CCR Translations
Cancer
Implications of the Bystander and Abscopal
Effects of Radiation Therapy
Vivek Verma1 and Steven H. Lin2
Siva and colleagues have demonstrated that localized thoracic
radiation resulted in DNA damage at out-of-eld sites. Although
these interesting ndings require validation, we discuss the impor-
In this issue of Clinical Cancer Research, Siva and colleagues
describe evidence of DNA damage to not only peripheral blood
lymphocytes coursing through the irradiated thorax, but sus-
tained DNA damage repair as showed by gH2AX foci within
eyebrow hair follicles far outside of the irradiated area (1). Several
cytokines are implicated to at least partially mediate these appar-
ent bystander effects. Although the nding is an elegant portrayal
of this phenomenon, it may have profound implications for both
normal tissue toxicity prevention and cancer therapy.
Cases of the out-of-eld "systemic effects" of radiotherapy
exerting tumoricidal control at distant sites, known as the "absco-
pal phenomena," have been sporadically described for decades
(2) and are likely contributed by complex interactions of the
immune system with localized inammation induced by radio-
therapy, including through both T-cell and cytokine signaling (3).
The proposed mechanisms, likely similar to what is responsible
for the bystander effect on normal tissue, are likely overly sim-
plistic (Fig. 1) but generally involve local tumor ablation, antigen
presentation, and inammatory mediators. The resultant systemic
effect may produce generalized symptoms that patients often
experience during protracted course of radiotherapy (e.g., fatigue,
anorexia). In the current study (1), it is still uncertain how DNA
damage as measured by gH2Ax foci in hair follicle cells is gen-
erated. However, unlike peripheral blood lymphocytes (PBL),
which developed measurable gH2Ax foci at 1 hour that mostly
disappears at 24 hours, eyebrow hair follicle cells developed DNA
damage starting at 24 hours after the rst fraction, and persisted
even 4 weeks into radiotherapy and nearly recovered to basal
levels by 3 months after radiotherapy. The initial delay and
sustained time course suggests systemic inammatory effects
possibly mediated in part by cytokines and/or inammatory cells
gathering at distant sites away from the irradiated zones, although
the authors did not comment on whether these inammatory
1
Department of Radiation Oncology, University of Nebraska Medical
Center, Omaha, Nebraska. 2Department of Radiation Oncology, Uni-
versity of Texas M.D. Anderson Cancer Center, Houston, Texas.
Corresponding Author: Steven H. Lin, Department of Radiation Oncology, The
University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 97,
Houston, TX 77030. Phone: 713-563-8490; Fax: 713-563-2366; E-mail:
SHLin@mdanderson.org
doi: 10.1158/1078-0432.CCR-16-1512

2016 American Association for Cancer Research.
www.aacrjournals.org
Clinical
Research
tant clinical implications of these data, especially in the era of
immune therapies. Clin Cancer Res; 22(19); 47635.
2016 AACR.
See related article by Siva et al., p. 4817
cells could be seen in the vicinity of the hair follicle. miRNA and
exosomal signaling may also be involved, although the authors
could not nd evidence to support the latter. It is known that
certain inammatory cytokines can mediate DNA damage
response through elicitation of nitric oxide (NO) generation by
inducible NO synthase (iNOS; ref. 4). Interestingly, iNOS is an
enzyme induced in activated monocytes and macrophages, and
the authors discovered that CCL3 was signicantly upregulated at
4 weeks that was dose independent, much like the gH2Ax foci in
the hair follicles. It is known that CCL3 and iNOS are coexpressed
in activated macrophages, and CCL3 plays a role in inammatory
responses through binding CCR1 and 5 in mediating radiation-
induced lung injury (5). Whether this is the mechanism mediating
this response in distal sites in the hair follicles is uncertain;
possible future studies could explore the role of activated macro-
phages or iNOS expression in distant unirradiated areas.
Although it is known that an intact immune system is impor-
tant for radiation-killing effect on tumors (6), it could very well be
that indirect damage to normal tissues by the immunologic and
inammatory response may manifest as "silent" toxicities that
could result in an increased risk of secondary malignancy in the
appropriate patient populations, as the level of inammation
produced could be related to genetic susceptibility of individuals.
We acknowledge that it may be questionable that such small
numerical increases in DNA damage foci may portend to clinically
evident increase in toxicity or radiation-induced neoplasms, espe-
cially with the 3-month time course as seen in the data. However,
the "silent" toxicities experienced by highly radiation-sensitive
tissues, such as the bone marrow and gonads, may very well have
stochastic and long-term implications. Inammatory mediators
may modify gene expression via transcriptional and/or epigenetic
mechanisms. Importantly, these alterations can occur in
"bystander" germ cells, potentially creating a major conduit for
predisposition of radiation-induced malignancies in future gen-
erations (7).
The most logical extension to the current work is to ask the
question to what extent, similar DNA damage occurs in other
locations and organs. Radiation modality, tumor histology and
volume, location, timing of immunotherapy with radiotherapy,
and the patient's immune microenvironment may play a role,
among numerous other factors (8). Furthermore, it has been
recently reported using mathematical modeling that different
tumor locations may be more "immunogenic" than others (9).
The model encompasses several factors, not limited to physiologic
4763
 Verma and Lin

