concurrent chemoradiotherapy is used in most solid tumors either as a standard treatment or investigationally. For further details please

refer to the organ-specific literature. Abbreviations: 5-FU, 5-fluorouracil; FHX, 5-FU, hydroxyurea and radiation; HNC, head and neck cancer; MMC, mitomycin C.

the agents (Figure 1). This cooperative effect requires the agents to have non-overlapping toxicity profiles in order that both modalities can be used at effective doses without increasing normal tissue effects. When combined concurrently with radiotherapy, however, few chemotherapeutic agents meet this criterion, because limited single-agent activity or toxicitydriven dose reductions preclude the delivery of systemic dosing schedules. Many trials of concomitant chemoradiotherapy, however, have demonstrated decreased incidence of distant metastases compared with radiation alone. This evidence could indicate that chemotherapy delivered at radiosensitizing doses has some systemic spatial cooperative effect, or that the improved local control of chemoradiotherapy decreases subsequent metastases. The second interaction between radiation and chemotherapy is radiation sensitization, which is either additive or supra-additive: the interaction

within the radiation field leads to increased killing of cells (cytotoxic activity) either to the same degree as (additive) or more than (supraadditive) using both modalities sequentially (Figures 1 and 2). Strictly speaking, radiosensitizers shouldnt have inherent cytotoxic activity. The hypoxic cell sensitizers (e.g. misonidazole), and thymidine analogs (e.g. bromodeoxyuridine) are examples of true radiosensitizers; however, the radiosensitizers most commonly used today (cisplatin, 5-fluorouracil [5-FU], and taxanes) do have inherent cytotoxic activity and can increase damage to normal tissues, with a true benefit achieved only if the increase in antitumor effect is larger than the normal tissue damage (Figure 3). Infra-additive drugs possess radioprotective properties that lessen the cytoxic effect of radiation on the tumor and/or normal tissue. Ideally, such agents should be selective for normal tissue to allow administration of higher radiation doses. Several agents are being investigated

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Spatial cooperation No interaction modalities work independently Radiation: local control (in-field) Radiation toxicities Chemotherapy: distal control (out-of-field) Chemotherapy toxicities Supra-additivity (synergism)

In-field cooperation Molecular level Cellular level Tissue level Locoregional control

Independent toxicities Additivity Infra-additivity (antagonism)a

Radiosensitization Synergistic toxicities

patients had a statistically significant, although small (1.3%) decrease in weight loss.3 Concerns that radiation protectors might have a tumor protective effect has limited their use; however, two large meta-analyses did not confirm this concern.5,6 At doses lower than those used for normal tissue protection, amifostine has been shown to have antimutagenic properties.7 The agent palifermin, a recombinant human keratinocyte growth factor, reduces oral mucositis in patients undergoing radiation and chemotherapy for autologous stem-cell transplant and in metastatic colorectal cancer treated with 5-FU.8,9 This drug is currently undergoing phase III testing with concurrent chemoradiotherapy in patients with advanced head and neck cancer.
Determination of additive effects between chemotherapy and radiation

Figure 1 Rationale for adding chemotherapy to radiation. Spatial and in-field cooperation are the two idealized types of cooperation between radiation and chemotherapy. Both mechanisms can contribute synergistically to clinical benefit. aUsually not desirable as this could protect the tumor.

and have shown promising early results with radiation alone, but for concurrent chemoradiotherapy definitive phase III evidence does not currently support their routine use. One such agent, amifostinean organic thiophosphate might decrease cisplatin-induced or radiationinduced toxicity by acting as a scavenger of free radicals, as well as by binding to and neutralizing organoplatinums and alkylating agents, thereby preventing DNA adduct formation. Although decreased incidence of xerostomia in patients with head and neck cancer treated with radiotherapy alone was convincingly demonstrated in a large trial,2 the benefit with concurrent chemoradiotherapy remains unclear, as demonstrated by a phase III study showing no significant difference in xerostomia or mucositis rates.3 Although a single-institution trial of patients with advanced lung cancer randomized to receive concurrent cisplatin, etoposide, and twice-daily radiation demonstrated a decrease in grade 12 esophagitis, grade 3 pneumonitis, and neutropenic fever, an increase in sneezing, dysgeusia (loss of taste), and more importantly hypotension, was observed.4 In a larger phase III trial conducted by the Radiation Therapy Oncology Group, addition of amifostine to radiotherapy did not demonstrate any difference in grade 3 or greater esophagitis, although

