Treatment results of alternating chemoradiotherapy followed by proton beam therapy boost combined with intra-arterial infusion chemotherapy for stage III-IVB tongue cancer

A systematic review and meta-analysis of osteoradionecrosis following proton therapy in patients with head and neck cancer

INTRODUCTION

Head and neck cancer ranks as the seventh most common cancer worldwide. Proton therapy is widely used in head and neck cancer. Osteoradionecrosis(ORN) is currently a commonly investigated side effect of proton therapy. A meta-analysis is needed to investigate this topic.

MATERIAL/METHODS

Two authors searched three databases, including PubMed, Embase, and Cochrane Library; the search period was from inception to June 2023. The search keyword was set to be ((("osteoradionecrosis") OR ("osteonecrosis")) AND ("proton")).

RESULTS

We initially collected 410 articles, and after article selections, 22 articles remained in our systematic reviews. Due to the overlapping of patient populations, 17 studies were finally included in our meta-analysis. The pooled grade 3 or more ORN rate is 0.01(95 % CI = 0.01-0.03). Subgroup analysis showed that IMPT didn't reduce grade 3 or more ORN compared with 3DCPT (p = 0.15).

CONCLUSIONS

Our meta-analysis showed that severe ORN rarely occurred in proton therapy for head and neck cancer patients.

The ECAS system can superselectively administer anticancer drugs to numerous feeding arteries from the superficial temporal artery: A case report and literature review

Superselective intra-arterial chemoradiotherapy (SSIACRT) is one of the curative treatments for advanced oral cancer. SSIACRT can reportedly treat cervical lymph node metastases in the level I-IIA area by super selectively catheterizing the facial artery (FA) and infusing drugs. However, since advanced oral cancer lesions involve a number of feeding vessels, retrograde treatment requires the placement of catheters from the superficial temporal artery (STA) and occipital artery (OA). Furthermore, in the case of level IIB lymph node metastasis, the catheter must be changed because it is necessary to administer anticancer drugs to more than three routes, including the OA, when the feeding arteries of the primary tumor are combined. The external carotid artery sheath (ECAS) system used in the present study involves the insertion of a microcatheter or steering catheter from one route of the STA, allowing selection of numerous feeding vessels, including the OA. The ECAS system can facilitate the administration of chemotherapy via the STA simultaneously to the maxillary artery, lingual artery, FA and OA. The present study describes cases of maxillary gingival cancer and tongue cancer with cervical lymph node metastasis, which were treated with the ECAS system via the STA; the treatment successfully controlled both the primary tumor and cervical lymph node metastasis. In the two cases described in the present study, metastatic lymph nodes were found in the level ⅠB and ⅡB region, but were successfully treated by administering cisplatin via the OA, in addition to the primary lesion. To date, to the best of our knowledge, there is no case report clearly referring to the treatment of lymph node metastasis using the ECAS system. In conclusion, SSIACRT using ECAS may be considered a useful treatment for oral cancer with cervical lymph node metastasis.

The Evolving Role of Intra-arterial Chemotherapy in Adult and Pediatric Cancers: A Comprehensive Review

The development of intra-arterial chemotherapy (IAC) was driven by an ambition to mitigate systemic side effects, enhance the bioavailability of drugs, and optimize the efficacy of chemotherapeutic agents. While the initial research on IAC primarily examined its effectiveness in treating various liver malignancies, the application of this treatment has undergone significant advancements since its introduction. The primary objective of this article is to examine the current range of utilization of IAC, both with and without radiotherapy, while also evaluating the results of relevant clinical trials. Furthermore, this article explores potential future advancements and opportunities in this field. From the scoping review of available articles, it can be concluded that IAC is an effective treatment alternative and, sometimes, a better first-line option, but there is a need for more evidence to make IAC a regular treatment option available for patients.

