The treatment outcome and radiation-induced toxicity for patients with head and neck carcinoma in the IMRT era: a systematic review with dosimetric and clinical parameters

Feasibility and patient reported tolerance of cryotherapy with Cooral mouth cooling device in patients undergoing radiation therapy (CooRay): a pilot study

Background

Radiation-induced oral mucositis (RIOM) is a major side-effect of (chemo)radiation (CRT) of patients with head and neck cancer (HNC). This study tries to establish a novel cryotherapy (CyT) method using a mouth care device (MCD; Cooral®, BrainCool AB, Lund, Sweden) to prevent RIOM.

Methods

Patients were non-randomly assigned to use the MCD after every radiotherapy session for 30-60 minutes. Subjects were asked to answer daily questionnaires assessing tolerability of the intervention. Mucositis was assessed at baseline, once weekly and at weeks 1/3/6 after CRT. The primary endpoint was patient tolerance, defined by the time the MCD was used and the patients' perception. Secondary outcomes were the degree (CTCAE v5.0) and duration of RIOM.

Results

Ten patients were eligible with a mean age of 62 years. Four patients received concurrent platinum-based CRT, whereas the others received radiotherapy alone. Overall, 214 CyT sessions were performed (73% of planned CyT sessions). The mean daily CyT duration was 48 minutes (range, 30-60 minutes). All patients reported cooling as comfortable. Nine completed the intervention, one terminated it early due to hypersalivation. No Grade 4 RIOM was observed. Grade 3 mucositis was observed in 4 and Grade 2 in 3 cases.

Conclusions

The Cooral System was well tolerated, with a duration of application that was acceptable for most patients. We concluded that the MCD can be safely used in patients undergoing CRT. A prospective phase II trial, assessing the efficacy in preventing RIOM, is planned.

The Emerging Role of Nanoparticles Combined with Either Radiotherapy or Hyperthermia in Head and Neck Cancer: A Current Review

Head and neck cancer (HNC) includes various malignancies and represents the seventh most common cancer worldwide. The early diagnosis of HNC results in a 70-90% five-year survival rate, which declines with locally advanced stages of disease. Current care employs a multimodal strategy encompassing surgery, radiation therapy (RT), chemotherapy, and immunotherapy, while treatment options vary according to the stage, tumor features, and patient characteristics. About 75% of patients with HNC will benefit from RT, either as a primary treatment or as adjuvant therapy following surgical resection. Technological improvements in RT, such as intensity-modulated RT (IMRT) and image-guided RT (IGRT), have enhanced tumor targeting and minimized adjacent healthy tissue irradiation while also expanding RT to the recurrent or metastatic setting. Innovative therapeutic strategies for HNC integrate RT with immunotherapy, gene therapy, molecular targeted therapy, photodynamic therapy, photothermal therapy, and nanoparticles (NPs), with the objective of optimizing tumor control while reducing damage to normal tissues. NPs are emerging as possible radiosensitizers in HNC treatment, enhancing the efficacy of RT, chemotherapy, and immunotherapy. In vivo and in vitro studies on the irradiation of tumors containing gold (Au), gadolinium (Gd), and hafnium oxide (HfO2) NPs show promising results in enhancing tumor destruction and survival rates, indicating their potential for clinical application. Hyperthermia, investigated as an adjunct treatment, potentially improves outcomes when combined with RT or chemotherapy, with advancements in nanotechnology renewing interest in this approach in HNC. At present, NBTXR3 is the sole NP that is being investigated in clinical trials for the enhancement of HNC RT.

Does lower dose pilocarpine have a role in radiation-induced xerostomia in the modern radiotherapy era? A single-center experience based on patient-reported outcome measures

PURPOSE

This study aims to investigate the efficacy of lower dose pilocarpine in alleviating late dry mouth symptoms in head and neck cancer patients received radiotherapy.

METHODS

Eighteen head and neck cancer patients experiencing persistent dry mouth were enrolled in this study. All participants started pilocarpine treatment a median of 6 months post-radiotherapy. Initially, patients received pilocarpine at 5 mg/day, with a gradual increase to the recommended dose of 15 mg/day. A Patient-Reported Outcome Measurement (PROMs) questionnaire assessed symptoms' severity related to hyposalivation.

RESULTS

All patients reported symptomatic dry mouth above grade 2 before starting the medication. Pilocarpine treatment continued based on patients' self-assessment, with a median duration of 12 months (range, 3-36 months). The median daily maintenance dose was 10 mg (range, 5 to 20 mg). Total PROMs scores significantly decreased following medication, from 13 points (range 7-18 points) to 7 points (range 4-13 points) (p = 0.001). Significant improvements were observed in questions related to dry mouth (p < 0.001), water intake during eating (p = 0.01), carrying water (p = 0.01), taste (p < 0.001), and water intake during speech (p < 0.001). Initial and maintenance doses of pilocarpine were lower, and the duration of pilocarpine usage was shorter in patients treated with intensity-modulated radiation therapy compared to conformal radiotherapy (12 months vs. 25 months, p = 0.04).

CONCLUSION

Pilocarpine may be considered at doses lower for late-term dry mouth. With modern radiotherapy techniques effectively preserving the parotid gland, short-term use may be recommended in these patients. Future studies may enhance the development of a more robust patient selection criteria model.

Unravelling Quality of Life for Head and Neck Cancer Patients after VMAT Radiation Therapy: Insights from Toxicity, Dosimetry and Symptoms Correlation

(1) Background: Head and neck cancer treatment, including advanced techniques like Volumetric Modulated Arc Therapy (VMAT), presents challenges for maintaining patient quality of life (QoL). Thus, thoroughly investigating how radiation therapy (RT) affects patients has been proved essential. Derived by that, this study aims to understand the complex interactions between not only RT and QoL but also symptom severity, and treatment-related toxicities in three distinct time points of patient's treatment; (2) Methods: To achieve that, EORTC-QLQ-C30 and EORTC QLQ-H&N35 questionnaires were used in combination with EORTC_RTOG scoring criteria and Spearman's rho statistical analysis for 74 patients with cancer undergoing VMAT radiation therapy; (3) Results: The results revealed a significant improvement in the Overall Health Index post-treatment, indicating a temporary decline during therapy followed by subsequent recovery, often surpassing pre-treatment QoL levels. Concurrently a reduction in symptomatology was observed, notably in pain, swallowing difficulties, and dry mouth, aligning with prior research indicating decreased symptom burden post-treatment. However, Spearman's correlation coefficient analysis at two distinct time points during therapy uncovered varying degrees of correlation between dosimetric data at Organs at Risk (OARs) and reported symptoms, highlighting potential limitations in using QoL questionnaires as sole indicators of treatment efficacy. Our investigation into the correlation between dosimetric data, toxicity, and symptoms focused on the relationship between radiation doses and oral mucositis levels, a common toxicity in head and neck cancer patients. Significant associations were identified between toxicity levels and dosimetric parameters, particularly with OARs such as the parotid glands, oral cavity, and swallowing muscles, underlining the utility of the EORTC method as a reliable toxicity assessment tool; (4) Conclusions: To summarize, current research attempts to underscore the importance of refining QoL assessments for enhanced patient care. The integration of dosimetric data, symptom severity, and treatment-related toxicities in the QoL outcomes of head and neck cancer patients undergoing VMAT radiation therapy, can lead towards the optimization of treatment strategies and the improvement of patient outcomes in future patient-centered radiation therapy practices.