The type of interaction between chemotherapy and radiotherapy within the radiation field (supra-additivity, additivity, or infra-additivity) can be determined. For this purpose, Steel and Peckham described the isobologram analysis, which is based on an isoeffect concept for chemoradiotherapy interaction (Figure 2).1 Independent doseresponse curves for chemotherapy and radiotherapy are necessary to create a plot, called an isobologram. The isobologram is generated by plotting the dose of each agent (i.e. chemotherapy and radiotherapy) against each other, which produces a cytotoxic effect (isoeffect) on the axes of increasing dose of each agent. Two curves, named mode 1 and mode 2, can then be generated (Figure 2). The mode 1 curve results from the assumption that radiation and chemotherapy act independently, and is created by plotting a given dose of radiation against the dose of chemotherapy needed to produce an effect equal to the difference between the chosen cytotoxic effect and the effect of the current dose of radiation. The mode 2 curve assumes that radiation and chemotherapy have identical mechanisms of action. Points on this curve are generated by plotting doses of radiation against the doses of chemotherapy needed to increase the effect of the dose of radiation to the chosen cytotoxic effect. Multiple points on both of these lines are obtained by varying the radiation dose and calculating the appropriate doses of chemotherapy. Finally, the true (empiric) survival curve is generated for radiation and chemotherapy given in combination. The doses

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of each agent needed to produce the chosen cytotoxic effect are plotted. Points that fall below the envelope between mode 1 and 2 curves indicate supra-additivity, data points occurring within the envelope (between the two curves) indicate additivity, and data points above the envelope indicate infra-additivity. Further details and sample calculations are provided elsewhere.10,11 Other methods exist to determine types of additivity, including the median effect principle and the response surface approach, both of which are described in detail elsewhere.1215 Unfortunately, the concept of additivity is of limited use in clinical practice, as preclinical prediction of additivity does not translate well into clinical outcomes. The use of this method is, therefore, limited to forming hypotheses, which need to be confirmed empirically.
Quantification of the chemotherapy and radiation interaction

1.0

Infra-additivity (antagonistic effect)

RT dose

0.5

Additivity envelope (area between the mode 1 [upper] and mode 2 [lower] curves)

Supra-additivity (synergism) 0.0 0.0 0.5 Drug dose 1.0

The radiosensitizing ability of a drug can be expressed by the therapeutic ratio. This ratio is derived from sigmoid-shaped doseresponse curves, calculated by plotting the response of tissues (both normal and tumor) on the ordinate axis versus the chemotherapy or radiation therapy dose on the abscissa (Figure 3). The therapeutic ratio is defined as the quotient of the dose that produces a 50% tumor control rate and the dose that produces a 50% normal tissue toxicity rate. When chemotherapy is combined with radiation, both normal tissue and tumor control curves produced by radiation alone shift to the left because of the chemotherapyinduced sensitization of cells. Ideally, radiation sensitizers should influence the tumor response curve more than the normal tissue curve, thus resulting in a greater than one therapeutic ratio. Similar to the concept of additivity, therapeutic ratios are mainly hypothesis-forming and need to be tested empirically in phase I and II studies. Such preclinical data may help in the initial dose schedule selection for phase I trials.
Mechanisms of radiation resistance or failure

Figure 2 Schematic example of an isobologram depicting the combination of radiation and a systemic agent. The x and y axes show the isoeffective levels for radiation and drug. The thick line is the line of additivity, and the additivity envelope is based on the combined standard errors. Curves above the envelope represent antagonistic effects and curves below the envelope represent synergistic effects.1,41 Abbreviation: RT, radiotherapy.
100 Normal tissue Tumor

Response/toxicity rate (%) 0 Radiation dose (Gy)

Tumors have developed multiple strategies to resist radiation damage. Table 2 gives an overview of the most widely accepted mechanisms. Simplistically, larger tumors have a stochastic chance that some cells will survive radiotherapy. Moreover, hypoxic tumor cells have increased resistance to radiation; multiple studies have demonstrated that hypoxic cells exhibit 2.53.0

Figure 3 Schematic doseresponse curves for tumor and normal tissue damage with radiation. The offset between the two curves indicates the therapeutic range. Chemoradiotherapy leads to a shift of both curves to the left, ideally with a stronger shift of the tumor curve (as indicated by the longer arrow), increasing overall efficacy of treatment (radiation enhancement).120

times the resistance to radiotherapy damage compared with normoxic cells.1620 As shown in Figure 4, the phases of the cell cycle significantly influence the radiosensitivity of cells.21

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Table 2 Mechanisms of radioresistance.

Process affected Large tumor cell burden Mechanism Tumor size is inversely correlated with tumor response. Radiation-induced cell kill is a random eventthe higher the number of cells, the higher the chance of cells escaping a lethal hit.121,122 Oxygen is needed to generate ROS and other radicals with radiation. ROS are thought to be essential to the cytotoxic effect from radiation (reviewed in Cook et al.123). Hypoxia is present for two reasons: 1. increased interstitial pressure may cause hypoperfusion, hypoxia and acidosis;124126 2. cancer-related anemia contributes to local hypoxia (HIF1 is a marker of tumor hypoxia). Comments Upfront or completion surgery should be considered to reduce tumor bulk or residual disease.

