Cytogenetic damage of radiotherapy in long-term head and neck cancer survivors

Purpose: To evaluate cytogenetic damage of radiotherapy (RT) and chemoradiotherapy (CRT) in long-term head and neck cancer survivors.

Materials and methods: This study included 20 patients treated with RT (10 patients) or CRT (10 patients) for head and neck cancer. Nine healthy volunteers were included as control subjects. Cytochalasin B-blocked micronucleus (CBMN) assay was used to evaluate cytogenetic damage. To evaluate micronucleus (MN) by CBMN, the venous blood samples were drawn median 68 months (range 60–239 months) after the completion of treatment (RT or CRT) for head and neck cancer.

Results: Nuclear division index (NDI) and number of MN in mononuclear and binuclear lymphocytes were significantly higher in patients with head and neck cancer than in control subjects [1.19 (1.08–1.47) vs. 1.07 (1.04–1.14), p?p?p?=?0.020, respectively]. NDI and number of MN in mononuclear lymphocytes were significantly lower in control subjects compared patients received CRT and those received only RT, but there was no significant difference between patients received CRT and those received only RT. Number of MN in binuclear lymphocytes was significantly lower in control subjects compared to patients received CRT, but there was no significant difference between control subjects and those received only RT. Also there was no significant difference between patients received CRT and those received only RT in terms of number of MN in binuclear lymphocytes.

Conclusions: MN frequency of mononuclear and binuclear lymphocytes in medical follow-up of patients with head and neck cancer after RT could be important in evaluating cytogenetic damage of RT. However, further investigations are needed to provide quantitative correlations between MN yields and the clinical features in post-radiotherapy period.     

头颈部肿瘤患者放疗后放射性脑干损伤的临床特征分析

目的探讨头颈部肿瘤患者放疗后出现放射性脑干损伤的临床特征, 分析其预后, 为了解其疾病特点提供临床资料。方法收集中山大学孙逸仙纪念医院2013年8月至2021年9月的放射性脑干损伤13例患者一般资料和放疗相关资料, 回顾性分析其临床特征、影像学特征、治疗以及转归。结果 13例患者中女性4例, 男性9例, 发病年龄29～66(48.15±10.23)岁, 中位放疗剂量以及次数为70 Gy和33次, 从首次放疗到出现脑干病灶的中位潜伏时间为24个月。放射性脑干损伤患者主要临床表现为吞咽困难、饮水呛咳、构音不清以及头晕、行走不稳。MRI影像学特征为T1WI低信号、T2WI高信号, 不规则强化。中位随访时间为45个月, 7例治疗后好转, 6例无效, 其中3例死亡。接受激素治疗者预后与接受贝伐珠单抗治疗者比较差异无统计学意义(P=0.079)。结论放射性脑干损伤患者常表现为后组颅神经损伤及共济失调。病灶高发于脑桥、延髓, 呈T1WI低信号、T2WI高信号, 半数患者接受治疗后病情好转, 激素治疗与贝伐珠单抗治疗对其预后无明显差异。     

Acute mucosal reactions in patients with head and neck cancer

Purpose

To investigate the individual pattern of acute mucosal radiation reactions (AMRR) in patients with head and neck cancer who were treated with radiotherapy alone. Reactions were evaluated daily on an individual basis according to the Dische scoring system.

Materials and methods

Treatment of 87 head and neck cancer patients comprised either conventional fractionation- (CF; n?=?33), accelerated fractionation (AF; n?=?33), hyperfractionated- (HPEFX; n?=?12) or hypofractionated (HPOFX; n?=?9) radiotherapy with radical intent. Daily evaluation of AMRR progression was performed prospectively using a modified, morphologically functional Dische scoring system. The daily sums of the score parameters were subsequently used to construct an individual AMRR course curve for each patient.

Results

A latency period ranging from 3 to 14 days between the start of radiotherapy and the occurrence of the first AMRR symptom was observed in all patients. Based on the three different shapes of AMRR course curve observed during radiotherapy, three types of AMRR course can be described: (1) a continual increase in AMRR intensity until the completion of radiotherapy; (2) the incidence of a plateau phase following the increase in AMRR (increase–plateau course) and (3) decreasing AMRR intensity with a healing phase. A continual increase in AMRR intensity was observed in about 25?% of CF and AF patients and in more than 50?% of HPOFX treatments. This type of reaction was not observed in the HPEFX group. The increase–plateau course was noted in the majority of AF and CF patients; in almost half of those treated with HPOFX and in all HPEFX patients. A decreasing AMRR intensity course was observed in 23?% of all patients, although not observed at all in the HPEFX and HPOFX fractionation groups.

