Fatigue during chemoradiotherapy for nasopharyngeal cancer and its relationship to radiation dose distribution in the brain

The association analysis between fatigue and body composition loss in patients with nasopharyngeal carcinoma during radiotherapy: An observational longitudinal study

PURPOSE

This study aimed to reveal the association of fatigue with weekly changes in the body composition in patients with nasopharyngeal carcinoma (NPC) and identified the independent strength.

METHODS

Four body composition indexes and fatigue were assessed before treatment (T0, baseline) and once a week throughout radiotherapy (T1-T7). Generalized additive mixed models (GAMMs) were used to explore the trajectories and longitudinal relationships of fatigue and weekly changes in body composition. The marginal structural model (MSM) was used to control the effect of depression and anxiety.

RESULTS

The trajectories of fatigue in 105 participants reached a peak in the fifth week, and changes in body composition started appearing from the second week. Four body composition indexes, weight, body mass index (BMI), body fat rate, and lean body weight loss weekly were positively associated with fatigue. High magnitude of effects was revealed when anxiety and depression were controlled as time-dependent confounders. The positive associations with fatigue were manifested in patients aged >53 years, those with senior high and above education, no drinking, >5000 Y/month of family inflow, ≥ stage III, or those receiving a dose of ≥70 Gy, ≥3 cycles of induced chemotherapy, and ≤1 cycle of concurrent chemotherapy.

CONCLUSIONS

Loss of weight, BMI, body fat rate, and lean body weight could be used to independently evaluate the development of fatigue in patients with NPC during radiotherapy. Positive associations between fatigue and weekly body composition loss were found in patients with certain characteristics.

Fatigue following head and neck cancer radiotherapy: a systematic review of dose correlates

INTRODUCTIONS

Radical radiotherapy (RT) is the cornerstone of Head and Neck (H&N) cancer treatment, but it often leads to fatigue due to irradiation of brain structures, impacting patient quality of life.

OBJECTIVE

This study aimed to systematically investigate the dose correlates of fatigue after H&N RT in brain structures.

METHODS

The systematic review included studies that examined the correlation between fatigue outcomes in H&N cancer patients undergoing RT at different time intervals and brain structures. PubMed, Scopus, and WOS databases were used in the systematic review. A methodological quality assessment of the included studies was conducted following the PRISMA guidelines. After RT, the cohort of H&N cancer patients was analyzed for dose correlations with brain structures and substructures, such as the posterior fossa, brainstem, cerebellum, pituitary gland, medulla, and basal ganglia.

RESULT

Thirteen studies meeting the inclusion criteria were identified in the search. These studies evaluated the correlation between fatigue and RT dose following H&N RT. The RT dose ranged from 40 Gy to 70 Gy. Most of the studies indicated a correlation between the trajectory of fatigue and the dose effect, with higher levels of fatigue associated with increasing doses. Furthermore, five studies found that acute and late fatigue was associated with dose volume in specific brain structures, such as the brain stem, posterior fossa, cerebellum, pituitary gland, hippocampus, and basal ganglia.

CONCLUSION

Fatigue in H&N RT patients is related to the radiation dose received in specific brain areas, particularly in the posterior fossa, brain stem, cerebellum, pituitary gland, medulla, and basal ganglia. Dose reduction in these areas may help alleviate fatigue. Monitoring fatigue in high-risk patients after radiation therapy could be beneficial, especially for those experiencing late fatigue.

Chronic fatigue in long-term survivors of head and neck cancer treated with radiotherapy

BACKGROUND

There is lack of evidence on chronic fatigue (CF) following radiotherapy (RT) in survivors of head and neck cancer (HNC). We aimed to compare CF in HNC survivors > 5 years post-RT with a reference population and investigate factors associated with CF and the possible impact of CF on health-related quality of life (HRQoL).

MATERIAL AND METHODS

In this cross-sectional study we included HNC survivors treated in 2007-2013. Participants filled in patient-reported outcome measures and attended a one-day examination. CF was measured with the Fatigue Questionnaire and compared with a matched reference population using t-tests and Cohen's effect size. Associations between CF, clinical and RT-related factors were investigated using logistic regression. HRQoL was measured with the EORTC Quality of Life core questionnaire.

RESULTS

The median age of the 227 HNC survivors was 65 years and median time to follow-up was 8.5 years post-RT. CF was twice more prevalent in HNC survivors compared to a reference population. In multivariable analyses, female sex (OR 3.39, 95 % CI 1.82-6.31), comorbidity (OR 2.17, 95 % CI 1.20-3.94) and treatment with intensity-modulated RT (OR 2.13, 95 % CI 1.16-3.91) were associated with CF, while RT dose parameters were not. Survivors with CF compared to those without, had significantly worse HRQoL.

CONCLUSIONS

CF in HNC survivors is particularly important for female patients, while specific factors associated with RT appear not to play a role. The high CF prevalence in long-term HNC survivors associated with impaired HRQoL is important information beneficial for clinicians and patients to improve patient follow-up.

Could nutrition status predict fatigue one week before in patients with nasopharynx cancer undergoing radiotherapy?