Identification of Induced Radionuclides Produced from Dental Metals in Proton Beam Therapy for Head and Neck Cancer

Purpose

To identify the induced radionuclides produced from dental metals in proton beam therapy and investigate the accuracy of the Monte Carlo (MC) simulation by comparing the measured radioactivity.

Methods and Materials

Two dental metals of pure titanium and gold-silver-palladium alloy, commonly used in Japan, were used in this study. The dental metal placed at the center of Spread-out Bragg Peak was irradiated by 150-MeV passive scattering proton beam. The gamma rays emitted from the activated dental metals were measured using a high purity germanium (HPGe) detector. The induced radionuclides were identified from the measured gamma-ray energies. Furthermore, the Particle and Heavy Ion Transport code System v.3.24 and DCHAIN were used for the MC simulation. The measured radionuclides and their radioactivity were compared with the simulation results.

Results

In the MC simulation for the activated titanium, vanadium-47, with a half-life of 32.6 minutes had the strongest radioactivity among the induced radionuclides. The energy peaks of gamma rays emitted from titanium-51, scandium-43, scandium-44, and annihilation gamma rays were observed for the activated titanium in the HPGe detector. In the MC simulation for the activated gold-silver-palladium alloy, silver-108, with a half-life of 2.4 minutes had the strongest radioactivity. The energy peaks of gamma rays emitted from silver-104, silver-104 m, silver-108, and annihilation gamma rays were observed for the activated gold-silver-palladium alloy in the HPGe detector. Furthermore, the induced radionuclides and their radioactivity in the MC simulation were consistent with the measurement results for both dental metals, except for a few radionuclides.

Conclusions

We identify the induced radionuclides produced from 2 dental metals and compared their radioactivity between the measurements and the MC simulation. Although the identification of the induced radionuclides using the MC simulation remains uncertain, the MC simulation can be clinically effective for pre-estimating the induced radionuclides in proton beam therapy.

Initial Experience of Intra-Arterial Chemotherapy Using a Novel External Carotid Arterial Sheath System Combined with Radiotherapy and Systemic Chemotherapy for Locally Advanced Tongue Cancer

We retrospectively evaluated the safety and effectiveness of an external carotid arterial sheath (ECAS) for intra-arterial chemotherapy (IACT) for locally advanced tongue cancer. Thirty-one patients with the Union for International Cancer Control's 8th TNM stage III-IV tongue cancer underwent IACT using the ECAS combined with RT and systemic chemotherapy with either cisplatin and fluorouracil (FP) or docetaxel, cisplatin, and fluorouracil (TPF) between October 2015 and February 2021. The ECAS was inserted retrogradely via the superficial temporal artery, and the tip was placed in the external carotid artery between the maxillary and facial arteries. A microcatheter was inserted into each tumor-feeding artery through the ECAS under fluoroscopy, wherein cisplatin 50 mg/m² was administered. IACT was performed weekly with neutralization using sodium thiosulfate. Complete response of the primary lesion was achieved in 28/31 (90%) patients. The median follow-up for all patients was 39 months. The 3-year overall survival, progression-free survival, and local control rates were 81.6%, 74.2%, and 83.4%, respectively. Grade 3 and greater toxicities included oral mucositis (45%), neutropenia (39%), nausea (13%), anemia (10%), thrombocytopenia (10%), dry mouth (10%), and fever (3%). There were no severe complications associated with IACT. In conclusion, the ECAS is feasible and effective for locally advanced tongue cancer.

Proton Therapy in Head and Neck Cancer Treatment: State of the Problem and Development Prospects (Review)

Proton therapy (PT) due to dosimetric characteristics (Bragg peak formation, sharp dose slowdown) is currently one of the most high-tech techniques of radiation therapy exceeding the standards of photon methods.

In recent decades, PT has traditionally been used, primarily, for head and neck cancers (HNC) including skull base tumors. Regardless of the fact that recently PT application area has significantly expanded, HNC still remain a leading indication for proton radiation since PT’s physic-dosimetric and radiobiological advantages enable to achieve the best treatment results in these tumors.