Beneath the surface: A systematic review on intraoperative imaging techniques for deep margin assessment in oral squamous cell carcinoma

Resection margins of oral squamous cell carcinoma (SCC) are often inadequate. A systematic review on clinical intraoperative whole-specimen imaging techniques to obtain adequate deep resection margins in oral SCC is lacking. Such a review may render better alternatives for the current insufficient intraoperative techniques: palpation and frozen section analyses (FSA). This review resulted in ten publications investigating ultrasound (US), four investigating fluorescence, and three investigating MRI. Both US and fluorescence were able to image the tumor intraorally and perform ex-vivo imaging of the resection specimen. Fluorescence was also able to image residual tumor tissue in the wound bed. MRI could only be used on the ex-vivo specimen. The 95 % confidence intervals for sensitivity and specificity were large, due to the small sample sizes for all three techniques. The sensitivity and specificity of US for identifying < 5 mm margins ranged from 0 % to 100 % and 60 % to 100 %, respectively. For fluorescence, this ranged from 0 % to 100 % and 76 % to 100 %, respectively. For MRI, this ranged from 7 % to 100 % and 81 % to 100 %, respectively. US, MRI and fluorescence are the currently available imaging techniques that can potentially be used intraoperatively and which can image the entire tumor-free margin, although they have insufficient sensitivity for identifying < 5 mm margins. Further research on larger cohorts is needed to improve the sensitivity by determining cut-off points on imaging for inadequate margins. This improves the number of adequate resections of oral SCC's and pave the way for routine clinical implementation of these techniques.

Lack of association between XRCC1 SNPs and acute radiation‑induced injury or prognosis in patients with nasopharyngeal carcinoma

The response to radiation therapy (RT) is closely associated with DNA damage repair. X-ray repair cross-complementing group-1 (XRCC1) is a key gene in the DNA damage repair pathway, and SNPs in this gene alter the expression and activity of its effector protein, which may in turn affect sensitivity to RT. Therefore, the course of tumor treatment and local control rate can be influenced. In the present study, a group of 158 patients with nasopharyngeal carcinoma (NPC) who received intensity-modulated RT at Fujian Cancer Hospital (Fuzhou, China) between July 2012 and October 2013 were included in retrospective chart review and followed up. Plasma was collected before treatment for genotype analysis of the three SNPs of XRCC1, namely Arg194Trp, Arg280His and Arg399Gln. Acute radiation-induced injuries sustained during treatment was graded according to the Radiation Therapy Oncology Group scoring criteria. Post-treatment follow-up was performed until August 2020. In the 158 cases of NPC, no statistically significant association was observed between the three SNPs of the XRCC1 gene and the severity of acute radiation-induced injury or prognosis. However, the AA genotype of XRCC1-Arg399Gln tended to be associated with worse progression-free survival (PFS) compared with the GA + GG genotype, although this was not significant (P=0.069). In addition, multivariate logistic analysis showed that nodal stage was significantly associated with the occurrence of acute severe radiation-induced oral mucositis (P=0.018), and there was also a trend towards an association between nodal stage and the incidence of acute severe radiation-induced pharyngitis; however, this was not statistically significant (P=0.061). Furthermore, multivariate Cox regression analysis showed that older age, distant metastasis and higher clinical stage were independent risk factors for PFS in patients with NPC. In conclusion, relying solely on the aforementioned SNPs of the XRCC1 gene may not provide a robust enough basis to predict the response to RT or prognosis in patients with NPC.

Prophylaxis of Oral Mucositis with Iodine Solution during Concurrent Chemoradiation of Head and Neck Cancer: Preliminary Results of a Double-Blind, Randomized Controlled Trial

OBJECTIVE

This study aims to evaluate the clinical efficacy of an in-house iodine solution (IS) mouthwash for the prophylaxis of concurrent chemoradiation (CCRT) induced oral mucositis (OM) in head & neck cancer (HNC) patients.

METHODS

This prospective, double-blind, randomized controlled trial was conducted on 20 HNC patients, being treated with definite or postoperative CCRT, at the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. The patients were randomly assigned (1:1) to the treatment group or the control group. Patients in the treatment group gargled IS three times daily after meals, while patients in the control group gargled normal saline solutions (NSS). Assessment of OM was performed before starting CCRT, once a week during CCRT, and 4 weeks after CCRT was completed. The primary outcome was Oral Mucositis Assessment Scale (OMAS).

RESULTS

The mean weekly OMAS, pain score, and impact on swallowing score were not statistically significant in patients who rinsed with IS mouthwash compared to those who received NSS (p > 0.999 in every week). There was no difference in the mean onset to OM (all grades) (p = 0.704), and the mean duration of OM (all grades) (p = 0.365). Severe OM (WHO grade 3-4) occurred in three patients [IS=2, NSS=1] with the median onset of 45.50 & 33.00 days (p = NA), and the duration of 8.00 & 57.00 days (p = NA) in the IS and NSS groups, respectively. Oral candidiasis occurred in one patient from the NSS group while no secondary infection of oral mucosa was observed in the patients receiving IS mouthwash.

CONCLUSION

The study could not reach statistically significance to show that IS mouthwash was effective in of prevention CCRT-induced OM. Further study with a larger number of participants is encouraged.

A closer look at the resection margins of buccal mucosa cancer: Their influence on local recurrence free survival

BACKGROUND

The adequate surgical margin for local control of buccal mucosa squamous cell carcinoma (BMSCC) is under debate. This study investigates surgical margins and other factors associated with local recurrence free survival (LRFS) in a large cohort of BMSCC patients.

METHODS

Multiple factors were evaluated retrospectively in 97 patients with BMSCC. Cox-regression and Kaplan-Meier curves were used for analysis.

RESULTS

The local recurrence rate was 23%. The tumor-free margin was <5.0 mm in 89% of the patients and the deep margin was significantly more often inadequate. Multivariate analysis associated pT3-classification, former smokers, tumor-free margin status, and postoperative (chemo)radiation (PO(ch)RT) with local recurrence. Re-resections did not improve LRFS in patients with <5.0 mm tumor-free margins.

CONCLUSIONS

Adequate tumor-free margins are pivotal for LRFS of BMSCC. PO(ch)RT, not re-resection, can improve LRFS in patients with <5.0 mm tumor-free margins.

Ultrasound-guided resection for squamous cell carcinoma of the buccal mucosa: A feasibility study

BACKGROUND

Image-guided surgery could help obtain clear (≥5.0 mm) resection margins. This feasibility study investigated ultrasound-guided resection accuracy of buccal mucosa squamous cell carcinoma (BMSCC).

METHODS

MRI and ultrasound measurements of tumor thickness were compared to histology in 13 BMSCC-patients. Ultrasound measured margins (at five locations) on the specimen were compared to the corresponding histological margins.

RESULTS

Accuracy of in- and ex-vivo ultrasound (mean deviation from histology: 1.6 mm) for measuring tumor thickness was comparable to MRI (mean deviation from histology: 2.6 mm). The sensitivity to detect clear margins using ex-vivo ultrasound was low (48%). If an ex-vivo ultrasound cutoff of ≥7.5 mm would be used, the sensitivity would increase to 86%.

CONCLUSIONS

Ultrasound-guided resection of BMSCC's is feasible. In- and ex-vivo ultrasound measure tumor thickness in BMSCC accurately. We recommend ≥7.5 mm resection margins on ex-vivo ultrasound to obtain histological clear margins. Additional research is required to establish the effect of 7.5 mm ultrasound cutoff.

High miR-511-3p Expression as a Potential Predictor of a Poor Nutritional Status in Head and Neck Cancer Patients Subjected to Intensity-Modulated Radiation Therapy

Nutritional deficiencies, including malnutrition and its irreversible type cachexia, are often observed in patients with head and neck cancer (HNC). Among the various factors contributing to the occurrence of these disorders, inflammation seems to be crucial. The potential regulatory properties of miR-511-3p, e.g., post-translational alteration of expression of genes with protein products that are involved in inflammation, may be related to nutritional deficiencies observed in HNC patients. Therefore, the aim of our study was to assess the correlation between pretreatment miR-511-3p expression and nutritional status in patients undergoing radiotherapy (RT) due to HNC. In our retrospective study, 60 consecutively admitted patients treated with intensity-modulated radiotherapy (IMRT) due to advanced HNC were enrolled. The analysis of miR-511-3p expression was performed using real-time PCR. Significantly higher expression of miR-511-3p was observed in well-nourished patients compared to patients with moderate or severe malnutrition (p = 0.0001). Pretreatment expression of miR-511-3p may be a useful biomarker of nutritional deficiencies in patients subjected to IMRT due to HNC.