Conclusion

The course of AMRR during radiotherapy can differ between individual patients. After the initial increase in AMRR intensity, a stabilization of the reaction—visible as a plateau phase on the course curve—is observed in the majority of patients. A proportion of the irradiated patients experience a continual increase in AMRR intensity up until the end of radiotherapy. A further group of patients exists in whom signs of AMRR healing are observed during the final stages of radiotherapy.     

Acute mucosal radiation reactions in patients with head and neck cancer

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.     

DNA repair foci and late apoptosis/necrosis in peripheral blood lymphocytes of breast cancer patients undergoing radiotherapy

Abstract

Purpose: Double-strand breaks (DSB) repair and apoptosis are assumed to be key factors in the determination of individual variability in response to radiation treatment. In this study we investigated tumor protein p53 (TP53) binding protein 1 (53BP1) and phosphorylated histone 2A family member X (γH2AX) foci, γH2AX pan-staining and late apoptosis/necrosis (LAN) in lymphocytes from breast cancer (BC) patients undergoing radiotherapy.

Materials and methods: BC patients were subjected to local radiotherapy with fractionated doses using linear accelerator. Adverse reactions of patients were classified according to the Radiation Therapy Oncology Group (RTOG)/European Organization for Research and Treatment of Cancer (EORTC) criteria. Blood samples were collected before treatment, at various time-points during and after radiotherapy. Residual 53BP1 and γH2AX foci, γH2AX pan-staining were analyzed in peripheral blood lymphocytes (PBL) using the Metafer system and confocal laser scanning microscopy. LAN cells were counted by the trypan blue (TB) exclusion assay. Statistical analysis was performed using Mann–Whitney test, Spearman rank correlation test and analysis of covariance (ANCOVA).

Results: No statistically significant changes were observed in the levels of γH2AX foci during radiotherapy. In contrast, radiation-induced residual 53BP1 were detected already after the first fraction. Increased individual variability in the 53BP1 focus formation was observed during treatment. The background level of DNA repair foci and its individual variability in response to radiotherapy decreased after the end of radiotherapy indicating successful removal of DNA-damaging effects. A correlation between stage of cancer and 53BP1 focus formation was established which suggests the prognostic value of this test. We show that the fraction of LAN cells negatively correlates with the level of 53BP1 and positively correlates with individual radiosensitivity. Only weak correlation was observed between γH2AX pan-staining and LAN cells. Due to large interindividual variability, both in vivo assays, LAN and focus formation, have shown relatively low predictive power at the individual level.

Conclusions: It is likely that radiosensitive patients have less efficient mechanisms of elimination of apoptotic cells with DNA damage resulting in accumulation of LAN cells and facilitating adverse reactions. Our data suggested that the grade of adverse reaction may positively correlate with LAN cells in PBL before and during radiotherapy.     

蛋白质摄入水平在头颈肿瘤放化疗中的应用研究

目的 探讨蛋白质摄入量对头颈肿瘤患者根治性放化疗期间黏膜损伤和营养状况的影响。 方法 选取2018年7月至2019年12月南京大学医学院附属鼓楼医院收治的72例头颈肿瘤患者的临床资料进行前瞻性研究。采用数字随机表法将患者分为2组,根据剔除标准,最终干预组纳入患者32例[男性27例、女性5例,年龄（51.67±12.92）岁]、对照组29例[男性23例、女性6例,年龄（56.03±8.26）岁]。干预组在常规膳食基础上接受在院蛋白质补充方案[补充乳清蛋白粉50 g/d,使总蛋白质摄入量达1.5~2.0 g/（kg·d）];对照组采用在院常规膳食方案[蛋白质摄入量为1.0~1.2 g/（kg·d）]。所有患者均采用根治性同步放化疗方案。比较治疗前后2组患者的黏膜损伤程度、营养指标变化、治疗疗效和相关并发症。计数资料的比较采用四格表χ2检验;两样本均数的比较采用成组t检验。 结果 2组患者在年龄、身高、血压、心率（t=−1.59~1.26）、性别、学历和病种（鼻咽癌与其他疾病）（χ2=0.01~0.45）方面的差异均无统计学意义（均P>0.05）。在口腔黏膜损伤方面,干预组患者的损伤程度低于对照组[16%（5/32）对38%（11/29）],且差异有统计学意义（χ2=3.913,P=0.04）;在营养指标方面,干预组与对照组比较,除了骨骼肌、体脂肪和血红蛋白外,干预组在体重[（−2.80±2.66） kg对（−4.85±2.35） kg,t=3.18,P＜0.01]、体重指数[（−1.00±0.95） kg/m2对（−1.81±0.89） kg/m2,t=3.38,P＜0.01]、握力[（5.59±4.20） kg对（2.59±5.32） kg,t=2.46,P=0.02]和血清白蛋白[（−1.40±3.37）g/L对（−3.07±2.92） g/L,t=2.06,P=0.04]指标的维持上均优于对照组。2组在疗效评价、腹泻、便秘和发热指标上的差异均无统计学意义（χ2=0.24~1.30,均P＞0.05）。 结论 在头颈肿瘤根治性放化疗中,补充蛋白质有缓解患者放射性黏膜损伤程度的作用,在保持患者营养指标上也具有优势。     

