Cachexia induces head and neck changes in locally advanced oropharyngeal carcinoma during definitive cisplatin and image-guided volumetric-modulated arc radiation therapy

Anatomical change during radiotherapy for head and neck cancer, and its effect on delivered dose to the spinal cord

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A cohort of 133 head & neck cancer patients treated with TomoTherapy was examined.

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Differences between planned and delivered maximum spinal cord dose were small.

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Substantial weight loss and anatomical change during treatment was observed.

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No link between weight loss or anatomical change, and dose differences was seen.

Background and purpose

The impact of weight loss and anatomical change during head and neck (H&N) radiotherapy on spinal cord dosimetry is poorly understood, limiting evidence-based adaptive management strategies.

Materials and methods

133 H&N patients treated with daily mega-voltage CT image-guidance (MVCT-IG) on TomoTherapy, were selected. Elastix software was used to deform planning scan SC contours to MVCT-IG scans, and accumulate dose. Planned (D_P) and delivered (D_A) spinal cord D_2% (SCD_2%) were compared. Univariate relationships between neck irradiation strategy (unilateral vs bilateral), T-stage, N-stage, weight loss, and changes in lateral separation (LND) and CT slice surface area (SSA) at C1 and the superior thyroid notch (TN), and ΔSCD_2% [(D_A – D_P) D_2%] were examined.

Results

The mean value for (D_A – D_P) D_2% was −0.07 Gy (95%CI −0.28 to 0.14, range −5.7 Gy to 3.8 Gy), and the mean absolute difference between D_P and D_A (independent of difference direction) was 0.9 Gy (95%CI 0.76–1.04 Gy). Neck treatment strategy (p = 0.39) and T-stage (p = 0.56) did not affect ΔSCD_2%. Borderline significance (p = 0.09) was seen for higher N-stage (N2-3) and higher ΔSCD_2%. Mean reductions in anatomical metrics were substantial: weight loss 6.8 kg; C1LND 12.9 mm; C1SSA 12.1 cm²; TNLND 5.3 mm; TNSSA 11.2 cm², but no relationship between weight loss or anatomical change and ΔSCD_2% was observed (all r² < 0.1).

Conclusions

Differences between delivered and planned spinal cord D_2% are small in patients treated with daily IG. Even patients experiencing substantial weight loss or anatomical change during treatment do not require adaptive replanning for spinal cord safety.

Implications of weight loss for cancer patients receiving radiotherapy

PURPOSE OF REVIEW

Cancer-associated weight loss is a common comorbid condition best described among patients with advanced malignancy receiving systemic therapy, but its relationship to patients undergoing radiation treatment is less well described. We review the interaction between cancer-associated weight loss and radiation treatment as well as its prognostic significance.

RECENT FINDINGS

Multiple studies demonstrate a consistent detrimental effect of cancer-associated weight loss either existing prior to treatment or developing during radiotherapy. Emerging data suggest cancer-associated weight loss independently contributes to an aggressive malignant phenotype rather than simply reflecting a consequence of disease. Novel therapies are urgently needed to address the unmet burden of cancer-associated weight loss.

SUMMARY

Consideration of cancer-associated weight loss is important among patients receiving radiotherapy. Further study will further characterize the relationship and identify targetable biologic mechanisms of cancer cachexia.

The Impact of Skeletal Muscle Depletion on Head and Neck Squamous Cell Carcinoma

BACKGROUND

Skeletal muscle depletion and sarcopenia have been reported as poor prognostic factors for several types of cancer. The aim of this study was to investigate the prognostic impact of skeletal muscle depletion and sarcopenia on the outcomes in head and neck cancer patients.

METHODS

Patients with head and neck squamous cell carcinoma (HNSCC) treated from January 2013 to June 2014 were included in this study. The pretreatment cross-sectional area of skeletal muscle at the third lumbar vertebra (L3) was measured by computed tomography image analysis using the ImageJ software. L3 skeletal muscle index (SMI) and fat-free mass (FFM) were calculated.

RESULTS

Eighty-five patients with HNSCC were included. The cut-off value of sarcopenia was set at SMI <46.7 cm2/m2 (males) and 30.3 cm2/m2 (females). The cut-off value of FFM was set at 42.3 kg (males) and 30.6 kg (females). Patients with a low SMI (sarcopenia) and low FFM had a significantly poorer prognosis than others, especially those who received definitive radiotherapy. Sarcopenia and low FFM are independent factors for poor prognosis in patients with HNSCC.

CONCLUSION

The skeletal muscle area at L3 should be calculated when considering treatment options for head and neck cancer.

The Older Adult With Locoregionally Advanced Head and Neck Squamous Cell Carcinoma: Knowledge Gaps and Future Direction in Assessment and Treatment

Older adults with head and neck squamous cell carcinoma (HNSCC) pose unique treatment and supportive care challenges to oncologists and other cancer care providers. The majority of patients with HNSCC present with locoregionally advanced disease, for which combined-modality treatment integrating chemotherapy and radiation therapy is often necessary to maximize tumor control. However, applying these approaches to an older population with concomitant comorbidities and a higher risk of functional impairments remains challenging and is exacerbated by the paucity of studies involving older adults. The purpose of this article is to identify knowledge gaps in the evaluation and management of older adults with HNSCC-particularly those undergoing concurrent chemoradiation therapy-and their caregivers through a review of the literature conducted by clinicians, researchers, and patient advocates. The findings highlight the importance of a geriatric assessment and the therapeutic paradigms and challenges relevant to this population. Furthermore, we identify the need for additional research and interventions related to key supportive care issues that arise during and after treatment in older adults with locoregionally advanced HNSCC. On the basis of our findings, we prioritize these issues to guide future patient-oriented research endeavors to address these knowledge gaps and thus better serve this growing patient population.