MRI, FDG-PET/CT and Image-Guidance for Re-Irradiation of Locoregionally Recurrent or Second Primary Head-and-Neck Squamous Cell Carcinoma Patients - Results of a Multicenter Cohort Study

PURPOSE/OBJECTIVE(S)

To investigate patterns of care and prognostic benefits of MRI, FDG-PET/CT and image-guidance in re-irradiation of locoregionally recurrent or second primary head-and-neck squamous cell carcinomas (r/s HNSCCs) within a multicenter cohort study.

MATERIALS/METHODS

Patients receiving re-irradiation for r/s HNSCC between 2009 and 2020 at 16 tertiary cancer centers in Germany were retrospectively analyzed in terms of MRI and FDG-PET/CT usage for treatment planning and regarding image-guidance frequency during re-irradiation. Patterns of use of these modalities over time were analyzed by binary logistic regression analysis, and the association between the usage of these modalities and best locoregional treatment response was analyzed with chi-square tests. Cumulative incidence analyses of locoregional failures with death as competing event were performed.

RESULTS

In the total cohort of 297 patients, 226 (76%) were male, median age was 62 years (IQR, 56-70), and median ECOG was 1 (IQR, 1-2). There were 260 locoregionally recurrent HNSCCs, and 37 second primary HNSCCs; 44 patients (15%) had distant metastases at the time of re-irradiation. MRI and FDG-PET/CT was used for re-irradiation planning in 117 (39%) and 71 patients (24%), respectively. In median, image guidance (IGRT) was performed twice weekly (IQR, 1-5), usually with cone beam CTs or megavolt-CTs, and 85 patients (29%) received daily IGRT during re-irradiation. Usage of MRI (OR = 0.967; 95% CI, 0.892-1.048; p = .416), FDG-PET/CT (OR = 1.053; 95% CI, 0.960-1.156; p = .274), or daily IGRT (OR = 1.057; 95% CI, 0.968-1.115; p = .218) did not increase in frequency over time within the analyzed time span but was significantly dependent on the treatment center (χ2(15), P<.001 for all modalities). Daily IGRT was associated with a higher rate of at least stable disease after re-irradiation as assessed by RECIST criteria (χ2(1) = 4.011, p<.05). There was a trend towards better RECIST-assessed treatment response for MRI (χ2(1) = 3.223, p = .073) and FDG-PET/CT (χ2(1) = 2.792, p = .095) as part of the re-irradiation planning process. Incidence of locoregional failures was not dependent on MRI (SHR = 0.94; 95% CI, 0.67-1.33; p = 0.741, Fine-Gray), FDG-PET/CT (SHR = 0.88; 95% CI, 0.59-1.33; p = 0.552) or daily IGRT (SHR = 0.76; 95% CI, 0.51-1.14, p = 0.182), There was a trend towards lower acute grade 3/4-toxicities in patients receiving daily IGRT (χ2(1) = 3.354, p = 0.067).

CONCLUSION

Our data suggest that daily IGRT may increase disease control and should be regularly applied for re-irradiation of r/s HNSCCs. MRI and FDG-PET/CT usage were not associated with the incidence of locoregional failures after re-irradiation. However, prospective trials with multiparametric MRI and/or FDG-PET/CT for optimal re-irradiation planning are warranted.

Effects of multiple stressors on benthic invertebrates using Water Framework Directive monitoring data

Multiple stressors affect freshwater systems and cause a deficient ecological status according to the European Water Framework Directive (WFD). To select effective mitigation measures and improve the ecological status, knowledge on the stressor hierarchy and individual and joined effects is necessary. However, compared to common stressors like nutrient enrichment and morphological degradation, the relative importance of micropollutants such as pesticides and pharmaceuticals is largely unaddressed. We used WFD monitoring data from Saxony (Germany) to investigate the importance of 85 environmental variables (including 34 micropollutants) for 18 benthic invertebrate metrics at 108 sites. The environmental variables were assigned to five groups (natural factors, nutrient enrichment, metals, micropollutants and morphological degradation) and were ranked according to their relative importance as group and individually within and across groups using Principal Component Analyses (PCAs) and Boosted Regression Trees (BRTs). Overall, natural factors contributed the most to the total explained deviance of the models. This variable group represented not only typological differences between sampling sites but also a gradient of human impact by strongly anthropogenically influenced variables such as electric conductivity and dissolved oxygen. These large-scale effects can mask the individual importance of the other variable groups, which may act more specifically at a subset of sites. Accordingly, micropollutants were not represented by a few dominant variables but rather a diverse palette of different chemicals with similar contribution. As a group, micropollutants contributed similarly as metals, nutrient enrichment and morphological degradation. However, the importance of micropollutants might be underestimated due to limitations of the current chemical monitoring practices.