BACKGROUND

Patients with nasopharyngeal carcinoma (NPC) undergoing radiotherapy experience significant fatigue, which is frequently underestimated due to the lack of objective indicators for its evaluation. This study aimed to explore the longitudinal association between fatigue and nutrition status 1 week in advance.

METHODS

From January 2021 to June 2022, a total of 105 NPC patients who received intensity-modulated radiation therapy were enrolled in the observational longitudinal study. The significant outcomes, including the Piper Fatigue Scale-12 (PFS-12), the Scored Patient-Generated Subjective Global Assessment (PG-SGA), four body composition indices, and the Hospital Anxiety and Depression Scale (HADS), were assessed weekly from pre-treatment until the completion of radiotherapy (T0-T7) to explore their relationship.

RESULTS

The trajectories of PFS-12 and all dimensions for 105 participants reached a peak during the fifth week. Sensory fatigue consistently received the highest scores (T0 = 1.60 ± 2.20, T5 = 6.15 ± 1.57), whereas behavior fatigue exhibited the fastest increase over time (T0 = 1.11 ± 1.86, T5 = 5.47 ± 1.70). Higher PG-SGA scores were found to be weakly explainable for aggravating fatigue (β = 0.02 ~ 0.04). Unlike generalized additive mixed models, marginal structural models (MSM) produced larger effect values (β = 0.12 ~ 0.21). Additionally, body composition indices showed weakly negative relationships with fatigue in MSMs one week in advance.

CONCLUSIONS

The PG-SGA may be a more accurate predictor of future-week fatigue than individual body composition indicators, particularly when HADS is controlled for as a time-dependent confounder.

Understanding the Radiation Dose Variability in Nasopharyngeal Cancer: An Organs-at-Risk Approach

Objective This study aims to thoroughly assess the radiation dose distribution to critical organs in patients with nasopharyngeal carcinoma, focusing on the correlation between the radiation dosages for the various organs at risk (OARs) in nasopharyngeal cancer patients. Methods We meticulously analysed a dataset comprising 38 nasopharyngeal carcinoma patients, focusing on radiation dosages measured in Gray (Gy) and volumetric data in cubic centimetres (cc) of critical organs, including the lens, brainstem, spinal cord, optic nerve, optic chiasm, and cochlea. A detailed exploratory data analysis approach encompassed univariate, bivariate, and multivariate techniques. Results Our analysis revealed several key findings. The mean and median values across various dose measurements were closely aligned, indicating symmetrical distributions with minimal skewness. The histograms further corroborated this, showing evenly distributed dose values across different anatomical regions. The correlation matrix highlighted varying degrees of interrelationships between the doses, with some showing strong correlations while others exhibited minimal or no correlation. The 3D scatter plot provided a view of the multi-dimensional dose relationships, with a specific focus on the spinal cord, lens, and brainstem doses. The bivariate scatter plots revealed symmetrical distributions between the right and left lens doses and more complex relationships involving the brainstem and spinal cord, illustrating the intricacies of dose distribution in radiation therapy. Conclusion Our findings reveal distinct radiation exposure patterns to OARs of nasopharyngeal carcinoma. This research emphasises the need for tailored radiation therapy planning to achieve optimal clinical outcomes while safeguarding vital organs.

Measuring out-of-field dose to the hippocampus in common radiotherapy indications

BACKGROUND

The high susceptibility of the hippocampus region to radiation injury is likely the causal factor of neurocognitive dysfunctions after exposure to ionizing radiation. Repetitive exposures with even low doses have been shown to impact adult neurogenesis and induce neuroinflammation. We address the question whether the out-of-field doses during radiotherapy of common tumour entities may pose a risk for the neuronal stem cell compartment in the hippocampus.

METHODS

The dose to the hippocampus was determined for a single fraction according to different treatment plans for the selected tumor entities: Point dose measurements were performed in an anthropomorphic Alderson phantom and the out-of-field dose to the hippocampus was measured using thermoluminescence dosimeters.

RESULTS

For carcinomas in the head and neck region the dose exposure to the hippocampal region for a single fraction ranged from to 37.4 to 154.8 mGy. The hippocampal dose was clearly different for naso-, oro- and hypopharynx, with maximal values for nasopharynx carcinoma. In contrast, hippocampal dose levels for breast and prostate cancer ranged between 2.7 and 4.1 mGy, and therefore significantly exceeded the background irradiation level.

CONCLUSION

The mean dose to hippocampus for treatment of carcinomas in the head and neck region is high enough to reduce neurocognitive functions. In addition, care must be taken regarding the out of field doses. The mean dose is mainly related to scattering effects, as is confirmed by the data from breast or prostate treatments, with a very different geometrical set-up but similar dosimetric results.

