Serum Alpha-2-Macroglobulin as an intrinsic radioprotective factor in patients undergoing thoracic radiation therapy

ObjectiveTo investigate the impact of alpha-2-macroglobulin (A2M), a suspected intrinsic radioprotectant, on radiation pneumonitis and esophagitis. Additionally, we establish multifactorial predictive models for pneumonitis and esophagitis.\n\nMaterials/MethodsBaseline A2M levels were obtained for 258 patients prior to thoracic radiotherapy (RT). Dose-volume characteristics were extracted from treatment plans. Spearmans correlation (Rs) test was used to correlate A2M levels, smoking status and dosimetric variables with toxicities. Esophagitis and pneumonitis prediction models were built using least absolute shrinkage and selection operator (LASSO) logistic regression on 1000 bootstrapped datasets. Models were built using 2/3 of the data for training and 1/3 for validation.\n\nResultsThere were 36 (14.0%) patients with grade [≥]2 pneumonitis and 61 (23.6%) with grade [≥]2 esophagitis. The median A2M level was 191 mg/dL (range: 94-511). Never/former/current smoker status was 47 (18.2%)/179 (69.4%)/32 (12.4%). We found a significant correlation between baseline A2M levels and esophagitis (Rs=-0.18/p=0.003) and between A2M and smoking status (former or current) (Rs=0.13/p=0.04) but not between A2M and pneumonitis. On univariate analysis, significant parameters for grade [≥]2 esophagitis included number of fractions (Rs=0.47/p0.5 (p<0.0001). For pneumonitis, significant clinical parameters were treatment days (Rs=0.24/p=0.0001), chemotherapy use (Rs=0.22/p=0.0004), number of fractions (Rs=0.21/p=0.0007), dose per fraction (Rs=-0.18/p=0.0035), and total dose (Rs=0.15/p=0.013). The most significant dosimetric variable in lung and heart was D70 (Rs=0.28/p<0.0001) and max dose (Rs=0.27/p<0.0001), respectively. LASSO bootstrap logistic regression models on the validation data resulted in the area under the receiver operating characteristic curve of 0.84 and 0.75 for esophagitis and pneumonitis, respectively.\n\nConclusionOur findings show an association of higher A2M values with lower risk of radiation esophagitis and smoking status. Multivariate predictive models also confirmed a role of heart dose in the risk of pneumonitis.