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Peternel M, Jenko A, Peterlin P, Petrovič L, Strojan P, Plavc G. Comparison of conventional and hippocampus-sparing radiotherapy in nasopharyngeal carcinoma: In silico study and systematic review. Clin Transl Radiat Oncol 2024; 46:100751. [PMID: 38425692 PMCID: PMC10900111 DOI: 10.1016/j.ctro.2024.100751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
Background and purpose Radiation-induced damage to the hippocampi can cause cognitive decline. International recommendations for nasopharyngeal cancer (NPC) radiotherapy (RT) lack specific guidelines for protecting the hippocampi. Our study evaluates if hippocampi-sparing (HS) RT in NPC ensures target coverage and meets recommended dose limits for other at-risk organs. Materials and methods In a systematic literature review, we compared hippocampal D40% in conventional and HS RT plans. In an in silico dosimetric study, conventional and HS-VMAT plans were created for each patient, following international recommendations for OAR delineation, dose prioritization and acceptance criteria. We assessed the impact on neurocognitive function using a previously published normal tissue complication probability (NTCP) model. Results In four previous studies (n = 79), researchers reduced D40% hippocampal radiation doses in HS plans compared to conventional RT on average from 24.9 Gy to 12.6 Gy.Among 12 NPC patients included in this in silico study, statistically significant differences between HS and conventional VMAT plans were observed in hippocampal EQD2 Dmax (23.8 vs. 46.4 Gy), Dmin (3.8 vs. 4.6 Gy), Dmean (8.1 vs. 15.1 Gy), and D40% (8.3 vs. 15.8 Gy). PTV coverage and OAR doses were similar, with less homogeneous PTV coverage in HS plans (p = 0.038). This translated to a lower probability of memory decline in HS plans (interquartile range 15.8-29.6 %) compared to conventional plans (33.8-81.1 %) based on the NTCP model (p = 0.002). Conclusion Sparing the hippocampus in NPC RT is safe and feasible. Given the life expectancy of many NPC patients, their cognitive well-being must be paramount in radiotherapy planning.
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Affiliation(s)
- Monika Peternel
- Institute of Oncology, Department of Radiotherapy, Zaloška cesta 2, Ljubljana, Slovenia
| | - Aljaša Jenko
- Institute of Oncology, Department of Radiotherapy, Zaloška cesta 2, Ljubljana, Slovenia
| | - Primož Peterlin
- Institute of Oncology, Department of Radiotherapy, Zaloška cesta 2, Ljubljana, Slovenia
| | - Larisa Petrovič
- Institute of Oncology, Department of Radiotherapy, Zaloška cesta 2, Ljubljana, Slovenia
| | - Primož Strojan
- Institute of Oncology, Department of Radiotherapy, Zaloška cesta 2, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
| | - Gaber Plavc
- Institute of Oncology, Department of Radiotherapy, Zaloška cesta 2, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
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Chow JCH, Ho JCS, Cheung KM, Johnson D, Ip BYM, Beitler JJ, Strojan P, Mäkitie AA, Eisbruch A, Ng SP, Nuyts S, Mendenhall WM, Babighian S, Ferlito A. Neurological complications of modern radiotherapy for head and neck cancer. Radiother Oncol 2024; 194:110200. [PMID: 38438018 DOI: 10.1016/j.radonc.2024.110200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/21/2024] [Accepted: 02/29/2024] [Indexed: 03/06/2024]
Abstract
Radiotherapy is one of the mainstay treatment modalities for the management of non-metastatic head and neck cancer (HNC). Notable improvements in treatment outcomes have been observed in the recent decades. Modern radiotherapy techniques, such as intensity-modulated radiotherapy and charged particle therapy, have significantly improved tumor target conformity and enabled better preservation of normal structures. However, because of the intricate anatomy of the head and neck region, multiple critical neurological structures such as the brain, brainstem, spinal cord, cranial nerves, nerve plexuses, autonomic pathways, brain vasculature, and neurosensory organs, are variably irradiated during treatment, particularly when tumor targets are in close proximity. Consequently, a diverse spectrum of late neurological sequelae may manifest in HNC survivors. These neurological complications commonly result in irreversible symptoms, impair patients' quality of life, and contribute to a substantial proportion of non-cancer deaths. Although the relationship between radiation dose and toxicity has not been fully elucidated for all complications, appropriate application of dosimetric constraints during radiotherapy planning may reduce their incidence. Vigilant surveillance during the course of survivorship also enables early detection and intervention. This article endeavors to provide a comprehensive review of the various neurological complications of modern radiotherapy for HNC, summarize the current incidence data, discuss methods to minimize their risks during radiotherapy planning, and highlight potential strategies for managing these debilitating toxicities.
