RADPLAT: an alternative to surgery?

Complete response of glottic cancer to intra-arterial infusion chemotherapy combined with radiotherapy: A report of 4 cases

Surgical resection is recommended for advanced-stage, resectable glottic cancer. However, total laryngectomy results in the loss of vocal function and reduces patients' quality of life. At our institution, patients with cT3N0M0 stage III resectable glottic cancer who wish to preserve their larynx are treated with super-selective cisplatin infusion with concomitant radiotherapy (RADPLAT) to improve local control over systemic chemotherapy. Herein, we present 4 patients with glottic cancer who underwent biweekly intra-arterial infusion chemotherapy combined with radiation therapy 3 times. For intra-arterial infusion chemotherapy, 100 mg cis-diaminodichloroplatinum was infused into the superior thyroid artery, including the superior laryngeal artery branch. Thereafter, intensity-modulated radiation therapy was administered at doses of 70 Gy in 35 fractions for 3 patients and 66 Gy in 33 fractions for 1 patient. These patients showed complete response after chemoradiotherapy with no recurrence or metastases during the follow-up period to date (mean follow-up period: 56 months, range: 39-76 months).

Comparative Treatment Outcome in T3N0 Glottic Cancer With and Without Vocal Fold Fixation Receiving Radiation Therapy and Concurrent Low-Dose Intra-Arterial Cisplatin Infusion

OBJECTIVES

Selective radiotherapy and concomitant intra-arterial cisplatin infusion (m-RADPLAT) with a lower cisplatin dosage have been performed for organ and function preservation in patients with locally advanced squamous cell carcinoma of the larynx (SCC-L), and results showing a lower rate of adverse events have been reported. This study evaluated the treatment outcomes of patients with T3N0 glottic SCC-L with or without vocal fold fixation (VFF) who were treated with m-RADPLAT.

METHODS

We retrospectively reviewed the data of 33 patients with T3N0 SCC-L who received m-RADPLAT.

RESULTS

The vocal fold in patients with VFF 3 months after completing m-RADPLAT resumed normal movement in 15 patients (83%) and persisted fixation in 3 (17%). The 3-year local control, laryngeal cancer-specific survival, and overall survival rates of patients with or without VFF were 88.9% and 86.7%, 94.1% and 93.3%, and 88.9% and 86.7%, respectively. Additionally, the 3-year freedom from laryngectomy, laryngectomy-free survival, and laryngo-esophageal dysfunction-free survival rates of patients with or without VFF were 94.4% and 86.7%, 88.9% and 73.3%, and 83.3% and 73.3%, respectively. Grade 3 or higher toxicities were observed in all patients: leukopenia in 4 patients (12%), neutropenia in 5 (15%), anemia in 2 (6%), thrombocytopenia in 3 (9%), and mucositis in 2 (6%).

CONCLUSIONS

This study demonstrated that m-RADPLAT yielded VFF improvement and a favorable survival while maintaining laryngeal function not only in patients with T3N0 glottic SCC-L without VFF but also in patients with VFF.

MRI in head and neck cancer following chemoradiotherapy: what is the optimal delay to demonstrate maximal response?

OBJECTIVES

To investigate the optimal timing for post-chemoradiotherapy (CRT) reference magnetic resonance imaging (MRI) in head and neck cancer, so as to demonstrate a maximal treatment response. To assess whether this differs in human papillomavirus-related oropharyngeal cancer (HPV-OPC) and whether the MRI timing impacts on the ability to predict treatment success.

METHODS

Following ethical approval and informed consent, 45 patients (40 male, mean age 59.7 ± 7.9 years, 33 HPV-OPC) with stage 3 and 4 HNSCC underwent pre-treatment, 6- and 12-week post-CRT MRIs in this prospective cohort study. Primary tumour (n = 39) size, T2w morphology and diffusion weight imaging (DWI) scores, together with nodal (n = 42) size and necrotic/cystic change, were recorded. Interval imaging changes were analysed for all patients and according to HPV-OPC status. MRI descriptors and their interval changes were also compared with 2-year progression-free survival (PFS).

