NMR-based metabolomics in real-time monitoring of treatment induced toxicity and cachexia in head and neck cancer: a method for early detection of high risk patients

INTRODUCTION

Nutritional treatment in head and neck squamous cell carcinoma cancer (HNSCC) patients undergoing radio-/chemo-radiotherapy (RT/CHRT) is complex and requires a multidisciplinary approach. In this study the real-time dynamic changes in serum metabolome during RT/CHRT in HNSCC patients were monitored using NMR-based metabolomics.

OBJECTIVES

The main goal was to find the metabolic markers that could help prevent of acute radiation sequelae (ARS) escalation.

METHODS

170 HNSCC patients were treated radically with RT/CHRT. Blood samples were collected weekly, starting from the day before the treatment and stopping within the week after the RT/CHRT completion, resulting in a total number of 1328 samples. 1H NMR spectra were acquired on Bruker 400 MHz spectrometer at 310 K and analyzed using principal component analysis (PCA) and orthogonal partial least squares discriminant analysis (OPLS-DA). Additional statistical analyses were performed on the quantified metabolites.

RESULTS

PCA has detected a group of distinct outliers corresponding to ketone bodies (3HB, Ace, AceAce). These outliers were found to identify the individuals at high risk of weight loss, mainly by the 3HB changes, which was confirmed by the patients' medical data. In the OPLS-DA models a transition from the lowest to the highest weight loss is seen, defining the metabolic time trajectories for the patients from the studied groups during RT/CHRT. 3HB is a relatively sensitive marker that allows earlier identification of the patients at higher risk of > 10% weight loss.

CONCLUSION

Our findings indicate that metabolic alterations, characteristic for malnutrition or cachexia, can be detected already at the beginning of the treatment, making it possible to monitor the patients with a higher risk of weight loss.

Abstract P2-08-49: The role of neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR) andmonocyte – lymphocyte ratio (MLR) in prognosis of breast cancer patients

Introduction: Breast cancer (BC) is common malignancies in women.Biomarkers such as neutrophils, lymphocyte, neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), monocyte – lymphocyte ratio (MLR) and PLT have been demonstrated to be closely related to poor prognosis in several solid tumors. The objective of this study was to evaluate the blood PLR, NLR andMLR for its prognostic value in patients with breast cancer.Material and Methods: We retrospectively reviewed 436 breast cancer patients (all woman) diagnosed and treated in MSC Memorial Cancer and Institute of Oncology, Gliwice Branch in years 2005 - 2018. The median age of patients was 52.5 years (range from 25 to 78). We assessed the prognostic value (overall survival) of pretreatment PLR, NLR and MLRbased on univariate and multivariate analysis. The cut-off value of NLR was 'elevated' as >2.65, MLR value was 'elevated'as >0.28 and PLR cut-off value was 'elevated' as >190.9.Results: Median follow-up was 71 months (range, from 3 to 165 months). The 5-year and 10-year OS rates were 88.1% and 80.2%, respectively. The 5-year OS was lower in NLR > 2.65 in comparison to NLR<=2.65 (82.5% vs.89.6%, p=0.053), especially in subgroup of triple negative breast cancer (TNBC) (70.3% vs. 89.3%, p=0.034) and in patients with estrogen receptor negative status tumors (66.6% vs. 83.6%, p=0.018).Similarly, the 5-year OS was lower in patients with PLR > 190.9 in comparison to PLR<=190.9 (78.7% vs. 89.4%; p=0.020). The worse OS rate was also observed in subgroup with TNBC and PLR > 190.9 (68.2% vs. 88.5%, p=0.032) or in subgroup with ER negative steroid receptor status tumors with 'elevated' PLR (57.7% vs. 83.6%, p=0.002).The 'elevated' value of MLR (>0.28) was not associated with overall survival time in our group of patients (p=0.830), also in TNBC (p=0.219) and ER (-) (p=0.453) subgroups of patients. Multivariate analysis has showed that NLR and PLR were insignificantly negative prognostic factors in all analyzed group. However the analysis in subgroup of patients with ER (-) negative tumors has showed that higher NLR (p=0.013; HR=2.40; 95%CI 1.20-4.80) and higher PLR (p=0.012; HR=2.51; 95%CI 1.23-5.14) were an independent factors for lower OS together with metastatic lymph nodes (p=0.0001). Conclusion: Elevated pre-treatment NLR (>2.65) and PLR (>190.9) are associated with lower OS in breast cancer patients. In ER (-) subgroups of patients elevated NLR and PLR were significant independent prognostic factors. MLR did not affect overall survival.

