Radiation-induced acute injury of intensity-modulated radiotherapy versus three-dimensional conformal radiotherapy in induction chemotherapy followed by concurrent chemoradiotherapy for locoregionally advanced nasopharyngeal carcinoma: a prospective cohort study

An unmet need for pharmacology: Treatments for radiation-induced gastrointestinal mucositis

Gastrointestinal mucositis (GIM) continues to be a significant issue in the management of abdominal cancer radiation treatments and chemotherapy, causing significant patient discomfort and therapy interruption or even cessation. This review will first focus on radiotherapy induced GIM, providing an understanding of its clinical landscape. Subsequently, the aetiology of GIM will be reviewed, highlighting diverse contributing factors. The cellular and tissue damage and associated molecular responses in GIM will be summarised in the context of the underlying complex biological processes. Finally, available drugs and pharmaceutical therapies will be evaluated, underscoring their insufficiency, and highlighting the need for further research and innovation. This review will emphasize the urgent need for improved pharmacologic therapeutics for GIM, which is a key research priority in oncology.

A Neural Network-based Method for Predicting Dose to Organs at Risk in Intensity-modulated Radiotherapy for Nasopharyngeal Carcinoma

OBJECTIVE

A neural network method was used to establish a dose prediction model for organs at risk (OARs) during intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

In total, 103 patients with NPC were randomly selected for IMRT. Suborgans were automatically generated for OARs using ring structures based on distance to the target using a MATLAB program and the corresponding volume of each suborgan was determined. The correlation between the volume of each suborgan and the dose to each OAR was analysed and neural network prediction models of the OAR dose were established using the MATLAB Neural Net Fitting application. The R-value and mean square error in the regression analysis were used to evaluate the prediction model.

RESULTS

The OAR dose was related to the volume of the corresponding sub-OAR. The average R-values for the normalised mean dose (Dnmean) to parallel organs and serial organs and the normalised maximum dose (Dn0) to serial organs in the training set were 0.880, 0.927 and 0.905, respectively. The mean square error for each OAR in the prediction model was low (ranging from 1.72 × 10-4 to 7.06 × 10-3).

CONCLUSION

The neural network-based model for predicting OAR dose during IMRT for NPC is simple, reliable and worth further investigation and application.

Effect of Lactobacillus delbrueckii subsp. lactis on vaginal radiotherapy for gynecological cancer

The aim of this study was to evaluate the effect of Lactobacillus delbrueckii subsp. lactis (L.del) on vaginal microbiota (VM) dysbiosis and vaginal radiation injury in gynecologic cancer patients. The inhibitory effects of L.del on cervical cancer cells were also studied in vitro. Gynecologic cancer patients receiving radiotherapy were randomized into control and L.del intervention groups. The control group received radiotherapy, while the intervention group received radiotherapy and L.del intervention (1 capsule/day placed into the deep vagina from the first day of radiotherapy until the end of treatment). Vaginal swab samples were collected on the first day pre-treatment and the last day post-treatment. DNA from 54 patients was extracted and assessed by the 16S rRNA sequencing method. Radiotherapy resulted in vaginal microbiome dysbiosis characterized by increased phylogenetic diversity and increased abundance of Brevundimonas, Streptococcus and Prevotella, but a decreased abundance of Lactobacillus. Level 2 vaginal radiation injury was positively associated with the abundance of Brevundimonas and gram-negative non-fermenting bacteria. Administration of L.del attenuated the reduction of Lactobacillus while also inhibiting the abundance of Streptococcus and Prevotella, thereby ameliorating radiotherapy-related vaginal microbiota dysbiosis. CLD inhibited the in vitro proliferation of SiHa cells by altering the expression of BCL2, HPV16-E6, HPV16-E7, IL6, MAP7, BAX, Caspase-3, Caspase-9 and LTF. In conclusion, L. del application can alleviate radiation-induced vaginal dysbiosis and restore Lactobacillus dominance of the vaginal microbiome. Moreover, CLD was found to inhibit cell growth and promote the apoptosis of SiHa cells in vitro. The registration number for this clinical trial is ChiCTR1900021784.