Comprehensive and clinically accurate head and neck cancer organs-at-risk delineation on a multi-institutional study

Accurate organ-at-risk (OAR) segmentation is critical to reduce radiotherapy complications. Consensus guidelines recommend delineating over 40 OARs in the head-and-neck (H&N). However, prohibitive labor costs cause most institutions to delineate a substantially smaller subset of OARs, neglecting the dose distributions of other OARs. Here, we present an automated and highly effective stratified OAR segmentation (SOARS) system using deep learning that precisely delineates a comprehensive set of 42 H&N OARs. We train SOARS using 176 patients from an internal institution and independently evaluate it on 1327 external patients across six different institutions. It consistently outperforms other state-of-the-art methods by at least 3-5% in Dice score for each institutional evaluation (up to 36% relative distance error reduction). Crucially, multi-user studies demonstrate that 98% of SOARS predictions need only minor or no revisions to achieve clinical acceptance (reducing workloads by 90%). Moreover, segmentation and dosimetric accuracy are within or smaller than the inter-user variation.

Fatigue in head and neck cancer patients treated with radiotherapy: a prospective study of patient-reported outcomes and their association with radiation dose to the cerebellum

Purpose

Although fatigue is a known side effect in patients with head and neck cancer (HNC) receiving radiation therapy, knowledge regarding long-term fatigue and dose-response relationships to organs at risk is scarce. The aim of this prospective study was to analyze patient-reported fatigue in patients with HNC receiving radiation therapy and to explore any possible association with organ-at-risk doses.

Methods and Materials

Patients with HNC referred for curative radiation therapy were eligible for inclusion in the study. To assess patient-reported fatigue, quality of life questionnaires (European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-FA12) were distributed before treatment and 1, 3, 6, 12, 24, and 60 months after the start of treatment. Mean dose (D_mean) and near maximum dose (D2%) of the cerebellum and brain stem were evaluated in relation to baseline-adjusted fatigue scores at 3 months.

Results

One hundred twenty-six patients treated with intensity modulated radiation therapy between 2008 and 2010 were available for final analysis. Female sex and age <60 years were associated with higher fatigue at baseline, whereas patients also treated with chemotherapy had reduced physical and emotional fatigue at 6 months. Physical fatigue (QLQ-FA12 scale) increased from baseline up to 3 months (29 vs 59; P < .0001) but showed no difference compared with baseline from 1 to 5 years. Emotional fatigue was significantly lower at 5 years compared with baseline (14 vs 28; P < .0001). Patients with cerebellum D_mean > 3.5 Gy had higher mean physical fatigue scores at 3 months (38 vs 27; P = .036).

Conclusions

Although there is a significant increase in fatigue scores for patients with HNC up to 1 year after radiation therapy, this study showed a return to baseline levels at 5 years. A possible association was found between physical fatigue and a higher mean dose to the cerebellum.

Under-recognized toxicities of cranial irradiation

Cranial irradiation of primary or metastatic lesions is frequent, historically with 3D-conformal radiation therapy and now with stereotactic radiosurgery and intensity modulation. Evolution of radiotherapy technique is concomitant to systemic treatment evolution permitting long time survival. Thus, physicians have to face underestimated toxicities on long-survivor patients and unknown toxicities from combination of cranial radiotherapy to new therapeutics as targeted therapies and immunotherapies. This article proposes to develop these toxicities, without being exhaustive, to allow a better apprehension of cranial irradiation in current context.

Independent external validation using the EORTC HNCG-ROG 1219 DAHANCA trial data of NTCP models for acute oral mucositis

PURPOSE

To externally validate previously published Normal Tissue Complication Probability (NTCP) models developed by separate teams for grade 3 oral mucositis (g3OM).

MATERIALS AND METHODS

Two models were validated: a logistic model, based on 144 head and neck cancer (HNC) patients receiving induction chemotherapy followed by chemo-IMRT; a multivariable logistic model for prediction of g3OM for 253 patients receiving radical treatment for the head and neck squamous cell carcinoma (HNSCC). The EORTC HNCG-ROG 1219 DAHANCA trial dataset, consisting of 169 patients was used as the validation cohort. This cohort was treated with accelerated fractionated chemo-IMRT, with/without the hypoxic radiosensitizer Nimorazole for HNSCC. External validity was assessed using the scaled Brier score. Calibration was assessed in terms of calibration curves as well as measures of mean and weak calibration. Hosmer-Lemeshow was used for goodness-of-fit test. Discrimination was calculated using the area under the receiver operating curve (AUC-ROC).

RESULTS

The prevalence of g3OM in the validation cohort (35.5%) was similar to that of two development cohorts, i.e. 38.7% and 31.9% for Bhide logistic and Otter multivariable logistic models respectively. The scaled Brier scores showed good overall model performance. Perfect calibration was observed in the prevalence range of 20% to 40%. AUC-ROC was acceptable in external validation (0.67). The Hosmer-Lemeshow test showed good agreement between predicted and observed outcomes for two models.

CONCLUSION

The NTCP models were validated and lead to valid predictions in a wide range of diverse treatment techniques and patient characteristics, also when Nimorazole is added as hypoxic radiosensitizer.

Sexual satisfaction in nasopharyngeal carcinoma survivors: Rates and determinants

OBJECTIVES

Sexual health problems have been identified as an unmet need in head and neck cancer (HNC) survivors. In particular, little is known about such outcomes in survivors of nasopharyngeal cancer (NPC).