Citation Format: Huszno J, Kołosza Z, Mrochem Kwarciak J, Rutkowski T, Składowski K. The role of neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR) andmonocyte – lymphocyte ratio (MLR) in prognosis of breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-49.

Acute mucosal radiation reactions in patients with head and neck cancer. Patterns of mucosal healing on the basis of daily examinations

PURPOSE

The goal of this research was to evaluate the healing processes of acute mucosal radiation reactions (AMRR) in patients with head and neck cancer.

MATERIALS AND METHODS

In 46 patients with oral and oropharyngeal cancer patients irradiated with conventional (n = 25) and accelerated (n = 21) dose fractionation AMRR was evaluated daily during and after radiotherapy. Complex of morphological and functional symptoms according to the Dische score were collected daily until complete healing.

RESULTS

Duration of healing after the end of radiotherapy ranged widely (12-70 days). It was on the average 8 days longer for accelerated than for conventional radiotherapy (p = 0.016). Duration of dysphagia was also longer for accelerated irradiation (11 days, p = 0.027). Three types of morphological symptoms were observed as the last symptom at the end of AMRR healing: spotted and confluent mucositis, erythema, and edema. Only a slight correlation between healing duration and area of irradiation fields (r = 0.23) was noted. In patients with confluent mucositis, two morphological forms of mucosal healing were observed, i.e., marginal and spotted. The spotted form was noted in 71% of patients undergoing conventional radiotherapy and in 38% of patients undergoing accelerated radiotherapy. The symptoms of mucosal healing were observed in 40% patients during radiotherapy.

CONCLUSION

The wide range of AMRR healing reflects individual potential of mucosa recovery with longer duration for accelerated radiotherapy. Two morphological forms of confluent mucositis healing were present: marginal and spotted. Healing of AMRR during radiotherapy can be observed in a significant proportion of patients.

Predictors of radiotherapy outcome in patients with T2 supraglottic carcinoma

The decision regarding treatment of early supraglottic carcinoma remains controversial. Single institution clinical data of patients with T2 supraglottic carcinoma treated exclusively with radiotherapy in terms of prognostic factors and treatment results were analyzed. Patient-related factors that would potentially by useful for optimal therapeutic decision to be undertaken were especially investigated. Between 1994 and 2004, 78 patients with T2 supraglottic carcinoma underwent radiotherapy (RT) in Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Poland. There were 54 (69%) males and 24 (31%) females in the median age of 61 years. There were 17 (22%) patients with N+. Median body mass of patients before (BM0) and after RT (BM1) was 74 kg (range 45.2-130 kg) and 72.9 kg (range 49.9-122.5 kg), respectively. Median hemoglobin concentrations before (Hb0) and after (Hb1) RT were 14.3 and 13.4 g/dl, respectively. Median change of Hb concentration during RT (dHb) was -0.8 g/dl. All were treated up to total doses (TD) ranged from 62.5 to 72 Gy. The overall treatment time (OTT) ranged from 30 to 70 days. Estimates of local control (LC), ultimate local control (uLC), and overall survival (OS) were calculated using the Kaplan-Meier method. Log rank statistics, Cox proportional hazard model and step-wise Cox regression hazard model were employed to identify prognostic factors for LC, uLC, and OS in univariate and multivariate analyses. The 5-year LC, RC, uLC and OS rates were 85, 92, 88, and 56%, respectively. In multivariate analysis N+ (p = 0.01) and prolonged OTT (p = 0.03) significantly decreased LC. Females (p = 0.02), higher BM0 (p = 0.03), and HB0 (p = 0.006) significantly prolonged OS. Patient-related factors like gender, hemoglobin concentration, and body mass may predict treatment outcome. Radiotherapy is effective for T2 supraglottic carcinoma of the larynx unless higher dose intensity is provided. Involved regional lymph nodes significantly deteriorate locoregional cure.