RESULTS

All MRI descriptors significantly changed between pre-treatment and 6-week post-treatment MRI studies (p < .001). Primary tumour and nodal volume decreased between 6- and 12-week studies; however, interval changes in linear dimensions were only evident for HPV-OPC lymph nodes. Nodal necrosis scores also evolved after 6 weeks but other descriptors were stable. The 6-week nodal necrosis score and the 6- and 12-week nodal volume were predictive of 2-year PFS.

CONCLUSION

Apart from HPV-OPC patients with nodal disease, the 6-week post-CRT MRI demonstrates maximal reduction in the linear dimensions of head and neck cancer; however, a later reference study should be considered if volumetric analysis is applied.

KEY POINTS

• This study provides guidance on when early post-treatment imaging should be performed in head and neck cancer following chemoradiotherapy, in order to aid subsequent detection of recurrent tumour. • Lymph nodes in HPV-related oropharyngeal cancer patients clearly reduced in size from 6 to 12 weeks post-treatment. However, other lymph node disease and all primary tumours showed only a minor reduction in size beyond 6 weeks, and this required a detailed volumetric analysis for demonstration. • Timing of the reference MRI following chemoradiotherapy for head and neck cancer depends on whether the patient has HPV-related oropharyngeal cancer and whether there is nodal disease. MRI as early as 6 weeks post-treatment may be performed unless volumetric analysis is routinely performed.

Apparent diffusion coefficient agreement and reliability using different region of interest methods for the evaluation of head and neck cancer post chemo-radiotherapy

Objectives:

Post chemoradiotherapy (CRT) interval changes in apparent diffusion coefficient (ADC) have prognostic value in head and neck squamous cell cancer (HNSCC). The impact of using different region of interest (ROI) methods on interobserver agreement and their ability to reliably detect the changes in the ADC values was assessed.

Methods:

Following ethical approval, 25 patients (mean age 59.5 years, 21 male) with stage 3–4 HNSCC undergoing CRT were recruited for this prospective cohort study. Diffusion weighted MRI (DW-MRI) was performed pre-treatment and at 6 and 12 weeks following CRT. Two radiologists independently delineated ROIs using whole volume (ROI_v), largest area (ROI_a) or representative area (ROI_r) methods at primary tumour (n = 22) and largest nodal (n = 24) locations and recorded the ADC_mean. When no clear focus of increased DWI signal was evident at follow-up, a standardised ROI was placed (non-measurable or NM). Bland-Altman plots and interclass correlation coefficient (ICC) were assessed. Paired t-tests evaluated interval changes in pre- and post-treatment ADC_mean at each location, which were compared to the smallest detectable difference (SDD).

Results:

Excellent agreement was obtained for all ROI methods at pre-treatment (ICC 0.94–0.98) and 6-week post-treatment (ICC 0.94–0.98). At 12-week post-treatment, agreement was excellent (ICC 0.91–0.94) apart from ROI_r (ICC 0.86) and the NM nodal disease (ICC 0.87). There were significant interval increases in ADC_mean between pre-treatment and post-treatment studies, which were greater than the SDD for all ROIs.

Conclusions:

ADC_mean values can be reproducibly obtained in HNSCC using the different ROI techniques on pre- and post-CRT MRI, and this reliably detects the interval changes.

Applicability of a single camera-based catheter navigation system using teeth arch as an anatomical landmark for superselective intraarterial infusion in advanced oral cancer treatment

Superselective intraarterial infusion chemoradiotherapy is a modality of oral cancer therapy in which the artery feeding the tumor is catheterized. 3D information about the carotid artery is required to enable the surgeon to judge whether to advance, retract, or rotate the catheter. For this purpose, we proposed and conducted a model experiment to assess a new method of catheterization that applies a tracking system using registration with a monocular camera using the maxillary arch as the anatomical landmark. In this method, the preoperative 3D computer tomography angiographic image of the carotid artery that the catheter will be passed through is overlaid on the 2D video image. The mean TRE was 0.96 ± 0.36 mm and 0.88 ± 0.31 mm and 1.12 ± 0.46 mm when images were registered with the anterior and posterior teeth as the landmarks, respectively; the difference was not significant (p = 0.21). This tracking system that enables markerless registration simply by taking images of the maxillary anterior teeth with a single camera was convenient and effective for catheterization. In this study, we propose the new application of this tracking system and a novel method of catheterization for superselective intraarterial infusion chemoradiotherapy for oral cancer.