MATERIALS AND METHODS

A cross-sectional study of NPC survivors with ≥4y follow-up was undertaken. Sexual satisfaction was assessed using the optional "I am satisfied with my sex life" item of the FACT-H&N. Other patient-reported outcomes measures were also captured including fatigue (FACIT-F), HNC symptom burden (MDASI-HN), emotional distress (HADS) and frontal function (FrSBE). Univariate and multivariate analyses were performed to determine factors influencing sexual satisfaction.

RESULTS

The sexual satisfaction item was answered by 85/103 (83%) enrollees. Female (p < 0.001) and non-partnered (p = 0.0045) patients were more likely to abstain from answering. The distribution of responses were: "very much" (26%), "quite a bit" (21%), "somewhat" (20%), "a little bit" (13%) and "not at all" (20%). Sexual satisfaction was associated with multiple patient-reported measures on univariate analysis, including quality of life, fatigue, a priori selected HNC symptoms (pain, taste), emotional distress, frontal lobe function, body image and relationship strength. On multivariate analysis, only relationship strength and emotional distress remained significant. Sociodemographic factors (age, sex, marital status) and other selected orofacial toxicities were not significant.

CONCLUSIONS

Nearly half (47%) of our sample reported being in the higher satisfaction range. While reassuring in the context of comparative population level data, a number of factors including toxicity, psychological and social factors were associated with sexual satisfaction responses. Prospective evaluation of this unmet need is required.

Quality of Life, Toxicity and Unmet Needs in Nasopharyngeal Cancer Survivors

Concerted research efforts over the last three decades have resulted in improved survival and outcomes for patients diagnosed with nasopharyngeal carcinoma (NPC). The evolution of radiotherapy techniques has facilitated improved dose delivery to target volumes while reducing dose to the surrounding normal tissue, improving both disease control and quality of life (QoL). In parallel, clinical trials focusing on determining the optimal systemic therapy to use in conjunction with radiotherapy have been largely successful, resulting in improved locoregional, and distant control. As a consequence, neoadjuvant chemotherapy (NACT) prior to definitive chemoradiotherapy has recently emerged as the preferred standard for patients with locally advanced NPC. Two of the major challenges in interpreting toxicity and QoL data from the published literature have been the reliance on: (1) clinician rather than patient reported outcomes; and (2) reporting statistical rather than clinical meaningful differences in measures. Despite the lower rates of toxicity that have been achieved with highly conformal radiotherapy techniques, survivors remain at moderate risk of persistent and long-lasting treatment effects, and the development of late radiation toxicities such as hearing loss, cranial neuropathies and cognitive impairment many years after successful treatment can herald a significant decline in QoL. Future approaches to reduce long-term toxicity will rely on: (1) identifying individual patients most likely to benefit from NACT; (2) development of response-adapted radiation strategies following NACT; and (3) anticipated further dose reductions to organs at risk with proton and particle therapy. With increasing numbers of survivors, many in the prime of their adult life, research to identify, and strategies to address the unmet needs of NPC survivors are required. This contemporary review will summarize our current knowledge of long-term toxicity, QoL and unmet needs of this survivorship group.

Prevalence of metastases within the hypothalamic-pituitary area in patients with brain metastases

Aim

To quantify the prevalence of brain metastases involving the hypothalamic-pituitary (HT-P) area.

Introduction

Cognitive impairment and fatigue are common side effects of whole brain irradiation (WBI) comprising the quality of life (QoL) for survivors. While the former is related to radiation-induced hippocampal injury, the latter could be secondary to hormonal disbalance as a consequence of radiation of the HT-P area. Thus, sparing both regions from higher irradiation doses could reduce these sequelae.

Methods

T1 contrast medium enhanced magnetic resonance imaging (MRI) scans of 865 patients with brain metastases (4,280 metastases) were reviewed. HT-P area was individually contoured with a margin of 5 mm in order to evaluate the prevalence of brain metastases in this region.

Results

Involvement of the hypothalamic region was found in 26 patients (involvement rate of 3% for patients and 1% for metastases), involvement of the pituitary gland in 9 patients (1% for patients and < 1% for metastases). Binary logistical regression analysis revealed the presence of > 10 brain metastases as the only factor associated with hypothalamic involvement while no distinct factor was associated with an involvement of the pituitary gland.

Conclusion

The low prevalence of metastases within the HT-P area in patients with brain metastases calls for further studies examining whether sparing of this region might improve patients QoL.

Fatigue in patients with head and neck cancer undergoing radiation therapy: a prospective study

Objective

to identify the frequency of fatigue and domains affected in patients with head and neck cancer undergoing radiation therapy, at the beginning, middle and end of treatment.

Method

longitudinal and prospective study of quasi-experimental design, involving 60 patients with head and neck cancer. It should be highlighted that this article will address only the data of the Control Group. The dependent variables were collected through interview, using the revised Piper Fatigue Scale, which is a multidimensional instrument that assesses global, behavioral, affective and sensory/psychological domains. Data analysis was based on absolute and relative frequencies.