Study of dosimetry and clinical factors for assessment of xerostomia in head and neck squamous cell carcinoma treated by intensity-modulated radiotherapy: A prospective study

AIM:

Clinical and dosimetric factors related to toxicity in terms of xerostomia in patients with head and neck squamous cell cancer (HNSCC) treated with intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS:

Patients older than 18 years, with the WHO Performance Status Score <2 with primary diagnosis of HNSCC Stage II, III, and IV who had undergone primary or postoperative radiotherapy (RT) treated by IMRT at the center, from November 2015 to November 2016 were included in the study. Patients were assessed by physical examination and questioned to score their quality of life for dryness (HNDR) and stickiness (HNSS) by EORTC-HN-35 (Hindi or English version) at baseline (before treatment), at 3, 6, and 12 months following treatment. The validation of EORTC-HN-35 for HNDR and HNSS in patients was handed.

RESULTS:

Thirty patients were included in the study. The mean symptom score values for HNSS at baseline, 3, 6, and 12 months' post-RT treatment were 17.8, 62.2, 64.4, and 20.8, respectively. Dryness and stickiness also increased over 3–6 months in follow-up but slightly relieved at 12 months, but it could not reach to baseline. In subgroup analysis, at baseline mean score of dryness of mouth in elderly patients (≥60 years) (P = 0.248), poor performance status (Eastern Cooperative Oncology Group 2) (P = 0.80) and patients with advanced stage (Stage III and IVA) (P = 0.185) was higher. Correlation of normal tissue complication probability for xerostomia with contralateral mean parotid gland showed insignificant linearity with shallow curve.

CONCLUSION:

Patients remained symptomatic for xerostomia chiefly till 6 months' postirradiation, but it was slightly relieved in 12 months but could not reach the baseline. Dosimetric sparing ofcontralateral parotid resulted in decreased probability of developing xerostomia.

Polymorphism of the ITGAM gene (rs7193943) and bioelectric impedance analysis as potential predictors of cachexia in chronic heart failure

Cardiac cachexia (CC) is an unfavorable metabolic syndrome leading to exacerbation of chronic heart failure (CHF) and a higher risk of death. The main factor contributing to the development of cachexia is the ongoing inflammatory process mediated by genes (e.g. Integrin Subunit Alpha M-ITGAM). The study aimed to assess the relationship between a single nucleotide polymorphism (SNP) -323G > A of the ITGAM and the occurrence of nutritional disorders in patients with CHF. 157 CHF patients underwent clinical and nutritional screening. Body composition was evaluated by bioelectrical impedance analysis (BIA). Patients with cachexia were characterized by significantly lower weight, body mass index (BMI), lower fat mass (FM), albumin, and hemoglobin. Lower values of BIA parameters: capacitance of membrane (Cm), phase angle (PA), and impedance ratio (Z200/Z5) were noted in women. Those patients demonstrated significantly higher values of creatinine, c-reactive protein (CRP), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and pulmonary artery systolic pressure (PASP). A significantly higher risk of cachexia was reported in patients: aged ≥ 74 years (OR 3.55), with renal failure (OR 3.75), New York Heart Association classification (NYHA) III-IV (OR 2.83), with moderate or severe malnutrition according to the score of subjective global assessment (SGA) (OR 19.01) and AA genotype of ITGAM gene (OR 2.03). Determination of the -323G > A SNP in the ITGAM may prove to be a useful marker (after confirmation in further studies and appropriate validation) in the assessment of the risk of nutritional disorders in patients with CHF.

Stage Migration and Survival Trends in Laryngeal Cancer

BACKGROUND

During the last two decades, significant advancements in the treatment of laryngeal cancer have occurred. Although survival of head and neck cancer patients has improved over time, the temporal trend of laryngeal cancer survival is an area of controversy.

METHODS

From 2004 to 2016, 77,527 patients who had laryngeal cancer treated with curative intent in the United States were identified in the National Cancer Database. Relative and observed survival rates were assessed for temporal trends. Multinomial logistic regression investigated the relationship between American Joint Committee on Cancer (AJCC) stage and increasing calendar year.

RESULTS

No significant improvement in 2- or 5-year observed survival (OS) or relative survival (RS) was observed. The 5-year RS ranged from 61.72 to 63.97%, and the 5-year OS ranged from 54.26 to 56.52%. With each increasing year, the proportion of stage 4 disease increased, with risk for stage 4 disease at the time of diagnosis increasing 2.2% annually (adjusted odds ratio [aOR], 1.022; 95% confidence interval [CI], 1.017-1.028; p < 0.001). This increase was driven by a 4.7% yearly increase in N2 disease (aOR, 1.047; 95% CI, 1.041-1.053; p < 0.001), with an annual 1.2% increase in T3 disease (aOR, 1.012; 95% CI, 1.007-1.018; p < 0.001) and a 1.2% increase in T4 disease (aOR, 1.012; 95% CI, 1.005-1.018; p < 0.001).

CONCLUSION

Despite advances in the field, laryngeal cancer survival in the United States is not improving over time. This may be due to an increase in the proportion of stage 4 disease, driven primarily by increasing nodal disease. To achieve survival improvement commensurate with scientific and technologic advances, efforts should be made to diagnose and treat laryngeal cancer at earlier stages to prevent further stage migration.

Oral pH value predicts the incidence of radiotherapy related caries in nasopharyngeal carcinoma patients

Radiotherapy-related caries is a complication of radiotherapy for nasopharyngeal carcinoma; however, factors influencing the occurrence, accurate prediction of onset, and protective factors of radiotherapy-related caries remain unclear. This study analyzed risk factors, disease predictors, and protective factors for radiotherapy-related caries in nasopharyngeal carcinoma. This prospective study included 138 nasopharyngeal carcinoma patients receiving radical radiotherapy at our hospital during June 2012–December 2016 and were followed up for dental caries. Patients’ clinical data on radiotherapy were collected, dynamic monitoring was performed to assess changes in oral pH values, and a questionnaire survey was administered to collect patients’ lifestyle habits. Time-dependent cox regression trees, event-free Kaplan–Meier curve, Mann–Whitely U test were used to analysis the results. The median follow-up time was 30 (12–60) months. Radiotherapy-related caries occurred in 28 cases (20.3%). Univariate analyses showed that radiotherapy-related caries was associated with patient’s age, oral saliva pH value, green tea consumption, and radiation dose to sublingual glands, but not with the radiation dose to the parotid and submandibular glands. Multivariate analysis showed that oral saliva pH value [hazard ratio (HR) = 0.390, 95% confidence interval = 0.204–0.746] was an independent prognostic factor for radiotherapy-related caries. Patients with oral saliva pH values ≤ 5.3 in the 9th month after radiotherapy represented a significantly higher risks for radiotherapy-related caries (p < 0.001). Green tea consumption was associated with the occurrence of radiotherapy-related caries, and oral saliva pH values could predict the occurrence of radiotherapy-related caries. Limiting radiation doses to sublingual glands can reduce the occurrence of radiotherapy-related caries.