Tumor cell microenvironment/ hypoxia

Hypoxic cells are 2.53.0 times less radiation-sensitive than normoxic cells.18,44 Both hypoxia and HIF1 are adverse prognostic factors.127 Chemotherapy can increase radiation effect: 1. through reoxygenation second to tumor shrinkage (e.g. with paclitaxel46); 2. by killing hypoxic cells selectively (e.g. with tirapazamine or mitomycin C); 3. through resensitization of hypoxic cells to radiation (nitroimidazolesin development).

Inherent or acquired tumor cell resistance

Multiple mechanisms are thought to contribute, including mutated p5329, DNA repair gene amplification, increased levels of ROS scavengers, activation of prosurvival/poorprognosis oncogenes (EGFR,100,101 c-MET32). Regrowth of tumor cells between doses of radiotherapy or chemotherapy. Accelerated repopulation might lead to treatment failure and emergence of true radioresistance (see row above).22

Delays or interruptions in radiotherapy are known to lead to the development of radioresistance and allow such resistant cells to repopulate.

Repopulation

Accelerated radiation schemes are intended to prevent repopulation.128 Antimetabolites with activity in the S phase of the cell cycle (5-FU, hydroxyurea) also inhibit repopulation. EGFR inhibitors can block cell proliferation between radiotherapy fractions.101

Abbreviations: 5-FU, 5-fluorouracil; HIF1, hypoxia-inducible factor 1-alpha; ROS, reactive oxygen species.

One of the most commonly invoked underlying mechanisms in treatment failure22,23 is tumor cell repopulation, which results in a rapid growth between radiation fractions. Although incompletely understood, the stimulation of growth factors and the selection of resistant clones lead to rapid emergence of treatment resistance.22,24,25 In addition, rapidly proliferating tumors contain a high proportion of radioresistant cells in the S phase of the cell cycle. For further information on repopulation, readers should refer to the excellent review by Schmidt-Ullrich et al.26 Certain tumors are intrinsically radioresistant, while others acquire mechanisms of radioresistance during treatment. Intrinsic radioresistance is seen when there is an increased surviving fraction of tumor cells after 2 Gy radiotherapy; this result is often depicted in a clonogenic radiation cell survival curve assay. Small increases in radioresistance lead to large, logarithmic decreases in final cell kill after radiotherapy. In some tumors, such evaluation in radioresistance in pretreatment biopsies predicts for radiosensitivity and clinical

outcome, although these findings have so far not been widely reproducible.27,28 Activation of certain prosurvival pathways that prevent apoptosis can induce treatment resistance. Among the many pathways implicated are mutated p53,29 amplification of DNA repair genes, increased levels of reactive oxygen species scavengers, and activation of prosurvival/poorprognosis oncogenes such as EGFR,30,31 or c-MET (also known as MST1R).32,33 Recently, gene-expression profiling has identified that radiation-resistant tumors overexpress many genes related to interferon pathways or induced by interferon itself, especially STAT1. Radiosensitive cells transfected with STAT1 demonstrated radioprotection after exposure to 3.0 Gy radiation.34
General mechanisms of chemotherapy and radiotherapy interaction

Seven major interactions between chemotherapy and radiation will be explained here and are listed in Table 3. For most chemotherapeutic agents several interactions apply at the same time. First, DNA damage can be induced by both

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Taxanes Vinca alkaloids Etoposide Bleomycin G2

M Division G1

Cisplatin adduct

Radiation-induced single-strand breaka

Cisplatin and radiationinduced damage

Cell-cycle-independent: Platinating agents Alkylating agents

G0

Repair

Repair

Cell death

Figure 5 Increased DNA damage by addition of cisplatin to radiation. aRadiation can also induce other DNA damage, of which double-strand breaks are considered lethal.
S Vinca alkaloids 5-fluorouracil Methotrexate Hydroxyurea Doxorubicin Cytarabine Gemcitabine Etoposide

Most radiosensitive Most radioresistant

Figure 4 Cell-cycle schematic and respective sensitivity to chemotherapeutic agents.

chemotherapy and radiotherapy and synergy is possible. Ionizing radiation induces DNA base damage, alkali-labile sites, single-strand breaks, and double-strand breaks (DSBs). All of these errors can be rapidly repaired except for DSBs, which if not repaired are considered lethal.35,36 The integration of cisplatin into DNA or RNA in close proximity to a radiation-induced single-strand break can act synergistically to make the defect significantly more difficult to repair (Figure 5).37,38 Second, chemotherapy can inhibit post-radiation damage repair. DNA synthesis and repair share common pathways, which provide the rationale for using DNA synthesis inhibitors with radiation as a means of inducing cytotoxic damage to tumor cells. Agents affecting nucleoside and nucleotide metabolism can inhibit the repair of radiationinduced DNA damage in patients, and are among the most potent radiation sensitizers. Examples of such agents include the fluoropyrimidines, thymidine analogs, gemcitabine, and hydroxyurea. Third, administered concurrently, radiotherapy and chemotherapy often target different phases of the cell cycle and may cooperate to produce an additive effect (i.e. cytokinetic cooperation/ synchronization). The radiosensitivity of a cell is dependent on the phase of the cell cycle; cells in the S phase are the most radioresistant, and cells in the G2M phase of the cell cycle are the most radiosensitive (Figure 4).39,40 In addition,