Results

there was a predominance of males, age group between 41-60 years, low level of education and in regular use of alcohol and cigarettes. All domains in the fatigue scale had their scores increased, presenting median values of greater magnitude in Time 2 and Time 3, when compared to the Time 1 values, indicating an increase in fatigue levels during radiation therapy.

Conclusion

fatigue increased in the course of the radiation therapy, having all domains affected. Therefore, its evaluation throughout the treatment is important, as fatigue is a common and debilitating symptom on cancer patients.

Evolution and predictive factors of quality of life in patients undergoing oncologic surgery for head and neck cancer: A prospective multicentric study

OBJECTIVES

The purposes of this study were to assess the evolution of quality of life (QoL) in patients with head and neck squamous cell carcinoma (HNSCC) undergoing oncologic surgery and to determine the predictive factors of post-therapeutic QoL.

METHODS

All HNSCC patients who underwent primary surgery, between 2012 and 2014, were enrolled in this prospective multicentric study. Patients completed the EORTC QLQ-C30 and QLQ-H&N35 questionnaires before surgery and at 6 months after treatment. Predictive factors of post-therapeutic QoL scores were determined.

RESULTS

A total of 200 patients were included in this study. There was no significant deterioration of global QoL and no significant increase in general symptoms between the pre- and post-therapeutic periods, but a significant deterioration in role and social functioning, and an increase of most head and neck symptoms. Tumor stage, tumor site and treatment modalities (type of surgery, adjuvant therapy) were the main predictors of QoL scores. We found a negative correlation between satisfaction with the information received and global QoL score or several functioning scales.

CONCLUSION

HNSCC surgical treatment affects patients QoL mainly by increasing head and neck symptoms, which results in social and role functioning deterioration. These results are of great interest to improve multidisciplinary care of HNSCC patients.

Fatigue following radiation therapy in nasopharyngeal cancer survivors: A dosimetric analysis incorporating patient report and observer rating

PURPOSE

To explore for fatigue-related regions and the radiotherapy (RT) dose-fatigue relationship in nasopharyngeal cancer (NPC) survivors.

METHODS

Eighty disease-free NPC survivors completed the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN) after RT. Fatigue was evaluated by the MDASI-HN fatigue item (MDASI-HN-F) and Common Terminology Criteria for Adverse Events v3.0 (CTC-AE), between 6 and 36 months after RT to determine the presence of chronic fatigue. Skull base MRIs and planning CT/RT dose were retrievable for 56 patients. Dosimetric data were extracted for 10 MRI-defined potential fatigue at-risk structures (FARS): brainstem (BS), pituitary gland (PG), hypothalamus (HT), basal ganglia, internal capsule, pineal gland, sub-thalamic nuclei, thalamus, substantia nigra, and hippocampus (HC). Recursive partitioning analysis (RPA) was used to identify dose-volume effects associated with chronic fatigue.

RESULTS

56 pts formed the cohort. Thirty patients (54%) reported any fatigue per MDASI-HN-F. Thirty-three pts (59%) had any fatigue by CTC-AE. The maximum point doses (Dmax) for PG, BS, HC, and HT were numerically higher in patients with fatigue. Dmax and Dmean of the PG were significantly higher in patients with chronic fatigue, p ≤ 0.01. A dose-volume threshold of PG V52 Gy ≥16% (LogWorth 2.4, AUC 0.7) was identified on RPA, and potential sensitivity to the PG doses was observed in younger patients (<53 years-old).

CONCLUSION

A dose-fatigue relationship was identified for the pituitary gland, both patient-reported and observer ratings. We recommend limiting the Dmax of PG to <54 Gy and V52 Gy to <16%, particularly in young NPC patients, during plan optimization when achievable.

Soluble interleukin-6 receptor mediated fatigue highlights immunological heterogeneity of patients with early breast cancer who undergo radiation therapy

Purpose

This study aimed to explore the associations between dose-volume parameters of localized breast irradiation, longitudinal interleukin-6 soluble receptor (sIL-6R), and leukocyte counts as markers of an immune-mediated response and fatigue as a centrally-driven behavior.

Methods and Materials

This prospective cohort study recruited 100 women who were diagnosed with stage 0-IIIa breast cancer, prescribed 40 Gy in 15 fractions over 3 weeks adjuvant radiation therapy, and had no prior or concurrent chemotherapy. Dose-volume parameters were derived from treatment plans and related to serum sIL-6R concentrations, leukocyte counts, and a validated measure of self-reported fatigue at baseline, after 10 and 15 fractions, and 4 weeks after radiation therapy.

Results

sIL-6R concertation was significantly higher in patients with a total volume of tissue irradiated within the 50% isodose >2040 cm³ (P = .003). When controlling for body mass index, this result only remained significant after treatment. The volume of liver irradiated within the 10% isodose correlated with the sIL-6R concentration during and after radiation therapy (ρ = .3-.4; P = .03-.007). The 38% of the cohort that was classified as fatigued had a higher mean sIL-6sR concentration at all observation points, but the differences were only statistically significant during radiation therapy: Mean (standard deviation [SD]) after 15 fractions for fatigued patients was 47.6 ng/dL (11.2 SD) versus 41.6 ng/dL (11.4 SD) for nonfatigued patients (P = .01). Cohort leukocyte counts and leukocyte subsets decreased consistently from baseline and the values for the fatigued group were 4% lower at baseline and between 7% and 9% lower during and after treatment compared with those of the nonfatigued group but the differences were not statistically significant.