Dose-escalated re-irradiation improves outcome in locally recurrent head and neck cancer - Results of a large multicenter analysis

To determine efficacy and prognostic parameters of definitive re-irradiation of locoregionally recurrent squamous cell carcinoma of the head and neck (HNSCC).

MATERIALS AND METHODS

Patients with locoregionally recurrent or second primary HNSCC undergoing re-irradiation with modern radiotherapy technique were eligible for this multicentric retrospective analysis. Main endpoints were overall survival (OS), progression-free survival (PFS) and locoregional control (LC). Univariate analyses were performed using the Kaplan Meier Method (log-rank). For multivariable analysis, Cox regression was used.

RESULTS

A total of 253 patients treated between 2009 and 2020 at 16 university hospitals in Germany were included. The median follow up was 27.4 months (range 0.5-130). The median OS and PFS were 13.2 (CI: 10.7 - 15.7) months and 7.9 (CI: 6.7 - 9.1) months, respectively, corresponding to two-year OS and PFS rates of 29 % and 19 %. Rates of locoregional progression and "in-field-failure" were 62 % and 51 % after two years. Multivariable Cox regression analysis identified good ECOG performance status and high radiation dose as independent prognostic parameters for OS. Doses above 50 Gy (EQD2) achieved longer median OS of 17.8 months (vs 11.7 months, p < 0.01) and longer PFS of 9.6 months (vs 6.8 months, p < 0.01). In addition, there was a trend for worse survival in patients with tracheostomy (multivariable, p = 0.061). Concomitant systemic therapy did not significantly impact PFS or OS.

CONCLUSION

Re-irradiation of locally recurrent or second primary HNSCC is efficient, especially if doses above 50 Gy (EQD2) are delivered. ECOG performance score was the strongest prognostic parameter for OS and PFS.

Locomotor behavior of Neocaridina palmata: a study with leachates from UV-weathered microplastics

Weathering of plastics leads to the formation of increasingly smaller particles with the release of chemical compounds. The latter occurs with currently unknown environmental impacts. Leachate-induced effects of weathered microplastics (MPs) are therefore of increasing concern. To investigate the toxicity of the chemical mixtures from such plastics, we exposed the freshwater shrimp Neocaridina palmata to enriched leachates from unweathered and artificially weathered (UV-A/B light) MPs (≤1 mm) from recycled low-density polyethylene (LDPE-R) pellets and from a biodegradable, not fully bio-based starch blend (SB) foil. We analyzed the individual locomotor activity (moved distance and frozen events) on day 1, 3, 7 and 14 of exposure to five leachate concentrations equivalent to 0.40–15.6 g MPs L⁻¹, representing the upper scale of MPs that have been found in the environment. The median moved distance did not change as a function of concentration, except for the unweathered SB treatment on day 14 that indicated hyperactivity with increasing concentrations. Significant impacts were solely detected for few concentrations and exposure days. Generally, no consistent trend was observed across the experiments. We further assessed the baseline toxicity of the samples in the Microtox assay and detected high bioluminescence inhibitions of the bacterium Aliivibrio fischeri. This study demonstrates that neither the recycled nor the biodegradable material are without impacts on test parameters and therefore cannot be seen as safe alternative for conventional plastics regarding the toxicity. However, the observed in vitro toxicity did not result in substantial effects on the behavior of shrimps. Overall, we assume that the two endpoints examined in the atyid shrimp N. palmata were not sensitive to chemicals leaching from plastics or that effects on the in vivo level affect other toxic endpoints which were not considered in this study.

