Adverse event reporting and developments in radiation biology after normal tissue injury: International Atomic Energy Agency consultation

Potential screening assays for individual radiation sensitivity and susceptibility and their current validation state

Purpose: The workshop on 'Individual Radiosensitivity and Radiosusceptibility' organized by MELODI and CONCERT on Malta in 2018, evaluated the current state of assays to identify sensitive and susceptible subgroups. The authors provide an overview on potential screening assays detecting individuals showing moderate to severe early and late radiation reactions or are at increased risk to develop cancer upon radiation exposure.Conclusion: It is necessary to separate clearly between tissue reactions and stochastic effects such as cancer when comparing the existing literature to validate various test systems. Requirements for the assays are set up. The literature is reviewed for assays that are reliable and robust. Sensitivity and specificity of the assays are regarded and scrutinized for modifying factors. Accuracy of an assay system is required to be more than 90% to balance risks of adverse reactions against risk to fail to cure the cancer. No assay/biomarker is in routine use. Assays that have shown predictive potential for radiosensitivity include SNPs, the RILA assay, and the pATM assay. A tree of risk guideline for radiologists is provided to assist medical treatment decisions. Recommendations for effective research include the setup of common retrospective and prospective cohorts/biobanks to validate current and future tests.

Predictive value of single nucleotide polymorphisms in XRCC1 for radiation-induced normal tissue toxicity

Purpose

X-Ray Repair Cross Complementing 1 (XRCC1) functioning in the base excision repair pathway plays an important role in the repair of DNA single-strand breaks caused by ionizing radiation. The relationship between XRCC1 polymorphisms and the risk of radiation-induced side effects on normal tissues remains controversial. Therefore, we performed a comprehensive meta-analysis to elucidate these associations.

Materials and methods

A systematic literature search was carried out in PubMed, Medline (Ovid), Embase, Web of Science, Cochrane database, and the references of relevant studies. The pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated to evaluate the strength of the association.

Results

A total of 40 studies including 6,682 patients were eventually identified in this meta-analysis. Pooled results suggested that rs25487 Arg399Gln polymorphism significantly increased the risk of acute radiation-induced side effects (OR=1.29, 95% CI: 1.10–1.52, P=0.002), especially acute mucositis (OR=1.91, 95% CI: 1.17–3.11, P=0.01) and acute gastrointestinal and genitourinary toxicity (OR=1.49, 95% CI: 1.04–2.11, P=0.03). Furthermore, patients who received head and neck irradiation with rs25487 Arg399Gln polymorphism were more likely to experience radiotherapy (RT)-induced side effects (OR=1.46, 95% CI: 1.12–1.90, P=0.005). However, no statistically significant correlations were identified between rs25487 polymorphism and any late side effects and other irradiation areas. Likewise, no significant associations were detected between rs25489, rs1799782, or rs3213245 polymorphism and RT-induced toxicity.

Conclusion

Our meta-analysis demonstrated that XRCC1 rs25487 Arg399Gln polymorphism had a significant predictive value and might predict a risk of severely acute RT-induced adverse effects, especially in acute mucositis and acute gastrointestinal and genitourinary toxicity, or in patients with head and neck irradiation. However, large-scale and well-designed studies are required to further evaluate the predictive value of XRCC1 variations on radiation-induced side effects in order to identify radiosensitive patients and predict radiotoxicity.

Restoration of Facial Form and Lip Competence in a Patient with a Midfacial Defect

Squamous cell carcinoma (SCC) of the head and neck can be treated with a combination of modalities. There is an esthetic and functional compromise with midfacial defects secondary to ablative surgery and adjuvant therapies for SCC. Osteoradionecrosis, tissue contracture, and trismus, are all negative side effects of treatment and can impact a patient's function and possibly their nutrition. In this report, we describe a procedure for fabrication of a prosthesis that provides cosmetic improvement and labial competence to maintain caloric intake.

State-of-the-Art Advances in Radiation Biodosimetry for Mass Casualty Events Involving Radiation Exposure

With the possibility of large-scale terrorist attacks around the world, the need for modeling and development of new medical countermeasures for potential future chemical, biological, radiological and nuclear (CBRN) has been well established. Project Bioshield, initiated in 2004, provided a framework to develop and expedite research in the field of CBRN exposures. To respond to large-scale population exposures from a nuclear event or radiation dispersal device (RDD), new methods for determining received dose using biological modeling became necessary. The field of biodosimetry has advanced significantly beyond this original initiative, with expansion into the fields of genomics, proteomics, metabolomics and transcriptomics. Studies are ongoing to evaluate the use of lymphocyte kinetics for dose assessment, as well as the development of field-deployable EPR technology. In addition, expansion of traditional cytogenetic assessment methods through the use of automated platforms and the development of laboratory surge capacity networks have helped to advance our biodefense preparedness. In this review of the latest advances in the field of biodosimetry we evaluate our progress and identify areas that still need to be addressed to achieve true field-deployment readiness.

Quad shot: a short but effective schedule for palliative radiation for head and neck carcinoma

Background:

To evaluate a 2-day course of palliative radiation in patients diagnosed to have inoperable or metastatic head and neck carcinoma.