Conclusions

This is the first study to show that localized irradiation induces increased systemic sIL-6R during treatment in participants who reported elevated levels of fatigue before, during, and after treatment. This behavioral response appears to reflect a variation in innate host immunity, which then mediates the cellular and/or psychological stress of radiation therapy.

Practice patterns for the radical treatment of nasopharyngeal cancer by head and neck oncologists in the United Kingdom

OBJECTIVE

Advances in radiation delivery, imaging techniques, and chemotherapy have significantly improved treatment options for non-metastatic nasopharyngeal cancers (NPC). However, their impact on the practice in the United Kingdom (UK), where this tumour is rare, is unknown. This study examined the current attitudes of UK head and neck oncologists to the treatment of NPC.

METHODS

UK head and neck oncologists representing 19/23 cancer networks were sent an invitation email with a personalised link to a web-based survey designed to identify the influence of tumour and nodal staging on current NPC management practices.

RESULTS

26/42 (61%) of clinicians responded. Induction chemotherapy followed by concomitant chemoradiation was the treatment of choice for Stage III (69%) and IVa/b (96%), with cisplatin and 5-fluorouracil combination being the most commonly used induction chemotherapy regimen (88%). 16 centres (61%) used a geometric approach, adding variable margins of 0-10 mm to the gross tumour volume to define their therapeutic dose clinical target volume. 54% of respondents used 3 radiotherapy (RT) prescription doses to treat NPC. Retropharyngeal nodal region irradiation policy was inconsistent, with nearly one-quarter treating the entire group to a radical dose.

CONCLUSION

Significant heterogeneity currently exists in the RT practice of NPC in the UK. A consensus regarding the optimal curative, function-sparing treatment paradigm for NPC is necessary to ensure cancer survivors have satisfactory long-term health-related quality of life. Advances in knowledge: This is the first study to highlight the significant variation in RT practice of NPC in the UK.

Brainstem dose is associated with patient-reported acute fatigue in head and neck cancer radiation therapy

BACKGROUND AND PURPOSE

Radiation (RT) dose to the central nervous system (CNS) has been implicated as a contributor to treatment-related fatigue in head and neck cancer (HNC) patients undergoing radiation therapy (RT). This study evaluates the association of RT dose to CNS structures with patient-reported (PRO) fatigue scores in a population of HNC patients.

MATERIALS AND METHODS

At pre-RT (baseline), 6th week of RT, and 1-month post-RT time points, Multidimensional Fatigue Inventory (MFI-20) scores were prospectively obtained from 124 patients undergoing definitive treatment for HNC. Medulla, pons, midbrain, total brainstem, cerebellum, posterior fossa, and pituitary dosimetry were evaluated using summary statistics and dose-volume histograms, and associations with MFI-20 scores were analyzed.

RESULTS

Maximum dose (Dmax) to the brainstem and medulla was significantly associated with MFI-20 scores at 6th week of RT and 1-month post-RT time points, after controlling for baseline scores (p<0.05). Each 1Gy increase in medulla Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.026), and 0.25 (p=0.037), at the 6th week of RT and 1-month post-RT, respectively. Each 1Gy increase in brainstem Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.027), and 0.25 (p=0.037) at the 6th week of RT, 1-month post-RT, respectively. Statistically significant associations were not found between dosimetry for the other CNS structures and MFI-20 scores.

CONCLUSIONS

In this analysis of PRO fatigue scores from a population of patients undergoing definitive RT for HNC, maximum dose to the brainstem and medulla was associated with a significantly increased risk of acute patient fatigue.

Comparison of intensity modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) and a 3-dimensional conformal parotid gland-sparing radiotherapy (ConPas 3D-CRT) in treatment of nasopharyngeal carcinoma: a mono-institutional experience

AIM

To compare intensity modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) and a 3-dimensional conformal parotid gland-sparing radiotherapy (ConPas 3D-CRT) in treatment of nasopharyngeal carcinoma with regard to outcomes and dose distribution to the planning target volumes (PTVs) and to the organs at risk (OARs).

METHODS

The treatment records of 24 patients with histologically proven carcinoma of the nasopharynx treated with ConPas 3D-CRT or IMRT-SIB technique between May 2009 and December 2016 were assessed.

RESULTS

The mean dose and dose to 50% parotid glands volume as well as the maximal dose to the spinal cord were significantly lower in the IMRT-SIB than in the ConPas 3-CRT group (p < 0.05; p < 0.05; p < 0.01, respectively). IMRT-SIB was also superior in coverage of PTVs. The 3-year overall survival (OS) and disease-free survival (DFS) of patients in the IMRT-SIB and ConPas 3D-CRT groups were 77 and 81% (p = 0.93), 51.9 and 70.7% (p = 0.83), respectively.