[Prognostic factors in radiotherapy for hypopharyngeal cancer]

This paper presents influence of selected prognostic factors on results of hypopharyngeal cancer radiotherapy used as only treatment in 97 patients irradiated in Centre of Oncology-Institute in Gliwice between 1980-1987. One-variant analysis showed statistically significant influence of gender, decrease of haemoglobin level during radiotherapy and higher T and N stages. Multivariant analysis demonstrated, that only locoregional status and treatment time has decisive importance on radiotherapy results. Thus, better results of treatment depend on lower T and N stages and correct radiotherapy time.

[The effectiveness of combined treatment for laryngeal cancer in Silesia region during the years 1987-1996]

Between 1987-1996, 484 patients with laryngeal cancer were treated by surgery and adjuvant radiotherapy. The 25-30% therapeutic gain was noted when to compare the first period of the study (1987-1992) with the second (1993-1996). The increment of effectiveness of combined treatment for larynx cancer is probably the result of better quality of surgical procedures and individualization of radiation treatment.

[Unconventional accelerated irradiation of advanced pharyngolaryngeal cancer as an alternative treatment compare to surgery. The interim results of randomized clinical trial]

The paper presents preliminary results (3 year tumour control and survival) of clinical randomized trial comparing accelerated fractionation (7 fx a week) with conventional (5 fx a week) radiotherapy (RT) for advanced pharyngo-laryngeal cancer. Significant treatment gain (p < 0.001) and good tolerance associated with accelerated RT was noted (82% of disease-free and 79% of overall survival). These results are similar with combined (total laryngectomy + postoperative RT) policy and, additionally, accelerated RT offers a high chance of larynx preservation.

[Comparison of natural history of squamous cell carcinoma and nondifferentiated carcinoma localized in oro- and nasopharynx]

Aim of this study is comparison of natural history between two subtypes of cancer: squamous and undifferentiated, which were localised in oro- and nasopharynx. Analysis has contained 175 patients with undifferentiatied and 510 patients with squamous cell cancers of oro- and nasopharynx, who were treated in Centre of Oncology--Institute branch Gliwice in 1980-1998. Presence of undiferentiated subtypes were bounded with shortening time of presence the symptoms of disease, most frequent exophytic type of infiltration than in squamous cancer with ulcerative--necrotic type of infiltration. Higher aggressiveness of undifferentiated cancer is based on higher frequency of distant and nodal metastases, metastases to contralateral nodes and higher percentage of conglomerates.

[[Radical radiotherapy in patients with laryngeal cancer in clinical material of Institute Oncology in Gliwice treated in year 1990-1996]

This paper presents influence of selected prognostic factors on results of laryngeal cancer radiotherapy used as the only treatment in 541 patients irradiated in Centre of Oncology-Institute in Gliwice between 1990-1996. The 3-year actuarial disease-free survival was 47.5% for supraglottic cancer and 67% for glottic cancer. Primary tumour localisation in glottis correlates with more favourable prognosis than that in supraglottic. For extralaryngeal involvement the most favourable prognosis was infiltration of cartilages and the worst one for the hypopharyngeal and oropharyngeal involvement. Pretreatment tracheostomy significantly correlates with the worst results.

[Head and neck lymph node metastases from unknown primary site]

The aim of this paper was to evaluate the group of 50 patients with cervical nodes metastases from unknown primary site treated between 1980-1995 in Maria Sk_odowska-Curie Memorial Institute of Oncology in Gliwice. There were 42 males and 8 females ranging in age from 26 to 85 years (median 60). 24 patients underwent combined therapy (surgery with postoperative radiotherapy), 22 underwent radiotherapy. Only 4 patients were treated with surgery alone. 3-years DFS rates were 59% in group treated with combined method, and 10% in group treated only with radiation therapy (p = 0.003). After a median follow up of 39 months 10 primary tumors were discovered--8 in head and neck region, 2 in lower respiratory tracts. DFS rate in group with discovered primary tumors was 40%.