Polymorphism of The Regulatory Region of the ITGAM Gene (-323G>A) as a Novel Predictor of a Poor Nutritional Status in Head and Neck Cancer Patients Subjected to Intensity-Modulated Radiation Therapy

Background: The most serious disturbance of the nutritional status is neoplastic cachexia. The main factor contributing to the development of cachexia is the ongoing inflammatory process. The gene associated with the development of the inflammatory response is ITGAM. Therefore, the aim of the study was to assess the relationship between a single nucleotide polymorphism (SNP)-323G>A of the ITGAM gene and the occurrence of nutritional disorders in patients undergoing radiotherapy (RT) due to head and neck cancers (HNC). Methods: The study involved 71 patients with HNC treated with intensity-modulated radiotherapy (IMRT). SNP analysis of the ITGAM gene (-323G>A) was performed using commercial molecular probes and Real-Time PCR. Results: The presence of the A allele of the ITGAM gene significantly (over 14-fold) reduced the risk of severe disturbances in nutritional status assessed according to the subjective global assessment (SGA) scale (odds ratio (OR) = 0.07; p = 0.0213). The GG genotype of this gene was associated with an over three-fold higher risk of shortened overall survival (OR = 3.01; p = 0.0376). Conclusions: Determination of the SNP (-323G>A) of the ITGAM gene may prove to be a useful marker in the assessment of the risk of nutritional disorders in patients with HNC undergoing RT.

Brachytherapy in head and neck malignancies: Indian Brachytherapy Society (IBS) recommendations and guidelines

PURPOSE

Brachytherapy (BT) forms major treatment modality in squamous cell carcinoma of head and neck cancers (HNC). However, there is a dearth of literature and guidelines for the use in various indications. High-dose-rate brachytherapy (HDR-BT) in Indian scenario is an important treatment modality, and the recommendations in this guidelines aim to provide the necessary recommendations for the use of HDR-BT for uniform application across the country in patients with HNC.

MATERIAL AND METHODS

A panel consisting of members of the Indian Brachytherapy Society (IBS), based on their clinical experience was invited. The process involved defining important steps, precautions, target volumes and indications, thorough literature review, and discussion with fellow members. The guidelines were established and formulated the recommendations for HDR-BT based on available evidences and individual experience for sites, relevant to Indian settings.

RESULTS

The IBS recommends the use of HDR brachytherapy as a part of treatment of head and neck tumors. The scope of these guidelines and recommendations included practical suggestions, ensuring efficient use of brachytherapy treatment as radical with external beam radiotherapy (EBRT) boost, palliative and adjuvant as definitive, or re-radiation as salvage for HNC in India. The IBS has made specific site-wise recommendations for previously untreated and recurrent HNC patients on their selection criteria, implant techniques, target volume definition, and HDR treatment parameters, such as time, dose rate, total dose, and fractionation schedules. Limited experience exists with HDR-BT in patients with head and neck cancers in India and across the globe.

CONCLUSIONS

IBS provided a consensus statement and guidelines for the head and neck brachytherapy and believed that these recommendations will overcome the fear of practicing radiation oncologists. This should generate interest amongst students and will help radiation oncologists all across the country to use the art of brachytherapy carefully in HNC patients, with better curative and salvage options.

Cost-effectiveness of treating head and neck cancer using intensity-modulated radiation therapy: implications for cancer control program in India

Background

The newer cancer treatment technologies hold the potential of providing improved health outcomes at an additional cost. So it becomes obligatory to assess the costs and benefits of a new technology, before defining its clinical value. We assessed the cost-effectiveness of intensity-modulated radiotherapy (IMRT) as compared to 2-dimensional radiotherapy (2-DRT) and 3-dimensional radiotherapy (3D-CRT) for treating head and neck cancers (HNC) in India. The cost-effectiveness of 3-DCRT as compared to 2-DRT was also estimated.

Methods

A probabilistic Markov model was designed. Using a disaggregated societal perspective, lifetime study horizon and 3 percent discount rate, future costs and health outcomes were compared for a cohort of 1000 patients treated with any of the three radiation techniques. Data on health system cost, out of pocket expenditure, and quality of life was assessed through primary data collected from a large tertiary care public sector hospital in India. Data on xerostomia rates following each of the radiation techniques was extracted from the existing randomized controlled trials.

Results

IMRT incurs an incremental cost of $7,072 (2,932–13,258) and $5,164 (463–10,954) per quality-adjusted life year (QALY) gained compared to 2-DRT and 3D-CRT, respectively. Further, 3D-CRT as compared to 2-DRT requires an incremental cost of $8,946 (1,996–19,313) per QALY gained.

Conclusion

Both IMRT and 3D-CRT are not cost-effective at 1 times GDP per capita for treating HNC in India. The costs and benefits of using IMRT for other potential indications (e.g. prostate, lung) require to be assessed before considering its introduction in India.

Effects of Surgery Combined with Chemoradiotherapy on Short- and Long-Term Outcomes of Early-Stage Nasopharyngeal Carcinoma

Objective

The efficacy of surgery as the primary treatment modality for nasopharyngeal carcinoma (NPC) is yet to be clarified. Therefore, we aimed to explore the short- and long-term efficacy of surgery for early-stage NPC.

Methods

We retrospectively evaluated 341 patients diagnosed with early-stage NPC between September 2010 and December 2015. Among them, 58 patients underwent endoscopic nasopharyngectomy combined with chemoradiotherapy, whereas 283 patients underwent conventional chemoradiotherapy. The patients who underwent concurrent chemoradiotherapy or radiotherapy alone were matched to patients who underwent surgery in a 1:2 ratio using propensity score matching to analyze the clinical efficacy of each therapeutic modality. The primary endpoint was survival, and the secondary endpoints were tumor regression rate and reduction in Epstein–Barr virus (EBV)-DNA levels.

Results

After matching, 156 patients were enrolled (58 patients in the surgery group; 98 patients in the non-surgery group). The baseline data of the matched patients had good inter-group comparability (All P>0.05). The surgery group had significantly higher 5-year overall survival (98.30% vs. 91.70%), disease-free survival (98.30% vs. 81.40%), and recurrence-free survival (100.00% vs. 90.10%) rates than did the non-surgery group (All P<0.05). In total, 0 and 14 patients in the surgery and non-surgery groups, respectively, had residual cancer at the end of treatment (P=0.001). All patients in the surgery group tested negative for EBV-DNA, whereas two patients in the non-surgery group tested positive. The incidence of hematologic toxicity during treatment was similar between the two groups (All P>0.05). Still, the incidence of severe oral mucositis was lower in the surgery group than in the non-surgery group (37.9% vs. 54.08%, P=0.051).

Conclusion

Surgery can improve the clearance rate of EB virus and reduce tumor residue. Surgery may be a safe and effective treatment for early NPC.

Assessment of tumour depth in early tongue cancer: Accuracy of MRI and intraoral ultrasound

OBJECTIVES

Complete resection of tongue cancer is necessary to achieve local control. Unfortunately, deep resection margins are frequently inadequate. To improve deep margin control, accurate knowledge of tumour thickness is pivotal. Magnetic resonance imaging (MRI) and intraoral ultrasound (ioUS) are frequently applied for tumour staging. This study explores the accuracy of these techniques to estimate depth of invasion.

MATERIALS AND METHODS

The data of patients with a T1-2 tongue cancer that had been treated surgically between 2014 and 2018 were retrospectively analysed. Measurements that had been taken by either MRI or ioUS were compared with those taken during histopathology.

RESULTS

A total of 83 patients with tongue cancer had undergone a pre-operative MRI and 107 had been studied through an ioUS. Tumour thickness measured by MRI (r = 0.72) and ioUS (r = 0.78) correlated significantly (p < 0.001) with histopathological depth of invasion (DOI). In tumours with a DOI of 0-10 mm, MRI has a mean absolute difference with histopathology of 3.1 mm (SD 3.2 mm) and ioUS of 1.6 mm (SD 1.3 mm). In tumours with a DOI greater than 10 mm, MRI has a mean absolute difference of 3.5 mm (SD 3.0 mm) and ioUS of 4.7 mm (SD 3.5 mm).

