Impact of Endogenous and Exogenous Factors on Radiation Sequelae. In: Dunst J, Sauer R, editors. Late Sequelae in Oncology. Berlin: Springer Berlin Heidelberg; 1995. pp. 3-12. [DOI: 10.1007/978-3-642-46794-3_1]

Improving Patients' Life Quality after Radiotherapy Treatment by Predicting Late Toxicities

Personalized treatment and precision medicine have become the new standard of care in oncology and radiotherapy. Because treatment outcomes have considerably improved over the last few years, permanent side-effects are becoming an increasingly significant issue for cancer survivors. Five to ten percent of patients will develop severe late toxicity after radiotherapy. Identifying these patients before treatment start would allow for treatment adaptation to minimize definitive side effects that could impair their long-term quality of life. Over the last decades, several tests and biomarkers have been developed to identify these patients. However, out of these, only the Radiation-Induced Lymphocyte Apoptosis (RILA) assay has been prospectively validated in multi-center cohorts. This test, based on a simple blood draught, has been shown to be correlated with late radiation-induced toxicity in breast, prostate, cervical and head and neck cancer. It could therefore greatly improve decision making in precision radiation oncology. This literature review summarizes the development and bases of this assay, as well as its clinical results and compares its results to the other available assays.

A literature-based meta-analysis of clinical risk factors for development of radiation induced pneumonitis

INTRODUCTION

The risk of developing side effects after radiotherapy is not only dependent on radiation dose, but may also be affected by patient-related risk factors. Here we perform a literature-based meta-analysis to estimate the effect of various clinical risk factors on the incidence of symptomatic radiation pneumonitis (RP).

MATERIAL AND METHODS

A systematic review of English language articles in the Pubmed, Embase and Cochrane controlled trials registers. Studies with the mesh term "radiation pneumonitis" or the search term "radiation pneumonitis" were included. Additional studies were identified by manual searching of the references. Studies reporting crude incidence or odds ratios (OR) for radiation pneumonitis vs. age, disease location, smoking status, chemotherapy schedule or comorbidity were included. A systematic overview (meta-analysis) was conducted to synthesize data across multiple studies.

RESULTS

Significant risk factors for RP were: older age (OR = 1.7, p < 0.0001); disease located in mid-lower lung (OR = 1.9, p = 0.002); presence of comorbidity (OR = 2.3, p = 0.007). Ongoing smoking was found to protect against RP (OR = 0.6, p = 0.008). History of smoking tended to protect against RP (OR = 0.7, p = 0.06). Sequential (rather than concomitant) chemotherapy scheduling (OR = 1.6, p = 0.01) increased RP risk, but treatment intensity and patients selection are likely confounders.

CONCLUSION

This systematic overview revealed several clinical risk factors for RP that have not been unambiguously identified in the literature. These risk factors should be considered when defining dose-volume constraints for radiation treatment plan optimization.

Reduction of radiation pneumonitis by V20-constraints in breast cancer

Introduction

Adjuvant local-regional radiotherapy (LRRT) is routinely recommended for breast cancer patients. It is well known being related to pulmonary side-effects. We studied post-RT radiological changes on X-ray and CT, and correlated the findings with Quality of Life (QoL), common dosimetric factors and co-variates. The results were compared with a previously reported cohort of 137 irradiated women.

Methods

88 women underwent chest X-ray and CT pre-and 4-5 months after 3-D planned LRRT, minimizing the dose to the ipsilateral lung to V₂₀ < 30%. The lung field was divided into 3 regions and the development of post-RT density changes were graded (0-3). Patients with radiological changes were compared with non-responders. Clinical symptoms were registered and data on patient and treatment related co-variates were gathered prospectively. The ipsilateral lung dosimetric factors V₁₃, V₂₀, V₃₀ and mean dose were calculated and QoL was assessed before and 4 months after RT.

Results

The use of dose-volume constraints significally reduced moderate-severe radiological changes on chest X-ray compared with our earlier study (Chi square trend test: p < 0.001). Symptomatic pneumonitis was also rare in the present study. No agreement was found between CT and chest X-ray as diagnostic tools for post-RT pneumonitis. V₁₃ correlated independently with radiological changes on CT (logistic regression: p = 0.04; ROC area: 0.7). The Co-variates smoking habits, age, chemotherapy, endocrine or trastuzumab therapy did not influence the outcome on multivariate analysis. QoL changes in physical function, i.e. fatigue, dyspnoea were not detected but there was a trend for a worse recovery after chemotherapy in patients with high V₁₃ (Spearman Rank Correlation: p < 0.05).

Conclusions

The use of dose-volume constraints significantly reduced post-RT radiological changes on chest X-ray in LRRT for BC. The lung changes on CT were also generally limited when we used this strategy and was not always picked up on chest X-ray. Variation in V₁₃ alone was correlated with occurrence of lung changes on CT.

[The therapeutic management of radiogenic oral mucositis]

BACKGROUND

Acute reactions of oral mucosa are a frequent side effect of radiotherapy, which often necessitates interruption of the treatment. Marked proliferation of tumor stem cells during treatment interruptions may occur in squamous cell carcinomata, which represent the majority of tumors in the head and neck area. Hence a fatal consequence of treatment breaks may be a significant decrease in tumor cure rates. Furthermore, marked acute responses frequently result in increased late sequelae ("consequential damage"). Therefore, amelioration of the mucosal response aiming at avoiding treatment breaks and at reduction of late reactions could definitely increase the therapeutic success of radiation treatment.

PATIENTS AND METHOD

Various possibilities for the therapeutic management of radiation-induced oral mucositis with a symptomatic or radio- and epithelial biological background are summarized and presented systematically.

RESULTS

A variety of prophylactic and therapeutic methods have been proposed for the management of acute radiation reactions of the oral mucosa. Frequently, their efficacy has been established for chemotherapy or in combination with other immunosuppressive treatments. Hence, systematical rather than local effects have to be considered.

CONCLUSIONS

In general, prophylaxis of oral mucositis is mainly based on dental restoration or edentation, in combination with frequent oral hygienic measures after the meals and with antiseptic mouthwashes. Intensive personal care is recommended. The necessity of a percutaneous endoscopic gastrostoma is dependent on the status of the patient and on size and localization of the treatment area, i.e. the impairment of food uptake which is to be expected. Therapeutic intervention is restricted to local or systemic treatment of pain and local application of antimycotics and antibiotics.

Skin treatment with bepanthen cream versus no cream during radiotherapy--a randomized controlled trial

In several radiotherapy departments, dexpanthenol cream (Bepanthen 'Roche') has been used extensively to ameliorate acute radiotherapy skin reactions. The evidence base for this practice is obscure as no randomized trials have been performed. In the present clinical prospective study of 86 patients we have compared Bepanthen cream with no topical ointment at all. The cream was applied on randomly selected parts of treatment fields in laryngeal and breast cancer patients, and so each patient acted as his own control. Seven patients were withdrawn from analysis. Scoring of skin reactions in 16 laryngeal and 63 breast cancer patients was performed without knowledge of which area that had been given cream or not. Endpoints were a modified skin reaction grading according to EORTC/RTOG, and itching/pain in treated fields. The study did not indicate any clinically important benefits of using Bepanthen cream for ameliorating radiogenic skin reactions under the conditions applied.