cytokinetic cooperation of S-phase-specific agents (e.g. camptothecins, 5-FU, hydroxyurea) is seen if cells are exposed in close temporal proximity to radiation.41 Some drugs (e.g. taxanes) are able to synchronize with the cell cycle of tumor cells to allow increased efficacy of subsequent radiotherapy (called synchronization or cell-cycle pooling). This process was successfully shown in vitro, although the conceptespecially its applicability in vivoremains controversional.11,42,43 Fourth, the increased resistance of hypoxic cells to radiation (Table 2) means that hypoxic cell sensitizers may be beneficial.18,44 Hypoxia is common in many cancers and was shown to be a marker of aggressive clinical behavior and poor prognosis.45 Chemotherapy can help eliminate these resistant cells and increase the efficacy of radiotherapy via multiple mechanisms (Table 3). Tirapazamine, and potentially mitomycin C, preferentially kill hypoxic cells. Additionally, paclitaxel,46 and EGFR inhibitors,24 were shown to shrink tumors, thereby increasing perfusion and oxygenation and reducing radioresistant hypoxic areas. This hypoxic effect might be applicable for many other agents. Fifth, repopulation of rapidly proliferating tumors is usually mediated by overexpression of growth factors and growth factor receptors, as well as increased activity of downstream signaling pathways, and the presence of activating mutations in genes involved at all levels of the signaling pathways. Agents that target the S phase of the cell cycle, such as 5-FU, irinotecan, and hydroxyurea, as well as those that inhibit proliferation and/or growth factor pathways, such as EGFR inhibitors, may be effective in preventing tumor cell repopulation, thereby radiosensitizing tumor cells.24,47 In addition to their antiproliferative effects that prevent tumor cell repopulation, EGFR

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Table 3 Mechanisms of chemotherapy and radiotherapy interaction.

Process affected Increased radiation damagea Mechanisma Incorporation of chemotherapy drug into DNA/RNA Drug examples 5-FU: incorporation into DNA, increasing susceptibility to RT damage Cisplatin: cross-links with DNA or RNA (intrastrand and interstrand); works for both hypoxic and oxygenated cells51 Halogenated pyrimidines (e.g. 5-FU, bromodeoxyuridine, iododeoxyuridine) Nucleoside analogs (e.g. gemcitabine, fludarabine) Cisplatin Methotrexate Camptothecins and doxorubicin Etoposide Hydroxyurea Carmustine, lomustine Taxanes lead to cell-cycle arrest via tubulin stabilization Nucleoside analogs (e.g. gemcitabine, fludarabine), etoposide, methotrexate, hydroxyurea

Inhibition of DNA repair processa

Interference with the DNA repair process after radiation

Cell-cycle interference (cytokinetic cooperation and synchronization)a

Most cytotoxic chemotherapies as well as radiation are cell-cycle-specific, and proliferating cells are most susceptible Accumulation of cells in the G2 and M phases (the most radiosensitive phases) Elimination of radioresistant cells in the S phase Reoxygenation second to tumor shrinkage. Hypoxic cells are 2.53.0 times less radiation-sensitive than normoxic cells18,44 Chemotherapy can help to eliminate hypoxic cells Systemic therapy can slow or stop rapid proliferation, which could otherwise be the basis for repopulation phenomenon

Enhanced activity against hypoxic cellsa

Most chemotherapeutic agents; described in particular for paclitaxel45 Tirapazamine, mitomycin (selective killing of hypoxic cells); nitroimidazoles (resensitize hypoxic cells to radiation) Most chemotherapeutic agents, in particular: Antimetabolites with activity in the S phase inhibit repopulation (e.g. 5-FU, hydroxyurea) EGFR inhibitors, which impede cell proliferation between RT fractions100 EGFR inhibitorsshown for anti-EGFR antibody, PKI166 (small-molecule TKI), and EGFR antisense,129131 but on the basis of clinical experience likely to be a class effect49,132 Effect demonstrated for taxane-based CRT including paclitaxel as well as docetaxel29,50 Low-dose fraction radiation

Radiotherapy enhancement by preventing repopulationa

Inhibition of prosurvival and poor prognosis markersa Hyperradiation sensitivityb

Targeted therapies (best demonstrated for EGFR inhibition) block signaling pathways that might be responsible for radioresistance and poor prognosis HNSCC cells resistant to standard-fraction CRT can be resensitized to CRT by using smaller fraction sizes (<1 Gy) more frequently

aChemoradiotherapy potentiation through drug addition. bChemoradiotherapy potentiation through alteration in radiation administration. Abbreviations: 5-FU, 5-

fluorouracil; CRT, chemoradiotherapy; HNSCC, head and neck squamous cell carcinoma; RT, radiotherapy; TKI, tyrosine kinase inhibitor.