The effect of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement on swallowing and swallow-related outcomes in patients undergoing radiotherapy for head and neck cancer: a systematic review

Patients undergoing radiotherapy for head and neck cancer (HNC) often experience malnutrition and dehydration during treatment. As a result, some centres place PEG tubes prophylactically (pPEG) to prevent these negative consequences. However, recent research has suggested that pPEG use may negatively affect swallowing physiology, function and/or quality of life, especially in the long term. The purpose of this study was to systematically review the literature on pPEG use in HNC patients undergoing radiotherapy and to determine its impact on swallowing-related outcomes. The following electronic databases were searched for all relevant primary research published through February 24, 2014: AMED, CINAHL, the Cochrane Library, Embase, Healthstar, Medline, and PsycINFO. Main search terms included HNC, radiotherapy, deglutition disorders, feeding tube(s), and prophylactic or elective. References for all accepted papers were hand searched to identify additional relevant research. Methodological quality was assessed using Cochrane's Risk of Bias. At all levels, two blinded raters provided judgments. Discrepancies were resolved by consensus. The search retrieved 181 unique citations. Twenty studies met our inclusion criteria. Quality assessment revealed that all studies were at risk for bias due to non-randomized sampling and unreported or inadequate blinding. Ten studies demonstrated selection bias with significant baseline differences between pPEG patients and controls. Results regarding the frequency and severity of dysphagia and swallowing-related outcomes were varied and inconclusive. The impact of pPEG use on swallowing and swallowing-related outcomes remains unclear. Well-controlled, randomized trials are needed to determine if pPEG places patients at greater risk for developing long-term dysphagia.

Survival in unresectable sinonasal undifferentiated carcinoma treated with concurrent intra-arterial cisplatin and radiation

We report the successful use of RADPLAT to treat a patient with an unresectable T4N0 sinonasal undifferentiated carcinoma. This patient received 4 cycles of weekly intra-arterial cisplatin together with thiosulfate infusion with concurrent radiation therapy. Radiation therapy was given in 28 daily fractions to 54 Gy using intensity-modulated radiation therapy followed by a hypofractionated stereotactic boost of 3 fractions to 13 Gy to a total dose of 67 Gy in 31 fractions to the nasal sinus and bilateral neck. Intra-arterial cisplatin was administered using a bilateral approach due to the midline site of this tumor. Within days of the first intra-arterial cisplatin, there was an obvious decrease in tumor size. She has been followed with magnetic resonance imaging and positron emission tomography, and remains disease-free 47 mo post-treatment. Centers with expertise in intra-arterial chemotherapy could consider the RADPLAT approach for patients with unresectable sinonasal undifferentiated carcinoma.

Somatic evolution of head and neck cancer - biological robustness and latent vulnerability

Despite recent advancements in multidisciplinary treatments, the overall survival and quality of life of patients with advanced head and neck squamous cell carcinoma (HNSCC) have not improved significantly over the past decade. Molecular targeted therapies, which have been addressed and advanced by the concept of “oncogene addiction”, have demonstrated only limited successes so far. To explore a novel clue for clinically effective targeted therapies, we analyzed the molecular circuitry of HNSCC through the lens that HNSCC is an evolving system. In the trajectory of this somatic evolution, HNSCC acquires biological robustness under a variety of selective pressures including genetic, epigenetic, micro‐environmental and metabolic stressors, which well explains the major mechanism of “escaping from oncogene addiction”. On the other hand, this systemic view appears to instruct us approaches to target latent vulnerability of HNSCC that is masked behind the plasticity and evolvability of this complex adaptive system.

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There is an urgent need to develop a novel conceptual framework for the treatment of HNSCC.

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The biological robustness of HNSCC was analyzed through a somatic evolution model.

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This model well explains the mechanism of “escaping from oncogene addiction”.

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We discuss about the possible approaches to target vulnerability of evolving HNSCC.

Simulation of haemodynamic flow in head and neck cancer chemotherapy

Background

In recent years, intra arterial chemotherapy has become an important component in head and neck cancer treatment. However, therapy success can vary significantly and consistent treatment guidelines are missing. The purpose of this study was to create a computer simulation of the chemical agent injection in the head and neck arteries to investigate the distribution and concentration of the chemical.