The present review is devoted to PT usage in HNC treatment in the world and Russian medicine, the prospects for further technique development, the assessment of PT’s radiobiological features, a physical and dosimetric comparison of protons photons distribution. The paper shows PT’s capabilities in the treatment of skull base tumors, HNC (nasal cavity, paranasal sinuses, nasopharynx, oropharynx, and laryngopharynx, etc.), eye tumors, sialomas. The authors analyze the studies on repeated radiation and provide recent experimental data on favorable profile of proton radiation compared to the conventional radiation therapy.

The review enables to conclude that currently PT is a dynamic radiation technique opening up new opportunities for improving therapy of oncology patients, especially those with HNC.

Therapeutic Options in Unresectable Oral Squamous Cell Carcinoma: A Systematic Review

Purpose

This review describes the current scientific evidence of therapeutic options in unresectable oral squamous cell carcinoma.

Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched MEDLINE (Via PubMed) to identify studies assessing treatments for unresectable oral squamous cell carcinoma. The methodological quality assessment of the included studies was performed using the Joanna Briggs Institute (JBI) checklist tool. The evidence was organized and presented using tables and narrative synthesis.

Results

Thirty-three studies met the eligibility criteria. Most studies had an observational design. The sample size varied from 16 to 916 participants. The methodology quality of the included studies ranged from 2.5 to 10 using the JBI tool. Overall, the optimal treatment of patients with unresectable oral cancer is challenging, so there is a sprinkling of studies assessing a variety of therapeutic options, such as radiotherapy, chemotherapy, concurrent chemoradiotherapy, immunotherapy, targeted therapy plus chemotherapy or radiotherapy, and gene therapy plus chemotherapy.

Conclusion

There is lacking evidence about the benefits of some therapeutic options for unresectable oral squamous cell carcinoma. Overall, these patients can be treated using a multimodal approach such as concurrent chemoradiotherapy or induction chemotherapy followed by chemoradiotherapy, which have shown good clinical outcomes. However, other options could be considered depending on the assessment of risk/benefits, tumor extension, and patient values and preferences.

Oncological outcomes of total glossectomy procedure for advanced tongue cancer: a single-centre experience

Surgeons treating advanced carcinoma of the tongue with total glossectomy face many conflicts in view of the morbidity and poor functional and survival outcomes following surgery. It is pertinent to study the patients undergoing total tongue compartment resection as a separate cohort to analyse their outcomes. This study investigated the oncological outcomes of 150 patients with advanced tongue squamous cell carcinoma who underwent total glossectomy. The results suggest that compartment resection significantly improved local control, irrespective of margin status. The presence of multiple positive nodes was found to be an independent poor prognostic factor, and adjuvant radiation significantly improved survival. Total glossectomy is feasible and safe in both the primary and salvage setting and should be considered as the surgical option for advanced tongue cancer.

Proton therapy for head and neck squamous cell carcinomas: A review of the physical and clinical challenges

The quality of radiation therapy has been shown to significantly influence the outcomes for head and neck squamous cell carcinoma (HNSCC) patients. The results of dosimetric studies suggest that intensity-modulated proton therapy (IMPT) could be of added value for HNSCC by being more effective than intensity-modulated (photon) radiation therapy (IMRT) for reducing side effects of radiation therapy. However, the physical properties of protons make IMPT more sensitive than photons to planning uncertainties. This could potentially have a negative effect on the quality of IMPT planning and delivery. For this review, the three French proton therapy centers collaborated to evaluate the differences between IMRT and IMPT. The review explored the effects of these uncertainties and their management for developing a robust and optimized IMPT treatment delivery plan to achieve clinical outcomes that are superior to those for IMRT. We also provide practical suggestions for the management of HNSCC carcinoma with IMPT. Because metallic dental implants can increase range uncertainties (3-10%), patient preparation for IMPT may require more systematic removal of in-field alien material than is done for IMRT. Multi-energy CT may be an alternative to calculate more accurately the dose distribution. The practical aspects that we describe are essential to guarantee optimal quality in radiation therapy in both model-based and randomized clinical trials.