inhibitors and antiangiogenic agents can block signaling pathways that are responsible for aggressive tumor biology, poor prognosis, and radioresistance. Although the exact mechanisms of various targeted therapies vary and are generally poorly understood, preclinical48 and clinical49 data support the rationale for radiosensitizing properties as a consequence of inhibiting the detrimental effects of the agents targets. Finally, some tumors resistant to standard chemoradiotherapy respond to alterations in radiation fractionation. This phenomenon, termed hyperradiation sensitivity,

is observed at radiation doses greater than 1 Gy. Preclinically, for both paclitaxel and docetaxel, low-dose fractionated radiation can overcome radioresistance.50 Clinical trials evaluating this technique are currently underway.
Specific mechanisms of chemotherapy and radiotherapy interaction

Platinum analogs Cisplatin is one of the most commonly used drugs for concurrent chemoradiotherapy. Through interactions with nucleophilic sites on DNA and RNA, cisplatin introduces intrastrand

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and interstrand cross-links, thereby distorting the DNA structure, and blocking nucleotide replication and transcription. Active in both hypoxic and well-oxygenated cells,51 several potential mechanisms for cisplatin-mediated radiation sensitization were reported and summarized by Wilson and co-workers.41 It has been proposed that radiation induces free radicals and subsequently the formation of toxic platinum intermediates, which increase cell killing.52 Moreover, ionizing radiation can increase cellular uptake of platinum.53 Damage to DNA by ionizing radiation that typically would be repairable can become fixed and lethal through cisplatins freeelectron-scavenging capacity. This inhibition of DNA repair (Figure 5)54 leads to an increased incidence of cell-cycle arrest and apoptotic cell death after radiation.41,55 In vitro studies have shown that the most synergistic combination of cisplatin and radiation involves low doses of each, either of which would be insufficient to cause cell death if administered alone. Cisplatin would seem to inhibit the sublethal damage repair process implicated in the recovery of insufficiently radiated cells.41 Radiosensitization by cisplatin and carboplatin may be limited to cells with an intact homologous recombination repair system,41,56 but radiosensitization is not impacted by hypoxia. Oxaliplatin, a cisplatin-related compound, has been shown to have activity in cisplatinresistant systems and unaltered sensitivity in mutated mismatch-repair systems.49 Although less well studied, oxaliplatin is postulated to have similar radiosensitization mechanisms to those of cisplatin.41
Antimetabolite-based chemoradiotherapy

5-FU radiosensitization is postulated to occur by the agents effect on the proportion of cells in the radioresistant S phase of the cell cycle. When given in standard doses, 5-FU is able to kill cells in the S phase. Additionally, at sublethal concentrations, 5-FU pre-incubation is hypothesized to radiosensitize tumor cells through changes in the S-phase cell-cycle checkpoint, which allow inappropriate progression out of the S phase into the G2 phase. This conjecture is supported by the fact that blocking the entry of cells into S phase prevents radiosensitization for a similar pyrimidine analog, fluorodeoxyuridine.57,58 Impaired repair of radiation-induced DSBs might also contribute to 5-FU cytotoxicity and radiosensitization.57,58 Capecitabine Capecitabine is an oral prodrug that is converted to 5-FU via thymidine phosphorylase. Radiation has been shown to preferentially increase tumor thymidine phosphorylase levels via induction of tumor necrosis factor. In a colon cancer fluoropyrimidine-resistant xenograft model, exposure to capecitabine before irradiation demonstrated a supra-additive effect compared with radiation alone.60 Clinical trials are actively exploring the role of the combination of capecitabine and radiation therapy. Gemcitabine Gemcitabine is a widely used S-phase cell-cyclespecific pyrimidine analog that hinders DNA synthesis and repair through depletion of deoxynucleoside triphosphates that are required by two enzymes: DNA polymerase and ribonucleotide reductase. Gemcitabine has shown activity in many solid tumors, either alone or in combination with other agents (e.g. cisplatin or carboplatin).61 Initial clinical studies of pancreatic and lung cancer demonstrated marked toxicity of gemcitabine-based chemoradiotherapy and dampened enthusiasm for the efficacy of this drug, since only doses much lower than those used without radiation could be administered safely. Recent data from multi-institutional studies have shown that full doses of gemcitabine can be delivered with aggressive conformal radiation techniques.6264 In preclinical models, the potent radiosensitizing properties of gemcitabine were most pronounced with exposure to low doses of the agent at least 24 h before irradiation. Interestingly, sensitization persisted for up to

5-fluorouracil The halogenated pyrimidine nucleoside analog 5-FU is used extensively with radiation.57,58 This analog impedes nucleic acid synthesis through thymidylate synthase inhibition, depleting the pool of nucleotide triphosphates, leading to cellcycle changes, DNA fragmentation, and ultimately cell death.59 When 5-FU is incorporated into RNA and DNA it inhibits not only DNA synthesis, but also transcription and protein synthesis. Optimal 5-FU radiosensitization requires continuous administration of the agent during radiation because of the need for continuous thymidylate synthase inhibition, the short half-life of plasma 5-FU and intracellular phosphorylated 5-FU metabolites.