Aim:

To evaluate the symptom relief and quality of life in these patients after this short course of radiation.

Settings and Design:

A pilot study was conducted in a tertiary care institute in India.

Materials and Methods:

Fifteen patients with stage IV B/C disease, KPS 50-70, were inducted after informed consent. External radiation was given in 2 days, two fractions per day, 6 h apart to a total dose of 14 Gy. Washington University quality of life questionnaire (QOL) was used for assessing QOL before and after radiation. Patients who had more than 50% regression of disease received a second course of similar radiation. All patients were followed up for a mean duration of 6 months.

Statistical Analysis:

The Wilcoxon signed rank test was used to evaluate the difference between the QOL scores before and after treatment.

Results and Conclusions:

Out of these 15 patients, majority (13) were males and the mean age of the patients was 62 years. After the first course, all patients had good symptom relief, improvement in the QOL, and 13 out of 15 had more than 50% objective response. The short duration of the treatment was favored by the outstation patients and their attendants. It may be concluded that this short course of radiation is an effective tool for palliative radiation and merits a larger randomized trial.

Split-course palliative radiotherapy for advanced non-small cell lung cancer

PURPOSE

Palliative chest radiotherapy (RT) for lung malignancies is effective in relieving serious chest symptoms from tumor bleeding or mass effect on major airways, vessels, and nerves. Albeit an important subject, there is a lack of consensus for an optimal palliative RT regimen. We report the outcomes of a split-course palliative chest RT, a frequently used schema at our institution.

METHODS AND MATERIALS

Records of 140 patients treated between 1995 and 2006 were reviewed. Treatment was prescribed to an initial 25 Gy in 10 fractions through anterior-posterior/posterior-anterior beam arrangements. After a 2-week rest period, patients were selected to receive an additional 10 Gy (anterior-posterior/posterior-anterior) followed by off-cord beams to a final dose of 50 to 62.5 Gy. Symptom relief and toxicity during RT and after completion of RT were assessed from clinician notes and patient-reported symptom inventory forms. Second, the impact on survival was assessed.

RESULTS

Symptomatic relief was observed in 52 to 84% of patients with durable palliation in 58%. There were no grade 3 to 5 toxicities. Grades 1 and 2 esophagitis and pneumonitis were observed in 34 and 8% patients, respectively. Median survival was 5 months.

CONCLUSIONS

A majority of patients experienced symptomatic improvement. The built-in 2-week break allowed for selection of patients for high-dose palliative radiation and balanced treatment benefits with potential side effects. Cancer survival was not adversely affected by treatments in this population with mostly advanced disease. This regimen is a viable option for patients who cannot tolerate a protracted, uninterrupted course of treatment.

The impact of radiotherapy late effects on quality of life in gynaecological cancer patients

The aims of this study were to assess changes in quality of life (QoL) scores in relation to radical radiotherapy for gynaecological cancer (before and after treatment up to 3 years), and to identify the effect that late treatment effects have on QoL. This was a prospective study involving 225 gynaecological cancer patients. A QoL instrument (European Organisation for the Research and Treatment of Cancer QLQ-C30) and late treatment effect questionnaire (Late Effects Normal Tissues - Subjective Objective Management Analysis) were completed before and after treatment (immediately after radiotherapy, 6 weeks, 12, 24 and 36 months after treatment). Most patients had acute physical symptoms and impaired functioning immediately after treatment. Levels of fatigue and diarrhoea only returned to those at pre-treatment assessment after 6 weeks. Patients with high treatment toxicity scores had lower global QoL scores. In conclusion, treatment with radiotherapy for gynaecological cancer has a negative effect on QoL, most apparent immediately after treatment. Certain late treatment effects have a negative effect on QoL for at least 2 years after radiotherapy. These treatment effects are centred on symptoms relating to the rectum and bowel, for example, diarrhoea, tenesmus and urgency. Future research will identify specific symptoms resulting from late treatment toxicity that have the greatest effect on QoL; therefore allowing effective management plans to be developed to reduce these symptoms and improve QoL in gynaecological cancer patients.

Long-term morbidity of adjuvant whole abdominal radiotherapy (WART) or chemotherapy for early stage ovarian cancer

The aim of the study was to evaluate long-term toxicity of adjuvant treatment in early stage ovarian cancer survivors. Data from all patients treated in one hospital for early stage ovarian cancer diagnosed between 1980 and 1990 were collected using a structured data form. In 93 FIGO stages I and II patients, cytoreductive and staging surgery was performed; 15 received no adjuvant treatment (controls), 39 whole abdominal radiotherapy (WART) and 39 platin-based chemotherapy. Median age at diagnosis was 54 years (range 21-83 years). During follow-up, 49/93 (53%) patients have died with a median overall survival of 18.4 years (95% CI 12.8-23.9). In both the radiotherapy and the chemotherapy group, 50% of patients reported long-term side-effects (all grades) versus 13% of controls. Two patients in the WART group died from bowel complications. Secondary malignancies were observed in 16 patients. Of all patients alive at the last follow-up, 12/17 (71%) patients treated with radiotherapy and 11/18 (61%) treated with chemotherapy experienced long-term morbidity versus 2/9 (22%) controls (P=0.03).