Efficacy and Safety of Intro-Arterial Chemotherapy Combined with Radiotherapy on Head and Neck Cancer: A Systematic Review and Meta-Analysis

Objectives: Intro-arterial chemotherapy combined with radiotherapy (IACRT) for the treatment of head and neck cancer (HNC) underwent a revival in recent years. Although many clinical trials have reported favorable outcomes, the effect of IACRT for HNC is still controversial. Therefore, this study was designed to evaluate the efficacy and safety of IACRT for HNC.

Methods: The relevant articles published before August 2019 were searched from PubMed, Embase, Cochrane Library, Web of Science and PMC databases. Data were extracted and the combined complete response (CR), overall survival (OS) and toxicity incidence with 95% credible interval (CI) were examined from eligible studies.

Results: Thirty-four studies comprising 1890 patients were included. IACRT achieved high CR (0.81, 95% CI: 0.76-0.86, P < 0.001), 3-year OS (0.75, 95% CI: 0.68-0.82, P < 0.001) and 5-year OS (0.68, 95% CI: 0.61-0.75, P < 0.001). The 3-year OS rate of stage III cancer (0.75, 95% CI: 0.53-0.97, P< 0.001) was higher than stage IV (0.52, 95% CI: 0.37-0.66, P = 0.025). Meanwhile, the 5-year OS of T3 cancer (0.87, 95% CI: 0.73-1.01, P = 0.028) was higher than T4 (0.53, 95% CI: 0.42-0.63, P = 0.286). Additionally, oral diseases, mucositis, leukopenia and dermatitis were the major toxicities of IACRT, which were all reversible.

Conclusion: IACRT is an efficient and safe modality for HNC, which could achieve favorable cancer response and higher survival rate with acceptable toxicities, even for advanced HNC.

Early clinical outcomes of helical tomotherapy/intensity-modulated proton therapy combination in nasopharynx cancer

This study aimed to evaluate the feasibility of combining helical tomotherapy (HT) and intensity‐modulated proton therapy (IMPT) in treating patients with nasopharynx cancer (NPC). From January 2016 to March 2018, 98 patients received definitive radiation therapy (RT) with concurrent chemotherapy (CCRT). Using simultaneous integrated boost and adaptive re‐plan, 3 different dose levels were prescribed: 68.4 Gy in 30 parts to gross tumor volume (GTV), 60 Gy in 30 parts to high‐risk clinical target volume (CTV), and 36 Gy in 18 parts to low‐risk CTV. In all patients, the initial 18 fractions were delivered by HT, and, after rival plan evaluation on the adaptive re‐plan, the later 12 fractions were delivered either by HT in 63 patients (64.3%, HT only) or IMPT in 35 patients (35.7%, HT/IMPT combination), respectively. Propensity‐score matching was conducted to control differences in patient characteristics. In all patients, grade ≥ 2 mucositis (69.8% vs 45.7%, P = .019) and grade ≥ 2 analgesic usage (54% vs 37.1%, P = .110) were found to be less frequent in HT/IMPT group. In matched patients, grade ≥ 2 mucositis were still less frequent numerically in HT/IMPT group (62.9% vs 45.7%, P = .150). In univariate analysis, stage IV disease and larger GTV volume were associated with increased grade ≥ 2 mucositis. There was no significant factor in multivariate analysis. With the median 14 month follow‐up, locoregional and distant failures occurred in 9 (9.2%) and 12 (12.2%) patients without difference by RT modality. In conclusion, comparable early oncologic outcomes with more favorable acute toxicity profiles were achievable by HT/IMPT combination in treating NPC patients.