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48 h, and radiation exposure before exposure to gemcitabine did not lead to sensitization. These observations are consistent with the time needed to deplete deoxynucleoside triphosphates (dATP) and transition through the S phase of the cell cycle.6567 It seems that incorporation of incorrect bases secondary to deoxynucleoside triphosphate depletion and S-phase accumulation are the basis of the radiosensitizing properties of gemcitabine.65 Pemetrexed This compound is a novel multitargeted antifolate that inhibits thymidylate synthase, dihydrofolate reductase, and glycinamide ribonucleotide formyl-transferase, all of which are key enzymes involved in nucleotide synthesis. Preclinical data suggest synergistic antitumor activity of pemetrexed and concurrent radiotherapy, and interference with DNA synthesis is thought to be the primary cytotoxic mechanism.68 Pemetrexed is not cell-cycle-specific as it shows equal efficacy in the G1 and S phases of the cell cycle.69 Although the exact interaction of pemetrexed with radiation is not fully understood, it has been postulated that prolongation of the S phase by radiation increases the intracellular drug exposure time and toxicity. Pemetrexed-based chemoradiotherapy is in phase I clinical testing in several tumor types.70 Hydroxyurea Hydroxyurea acts as a radiation enhancer in vitro and in vivo51 and is useful for the treatment of head and neck cancer.71 This drug was previously used for squamous-cell carcinoma of the cervix (replaced by cisplatin)72 and gliomas (replaced by temozolomide),73 and was proposed for the treatment of pancreatic cancer (replaced by 5-FU and potentially gemcitabine).74 Ribonucleotidereductase inhibition prevents radiation-induced DNA damage repair during nucleotide excision. Furthermore, hydroxyurea might also synchronize cancer cells at the G1S checkpoint.74 The double action of hydroxyurea of cell-cycle synchronizing and DNA damage repair inhibition has been suggested as a mechanism for its more efficacious action as a radiation sensitizer at doses lower than for the ribonucleotide-reductase inhibitors gemcitabine and trimidox.74 Antimetabolites such as hydroxyurea are selectively cytotoxic to cells that are in the relatively radioresistant S phase of the cell cycle, which might contribute to overcoming radioresistance.

Taxane-based chemoradiotherapy

Paclitaxel and docetaxel form high-affinity bonds with microtubules, promoting tubulin polymerization and stabilization. At high doses, these drugs block prophase to metaphase progression, disrupting the centrosome network and thereby causing cell death.75 Despite the structural similarities of these two agents, differences in excretion and cell-cycle tropism instigate differing temporal interactions of paclitaxel and docetaxel with radiation.76 Two mechanisms for paclitaxel and docetaxel radiosensitization have been proposed. The standard explanation is that cells remain in the G2M phase of the cell cycle, leading to synchronization (cell-cycle pooling) of tumor cells at a point of maximum radiosensitivity,11,42 but it is still unclear whether cell-cycle redistribution occurs, especially in vivo.43 True synchronization in large tumors seems unlikely, and may not increase the therapeutic index as normal cells are also affected.77 Alternatively, taxanes can induce tumor shrinkage, improving perfusion and subsequent reoxygenation. As hypoxic areas of the tumor are reoxygenated they become more sensitive to radiation-induced cell kill.46 Paradoxically, low doses of taxanes may induce protection against radiation via possible alterations in signal transduction pathways. Pretreatment of a human laryngeal squamous cell line with 7.5 nmol/l paclitaxel 6 h before irradiation induced subadditive effects via G2 blockade.78 Extensive single-agent and chemoradiotherapy taxane mechanisms are reviewed by Hennequin and Favaudon.11
Mitomycin-C-based chemoradiotherapy

Mitomycin C inhibits DNA and RNA synthesis by interfering with DNA cross-linking, primarily at the guanine and cytosine pairs. Although mitomycin C is not cell-cycle-specific, this agent is known to induce marked cell-cycle arrest at the G2M transition.79,80 In combination with radiation, mitomycin C acts as a hypoxic cell sensitizer and is thought to prevent repopulation, although the exact mechanism remains elusive.81
Tirapazamine-based chemoradiotherapy

Tirapazamine is the lead compound in a class that has selective cytotoxic activity under hypoxic conditions (hypoxic cell cytotoxic).82 Hypoxic tumor cells that are relatively resistant to radiotherapy exhibit aggressive growth behavior, and portend