Sequential chemotherapy and radiotherapy in advanced head and neck cancer

Eighty-six previously untreated patients with advanced squamous-cell carcinoma of the head and neck were entered into a prospective randomised controlled trial to evaluate whether the addition of a kinetically based chemotherapy regimen before and after radiotherapy would improve survival compared with radiotherapy alone. Survival at 30 months showed there was no evidence that the addition of chemotherapy to radiotherapy improved survival and that the chance of obtaining a significant result in favour of adjuvant chemotherapy was remote. We make a strong plea that all chemotherapy regimens for the treatment of squamous-cell carcinoma of the head and neck regions should be subjected to controlled prospective trials before they are widely adopted.     

Intensity-modulated radiotherapy in patients with head and neck cancer: a European single-centre experience

Objective

The purpose of this study was to analyse retrospectively the intensity-modulated radiotherapy (IMRT) results in patients with head and neck cancer (HNC) treated between November 2003 and June 2007.

Methods

Patients with early and locoregionally advanced HNC were treated with inverse-planned step-and-shoot IMRT. The prescribed dose varied from 66 Gy to 70 Gy in those receiving IMRT as definitive treatment and from 60 Gy to 70 Gy in the post-operative setting. IMRT was given alone, after induction chemotherapy (ICT), with concomitant chemotherapy (CRT) or with both. Acute and late toxicities are reported; locoregional control (LRC), locoregional relapse-free survival (LRRFS) and overall survival (OS) were calculated from the start of radiation.

Results

IMRT was used in 78 patients (48 as definitive treatment, 30 post-operatively), of whom 20 also received ICT and 35 CRT. Three patients stopped IMRT early, one for toxicity (mucosa). Acute toxicity scoring revealed 5 cases (6%) of severe skin toxicity and 65 cases (83%) of severe mucosal toxicity. After a median follow-up of 18.7 months, late toxicities included xerostomia (44%), loss of taste (14%) and fibrosis of the neck (9%). 16 patients had died, of whom 10 due to tumour recurrence/progression and 2 due to treatment (but not IMRT related). The LRC, LRRFS and OS at 3 years are 66.1%, 48.5% and 60.3% in the definitive IMRT group and 85.4%, 82.5% and 85.9% in the post-operative setting, respectively.