Swallowing function in advanced tongue cancer patients before and after bilateral neck dissection following superselective intra-arterial chemoradiotherapy for organ preservation: a case-control study

OBJECTIVE

This study aimed to evaluate swallowing function in advanced tongue cancer patients before and after bilateral neck dissection following superselective intra-arterial chemoradiotherapy (CRT).

METHODS

A videofluoroscopic swallowing study (VFSS) was used to evaluate swallowing function in 10 patients with advanced tongue cancer before and after bilateral neck dissection.

RESULTS

Laryngeal penetration increased in the postoperative VFSS. Temporal analysis comparing two time points revealed that, after surgery, oral transit time increased significantly, but there was no difference in pharyngeal delay time or pharyngeal transit time. Spatial analysis revealed significant decreases after surgery in the maximum distance of upper esophageal sphincter (UES) opening, the maximum distance of hyoid bone movement in both the anterior and superior direction, and the maximum velocity of hyoid bone movement.

CONCLUSIONS

Laryngeal penetration and aspiration increased as a result of limited hyoid movement and diminished UES opening after bilateral neck dissection following superselective intra-arterial CRT for advanced tongue cancer.

Proton Beam Therapy in Combination with Intra-Arterial Infusion Chemotherapy for T4 Squamous Cell Carcinoma of the Maxillary Gingiva

This study aimed to evaluate the therapeutic effect and toxicity of proton beam therapy in combination with intra-arterial infusion chemotherapy in patients with squamous cell carcinoma of the maxillary gingiva. Between December 2010 and March 2016, 30 patients with T4 squamous cell carcinoma of the maxillary gingiva were treated with radiotherapy and retrograde intra-arterial infusion chemotherapy using cisplatin (20⁻40 mg/m², 4⁻6 times). Radiotherapy was basically administered using boost proton beam therapy for primary tumor and neck lymph node tumors, following 36⁻40 Gy photon radiation therapy delivered to the prophylactic area, to a total dose of 70.4⁻74.8 Gy. The median follow-up was 33 months. The 3-year local control and overall survival rates were 69% and 59%, respectively. Major grade 3 or higher acute toxicities included mucositis, neutropenia, and dermatitis in 12 (40%), 5 (17%), and 3 (10%) patients, respectively. No grade 3 or higher late toxicities were observed. These results suggested that proton beam therapy in combination with intra-arterial infusion chemotherapy was not inferior to other treatment protocols and should be considered as a safe and effective option in patients with T4 squamous cell carcinoma of the maxillary gingiva.

Daily Cisplatin and Weekly Docetaxel versus Weekly Cisplatin Intra-Arterial Chemoradiotherapy for Late T2-3 Tongue Cancer: A Pilot and Feasibility Trial

Background and objectives: The aim of present study was to compare the treatment results of daily cisplatin (CDDP), weekly docetaxel (DOC) intra-arterial infusion chemotherapy combined with radiotherapy (DIACRT) regimen and weekly CDDP intra-arterial infusion chemotherapy combined with radiotherapy (WIACRT) for patients with tongue cancer. Materials and Methods: Between January 2007 and December 2016, a total of 11 patients treated with WIACRT and 45 patients treated with DIACRT were enrolled in the present study. In the DIACRT group, 25 patients had late T2, and 20 patients had T3. A total of nine patients had late T2 and two had T3 in WIACRT (p = NS). In DIACRT, the treatment schedule consisted of intra-arterial chemotherapy (DOC, total 60 mg/m²; CDDP, total 150 mg/m²) and daily concurrent radiotherapy (RT) (total, 60 Gy). In WIACRT, the treatment schedule consisted of intra-arterial chemotherapy (CDDP, total 360 mg/m²) and daily concurrent RT (total, 60 Gy). Results: The median follow-up periods for DIACRT and WIACRT were 61 and 66 months, respectively. The five-year local control (LC) and overall survival (OS) rate were 94.5% and 89.6% for the DIACRT group, and 60.6% and 63.6% for the WIACRT group, respectively. The LC rate and OS of the DIACRT group were significantly higher than those of the WIACRT group. As regards toxicities, no treatment-related deaths were observed during the follow-up periods in both groups. Conclusions: DIACRT was found to be feasible and effective for patients with tongue cancer and could become a new treatment modality.