CONCLUSION

Estimation of histopathological DOI in tongue cancers with DOI till 10 mm is very accurate through use of ioUS. ioUS tends to underestimate DOI in tumors exceeding 10 mm DOI. MRI tends to overestimate DOI in both thin and thick tumours. Since ultrasound measurements can be performed during surgery, ioUS could potentially guide the surgeon in the achievement of adequate resection margins.

Definitive-intent intensity-modulated radiation therapy provides similar outcomes to those previously published for definitive-intent three-dimensional conformal radiation therapy in dogs with primary brain tumors: A multi-institutional retrospective study

Radiotherapy with or without surgery is a common choice for brain tumors in dogs. Although numerous studies have evaluated use of three-dimensional conformal radiotherapy, reports of definitive-intent, IMRT for canine intracranial tumors are lacking. Intensity-modulated radiation therapy has the benefit of decreasing dose to nearby organs at risk and may aid in reducing toxicity. However, increasing dose conformity with IMRT calls for accurate target delineation and daily patient positioning, in order to decrease the risk of a geographic miss. To determine survival outcome and toxicity, we performed a multi-institutional retrospective observational study evaluating dogs with brain tumors treated with IMRT. Fifty-two dogs treated with fractionated, definitive-intent IMRT at four academic radiotherapy facilities were included. All dogs presented with neurologic signs and were diagnosed via MRI. Presumed radiological diagnoses included 37 meningiomas, 12 gliomas, and one peripheral nerve sheath tumor. One dog had two presumed meningiomas and one dog had either a glioma or meningioma. All dogs were treated in the macroscopic disease setting and were prescribed a total dose of 45-50 Gy (2.25-2.5 Gy per fraction in 18-20 daily fractions). Median survival time for all patients, including seven cases treated with a second course of therapy was 18.1 months (95% confidence of interval 12.3-26.6 months). As previously described for brain tumors, increasing severity of neurologic signs at diagnosis was associated with a worse outcome. Intensity-modulated radiation therapy was well tolerated with few reported acute, acute delayed, or late side effects.

Assessment of surgical tumor-free resection margins in fresh squamous-cell carcinoma resection specimens of the tongue using a clinical MRI system

BACKGROUND

Current intraoperative methods of visual inspection and tissue palpation by the surgeon, and frozen section analysis cannot reliably prevent inadequate surgical margins in patients treated for oral squamous-cell carcinoma (OSCC). This study assessed feasibility of MRI for the assessment of surgical resection margins in fresh OSCC specimens.

METHODS

Ten consecutive tongue specimens containing OSCC were scanned using 3 T clinical whole-body MRI. Two radiologists independently annotated OSCC location and minimal tumor-free margins. Whole-mount histology was the reference standard.

RESULTS

The positive predictive values (PPV) and negative predictive values (NPV) for OSCC localization were 96% and 75%, and 87% and 79% for reader 1 and 2, respectively. The PPV and NPV for identification of margins <5 mm were 38% and 91%, and 5% and 87% for reader 1 and 2, respectively.

CONCLUSIONS

MRI accurately localized OSCC with high inter-reader agreement in fresh OSCC specimens, but it seemed not yet feasible to accurately assess the surgical margin status.

Comparison between hypo-fractionated dose-escalated volumetric modulated arc therapy and conventional concurrent chemo-radiation in locally advanced head and neck cancer: a pilot study

Objective:

In the treatment of locally advanced head and neck cancer (LA-HNC), both dose escalation and hypo-fractionation can improve tumour control rates with uncertain role of addition of concurrent chemotherapy. We aimed at developing a new radiotherapy protocol for patients not eligible to receive the standard concurrent chemo-radiation therapy (CCRT) with little toxicity profile.

Methods:

A total of 63 LA-HNC patients were randomised to receive either: 70 Gy in 35 fx in 7 weeks concurrently with cisplatin 100 mg/m2 every 3 weeks for 3 doses (Arm A) or 74 Gy in 33 fx in 6·5 weeks (Arm B). Volumetric modulated arc therapy plans were created for both treatment arms. We compared the local control (LC), progression-free survival (PFS), overall survival (OS) and acute and late toxicity between the two arms.

Results:

A total of 33 patients were in Arm A versus 30 patients in Arm B with median follow-up 24·2 months. No significant differences in LC, PFS and OS between the two arms. Complete remission occurred in 54·5 and 63·3% of patients in Arms A and B, respectively. All toxicities were significantly less in Arm B than Arm A.

Conclusion:

Slightly dose-escalated hypo-fractionated regimen is safe and feasible and has comparable efficacy and less acute and late side effects than conventional dose CCRT with avoidance of chemotherapy-related toxicities in LA-HNC patients.

Intensity modulated radiation therapy and oral mucosa sparing in Head and neck cancer patients: A systematic review on behalf of Italian Association of Radiation Oncology - Head and neck working group

Oral mucositis is a common dose-limiting toxicity during radiotherapy with or without chemotherapy in head and neck cancer patients. This potentially severe complication globally worsens quality of life and negatively impacts local control and survival's outcomes. Several studies have been published on feasibility and/or clinical benefit of intensity modulated radiotherapy (IMRT) mucosa-sparing technique. In 2017, the Italian Association of Radiation Oncology Head and Neck Cancer Working Group organized a study group to perform a systematic review. The aim was to verify if practical indications, including dose-constraints and demonstrated clinical benefit, could be proposed for oral mucosa (OM)-sparing IMRT in order to reduce the incidence of severe acute mucositis. Although dose to OM should be reduced as much as possible without compromising target volumes coverage, it is still tricky to firmly state that OM-sparing procedure should be considered the standard of care, especially due to high subjective variability in OM contour.

Skin DVHs predict cutaneous toxicity in Head and Neck Cancer patients treated with Tomotherapy

PURPOSE

To explore the association between planning skin dose-volume data and acute cutaneous toxicity after Radio-chemotherapy for Head and Neck (HN) cancer patients.

METHODS

Seventy HN patients were treated with Helical Tomotherapy (HT) with radical intent (SIB technique: 54/66 Gy to PTV1/PTV2 in 30fr) ± chemotherapy superficial body layer 2 mm thick (SL2) was delineated on planning CT. CTCAE v4.0 acute skin toxicity data were available. Absolute average Dose-Volume Histograms (DVH) of SL2 were calculated for patients with severe (G3) and severe/moderate (G3/G2) skin acute toxicities. Differences against patients with none/mild toxicity (G0/G1) were analyzed to define the most discriminative regions of SL2 DVH; univariable and multivariable logistic analyses were performed on DVH values, CTV volume, age, sex, chemotherapy.

RESULTS

Sixty-one % of patients experienced G2/G3 toxicity (rate of G3 = 19%). Differences in skin DVHs were significant in the range 53-68Gy (p-values: 0.005-0.01). V56/V64 were the most predictive parameters for G2/G3 (OR = 1.12, 95%CI = 1.03-1.21, p = 0.001) and G3 (OR = 1.13, 95%CI = 1.01-1.26, p = 0.027) with best cut-off of 7.7cc and 2.7cc respectively. The logistic model for V56 was well calibrated being both, slope and R2, close to 1. Average V64 were 2.2cc and 6cc for the two groups (G3 vs G0-G2 toxicity); the logistic model for V64 was quite well calibrated, with a slope close to 1 and R2 equal to 0.60.

CONCLUSION

SL2 DVH is associated with the risk of acute skin toxicity. Constraining V64 < 3cc (equivalent to a 4x4cm2 skin surface) should keep the risk of G3 toxicity below or around 10%.