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Affiliation(s)
- James C H Chow
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region.
| | - Jason C S Ho
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region
| | - Ka Man Cheung
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region
| | - David Johnson
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong Special Administrative Region
| | - Bonaventure Y M Ip
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region; Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Jonathan J Beitler
- Harold Alfond Center for Cancer Care, Maine General Hospital, Augusta, ME, USA
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Antti A Mäkitie
- Department of Otorhinolaryngology, Head and Neck Surgery, Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan Medicine, Ann Arbor, MI, USA
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia
| | - Sandra Nuyts
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium; Laboratory of Experimental Radiotherapy, Department of Oncology, University of Leuven, Leuven, Belgium
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Silvia Babighian
- Department of Ophthalmology, Ospedale Sant'Antonio, Azienda Ospedaliera, Padova, Italy
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Chow JCH, Lee J, Lai MMP, Li S, Lau AMC, Ng BSY, Leung GGG, Li STY, Lui JCF, Cheung KM, Au KH, Wong KH, Lau AYL, Zee BCY. Multi-domain neurocognitive impairment following definitive intensity-modulated radiotherapy for nasopharyngeal cancer: A cross-sectional study. Radiother Oncol 2024; 193:110143. [PMID: 38341098 DOI: 10.1016/j.radonc.2024.110143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Neurocognitive impairment from inadvertent brain irradiation is common following intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC). This study aimed to determine the prevalence, pattern, and radiation dose-toxicity relationship of this late complication. MATERIALS AND METHODS We undertook a cross-sectional study of 190 post-IMRT NPC survivors. Neurocognitive function was screened using the Montreal Cognitive Assessment-Hong Kong (HK-MoCA). Detailed assessments of eight distinct neurocognitive domains were conducted: intellectual capacity (WAIS-IV), attention span (Digit Span and Visual Spatial Span), visual memory (Visual Reproduction Span), verbal memory (Auditory Verbal Learning Test), processing speed (Color Trail Test), executive function (Stroop Test), motor dexterity (Grooved Pegboard Test) and language ability (Verbal Fluency Test). The mean percentiles and Z-scores were compared with normative population data. Associations between radiation dose and brain substructures were explored using multivariable logistic regression. RESULTS The median post-IMRT interval was 7.0 years. The prevalence of impaired HK-MoCA was 25.3 % (48/190). Among the participants, 151 (79.4 %) exhibited impairments in at least one neurocognitive domain. The predominantly impaired domains included verbal memory (short-term: mean Z-score, -0.56, p < 0.001; long-term: mean Z-score, -0.70, p < 0.001), processing speed (basic: mean Z-score, -1.04, p < 0.001; advanced: mean Z-score, -0.38, p < 0.001), executive function (mean Z-score, -1.90, p < 0.001), and motor dexterity (dominant hand: mean Z-score, -0.97, p < 0.001). Radiation dose to the whole brain, hippocampus, and temporal lobe was associated with impairments in executive function, verbal memory, processing speed, and motor dexterity. CONCLUSIONS Neurocognitive impairment is prevalent and profound in post-IMRT NPC survivors. Cognitive assessment and rehabilitation should be considered part of survivorship care.
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Affiliation(s)
- James C H Chow
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Jack Lee
- Division of Biostatistics, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Maria M P Lai
- Division of Biostatistics, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sara Li
- Division of Biostatistics, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Adelina M C Lau
- Department of Clinical Psychology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Beni S Y Ng
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong SAR, China
| | - Gigi G G Leung
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong SAR, China
| | - Sharon T Y Li
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Jeffrey C F Lui
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Ka Man Cheung
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Kwok Hung Au
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Kam Hung Wong
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Alexander Y L Lau
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Benny C Y Zee
- Division of Biostatistics, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Auerbach H, Dzierma Y, Schürmann M, Rübe C, Rübe CE. Measuring out-of-field dose to the hippocampus in common radiotherapy indications. Radiat Oncol 2023; 18:64. [PMID: 37029409 PMCID: PMC10080875 DOI: 10.1186/s13014-023-02242-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/06/2023] [Indexed: 04/09/2023] Open
Abstract
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.
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Affiliation(s)
- Hendrik Auerbach
- Department of Radiation Oncology, Saarland University Medical Center, Homburg, Saar, Germany.
| | - Yvonne Dzierma
- Department of Radiation Oncology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Michaela Schürmann
- Department of Radiation Oncology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Christian Rübe
- Department of Radiation Oncology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Claudia E Rübe
- Department of Radiation Oncology, Saarland University Medical Center, Homburg, Saar, Germany
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Hippocampus sparing volumetric modulated arc therapy in patients with loco-regionally advanced oropharyngeal cancer. Phys Imaging Radiat Oncol 2022; 24:71-75. [PMID: 36217428 PMCID: PMC9547285 DOI: 10.1016/j.phro.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022] Open
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