IN CONCLUSION

Long-term follow-up of early stage ovarian cancer patients showed lasting GI morbidity in the survivors treated with adjuvant radiotherapy, which has therefore become obsolete. Cisplatin-based chemotherapy caused peripheral neuropathy versus virtual absence of problems in the survivors of just surgery, emphasising the need for strict criteria before instigating adjuvant treatment.

Predictive markers for normal tissue reactions: fantasy or reality?

Interpatient heterogeneity in normal tissue reactions varies considerably, yet the genetic determinants and the molecular mechanisms of therapeutic radiation sensitivity remain poorly understood. Predictive assays and markers for normal tissue reactions are still in their infancy, although some progress has been made, particularly, for predicting late toxicity. For instance the T-lymphocyte radiation-induced apoptosis assay was shown to significantly predict differences in late toxicity between individuals and an 18 gene classifier based on radiation-induced expression in subcutaneous fibroblasts has also been identified that differentiated between patients with a high and low risk of radiation-induced fibrosis. However, the technical set-up for gene expression measurements means that this latter assay is unlikely to be introduced soon into a routine clinical setting but has importantly allowed the identification of genes that are involved in the fibrotic process. Serum markers have also been identified that show potential for the prediction of patients who will develop acute and late pulmonary toxicity. Few genetic predictive markers for normal tissue reaction have been identified and validated. Many of the single nucleotide polymorphism association studies have been limited by size and the inclusion of subjects with different kinds of radiation morbidity. International collaboration to assemble well-defined cohorts and technological progress should mean that the identification and validation of such markers using candidate gene approaches and whole genome association studies, which have been successful in other research areas, will make rapid progress.

Effects of treatment intensification on acute local toxicity during radiotherapy for head and neck cancer: prospective observational study validating CTCAE, version 3.0, scoring system

PURPOSE

To quantify the incidence and severity of acute local toxicity in head and neck cancer patients treated with radiotherapy (RT), with or without chemotherapy (CHT), using the Common Terminology Criteria for Adverse Events, version 3.0 (CTCAE v3.0), scoring system.

METHODS AND MATERIALS

Between 2004 and 2006, 149 patients with head and neck cancer treated with RT at our center were prospectively evaluated for local toxicity during treatment. On a weekly basis, patients were monitored and eight toxicity items were recorded according to the CTCAE v3.0 scoring system. Of the 149 patients, 48 (32%) were treated with RT alone (conventional fractionation), 82 (55%) with concomitant CHT and conventional fractionation RT, and 20 (13%) with accelerated-fractionation RT and CHT.

RESULTS

Severe (Grade 3-4) adverse events were recorded in 28% (mucositis), 33% (dysphagia), 40% (pain), and 12% (skin) of patients. Multivariate analysis showed CHT to be the most relevant factor independently predicting for worse toxicity (mucositis, dysphagia, weight loss, salivary changes). In contrast, previous surgery, RT acceleration and older age, female gender, and younger age, respectively, predicted for a worse outcome of mucositis, weight loss, pain, and dermatitis. The T-score method confirmed that conventional RT alone is in the "low-burden" class (T-score = 0.6) and suggests that concurrent CHT and conventional fractionation RT is in the "high-burden" class (T-score = 1.15). Combined CHT and accelerated-fractionation RT had the highest T-score at 1.9.

CONCLUSIONS

The CTCAE v3.0 proved to be a reliable tool to quantify acute toxicity in head and neck cancer patients treated with various treatment intensities. The effect of CHT and RT acceleration on the acute toxicity burden was clinically relevant.

Improving the capture of adverse event data in clinical trials: the role of the International Atomic Energy Agency

PURPOSE

To report meetings of the Applied Radiation Biology and Radiotherapy section of the International Atomic Energy Agency (IAEA), organized to discuss issues surrounding, and develop initiatives to improve, the recording of adverse events (AE) in clinical trials.

METHODS AND MATERIALS

A first meeting was held in Atlanta, GA (October 2004). A second meeting was held in Denver, CO (October 2005) and focused on AE data capture. The National Cancer Institute Common Terminology Criteria for Adverse Events, version 3 (CTCAE) was suggested during the first meeting as the preferred common platform for the collection and reporting of AE data in its clinical trials. The second meeting identified and reviewed the current weaknesses and variations in the capture of AE data, and proposals to improve the quality and consistency of data capture were discussed.

RESULTS

There is heterogeneity in the collection of AE data between both institutions and individual clinicians. The use of multiple scoring systems hampers comparisons of treatment outcomes between centers and trials. There is often insufficient detail on normal tissue treatment effects, which leads to an underestimate of toxicity. Implementation of improved data capture was suggested for one of the ongoing IAEA clinical trials.

CONCLUSIONS

There is a need to compare the quality and completeness of data between institutions and the efficacy of structured/directed vs. traditional passive data collection. Data collection using the CTCAE (with or without a questionnaire) will be investigated in an IAEA multinational trial of radiochemotherapy and high-dose-rate brachytherapy in cervical cancer.