Radiotherapy for cutaneous head and neck cancer and parotid tumours: a prospective investigation of treatment-related acute swallowing and toxicity patterns

PURPOSE

Reports of acute treatment-related dysphagia and toxicities for patients with parotid tumours or cutaneous head and neck cancer (HNC) are limited. This study aimed to describe the severity and timing of dysphagia and related toxicities experienced during radiotherapy for cutaneous HNC and parotid tumours, to inform the nature of future speech pathology (SP) service models required during treatment.

METHODS

Prospective study of 32 patients with parotid tumours and 36 with cutaneous HNC undergoing curative non-surgical management. Dysphagia and acute toxicity data was collected weekly during treatment and at 2, 4 and 12 weeks post-treatment using the Functional Oral Intake Scale, diet descriptors and CTCAE v4.0.

RESULTS

In both groups, minimal treatment toxicities (grades 0-1) were observed. Xerostomia and dysgeusia were the most frequently reported grade 2 toxicities. Only 3% of parotid patients and 6% with cutaneous HNC experienced grade 3 dysphagia. Full or soft texture diets were maintained by > 70% of patients in both groups. Symptoms peaked in the final week of treatment and rapidly improved thereafter. Apart from xerostomia < 10% of patients had any grade 2 toxicity at 12 weeks post-treatment.

CONCLUSION

Patients in these subgroups of HNC experienced minimal treatment-related toxicity during radiotherapy. As such, the need for supportive symptom management by SP is low. Models that involve interdisciplinary surveillance of symptoms with referral to SP only when required may be best suited for these individuals to ensure issues are identified whilst minimising patient burden created by unnecessary routine SP appointments.

The Novel Prognostic Score Combining Red Blood Cell Distribution Width and Body Mass Index (COR-BMI) Has Prognostic Impact for Survival Outcomes in Nasopharyngeal Carcinoma

Background: A novel inflammation-and nutrition-based scoring system based on red blood cell distribution width and body mass index (COR-BMI) has prognostic value in nasopharyngeal carcinoma (NPC). Here, we assessed the prognostic value of COR-BMI in NPC.

Methods: Retrospective study of 2,318 patients with non-metastatic NPC treated at Sun Yat-sen University Cancer Center was conducted. Patients were stratified into three groups using the COR-BMI score, which is based on two objective and easily measurable parameters: red blood cell distribution width (RDW) and body mass index (BMI). Kaplan-Meier survival analyses were used to compare groups; multivariate Cox proportional models were used to calculate overall survival (OS) and disease-free survival (DFS).

Results: Four-year overall survival (OS) rates were 88.7%, 84.5%, and 71.4% for patients with COR-BMI scores of 0, 1, and 2 respectively (P = 0.006). Multivariate Cox proportional hazard analysis revealed COR-BMI was an independent predictor of OS (HR for COR-BMI 1: 1.239, 95% CI: 1.012-1.590; HR for COR-BMI 2: 2.367, 95% CI: 1.311-4.274, P = 0.013), but not DFS (P = 0.482). In subgroup analysis of metastatic NPC, OS rates decreased as COR-BMI increased. In patients with a COR-BMI score of 1, radiotherapy plus chemotherapy led to better OS than radiotherapy alone.

Conclusions: COR-BMI may serve as an indicator of poor prognosis in both NPC and metastatic NPC. Radiotherapy plus chemotherapy may benefit patients with a COR-BMI score of 1.

Oral mucosa tissue gene expression profiling before, during, and after radiation therapy for tonsil squamous cell carcinoma

Background

Radiation-therapy (RT) induces mucositis, a clinically challenging condition with limited prophylactic interventions and no predictive tests. In this pilot study, we applied global gene-expression analysis on serial human oral mucosa tissue and blood cells from patients with tonsil squamous cell cancer (TSCC) to identify genes involved in mucositis pathogenesis.

Methods and findings

Eight patients with TSCC each provided consecutive buccal biopsies and blood cells before, after 7 days of RT treatment, and 20 days following RT. We monitored clinical mucositis and performed gene-expression analysis on tissue samples. We obtained control tissue from nine healthy individuals. After RT, expression was upregulated in apoptosis inducer and inhibitor genes, EDA2R and MDM2, and in POLH, a DNA-repair polymerase. Expression was downregulated in six members of the histone cluster family, e.g., HIST1H3B. Gene expression related to proliferation and differentiation was altered, including MKI67 (downregulated), which encodes the Ki-67-proliferation marker, and KRT16 (upregulated), which encodes keratin16. These alterations were not associated with the clinical mucositis grade. However, the expression of LY6G6C, which encodes a surface immunoregulatory protein, was upregulated before treatment in three cases of clinical none/mild mucositis, but not in four cases of ulcerative mucositis.

Conclusion

RT caused molecular changes related to apoptosis, DNA-damage, DNA-repair, and proliferation without a correlation to the severity of clinical mucositis. LY6G6C may be a potential protective biomarker for ulcerative mucositis. Based on these results, our study model of consecutive human biopsies will be useful in designing a prospective clinical validation trial to characterize molecular mucositis and identify predictive biomarkers.

Cost of treatment for head and neck cancer in India

There are no published data on the cost of cancer treatment for guiding reimbursement decisions in India. The present study was designed to estimate the cost of treating head and neck cancer (HNC) with the aim of determining package rates. The present study was undertaken in the Departments of Radiotherapy and Otolaryngology of a large tertiary care hospital in North India. Economic health system costs incurred were assessed using a bottom-up methodology. Data on all resources-capital or recurrent, incurred on the delivery of HNC treatment were collected from April 2014 to March 2015. Following the cost-of-illness approach, patients were interviewed to elicit out-of-pocket (OOP) expenditure. A total of INR 40,993,017 (USD 0.67 million) was spent on radiotherapy care for treating HNC during 1 year. Salaries constituted the major component (42.6%) of this cost, followed by equipment/furniture (29%), space rent (20.7%), overheads and consumables (7.7%). In addition, INR 47,191 (USD 773) per HNC patient was spent on the surgery. Furthermore, patients spent an average amount ranging from INR 12,575 (USD 206) to INR 65,257 (USD 1069) on the different treatment therapies. In terms of package rates, cobalt radiotherapy alone was the cheapest (INR 38,714, USD 634), while intensity modulated radiotherapy (IMRT) was most expensive (INR 192,914, USD 3161). The estimates from the present study could be used for developing package rates under various publicly financed health insurance schemes as well as for the planning for creation of new cancer centres.

Coronarin D induces reactive oxygen species-mediated cell death in human nasopharyngeal cancer cells through inhibition of p38 MAPK and activation of JNK

Background and Purpose

Nasopharyngeal carcinoma (NPC) belongs to squamous cell carcinoma that occurs in the epithelial lining of the nasopharynx. Because of the anatomical position close to the cervical lymph node, some patients have a distant metastasis at the time of diagnosis that leads to treatment failure. Although early stages have a high curability and excellent prognosis, advanced NPC urgently requires new drugs developed to reinforce the effectiveness of therapy without noticeable side effects.

Experimental approach

Coronarin D (CD), a natural product extracted from the rhizomes of Hedychium coronarium, has been reported to possess anticancer potential. The aim of the present study was to determine the anticancer activity of CD and further elucidate the underlying molecular mechanisms.

Key Results

In this study, we first demonstrated that CD potently suppressed cell viability in various NPC cell lines. Treatment of cells with CD induced G2/M arrest, apoptosis, and autophagy. Further studies showed that CD increased the production of reactive oxygen species and subsequently activated both autophagy and apoptosis. Moreover, we found that CD-induced activation of p38 and JNK constituted major mechanisms involved in the apoptosis and autophagy triggered by CD. In particular, inhibition of autophagy could strengthen the cytotoxicity of CD, implying that autophagy seems to play a valuable survival and protective role in cancer cells.