Particle shape does not affect ingestion and egestion of microplastics by the freshwater shrimp Neocaridina palmata

The ingestion of microplastics (MPs) is well documented for various animals and spherical MPs (beads) in many studies. However, the retention time and egestion of MPs have been examined less, especially for irregular MPs (fragments) which are predominantly found in the environment. Furthermore, the accumulation of such particles in the gastrointestinal tract is likely to determine whether adverse effects are induced. To address this, we investigated if the ingestion and egestion of beads are different to those of fragments in the freshwater shrimp Neocaridina palmata. Therefore, organisms were exposed to 20-20,000 particles L-1 of either polyethylene (PE) beads (41 μm and 87 μm) or polyvinyl chloride (PVC) fragments (<63 μm). Moreover, shrimps were exposed to 20,000 particles L-1 of either 41 μm PE and 11 μm polystyrene (PS) beads or the PVC fragments for 24 h, followed by a post-exposure period of 4 h to analyze the excretion of particles. To simulate natural conditions, an additional fragment ingestion study was performed in the presence of food. After each treatment, the shrimps were analyzed for retained or excreted particles. Our results demonstrate that the ingestion of beads and fragments were concentration-dependent. Shrimps egested 59% of beads and 18% of fragments within 4 h. Particle shape did not significantly affect MP ingestion or egestion, but size was a relevant factor. Medium- and small-sized beads were frequently ingested. Furthermore, fragment uptake decreased slightly when co-exposed to food, but was not significantly different to the treatments without food. Finally, the investigations highlight that the assessment of ingestion and egestion rates can help to clarify whether MPs remain in specific organisms and, thereby, become a potential health threat.

[Acupuncture covered by statutory health insurance in Germany : An observational study based on claims data]

BACKGROUND

The coverage for acupuncture for chronic lower back or knee pain by the statutory health insurance was introduced in 2007. The aim of this study was to investigate characteristics of patients and providers of acupuncture and temporal and regional trends in the utilization of acupuncture.

METHODS

This retrospective observational study used anonymized statutory health insurance claims data from a sample of roughly four million subjects. The sample is representative of the German population regarding age and gender in 2013.

RESULTS

Lower back pain was the most common coded indication (86%) for billing acupuncture. Women were more often treated with acupuncture than men; the mean age was 61.1 years. For 63% acupuncture was billed in 2014 for the first time, 37% already had an acupuncture treatment in 2012 or 2013. Premature termination (<6 sessions) was observed in 14% of all insurants receiving acupuncture for the first time in 2014 for knee pain and in 21% of those with back pain. Overall there was a statistically significant decrease in the utilization of acupuncture from 2008 to 2015. Regional differences between East and West Germany and city states were observed. Half of all acupuncture treatments in 2014 were provided by 11% of all physicians who billed acupuncture at least once.

DISCUSSION

Higher utilization of acupuncture by women reflects the epidemiology of back and knee pain and their preference for alternative complementary medicine. On the one hand, the large proportion of patients treated repeatedly with acupuncture suggests perceived benefits. On the other hand, provision of acupuncture services is decreasing continuously and a relevant proportion of subjects are terminating treatment prematurely.

Human herpesvirus 6 in biopsies from patients with gastrointestinal symptoms after allogeneic stem cell transplantation

Gastrointestinal complications are frequent after allogeneic stem cell transplantation (allo-SCT). Main differential diagnoses are graft-versus-host disease (GvHD) and viral infections. In this retrospective analysis, we included 50 patients with severe vomiting or diarrhea in the first year after allo-SCT. One hundred two biopsies obtained by colonoscopy or endoscopy of the upper gastrointestinal tract were analysed by conventional histology for signs of GvHD and by qualitative polymerase chain reaction (PCR) for viral DNA of human herpesvirus 6 (HHV-6) and other virus of the herpes family. DNA of HHV-6 was detected in 38 of 75 initial samples (51%) and in 19 of 27 follow-up biopsies (70%). In the initial samples (n = 75), HHV-6 DNA was detected in 20/37 (54%) biopsies in the presence of GvHD compared to 18/38 (47%) biopsies without signs of GvHD. At the time of the first endoscopic investigation, most patients received antiviral prophylaxis with aciclovir. None of the follow-up biopsies was HHV-6 DNA negative after antiviral treatment with aciclovir, foscarnet or ganciclovir. By univariate analysis, no risk factor for HHV-6 detection could be demonstrated. In this cohort of patients with severe gastrointestinal complications, there was no significant difference in the overall survival between patients with or without HHV-6 DNA detection in the gastrointestinal tract. In summary, the detection of HHV-6 DNA had no impact on overall survival. Moreover, antiviral therapy against HHV-6 was without effect. Thus, positive PCR results in GI tract samples do not necessarily reflect reactivation of HHV-6. Further studies are needed to define the significance of HHV-6 for GI tract symptoms after allo-SCT.