CONCLUSION

IMRT-SIB provided additional spearing to parotid glands and spinal cord in comparison to ConPas 3D-CRT technique but without improvement of OS and DFS.

Systematic Review of Normal Tissue Complication Models Relevant to Standard Fractionation Radiation Therapy of the Head and Neck Region Published After the QUANTEC Reports

There has recently been an increasing interest in model-based evaluation and comparison of different treatment options in radiation oncology studies. This is partly driven by the considerable technical advancements in radiation therapy of the last decade, leaving radiation oncologists with a multitude of options to consider. In lieu of randomized trials comparing all of these different treatment options for varying indications, which is unfeasible, treatment evaluations based on normal tissue complication probability (NTCP) models offer a practical alternative. The Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) effort, culminating in a number of reports published in 2010, provided a basis for many of the since-implemented dose-response models and dose-volume constraints and was a key component for model-based treatment evaluations. Given that 7 years have passed since the QUANTEC publications and that patient-reported outcomes have emerged as an important consideration in recent years, an updated summary of the published radiation dose-response literature, which includes a focus on patient-reported quality of life outcomes, is warranted. Here we provide a systematic review of quantitative dose-response models published after January 1, 2010 for endpoints relevant to radiation therapy for head and neck cancer, because these patients are typically at risk for a variety of treatment-induced normal tissue complications.

Cognitive function and patient-reported memory problems after radiotherapy for cancers at the skull base: A cross-sectional survivorship study using the Telephone Interview for Cognitive Status and the MD Anderson Symptom Inventory-Head and Neck Module

BACKGROUND

Using patient-reported and objective assessment tools, we sought to quantify cognitive symptoms and objective cognitive dysfunction in patients irradiated for skull base cancer.

METHODS

Participants were assessed using the Telephone Interview for Cognitive Status (TICS) and the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN), with subsequent analysis.

RESULTS

Of the 122 participants analyzed, the majority (63%) had no frank detectable cognitive impairment by TICS, with frank impairment in 6%. Overall, mean patient-reported problems with memory (MDASI_memory ) was 3.3 (SD ±2.66). On recursive partition analysis, the MDASI_memory cutoff point of ≥5 was associated with detectable cognitive impairment by TICS (logworth 1.69; P = .02), yet no MDASI_memory threshold was associated with unambiguous absence of impairment by TICS.

CONCLUSION

Approximately one third of patients had ambiguous results by TICS assessment, for whom more rigorous testing may be warranted. Moderate to severe levels of patient-reported memory complaints on the MDASI-HN module may have utility as a screening tool for cognitive dysfunction in this population.

Radiation-induced neurocognitive dysfunction in head and neck cancer patients

It might seem odd that a special issue about Gianni Bonadonna would publish a review on radiation-induced neurocognitive dysfunction. Dr. Gianni Bonadonna is considered a pioneer in medical oncology history, mainly due to new and revolutionary treatment approaches proposed in breast cancer and Hodgkin lymphoma. He had an active role in the field of medical oncology, especially through lectures and textbooks. He shared his considerable insight of understanding cancer behavior and evaluating research advances over the years to prevent tumor recurrence and preserve patients from unnecessary toxicity. From a theoretical point of view, this complex vision is valid for all malignancies and can be indirectly shifted to every primary cancer, including head and neck cancer (HNC). During the last decades, multidisciplinary treatment for HNC has improved clinical outcomes but makes acute and late toxicity challenging. This article highlights the main central nervous structures that have a major impact on the development of neurocognitive dysfunction after radiotherapy for HNC. We briefly summarize the specific structure contouring instructions and the dose-volume histogram parameters. The aim is to raise awareness in clinicians in defining normal tissues to optimize radiotherapy regimens.

Strengthened Corticosubcortical Functional Connectivity during Muscle Fatigue

The present study examined functional connectivity (FC) between functional MRI (fMRI) signals of the primary motor cortex (M1) and each of the three subcortical neural structures, cerebellum (CB), basal ganglia (BG), and thalamus (TL), during muscle fatigue using the quantile regression technique. Understanding activation relation between the subcortical structures and the M1 during prolonged motor performance should help delineate how central motor control network modulates acute perturbations at peripheral sensorimotor system such as muscle fatigue. Ten healthy subjects participated in the study and completed a 20-minute intermittent handgrip motor task at 50% of their maximal voluntary contraction (MVC) level. Quantile regression analyses were carried out to compare the FC between the contralateral (left) M1 and CB, BG, and TL in the minimal (beginning 100 s) versus significant (ending 100 s) fatigue stages. Widespread, statistically significant increases in FC were found in bilateral BG, CB, and TL with the left M1 during significant versus minimal fatigue stages. Our results imply that these subcortical nuclei are critical components in the motor control network and actively involved in modulating voluntary muscle fatigue, possibly, by working together with the M1 to strengthen the descending central command to prolong the motor performance.

Induction Chemotherapy Followed by Chemo-intensity-modulated Radiotherapy for Locally Advanced Nasopharyngeal Cancer

AIMS

To determine the toxicity and tumour control rates after chemo-intensity-modulated radiotherapy (chemo-IMRT) for locally advanced nasopharyngeal cancers (LA-NPC).