Conclusions & Implications

These findings provide a promise for the use of CD in combination with autophagy inhibitors for treatment of human NPC cell lines.

Radiation-Induced Oral Mucositis

Radiation-induced oral mucositis (RIOM) is a major dose-limiting toxicity in head and neck cancer patients. It is a normal tissue injury caused by radiation/radiotherapy (RT), which has marked adverse effects on patient quality of life and cancer therapy continuity. It is a challenge for radiation oncologists since it leads to cancer therapy interruption, poor local tumor control, and changes in dose fractionation. RIOM occurs in 100% of altered fractionation radiotherapy head and neck cancer patients. In the United Sates, its economic cost was estimated to reach 17,000.00 USD per patient with head and neck cancers. This review will discuss RIOM definition, epidemiology, impact and side effects, pathogenesis, scoring scales, diagnosis, differential diagnosis, prevention, and treatment.

Aggressive Salivary Malignancies at Early Stage: Outcomes and Implications for Treatment

BACKGROUND

Few studies have examined whether the use of adjuvant treatment impacts survival for early stage high-grade salivary tumors.

METHODS

A retrospective review of the SEER database between 1973 and 2012 was performed. Patients with high-grade major salivary gland tumors including salivary duct carcinoma, carcinoma ex-pleomorphic adenoma, high-grade mucoepidermoid carcinoma, or adenocarcinoma, NOS were identified. Only stage I-II tumors were included. The impact of radiation status on observed and relative survival was examined.

RESULTS

Five hundred seventy-four patients with high-grade, early stage salivary tumors met inclusion criteria. Sixty-seven percent of patients received radiation therapy. There was no difference in observed or relative survival based on having received radiation.

CONCLUSIONS

Adjuvant radiation is indicated for advanced stage tumors or early stage tumors with adverse features. For early stage tumors without adverse features, there was no survival benefit from radiation therapy. Adjuvant radiation should be decided on a case-by-case basis for these patients.

Products based on olive oil, betaine, and xylitol in the post-radiotherapy xerostomia

AIM

The objective of this study was determining if the use of products based in olive oil, betaine and xylitol are efficacious to decrease the impact of the dry mouth in the quality of life of the patients with xerostomia due to radiotherapy treatment.

BACKGROUND

Following therapeutic irradiation of the head and neck, patients with profound xerostomia have complaints associated with oral dryness, speech, and taste. There is no strong evidence that any topical therapy is effective for relieving the symptom of dry mouth.

MATERIAL AND METHODS

40 patients who had been treated with radiotherapy for head and neck carcinoma and reported symptoms of dry mouth were included in the study. A xerostomia-related quality of life questionnaire, visual analogue scale questionnaire for subjective assessment of salivary dysfunction and salivary flow were reported before and 15 days after the use of topical products based on olive oil, betaina and xylitol.

RESULTS

The four primary quality of life areas demonstrated significantly greater improvement after the use of topical products and all eight VAS items had favourable changes. The reduction of symptoms was statistically significant in 7 of the 8 items. After the use of the products, there were improvements in salivary flow in 45%.

CONCLUSIONS

The use of products based on olive oil, betaine and xylitol, shaped like collutory, toothpaste, gel and spray significantly improved most symptoms and the quality of life limitations produced by dry mouth in patients treated with radiotherapy.

Dosimetric advantages of intensity-modulated proton therapy for oropharyngeal cancer compared with intensity-modulated radiation: A case-matched control analysis

A potential advantage of intensity-modulated proton therapy (IMPT) over intensity-modulated (photon) radiation therapy (IMRT) in the treatment of oropharyngeal carcinoma (OPC) is lower radiation dose to several critical structures involved in the development of nausea and vomiting, mucositis, and dysphagia. The purpose of this study was to quantify doses to critical structures for patients with OPC treated with IMPT and compare those with doses on IMRT plans generated for the same patients and with a matched cohort of patients actually treated with IMRT. In this study, 25 patients newly diagnosed with OPC were treated with IMPT between 2011 and 2012. Comparison IMRT plans were generated for these patients and for additional IMRT-treated controls extracted from a database of patients with OPC treated between 2000 and 2009. Cases were matched based on the following criteria, in order: unilateral vs bilateral therapy, tonsil vs base of tongue primary, T-category, N-category, concurrent chemotherapy, induction chemotherapy, smoking status, sex, and age. Results showed that the mean doses to the anterior and posterior oral cavity, hard palate, larynx, mandible, and esophagus were significantly lower with IMPT than with IMRT comparison plans generated for the same cohort, as were doses to several central nervous system structures involved in the nausea and vomiting response. Similar differences were found when comparing dose to organs at risks (OARs) between the IMPT cohort and the case-matched IMRT cohort. In conclusion, these findings suggest that patients with OPC treated with IMPT may experience fewer and less severe side effects during therapy. This may be the result of decreased beam path toxicities with IMPT due to lower doses to several dysphagia, odynophagia, and nausea and vomiting-associated OARs. Further study is needed to evaluate differences in long-term disease control and chronic toxicity between patients with OPC treated with IMPT in comparison to those treated with IMRT.

Is Pilocarpine Effective in Preventing Radiation-Induced Xerostomia? A Systematic Review and Meta-analysis

PURPOSE

To evaluate the efficacy of concomitant administration of pilocarpine on radiation-induced xerostomia in patients with head and neck cancers.

METHODS AND MATERIALS

The PubMed, Web of Science, Cochrane Library, and ClinicalTrials were searched to identify randomized, controlled trials studying the effect of concomitant administration of pilocarpine for radiation-induced xerostomia. Included trials were systematically reviewed, and quantifiable outcomes were pooled for meta-analysis. Outcomes of interest included salivary flow, clinician-rated xerostomia grade, patient-reported xerostomia scoring, quality of life, and adverse effects.

RESULTS

Six prospective, randomized, controlled trials in 8 articles were included in this systematic review. The total number of patients was 369 in the pilocarpine group and 367 in the control group. Concomitant administration of pilocarpine during radiation could increase the unstimulated salivary flow rate in a period of 3 to 6 months after treatment, and also reduce the clinician-rated xerostomia grade. Patient-reported xerostomia was not significantly impacted by pilocarpine in the initial 3 months but was superior at 6 months. No significant difference of stimulated salivary flow rate could be confirmed between the 2 arms. Adverse effects of pilocarpine were mild and tolerable.

CONCLUSIONS

The concomitant administration of pilocarpine during radiation increases unstimulated salivary flow rate and reduces clinician-rated xerostomia grade after radiation. It also relieves patients' xerostomia at 6 months and possibly at 12 months. However, pilocarpine has no effect on stimulated salivary flow rate.

Initial experience of radiotherapy plus cetuximab for Japanese head and neck cancer patients

In Japan, cetuximab with concurrent bioradiotherapy (BRT) for squamous cell carcinoma of head and neck (SCCHN) was approved in December 2012. We herein report our initial experience of BRT, with special emphasis on acute toxicities of this combination therapy. Thirty-one non-metastatic SCCHN patients who underwent BRT using cetuximab between July 2013 and June 2014 were retrospectively evaluated. All patients received cetuximab with a loading dose of 400 mg/m(2) one week before the start of radiotherapy, followed by 250 mg/m(2) per week during radiotherapy. The median cycle of cetuximab was seven cycles and the median dose of radiotherapy was 70 Gy. Twenty-five patients (80.6%) accomplished planned radiotherapy and six cycles or more cetuximab administration. Six patients (19.4%) discontinued cetuximab. Grade 3 dermatitis, mucositis and infusion reaction occurred in 19.4%, 48.3% and 3.2%, respectively. One patient experienced Grade 3 gastrointestinal bleeding caused by diverticular hemorrhage during BRT. Grade 3 drug-induced pneumonitis occurred in two patients. The response rate was 74%, including 55% with a complete response. BRT using cetuximab for Japanese patients with SCCHN was feasible as an alternative for cisplatin-based concurrent chemoradiation, although longer follow-up is necessary to evaluate late toxicities.