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a poor prognosis. Although widely recognized in its ability to enhance radiation,83 debate exists as to whether tirapazamines effects are additive or supra-additive.84,85 Regardless, theoretical models show that the killing of hypoxic cells might improve outcomes compared with standard radiosensitizers.86 Tirapazamines approximately 100-fold increased potency under anoxic conditions occurs via electron donation, which causes formation of transient oxidizing radicals. In normoxic tissue these radicals quickly bind available molecular oxygen, re-establishing the nontoxic parent compound. In the absence of oxygen, however, these oxidizing radicals induce the formation of DNA radicals by extracting a proton from the C4 location of the deoxyribose ring on the DNA.87 This process can lead to cytotoxic DNA-strand breaks. Additionally, unknown mechanisms decrease topoisomerase II activity in tirapazaminetreated cells.88 Although little or no cell killing is observed in normoxic cells, systemic side effects including fatigue, muscle cramps, and reversible ototoxicity were observed during the clinical administration of tirapazamine, and have been attributed to a loss of mitochondrial membrane potential.89
Temozolomide-based chemoradiotherapy

cancer line. This finding is probably attributable to radiation induction of MGMT. Additionally, temozolomide and radiation showed additive and supra-additive activity.97
Advances in radiotherapy

While most advances in concurrent chemoradiotherapy have focused on the integration of novel systemic agents, recent technological improvements in radiotherapy have impacted directly on concurrent chemoradiotherapy. Intensitymodulated radiation therapy (IMRT) has allowed better delivery of radiation to the target volumes, allowing sharp dose gradients between targets and normal tissues. After clinical implementation of IMRT, decreased acute gastrointestinal, skin, hematologic, and salivary toxicity rates were reported, which improved the therapeutic index of radiation.98 These decreases in normal tissue toxicity could also improve the therapeutic index of chemoradiation. Additionally, implementation of image-guided radiotherapy via linear accelerator-based kilovoltage techniques, and gating radiation delivery with the respiratory cycle, will improve day-to-day targeting and potentially decrease acute and chronic toxicities of chemoradiotherapy.
Molecular-targeted therapies in combination with chemoradiotherapy

Temozolomide is an orally administered cytotoxic alkylating agent, which readily crosses the bloodbrain barrier; 30% of plasma concentrations are achieved in the cerebrospinal fluid.90 Commonly used to treat gliomas, temozolomide causes DNA damage by methylation of the O-6 position of guanine and activates the p53-controlled DNA damage response pathway.91 Tumors with methylation of the O-6-methylguanine DNA-methyltransferase (MGMT), a p53 DNA damage repair enzyme, are preferentially radiosensitized.92,93 Temozolomide also inhibits signaling of radiationtriggered cell migration and invasiveness94 and decreases tumor cell repopulation. The aim of combining temozolomide with radiation is the use of an intrinsically active agent that has a different toxicity profile to radiation.95 In a study by Wedge et al.,96 a glioblastoma cell line with no MGMT activity was compared with a colorectal cancer cell line with high repair activity. Temozolomide and radiation were additive in the glioblastoma line, whereas antagonism was observed in the colorectal

In the past decade, the promises of moleculartargeted agents have increasingly come to fruition, and these agents have been combined with radiotherapy in an effort to optimize the therapeutic index of drug dosing. Molecular-targeted therapies are an attractive option combined with chemoradiotherapy because they are more specific for the target and can inhibit radioresistance pathways. An extensive review of molecular-targeted agents and their interaction with radiotherapy has been published by Ma et al.99 EGFR-targeted therapies and chemoradiotherapy The membrane-bound receptor tyrosine kinase EGFR is activated upon binding of the ligand (transforming growth factor , epidermal growth factor), which induces dimerization and subsequent phosphorylation of the intracellular EGFR tyrosine residues. Upon activation, intracellular signaling cascades mediate various cellular responses important for tumor survival and growthnamely, increased proliferation, invasion, angiogenesis, and metastasis, and concomitant decreased apoptosis.

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EGFR (erbB1) and the EGFR family members erbB24 are deregulated in head and neck, lung, breast, and colorectal cancers. Increased EGFR protein expression correlates with increased tumor size, recurrence risk, and radioresistance, and with decreased survival.100,101 Cell culture experiments of radiation-induced EGFR expression and increased radioresistance, demonstrated by the addition of exogenous EGF, indicated a causal link between EGFR and radioresistance.102 Preclinical studies with the EGFR inhibitors cetuximab, gefitinib, and erlotinib show enhanced radiosensitivity leading to supraadditive efficacy both in vitro and in vivo.49,100,103 Proposed mechanisms for radiosensitization via EGFR inhibitors include inhibition of cell proliferation, impairment of DNA damage repair,104 attenuation of tumor neoangiogenesis, inhibition of radiation-induced EGFR nuclear import,105 and promotion of radiation-induced apoptosis.106,107 In particular, the antiproliferative effects of EGFR inhibition most likely prevent repopulation,100 a major mechanism implicated in radioresistance. The other mechanisms may well have a role in the supra-additivity of the anti-EGFR radiation combination. Antiangiogenic and anti-VEGF therapy in combination with radiation Angiogenesis is essential for sustained tumor growth, and many new cancer therapies are directed against modification of the tumor vasculature.108,109 The process of angiogenesis is mediated by multiple proangiogenic and antiangiogenic factors, with VEGF having a central role.108,109 Anti-VEGF agents fall into two broad categories: those that target the VEGR ligand, such as bevacizumab, and those that target the receptor, such as PTK787 (an antibody to VEGFR-2). Other antiangiogenic strategies include antiangiogenic factor administration to counterbalance proangiogenic stimuli, inhibition of extracellular matrix degradation enzymes, integrin antagonists, and therapies with direct endothelial cell toxicity. Two mechanisms for radiosensitization with antiangiogenic agents have been proposed and could exist in parallel.109,110 The traditional view is that antiangiogenic destruction of tumor vessels leads to hypoxia and starvation, which paradoxically could also increase tumor resistance.111 Increasingly, however, findings