Conclusion

We consider IMRT for locoregional HNC feasible not only as a single modality but also after surgery, after induction chemotherapy and concurrently with chemotherapy.Locoregional head and neck cancer (HNC) poses a major therapeutic and technological challenge. Different strategies have been applied to improve treatment outcome, such as altered fractionation radiotherapy [1^,2], concurrent chemoradiotherapy [3-8], bioradiation (i.e. concurrent use of radiation and cetuximab [9]) and also, recently, the use of a more effective induction chemotherapy followed by (chemo-) radiation (i.e. sequential therapy) [10^,11].Radiotherapy techniques have evolved strongly during the last decade with the implementation of intensity-modulated radiotherapy (IMRT). The sharp dose fall-off gradient of this technique permits the administration of a highly conformal and more homogeneous dose to the planning target volume (PTV) [12] than conventional and conformal radiotherapy. This allows better sparing of the organs at risk (e.g. parotid glands, submandibular and minor salivary glands, larynx and swallowing structures), leading to a decrease in acute and late side effects [13-16]. This may open a window for treatment intensification of radiotherapy alone or combined with chemotherapy and/or targeted therapy. In addition, IMRT permits the administration of different doses to different adjacent risk zones at the same time, so-called “dose painting”.For a long time, however, a major problem of IMRT was the lack of hard evidence of its superiority over the more classic irradiation techniques. Kam et al [17] showed in a prospective randomised study, without concurrent chemotherapy, significantly less observer-rated severe xerostomia and a significantly higher stimulated parotid and whole saliva flow rate after IMRT treatment for early stage nasopharyngeal carcinoma than two-dimensional radiotherapy. Interestingly, this was not in concordance with patient-reported outcome. Very recently, Nutting et al [18] reported the first phase III multicentre randomised controlled trial in patients with HNC showing significantly less Grade 2 or more xerostomia at 12 and at 18 months in the IMRT arm than the conventional radiotherapy arm, both without concurrent chemotherapy. No differences in acute mucositis or pain scores were found, although the IMRT group suffered from significantly more acute fatigue of Grade 2 or more.However, a clear survival benefit of IMRT over the more classic three-dimensional conformal radiation therapy has not been shown as yet [19^,20], and there are some concerns about the theoretically higher risk of induction of secondary cancers by IMRT because of the increased low-dose irradiated volume [21^,22]. IMRT might also lead to unexpected higher toxicity in areas that were not in the classic two-dimensional beam path but that are irradiated in the IMRT set-up, especially in combination with concurrent chemotherapy [23]. Therefore, experiences of IMRT, with and without induction and/or concurrent chemotherapy, should be reported and shared.In this article we review the results of IMRT in patients with early and locoregionally advanced HNC treated at our hospital between November 2003 and June 2007.     

The prognostic value of time parameters in adjuvant radiotherapy of head and neck cancer. A retrospective analysis of 138 patients]

PURPOSE: To answer the question, how the parameters waiting time, radiation treatment time and overall treatment time (OTT) influenced the endpoints overall (OS), event-free (EFS) and local recurrence-free survival (LRFS) in patients with locally advanced head-and-neck cancer, who had received postoperative radiotherapy. PATIENTS AND METHODS: 138 patients were included into a retrospective analysis from 10/1993 to 05/2000. Besides the time parameters waiting time, radiation treatment time and OTT, tumor- and therapy-related parameters (T-, N-, R-status, grading, tumor site, surgical technique, and postoperative hemoglobin < 12 g/dl) with potential impact on the endpoints were investigated in the univariate analysis (Kaplan-Meier log-rank test). Individual parameters with a significant impact (p = 0.05) were subjected to a multivariate Cox regression analysis. RESULTS: Besides a postoperative hemoglobin value < 12 g/dl, in the univariate analysis an OTT >/= 105 days negatively influenced all endpoints, as well as a radiation treatment time >/= 60 days. On multivariate Cox regression analysis, postoperative hemoglobin < 12 g/dl and an OTT >/= 105 days were identified as independent negative prognostic factors for all endpoints. CONCLUSION: The waiting time should be managed according to the ASARA (as short as reasonably achievable) recommendation, radiation treatment should not be protracted exceeding an overall treatment of 105 days. Generally, time parameters should be routinely included in the standard tumor documentation, thus facilitating further evaluation of these prognostically relevant factors.     

Lack of a correlation between γH2AX foci kinetics in lymphocytes and the severity of acute normal tissue reactions during IMRT treatment for head and neck cancer

Purpose:?To investigate the phosphorylated histone H2A isoform X (γH2AX) foci kinetics as an indicator for the development of acute normal tissue complications during Intensity-Modulated Radiotherapy (IMRT) for head and neck cancer (HNC) patients.

Materials and methods:?Microscopic scoring of the γH2AX foci was used to evaluate the DNA-double-strand-break repair capacity in from Ataxia-Telangiectasia (A-T) patients derived lymphoblastoid cell lines (LCL) and T-lymphocytes isolated from 31 IMRT treated HNC patients. Cells were irradiated in vitro with 0.5 Gy given at high-dose-rate (HDR) and examined at several times up to 24?h after irradiation. The patients were subdivided in three groups showing mild, moderate and severe acute normal tissue complications based on their Common Toxicity Criteria grades for dysphagia, mucositis and dermatitis during the radiotherapy course.