Evaluation of oral prophylaxis during and after intensity-modulated radiotherapy due to head and neck cancer--a retrospective study

OBJECTIVES

The aim of this study was to retrospectively analyze the influence of a prophylaxis protocol of head and neck tumor (HNT) patients during and after intensity-modulated radiotherapy (IMRT).

MATERIAL AND METHOD

In this 5-year retrospective study (2009-2013), 70 (m 55, f 15; age range 28-8 years; median 58.7 years) out of 248 HNT patients of the Clinic of Cranio-Maxillofacial and Oral Surgery at the University of Zurich, Switzerland, fulfilled the inclusion criteria. Parameters of investigation were the salivary flow rates, possible dental foci and the dental status, oral side effects of radiotherapy, the prophylaxis protocol, and patient's compliance to this protocol. The following time points before during and after IMRT (6 weeks) were analyzed: prior to IMRT, 2-4 weeks, 6 weeks and 3, 6, and 12 months after the onset of radiotherapy.

RESULT

Unstimulated salivary flow rate, pH value of unstimulated salivary, and stimulated salivary flow rate showed a significant reduction over time (p < 0.001). One year after IMRT, both unstimulated and stimulated salivary flow showed a statistically significant lower salivary flow. The number of caries-affected sites per patient was significantly higher for patients with low compliance to the prophylaxis protocol (mean: low compliance 1.36, high compliance 0.26). Almost 75% of the evaluated patients suffered immediate gustatory change, and 47.1% showed signs of radiostomatitis through IMRT.

CONCLUSIONS

High compliance to the prophylaxis protocol during and after radiotherapy is a key factor for the reduction of radiation side effects on dental hard tissue.

CLINICAL RELEVANCE

High compliance to a monitored prophylaxis program is crucial for patients after head and neck surgery.

Sino-nasal mucosal malignant melanoma

A 49-year-old man with a history of left nasal discharge and nasal cavity blockage for 5 months was diagnosed with sino-nasal mucosal malignant melanoma on nasal biopsy. On CT scan, the tumour involved the nasal cavity, left maxillary sinus, ethmoid sinus and medial left orbit. The tumour was grossly excised and adjuvant radiation therapy was offered. The patient was planned for an Intensity Modulated Radiotherapy technique to keep tolerance doses of organs at risk within normal limits and at same time deliver the intended dose of radiation to the tumour site, using 66 Gy in 33 fractions. Owing to the anatomical complexity of the sino-nasal region, precision radiotherapy (RT) is mandatory to optimally irradiate the tumour area while sparing critical surrounding normal structures from late toxicity of RT. Established dose constraints for at-risk organs can only be accomplished through this novel technique of RT. However, despite advances in techniques, current treatment modalities have not significantly made an impact on survival of these patients.

Helical tomotherapy in head and neck cancer: a European single-center experience

BACKGROUND

We report on a retrospective analysis of 147 patients with early and locoregionally advanced squamous cell head and neck cancer (SCCHN) treated with helical tomotherapy (HT).

PATIENTS AND METHODS

Included were patients with SCCHN of the oral cavity (OC), oropharynx (OP), hypopharynx (HP), or larynx (L) consecutively treated in one radiotherapy center in 2008 and 2009. The prescribed HT dose was 60-66 Gy in the postoperative setting (group A) and 66-70 Gy when given as primary treatment (group B). HT was given alone, concurrent with systemic therapy (ST), that is, chemotherapy, biotherapy, or both, and with or without induction therapy (IT). Acute and late toxicities are reported using standard criteria; locoregional failure/progression (LRF), distant metastases (DM), and second primary tumors (SPT) were documented, and event-free survival (EFS) and overall survival (OS) were calculated from the start of HT.

RESULTS

Group A patients received HT alone in 22 cases and HT + ST in 20 cases; group B patients received HT alone in 17 cases and HT + ST in 88 cases. Severe (grade ≥ 3) acute mucosal toxicity and swallowing problems increased with more additional ST. After a median follow-up of 44 months, grade ≥2 late toxicity after HT + ST was approximately twice that of HT alone for skin, subcutis, pharynx, and larynx. Forty percent had grade ≥2 late xerostomia, and 29% had mucosal toxicity. At 3 years, LRF/DM/SPT occurred in 7%/7%/17% and 25%/13%/5% in groups A and B, respectively, leading to a 3-year EFS/OS of 64%/74% and 56%/63% in groups A and B, respectively.

CONCLUSION

The use of HT alone or in combination with ST is feasible and promising and has a low late fatality rate. However, late toxicity is nearly twice as high when ST is added to HT.

Actual anatomical and dosimetric changes of parotid glands in nasopharyngeal carcinoma patients during intensity modulated radiation therapy

The goal of this study was to evaluate the actual anatomical and dosimetric changes of parotid glands in nasopharyngeal carcinoma patients during intensity modulated radiation therapy. With helical tomotherapy, its planning system, and adaptive software, weekly anatomical and dosimetric changes of parotid glands in 35 NPC patients were evaluated. Interweekly parotid volume varied significantly (P < 0.03). The rate of volume change reached the highest level at the 16th fraction. The average V₁ increased by 32.2 (left) and 28.6 (right), and the average D₅₀ increased by 33.9 (left) and 24.93 (right), respectively. Repeat data comparison indicated that the V₁ and D₅₀ varied significantly among different fractions (both with P = 0.000). The variation of parotid volume was inversely correlated with that of the V₁ and D₅₀ (both with P = 0.000). In conclusion, parotid volume and actual dose vary significantly in NPC patients during IMRT. Replanning at the end of the fourth week of IMRT may have clinical benefits.

Low dose cranial irradiation-induced cerebrovascular damage is reversible in mice

Background

High-dose radiation-induced blood-brain barrier breakdown contributes to acute radiation toxicity syndrome and delayed brain injury, but there are few data on the effects of low dose cranial irradiation. Our goal was to measure blood-brain barrier changes after low (0.1 Gy), moderate (2 Gy) and high (10 Gy) dose irradiation under in vivo and in vitro conditions.

Methodology

Cranial irradiation was performed on 10-day-old and 10-week-old mice. Blood-brain barrier permeability for Evans blue, body weight and number of peripheral mononuclear and circulating endothelial progenitor cells were evaluated 1, 4 and 26 weeks postirradiation. Barrier properties of primary mouse brain endothelial cells co-cultured with glial cells were determined by measurement of resistance and permeability for marker molecules and staining for interendothelial junctions. Endothelial senescence was determined by senescence associated β-galactosidase staining.

Principle Findings

Extravasation of Evans blue increased in cerebrum and cerebellum in adult mice 1 week and in infant mice 4 weeks postirradiation at all treatment doses. Head irradiation with 10 Gy decreased body weight. The number of circulating endothelial progenitor cells in blood was decreased 1 day after irradiation with 0.1 and 2 Gy. Increase in the permeability of cultured brain endothelial monolayers for fluorescein and albumin was time- and radiation dose dependent and accompanied by changes in junctional immunostaining for claudin-5, ZO-1 and β-catenin. The number of cultured brain endothelial and glial cells decreased from third day of postirradiation and senescence in endothelial cells increased at 2 and 10 Gy.

Conclusion

Not only high but low and moderate doses of cranial irradiation increase permeability of cerebral vessels in mice, but this effect is reversible by 6 months. In-vitro experiments suggest that irradiation changes junctional morphology, decreases cell number and causes senescence in brain endothelial cells.