Case-control study analyzing the relationship between oral microcirculation and oral mucositis and pain in patients under antineoplastic therapy

The study aimed to evaluate the relation between microcirculation of the genian region using laser Doppler flowmetry and oral mucositis (OM) and pain in individuals undergoing antineoplastic therapy. A case-control clinical study was conducted with the participants divided into three groups: chemotherapy (CTG), radiation therapy and chemotherapy group (RCTG), and control group (CG). Pain was assessed by visual analog scale; OM was classified by oral mucositis assessment and WHO scales. The blood flow was assessed by laser Doppler flowmetry. Kruskal-Wallis statistical test, Friedman test, and Spearman test were used for statistical analysis of this study. CTG (7 individuals/25.93%) showed the worst manifestations of OM between 2nd and 4th evaluations (OM-WHO: T2, p = 0.006; T3, p = 0.006; T4, p = 0.003; OM-OMAS: T2, p = 0.004; T3, p = 0.000; T4, p = 0.011), and increased blood flow over time, with the exception of the 3rd evaluation (p = 0.138). The RCTG (9 individuals/33.33%) showed the worst manifestations of oral mucositis on the 4th week (OM-WHO and OM-OMAS: p = 0.000) with a decrease in blood flow (p = 0.068). The decreased blood flow is associated with greater severity of oral mucositis and greater pain intensity.

Radiation-induced alterations in multi-layered, in-vitro skin models detected by optical coherence tomography and histological methods

BACKGROUND

Inflammatory skin reactions and skin alterations are still a potential side effect in radiation therapy (RT), which also need attention for patients' health care.

METHOD

In a pre-clinical study we consider alterations in irradiated in-vitro skin models of epidermal and dermal layers. Typical dose regimes in radiation therapy are applied for irradiation. For non-invasive imaging and characterization optical coherence tomography (OCT) is used. Histological staining method is additionally applied for comparison and discussion.

RESULTS

Structural features, such as keratinization, modifications in epidermal cell layer thickness and disorder in the layering-as indications for reactions to ionizing radiation and aging-could be observed by means of OCT and confirmed by histology. We were able to recognize known RT induced changes such as hyper-keratosis, acantholysis, and epidermal hyperplasia as well as disruption and/or demarcation of the dermo-epidermal junction.

CONCLUSION

The results may pave the way for OCT to be considered as a possible adjunctive tool to detect and monitor early skin inflammation and side effects of radiotherapy, thus supporting patient healthcare in the future.

Chemotherapy for locoregionally advanced nasopharyngeal carcinoma: Who really needs it

OBJECTIVES

The CSCO and ASCO guidelines in 2021 recommend chemotherapy for stage III-IVA (8th edition of AJCC staging) nasopharyngeal carcinoma (NPC). Actually, patients with stage T3-4N0M0 are often excluded from various clinical trials of the locoregionally advanced NPC, and the survival benefit of chemotherapy in such patients has always been controversial. This study aims to explore the benefit of chemotherapy in patients with locoregionally advanced NPC, especially those with negative lymph nodes.

METHODS

A total of 2741 patients were extracted from the SEER database. After a 1:1 PSM analysis, 272 patients were obtained to further explore whether the addition of chemotherapy would achieve survival benefits.

RESULTS

After PSM, Kaplan-Meier curves showed that the overall survival (OS) of patients receiving chemoradiotherapy (p = 0.031) was higher than those receiving radiotherapy alone. Similar results were observed for cancer-specific survival (CSS). We further stratified the patients according to lymph node status and found that the addition of chemotherapy in patients with positive lymph nodes could significantly improve 5-year OS rates (58.08% vs. 43.95%; p = 0.025) and 5-year CSS rates (67.42% vs. 51.95%; p = 0.015) compared with radiotherapy alone, but there was no additional benefit of chemotherapy in patients with negative lymph nodes. For all 449 cases of T3-4N0M0 NPC, radiotherapy improved the OS rates (HR 0.293, 95% CI 0.203-0.424) and the CSS rates (HR 0.252, 95% CI 0.171-0.371) compared with no radiotherapy, while chemotherapy did not show significant survival benefit compared with no chemotherapy.

CONCLUSION

Our results reveal that stage T3-4N0M0 NPC may be exempted from chemotherapy, and use radiotherapy alone to reduce toxic and side effects. These results still need to be verified by future prospective trials.

Clinical Characteristics and Predictive Outcomes of Recurrent Nasopharyngeal Carcinoma-A Lingering Pitfall of the Long Latency