MATERIALS AND METHODS

Patients with LA-NPC were enrolled in a trial to receive induction chemotherapy followed by parotid-sparing chemo-IMRT. The primary site and involved nodal levels received 65 Gy in 30 fractions and at risk nodal levels received 54 Gy in 30 fractions. Incidence of ≥grade 2 subjective xerostomia was the primary end point. Secondary end points included incidences of acute and late toxicities and survival outcomes.

RESULTS

Forty-two patients with American Joint Committee on Cancer stages II (12%), III (26%) and IV (62%) (World Health Organization subtype: I [5%]; II [40%]; III [55%]) completed treatment between January 2006 and April 2010 with a median follow-up of 32 months. Incidences of ≥grade 2 acute toxicities were: dysphagia 83%; xerostomia 76%; mucositis 97%; pain 76%; fatigue 99% and ototoxicity 12%. At 12 months, ≥grade 2 subjective xerostomia was observed in 31%, ototoxicitiy in 13% and dysphagia in 4%. Two year locoregional control was 86.2% (95% confidence interval: 70.0-94.0) with 2 year progression-free survival at 78.4% (61.4-88.6) and 2 year overall survival at 85.9% (69.3-93.9).

CONCLUSIONS

Chemo-IMRT for LA-NPC is feasible with good survival outcomes. At 1 year, 31% experience ≥grade 2 subjective xerostomia.

Evaluation of the Risk of Grade 3 Oral and Pharyngeal Dysphagia Using Atlas-Based Method and Multivariate Analyses of Individual Patient Dose Distributions

PURPOSE

The study aimed to apply the atlas of complication incidence (ACI) method to patients receiving radical treatment for head and neck squamous cell carcinomas (HNSCC), to generate constraints based on dose-volume histograms (DVHs), and to identify clinical and dosimetric parameters that predict the risk of grade 3 oral mucositis (g3OM) and pharyngeal dysphagia (g3PD).

METHODS AND MATERIALS

Oral and pharyngeal mucosal DVHs were generated for 253 patients who received radiation (RT) or chemoradiation (CRT). They were used to produce ACI for g3OM and g3PD. Multivariate analysis (MVA) of the effect of dosimetry, clinical, and patient-related variables was performed using logistic regression and bootstrapping. Receiver operating curve (ROC) analysis was also performed, and the Youden index was used to find volume constraints that discriminated between volumes that predicted for toxicity.

RESULTS

We derived statistically significant dose-volume constraints for g3OM over the range v28 to v70. Only 3 statistically significant constraints were derived for g3PD v67, v68, and v69. On MVA, mean dose to the oral mucosa predicted for g3OM and concomitant chemotherapy and mean dose to the inferior constrictor (IC) predicted for g3PD.

CONCLUSIONS

We have used the ACI method to evaluate incidences of g3OM and g3PD and ROC analysis to generate constraints to predict g3OM and g3PD derived from entire individual patient DVHs. On MVA, the strongest predictors were radiation dose (for g3OM) and concomitant chemotherapy (for g3PD).

Brain-sparing methods for IMRT of head and neck cancer

PURPOSE

Radical radiotherapy for head and neck cancer (HNC) may deliver significant doses to brain structures. There is evidence that this may cause a decline in neurocognitive function (NCF). Radiation dose to the medial temporal lobes, and particularly to the hippocampi, seems to be critical in determining NCF outcomes. We evaluated the feasibility of two alternative intensity-modulated radiotherapy (IMRT) techniques to generate hippocampus- and brain-sparing HNC treatment plans to preserve NCF.

METHODS AND MATERIALS

A planning study was undertaken for ten patients with HNC whose planning target volume (PTV) included the nasopharynx. Patients had been previously treated using standard (chemo)-IMRT techniques. Bilateral hippocampi were delineated according to the RTOG atlas, on T1w MRI co-registered to the RT planning CT. Hippocampus-sparing plans (HSRT), and whole-brain/hippocampus-sparing fixed-field non-coplanar IMRT (BSRT) plans, were generated. DVHs and dose difference maps were used to compare plans. NTCP calculations for NCF impairment, based on hippocampal dosimetry, were performed for all plans.

RESULTS

Significant reductions in hippocampal doses relative to standard plans were achieved in eight of ten cases for both HSRT and BSRT. EQD2 D40% to bilateral hippocampi was significantly reduced from a mean of 23.5 Gy (range 14.5-35.0) in the standard plans to a mean of 8.6 Gy (4.2-24.7) for HSRT (p = 0.001) and a mean of 9.0 Gy (4.3-17.3) for BSRT (p < 0.001). Both HSRT and BSRT resulted in a significant reduction in doses to the whole brain, brain stem, and cerebellum.

CONCLUSION

We demonstrate that IMRT plans for HNC involving the nasopharynx can be successfully optimised to significantly reduce dose to the bilateral hippocampi and whole brain. The magnitude of the achievable dose reductions results in significant reductions in the probability of radiation-induced NCF decline. These results could readily be translated into a future clinical trial.