Proton Therapy for Head and Neck Cancers

Because of its sharp lateral penumbra and steep distal fall-off, proton therapy offers dosimetric advantages over photon therapy. In head and neck cancer, proton therapy has been used for decades in the treatment of skull-base tumors. In recent years the use of proton therapy has been extended to numerous other disease sites, including nasopharynx, oropharynx, nasal cavity and paranasal sinuses, periorbital tumors, skin, and salivary gland, or to reirradiation. The aim of this review is to present the physical properties and dosimetric benefit of proton therapy over advanced photon therapy; to summarize the clinical benefit described for each disease site; and to discuss issues of patient selection and cost-effectiveness.

Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association

Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.

Clinical outcomes of retrograde intra-arterial chemotherapy concurrent with radiotherapy for elderly oral squamous cell carcinoma patients aged over 80 years old

Background

The aim of this retrospective observational study was to evaluate toxicities, overall survival, and locoregional control in elderly oral squamous cell carcinoma patients who had undergone retrograde intra-arterial chemotherapy combined with radiotherapy.

Methods

Thirty-one elderly patients over 80 years old with oral squamous cell carcinoma were enrolled in present study. The treatment schedule consisted of intra- arterial chemotherapy (docetaxel, total 60 mg/m²; cisplatin, total 150 mg/m²) and daily concurrent radiotherapy (total, 60 Gy) for 6 weeks.

Results

The median patient age was 82.5 years old (range, 80–88 years). Of the 31 patients, six (19%) had stage II, 6 (19%) had stage III, 17 (55%) had stage IVA, and 2 (6%) had stage IVB. The median follow-up period for all patients was 37 months (range, 7–86 months). The 3-year overall survival and locoregional control rates were 78% and 81%, respectively. The major acute grade 3 adverse events were oral mucositis in 22 (71%) patients, neutropenia in 16 (52%), and dermatitis in 11 (35%). With respect to late toxicities, 1 patient (3%) developed grade 3 osteoradionecrosis of the jaw. No grade 4 or higher toxicities were observed during the treatment and follow-up periods.

Conclusions

Retrograde intra-arterial chemotherapy combined with radiotherapy was effective in improving overall survival and locoregional control even for elderly patients.

A Nucleoside Anticancer Drug, 1-(3-C-Ethynyl-β-D-Ribo-Pentofuranosyl)Cytosine, Induces Depth-Dependent Enhancement of Tumor Cell Death in Spread-Out Bragg Peak (SOBP) of Proton Beam

The effect of 1-(3-C-ethynyl-β-D-ribo-pentofuranosyl)cytosine (ECyd) on proton-induced cell death was evaluated in human lung carcinoma cell line A549 and Chinese hamster fibroblast cell line V79 to enhance relative biological effectiveness (RBE) within the spread-out Bragg peak (SOBP) of proton beams. Treatment with ECyd significantly enhanced the proton-induced loss of clonogenicity and increased senescence at the center, but not at the distal edge of SOBP. The p53-binding protein 1 foci formation assay showed that ECyd decelerated the rate of DNA double-strand break (DSB) repair at the center, but not the distal region of SOBP, suggesting that the ECyd-induced enhancement of proton-induced cell death is partially associated with the inhibition of DSB repair. This study demonstrated that ECyd enhances proton-induced cell killing at all positions of SOBP, except for the distal region and minimizes the site-dependent differences in RBE within SOBP. Thus, ECyd is a unique radiosensitizer for proton therapy that may be useful because it levels the biological dose within SOBP, which improves tumor control and reduces the risk of adverse effects at the distal edge of SOBP.