Purpose: To investigate the clinical characteristics, risk factors, and clinical outcomes of long-latent recurrence (>five years) of nasopharyngeal carcinoma (NPC). Methods: This retrospective study enrolled newly diagnosed NPC patients from the Chang Gung Research Database between January 2007 and December 2019. We analyzed the patients’ characteristics and survival outcomes after recurrence. Results: A total of 2599 NPC patients were enrolled. The overall recurrence rate was 20.5%, while 8.1% of patients had long-latent recurrence (>five years). These patients had a higher percentage of initial AJCC (The American Joint Committee on Cancer) stage I/II (60.5%, p = 0.001) and local recurrence (46.5%, p < 0.001). Unresectable rT3 and rT4 were found in 60% of patients when recurrence and 30% of local recurrence occurred in the skull base, which could not be detected by the regular endoscopy. The five-year overall survival rate of long-latent recurrence was 19.7%. Alive patients tended to be asymptomatic but have regular follow-ups with the interval less than six months. Multivariate analysis showed age and initial advanced AJCC stages were independent risk factors of death after recurrence. In contrast, patients with recurrence between two and five years, salvage surgeries, and regional recurrence had favorable survival outcomes. Conclusion: Long-latent NPC recurrence is not rare, and the survival outcome is poor. Regular follow-up for early detection of NPC recurrence is necessary even after five years of disease-free period.

Induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma: A systematic review and meta-analysis

Background

Adding induction chemotherapy to concurrent platinum-based chemoradiotherapy has significantly prolonged the survival time of patients with locoregionally advanced nasopharyngeal carcinoma. In this study, we intend to evaluate the survival outcomes, responses, and incidences of toxicities of induction chemotherapy and the differences between different strategies.

Methods

A comprehensive search was conducted in PubMed, Embase, Web of Science, and Cochrane CENTRAL on August 10, 2021. Single-arm or multi-arm prospective clinical trials on induction chemotherapy without targeted therapies or immune checkpoint inhibitors were included. Primary outcomes included survival outcomes, objective response rate, and disease control rate, and the secondary outcome was the rates of grade 3 or higher treatment-related adverse events.

Results

The 39 studies included in the systematic review and meta-analysis comprised 36 clinical trials and 5389 patients. The estimates for 3-year overall and fail-free survival rates were 87% and 77%. The estimates for 5-year rates of overall and fail-free survival were 81% and 73%. Gemcitabine plus platinum and docetaxel combined with 5-fluorouracil plus platinum strategies were associated with the highest rates of 3-year and 5-year overall survival. The objective response and disease control rates were 85% and 98% after the completion of induction chemotherapy. Neutropenia (27%) and nausea/vomiting (7%) were the most common grade 3 or higher treatment-related hematological and non-hematological adverse events during the induction phase.

Conclusions

Different induction chemotherapeutic strategies appear to have varying effects and risks; a comprehensive summary of the survival outcomes, responses, and toxicities in clinical trials may provide a crucial guide for clinicians.

Benefits of immunonutrition in patients with head and neck cancer receiving chemoradiation: A phase II randomized, double-blind study

BACKGROUND & AIMS

The benefits of immunonutrition in patients with head and neck cancer (HNC), especially for those undergoing definitive concurrent chemoradiation (CCRT), remain unclear. We evaluated the benefits of immunonutrition regarding the prevention of severe oral mucositis. Secondary objectives included assessments of other treatment-related toxicities, changes of nutritional and inflammatory marker levels, treatment tolerance, and survival.

METHODS

In total, 110 patients with HNC undergoing definitive CCRT including 3-week cycles of cisplatin were enrolled in our double-blind phase II study. Patients were randomly assigned to receive an immunonutrient formula containing omega-3-fatty acids, arginine, dietary nucleotides, and soluble fiber (n = 55) or an isocaloric isonitrogenous control (n = 55). All patients received the assigned product 5 consecutive days before each chemotherapy session. The proportion of patients with severe oral mucositis was compared between the immunonutrients and control groups.

RESULTS

The rates of nasopharyngeal cancer (NPC) were 67% and 51% in the immunonutrients and control groups, respectively. All patients had 100% compliance to the assigned product. There was no difference of the proportion of patients with grade 3-4 oral mucositis between the two groups (62% vs. 67%, p = 0.690). At the time of analyses, survival tended to be better in the immunonutrients group. The 3-year progression-free survival rates were 69% (95% confidence interval [CI] = 55%-80%) and 44% (95% CI = 30%-57%) in the immunonutrients and control groups, respectively (p = 0.056), whereas the 3-year overall survival rates in these groups were 69% (95% CI = 54%-80%) and 50% (95% CI = 36%-66%; p = 0.065), respectively. In subgroup analyses according to the primary tumor location, the survival benefits were apparently maintained in patients with NPC.

CONCLUSIONS

Although our study did not demonstrate a reduced risk of severe oral mucositis, we found that immunonutrition might improve survival. Larger studies are needed to determine the optimal dose and schedule of immunonutrition to prevent oral mucositis. In addition, randomized phase III trials evaluating the survival benefits of immunonutrition in patients with cancer are required, and NPC might be a primary malignancy of interest.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT05101889.