Results:?For the ATM (Ataxia-Telangiectasia-Mutated) defective LCL, a lower number of radiation-induced foci and a somewhat less efficient repair capacity was observed. No correlation was found between the γH2AX foci kinetics pattern and the risk for acute normal tissue complications among the three patient subgroups.

Conclusions:?Scoring of γH2AX foci after in vitro irradiation of isolated T-lymphocytes of HNC patients cannot be applied to predict for the development of acute normal tissue complications.     

Thermographic changes following preoperative radiotherapy in head and neck cancer.

Thermography was used to assess vascular changes during and after head and neck irradiation in an attempt to predict the optimum time for surgery for patients receiving preoperative radiotherapy. Thermography is performed every one or two weeks throughout treatment and at longer periods after treatment. Eight of the 16 patients studied has an initial decrease in temperature during the first two weeks. The maximum increase was observed during the fifth week after receiving 5,000 rads. Return to pretreatment temperature levels was a gradual process, occurring between three and six weeks after completion of radiotherapy.     

Significance of p16 expression in head and neck cancer patients treated with radiotherapy and cetuximab

Background

HPV-infection, p16 positivity, and EGFR expression have been correlated with favorable responses of head and neck cancer patients treated with radiotherapy (RT) with or without chemotherapy. However, a possible correlation of HPV/p16 and EGFR status on the effect of RT in combination with cetuximab has not been sufficiently investigated.

Materials and methods

We analyzed tumor samples for p16 and EGFR expression and correlated these variables with treatment outcome. Cox-proportional-hazard regression models were applied to compare the risk of death among patients stratified according to risk factors. Survival was estimated by the Kaplan–Meier method. Results were compared with an institutional historical control group treated without cetuximab and with published data.

Results

Expression of p16 was predominantly found in oropharyngeal squamous cell cancer patients (OPSCC; 36.6?% positivity; 92?% of all cases), while EGFR was expressed at high levels in all tumor subsites (82?%). p16 expression was associated with improved overall survival in irradiated OPSCC patients (2-year overall survival of 80?% in p16-positive vs. 33?% overall survival in p16-negative patients). In a multivariable analysis covering all tumor sites, nodal stage (>?N2a vs. ≤?N2a) and tumor site (OPSSC vs. non-OPSCC) had an impact on overall survival.

Conclusion

Our results show that p16 positivity is associated with a favorable outcome in OPSCC patients treated with RT and cetuximab.     

A randomised clinical trial to contrast radiotherapy with radiotherapy and methotrexate given synchronously in head and neck cancer

Three hundred and thirteen patients with squamous cell cancer of the head and neck were entered in a randomised clinical trial to determine whether the addition of methotrexate during the course of irradiation improved the rate of primary control and subsequent survival. The overall primary control (P = 0.016) and survival (P = 0.075) for the patients receiving methotrexate was better than the patients treated by radiotherapy alone. The improvement in primary control (P = 0.0019) and survival (P = 0.0089) in patients with oropharyngeal cancers who had methotrexate in addition to radiotherapy is statistically significant. The treatment was well tolerated and there has been no increase of late morbidity.     

Cardiovascular sequel of neck irradiation in head and neck cancer patients

Purpose: The baroreflex is an important afferent mechanism controlling autonomic functions. As afferent nerves course through the neck, they are susceptible to damage by neck irradiation in head and neck cancer patients. With increased survival of head and neck cancer patients because of improved therapy, the cardiovascular morbidity and mortality in them have become apparent and this is of clinical concern. There are few case reports of baroreflex failure as a chronic sequel to neck irradiation.

Objectives: The present study evaluated the changes in cardio-autonomic tone and postural cardiovascular reflex in neck-irradiated patients.

Methods: Head and neck cancer patients who had received neck irradiation (n?=?15) and healthy controls (n?=?15) were evaluated for heart rate variability with time domain analysis of 5?min ECG recording. Postural cardiovascular reflexes were studied with changes in blood pressure and heart rate in the lying to standing test.

Results: Our results suggest that there is a reduction in overall time domain measures of heart rate variability and weakened postural reflexes in neck-irradiated patients.

Conclusion: Decreased heart rate variability in neck-irradiated patients reflects an independent risk of cardiovascular morbidity. The early detection of cardiovascular impairment in such patients may help healthcare professionals in providing better care. Furthermore, the dose delivered to the carotid sinus should be monitored and restricted.