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distant tumor cells bystander cells

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2016 American Association for Cancer Research

Figure 1.
Simplied mechanism of how local radiation may induce a bystander or abscopal effect to cause DNA damage at distal sites. Radiation induces a number of changes
during the cell-killing process that can elicit a number of inammatory mediators from the dying cancer cell that either attract or activate immune-related
cells with the tumor microenvironment. These cells can generate additional cytokines that act locally and circulate systemically or propagate either hematogenously
or lymphatically to act on normal tissues and tumor cells located at distant sites apart from the irradiated primary tumor. DCs, dendritic cells.

blood ow and imprinting of T cells by antigen-presenting cells.
Despite the virtual nature of the work, the prominent theme
remains that factors increasing T-cell trafcking to metastatic sites
may be most associated with likelihood of observing an induced
abscopal response. Similarly, it remains to be deduced whether
particular "bystander" sites have greater proclivities to receive
DNA damage from inammatory mediators. Moreover, studies
have shown that these phenomena may occur with large, ablative
doses (10); albeit in different treatment conditions, others have
not validated this notion (11). Although many tumors are radio-
therapeutically treated using hypofractionated regimens, it would
be of great importance to assess whether these regimens produce
altered levels of postirradiation inammation as compared with
conventional fractionation.
Furthermore, the exploding eld of immunotherapies has
generated feverish interests in whether abscopal responses could
be harnessed for cancer therapy, with ever burgeoning numbers of
combination radiationimmunotherapy trials. The historically
unreliability of a "systemic anti-cancer effect of radiotherapy"
appears to be more reproducible with the combination of immu-
notherapies, such as the immune checkpoint inhibitors. A sem-
inal study by Golden and colleagues illustrated the most consis-
tent detection of the abscopal phenomenon to date, in 11 of 41
(27%) prospectively treated patients with various metastatic
cancers (12). One of at least three actively metastatic lesions was
irradiated (35 Gy/10 fractions), and granulocyte macrophage
colonystimulating factor (GM-CSF) was coadministered. GM-
CSF by itself is not expected to generate any tumor response;
however, the median survival of patients demonstrating an absco-
pal response (dened as
30% size reduction) experienced nearly
3-fold increased survival (21 vs. 8 months). This is a strong
rationale to use when similar approaches are being considered
for oligometastatic cancers, as well as high-risk nonmetastatic
cancers, to enhance "cures." However, we must proceed cautious-
ly, as immune activation that works great for the abscopal effect
will likely also exacerbate the bystander effect, to exert degrees of
systemic normal tissue toxicities beyond what immunotherapies
are causing by themselves.
In summary, Siva and colleagues have demonstrated the radi-
ation bystander phenomenon manifested as persistent DNA
damage foci in the hair follicles well outside the irradiated zone
in the thorax. Although this may be understood as the end result
of the systemic inammation that is induced by localized radio-
therapy, much needs to be learned about the mechanism and

4764 Clin Cancer Res; 22(19) October 1, 2016 Clinical Cancer Research

long-term consequence of this effect. The current study is a
demonstration that systemic normal tissue injury likely occurs
alongside the "abscopal effect," with ablative radiotherapy as the
"re starter" in the presence of cancer immunotherapies. The
clinical implications of this interesting work for both oncogenic
treatments and normal tissue toxicities, especially in this era of
immune-stimulation therapies, cannot be overstated.
Disclosure of Potential Conicts of Interest
S.H. Lin is a consultant/advisory board member for AstraZeneca, ProCure,
and US Oncology and reports receiving commercial research grants from Elekta,
Peregrine Pharmaceuticals, Roche/Genentech, and STCube Pharmaceuticals.
No potential conicts of interest were disclosed by the other author.
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www.aacrjournals.org
Bystander and Abscopal Effects of Radiotherapy
Authors' Contributions
Conception and design: S.H. Lin
Development of methodology: S.H. Lin
Acquisition of data (provided animals, acquired and managed patients,
provided facilities, etc.): V. Verma, S.H. Lin
Analysis and interpretation of data (e.g., statistical analysis, biostatistics,
computational analysis): V. Verma, S.H. Lin
Writing, review, and/or revision of the manuscript: V. Verma, S.H. Lin
Administrative, technical, or material support (i.e., reporting or organizing
data, constructing databases): S.H. Lin
Study supervision: S.H. Lin
Received July 8, 2016; accepted July 13, 2016; published OnlineFirst July 25,
2016.
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