The impact of delivered dose errors on local control of irradiated advanced laryngeal cancer

On the basis of 1,015 entrance and 863 exit dose in vivo measurements, 863 calculations of midline dose were done, and the average deviation and ranges of its value were estimated. Data of 710 advanced larynx cancers were reviewed in order to achieve dose-response relationship. Patients data were fitted directly to L-Q model using maximum likelihood estimation. In 16.5% of measurements the deviation of midline dose was larger than -5.2%. A steep dose response relationship for TCP was found. Considering -5.2% deviation of 2 Gy fraction and 72 Gy of total dose, the 17% (from 48 to 31%) decrease of TCP was found. It shows that deviations of delivered dose influence the tumor control probability and that after systematic error finding during fractionated radiotherapy the value of remaining fraction size and total dose should be modified to compensate the change of TCP.

Comparative estimation of cure rates for supraglottic and glottic cancer in radiotherapy

There are some clinical evidences, that the same types of tumors originated from neighboring anatomical structures can significantly differ in their response to radiation therapy. Squamous cell cancer of supraglottis and glottis could be good examples of this phenomenon. The purpose of the study was to compare the radiocurability of cancers localized in the upper and medium level of the larynx. From 1985 to the end of 1989, 544 patients with squamous cell cancer of the larynx were treated by radiotherapy alone. There were 388 patients with supraglottic cancer and 156 patients with glottic cancer. The total dose was in the range of 59-74 Gy. The end-point criteria were overall (OS) and disease-free survival (DFS). Generally, 5-year overall and disease-free survival rates were significantly more favorable for glottic cancer patients than for supraglottic cancer (67 and 63% vs. 40 and 36%, respectively). Significant differences in both disease-free and overall survival between supraglottic and glottic cancer in aspect of several analyzed clinical prognostic factors were found for: male sex, age, pattern of tumor growth, clinical performance status, radiation total dose lower than 70 Gy, fraction doses and overall treatment time. In all these prognostic categories 5-year survival rates were lower for supraglottic cancer patients. This tendency disappeared when the treatment results were compared in aspect of tumor stage (T). Tumor cure doses for 50% probability of local control (TCD50) in supraglottic cancer were estimated as: 61 Gy (T(1+2)) and 66 Gy (T3). In glottic cancer the lower TCD50 values of 54.5 Gy (T(1+2)) and 61 Gy (T3) were found in comparable treatment time. The comparative estimation of cure rates (i.e. OS and DFS) of laryngeal cancer treated by radiation alone showed that in aspect of almost all analyzed prognostic factors the greater risk of treatment failure was significantly associated with supraglottic origin.

[The effectiveness of radiotherapy and the prognostic value of Hb level for patients with early glottic cancer (T1N0, T2N0)]

Effectiveness of radiotherapy as a sole treatment modality was analysed in a group of 225 patients with glottic cancer in stage T1 (153 patients) or T2 (72 patients) without metastases in regional neck lymph nodes. All patients were irradiated with gamma 60Co or 10 MeV photons 5 times per week conventional treatment with the dose of 2.0-2.5 Gy per fraction. The total dose was in the range of 60-70 Gy given in overall treatment time of 30-61 days. 3-year local control rate was 88% for T1 patients and 54% for T2. In group T1 total dose of 65-70 Gy correlated with a high, 94-100%, local rate whereas in group T2 for the same range of total dose, extension of overall treatment time beyond 45 days caused significant decrease in local tumour control of about 3% for each one day of treatment protraction. Moreover, the Hb level was found to be a significant prognostic factor and its value below 12 g/dl correlated with remarkably lower local control of glottic cancer of about 30% comparing with patients with Hb level above 12 g/dl.

[Prognostic factors in radiotherapy of supraglottic cancer]

In 971 patients with squamous cell carcinoma of supraglottic larynx several clinical and physical prognostic factors were evaluated. There were 55% of patients with advanced primary tumours and 71% of patients with no regional neck metastases. All patients were irradiated radically using external megavoltage beam. The total dose was in range 60-70 Gy for 95% of patients. The 3-year local control rate and 3-year overall in whole group were 41% and 50% respectively. Clinical stage, haemoglobin level at the end of treatment, overall treatment time, sex and total dose were estimated as an independent and important prognostic factors for the outcome in radiotherapy of supraglottic larynx cancer.