show that increases in blood flow, oxygen, and drug delivery (i.e. a transient normalization of the abnormal structure and function of tumor vessels) is seen as the underlying mechanism of antiangiogenic therapies.109 Radiosensitizing properties were first reported for angiostatin when Weichselbaum and colleagues demonstrated that the combination of angiostatin and radiation was synergistic and decreased radioresistance.112 These results have also been confirmed for antiangiogenic small-molecule tyrosine kinase inhibitors.113 Additionally, endostatin showed additivity with radiation regarding tumor regression, growth inhibition, angiogenesis, and enhanced apoptosis.114 These mechanisms could be caused by enhancement of tumor oxygenation, leading to increased radiosensitivity, as well as direct tumor growth delay.110,112 Novel targeted therapies with radiosensitizing properties Receptor tyrosine kinases other than EGFR are also potential targets for novel radiosensitizers. Overexpression of c-Met has been linked to poor prognosis in many cancers,115 and synergism with radiation has been described in glioblastoma cell lines.116 Other receptor tyrosine kinases such as insulin-like growth factor receptor or ephrin receptors are additional candidates. Another innovative strategy that has been tested in phase I clinical trials is radiation-induced activation of gene transcription. For example, TNFerade (GenVec, Gaithersburg, MD) is a replicationdeficient adenovirus vector with an early growth response protein 1 (EGR1) radiation-inducible promoter leading to intratumoral human tumor necrosis factor production. Initial applications of this agent in esophageal, rectal, and pancreatic cancer, as well as in sarcomas, have shown proof of principal, with extensive tumor necrosis as a sign of activity.117 Additional studies in head and neck cancer are ongoing. With the increasing understanding of cancer biology, hundreds of novel targeted agents are scheduled to come into preclinical and clinical development in the next decade. Among these agents proteasome inhibitors, and agents that target mammalian target of rapamycin, have shown promising results when combined with radiotherapy.118,119 For further information on the interaction of targeted agents with radiation, readers are referred to the excellent review by Ma and coauthors.99

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CONCLUSION

In summary, concurrent chemoradiotherapy is a highly efficacious locoregional treatment option for solid tumors, which can be used alone or combined with surgery or induction/consolidation chemotherapy. Through our increased understanding of the molecular basis of chemotherapy and radiation interactions, we have gained insights into how to best use and potentially combine agents with radiation, with benefits beginning to be seen in patients. Novel targeted therapies and agents specific for hypoxic or radiated cells hold promise for further significant improvement of therapeutic ratios. Concurrent chemoradiotherapy already offers excellent locoregional control with an acceptable toxicity profile for the treatment of many locoregional advanced tumors. In the final article of this two-article series we will examineusing the example of head and neck cancerspecific concurrent chemoradiotherapy treatment options and the underlying clinical evidence. Head and neck cancer is often a locoregionally confined disease, and this is exemplified by the profound impact and benefit that concurrent chemoradiotherapy can have for patients.
KEY POINTS
Concurrent chemoradiotherapy has improved cancer care during the past two decades in multiple diseases, and can be used in the neoadjuvant, primary (definitive), or adjuvant setting Chemotherapy or targeted agents can increase the efficacy of radiation Radiosensitizing effects (interaction within the radiation field) can be additive or supra-additive Multiple mechanisms underlie radiosensitizing properties of chemotherapeutic agents and include increased radiation damage, inhibition of DNA repair, cell-cycle synchronization, increased cytotoxicity against hypoxic cells, inhibition of prosurvival pathways, and abrogation of rapid tumor cell repopulation Radioresistance occurs through multiple mechanisms, such as a large tumor burden, hypoxia, rapid tumor cell repopulation, as well as the constitutive or acquired activation of radioresistance signaling pathways In addition to the classic chemotherapeutic agents with radiosensitizing properties (i.e. cisplatin and paclitaxel), several novel agents show promising interactions with radiation (e.g. EGFR inhibitors, pemetrexed, tirapazamine, and potentially several other targeted therapies)

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Acknowledgments
The authors would like to acknowledge the generous help of Dr Blase Polite and Dr Samir Undevia in reviewing organ-specific data.

Competing interests
EE Vokes has declared associations with the following companies: AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Genentech, ImClone, OSI and sanofiaventis. See the article online for full details of the relationship. The other authors declared they have no competing interests.

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