Methods

Realistic three dimensional patient specific geometry was created from image scan data. Pulsatile blood flow, turbulence, the chemical agent injection via a catheter, and the mixture between blood and the chemical were then simulated through the arterial network by computational fluid dynamics software.

Results

The results show a consistent chemical distribution throughout all the arteries and this is ineffective. In addition, due to high wall shear stress and turbulence at the inner bifurcation wall, serious complications during the treatment could occur, for instance haemolysis or thrombosis.

Conclusions

The modelled catheter position is insufficient to provide a high chemical agent concentration in the desired tumour feeding artery, which is vital for therapy success.

Detection of locoregional recurrent head and neck cancer after (chemo)radiotherapy using modern imaging

After radiotherapy with or without chemotherapy differentiation between residual and recurrent head and neck cancer and (chemo)radiation sequelae is often difficult. Currently, most physicians aggressively pursue potential recurrences, leading to a high rate of futile invasive diagnostic, e.g. examinations under general anaesthesia with taking of biopsies, and surgical procedures, e.g. planned neck dissections, and a waste of health care resources. Therefore, diagnostic techniques which reliably select patients who should undergo these procedures are warranted. Conventional imaging techniques are not reliable enough for this purpose. Potential imaging techniques to detect residual and recurrent locoregional disease after chemoradiation are (serial) CT or MRI and FDG-PET, eventually in combination with specific response criteria or scoring systems. Diffusion MRI and PET/CT may further improve these techniques. FDG-PET may help to select patients clinically suspected of recurrent laryngeal carcinoma after radiotherapy for direct laryngoscopy under general anaesthesia. It is not yet clear whether FDG-PET can reliable avoid futile routine evaluation by examination under general anaesthesia in oral and oropharyngeal cancer and planned neck dissection when a residual mass persists in the neck after (chemo)radiation. The most reliable scoring criteria and the optimal time interval between completion of radiation and FDG-PET still has to be assessed.

Intra-arterial chemoradiotherapy for locally advanced oral cavity cancer: analysis of therapeutic results in 134 cases

The objective of this study was to investigate the therapeutic results of arterial injection therapy via the superficial temporal artery for 134 cases of stages III and IV (M0) oral cavity cancer retrospectively, and to clarify the prognostic factors. We administered intra-arterial chemoradiotherapy by continuous infusion of carboplatin in 65 cases from January 1993 to July 2002. Systemic chemotherapy was performed on 26 cases at the same time. We administered intra-arterial chemoradiotherapy by cisplatin with sodium thiosulphate in 69 cases from October 2002 to December 2006. Systemic chemotherapy was performed on 48 cases at the same time. The 3-year local control rate was 68.6% (T2-3: 77.9%; T4: 51.3%), and the 3-year survival rate was 53.9% (stage III: 62.9%; stage IV: 45.3%). Regarding the results of multivariate analysis of survival rates, age (<65), selective intra-arterial infusion, and the use of cisplatin as an agent for intra-arterial infusion were significant factors. The therapeutic results of intra-arterial chemoradiotherapy via the superficial temporal artery were not inferior to the results of surgery. In particular, the results of arterial injection therapy by cisplatin with sodium thiosulphate were excellent, so we believe that it will be a new therapy for advanced oral cavity cancer.

FANCD2 depletion sensitizes cancer cells repopulation ability in vitro

Inactivation of Fanconi anemia/BRCA pathway in some cancers causes increased sensitivity to various drugs used for chemo-therapy. Several approaches have been suggested to artificially disrupt this pathway for better treatment. In our study, we have utilized RNA interference technique to knock-down the expression of FANCD2 and sensitize cancer cells undergoing treatment with DNA damaging agents. For this purpose, we transiently depleted FANCD2 by siRNA in a number of breast, bladder, or liver cancer cell lines and screened for mitomycin C or gamma-irradiation sensitivity changes. We could show that knocking-down FANCD2 gene expression increases sensitivity of cancer cells to mitomycin C and to less extent to gamma-rays. Importantly, this effect strongly correlates to repopulation ability of cancer cells and those cell lines with significant FANCD2 depletion revealed decreased recurrence capacity. In summary, the results we presented show proof of principle that opens new possibilities for further preclinical trials.