Adverse Radiation Therapy Effects in the Treatment of Head and Neck Tumors

Investigating In Vivo Tumor Biomolecular Changes Following Radiation Therapy Using Raman Spectroscopy

Treatment resistance is a major bottleneck in the success of cancer therapy. Early identification of the treatment response or lack thereof in patients can enable an earlier switch to alternative treatment strategies that can enhance response rates. Here, Raman spectroscopy was applied to monitor early tumor biomolecular changes in sensitive (UM-SCC-22B) and resistant (UM-SCC-47) head and neck tumor xenografts for the first time in in vivo murine tumor models in response to radiation therapy. We used a validated multivariate curve resolution-alternating least-squares (MCR-ALS) model to resolve complex multicomponent Raman spectra into individual pure spectra and their respective contributions. We observed a significant radiation-induced increase in the contributions of lipid-like species (p = 0.0291) in the radiation-sensitive UM-SCC-22B tumors at 48 h following radiation compared to the nonradiated baseline (prior to commencing treatment). We also observed an increase in the contribution of collagen-like species in the radiation-resistant UM-SCC-47 tumors at 24 h following radiation compared to the nonradiated baseline (p = 0.0125). In addition to the in vivo analysis, we performed ex vivo confocal Raman microscopic imaging of frozen sections derived from the same tumors. A comparison of all control and treated tumors revealed similar trends in the contributions of lipid-like and collagen-like species in both in vivo and ex vivo measurements; however, when evaluated as a function of time, longitudinal trends in the scores of collagen-like and lipid-like components were not consistent between the two data sets, likely due to sample numbers and differences in sampling depth at which information is obtained. Nevertheless, this study demonstrates the potential of fiber-based Raman spectroscopy for identifying early tumor microenvironmental changes in response to clinical doses of radiation therapy.

Knowledge, attitude, and practice toward advanced precision radiotherapy among patients with head and neck cancer

Background

Advancements in radiotherapy (RT) technology have led to the prominence of precision RT in head and neck cancer (HNC) treatment. The new progress in precision RT offers more efficient therapy, potentially improving outcomes for HNC patients.

Objective

The present cross-sectional study aimed to assess the knowledge, attitude, and practice (KAP) of patients in advanced precision RT for HNC treatment.

Methods

This study enrolled HNC patients at the Affiliated Hospital of Hebei University of Engineering between October 2023 and May 2024. Then, the demographic data and KAP scores were collected using an investigator-designed questionnaire. Afterwards, descriptive statistics were provided for all study variables, and the relationship among KAP was analyzed using appropriate statistical tests, including Spearman correlation, logistic regression, and path analysis.

Results

A total of 436 participants with a mean age of 52.03 ± 12.19 years old were included. The mean knowledge score, attitude score, and practice score were 18.33 ± 4.21, 36.14 ± 1.71, and 26.26 ± 1.83, respectively. Although most of the participants were unfamiliar with advanced precision RT, they expressed a high willingness to follow their doctor's recommendation for this treatment. The multivariable analysis revealed a positive association between attitude score and proactive practice. The path analysis revealed that knowledge directly influenced attitude and practice, while attitude directly impacted practice.

Conclusion

HNC participants had poor knowledge of advanced precision RT techniques, but had a positive attitude and the willingness to undergo treatment when recommended by their physicians. These results suggest that improving patients' awareness for advanced precision RT can help to promote better attitude and advanced precision RT practice.

The Prediction of Radiation-Induced Trismus by the Apparent Diffusion Coefficient Values of Masseter Muscles before Chemoradiotherapy in Locally Advanced Nasopharyngeal Carcinomas

PURPOSE

Although the apparent diffusion coefficient (ADC) value from diffusion-weighted imaging can provide insights into various pathological processes, no studies have examined the relationship between the pre-concurrent chemoradiotherapy (CCRT) mean ADC (ADCmean) values of the masseter muscles and radiation-induced trismus (RIT) in locally advanced nasopharyngeal carcinoma (LA-NPC) patients. Therefore, the current research aimed to investigate the significance of pre-CCRT masseter muscle ADCmean values for predicting the RIT rates in LA-NPC patients treated with definitive CCRT.

MATERIALS AND METHODS

The pre-CCRT ADCmean values of the masseter muscles and the post-CCRT RIT rates were evaluated. A receiver operating characteristic curve analysis was employed to determine the optimal ADCmean cutoff. The primary objective was to examine the relationship between the pre-CCRT masseter muscle ADCmean values and the post-CCRT RIT rates.

RESULTS

Seventy-seven patients were included. The optimal ADCmean cutoff value was 1381.30 × 10-6 mm2/s, which divided the patients into two groups: an ADCmean < 1381.30 × 10-6 mm2/s (n = 49) versus an ADCmean > 1381.30 × 10-6 mm2/s (n = 28). A masseter muscle ADCmean > 1381.30 × 10-6 mm2/s was found to be associated with significantly higher RIT rates than an ADCmean < 1381.30 × 10-6 mm2/s (71.42% vs. 6.12%; p < 0.001). The multivariate analysis results confirmed a pre-CCRT masseter muscle ADCmean > 1381.30 × 10-6 mm2/s as an independent predictor of RIT.

CONCLUSIONS

Our study presents the first evidence establishing a connection between elevated masseter muscle ADCmean values and higher RIT rates in LA-NPC patients following CCRT. If confirmed with further research, these findings may help to categorize the risk of RIT in these patients.

Novel Index Combining Pan-Immune-Inflammatory Index and Hemoglobin Levels (PIV/Hb) Predicts Trismus Rates Efficiently after Chemoradiotherapy in Locally Advanced Nasopharyngeal Cancer

Purpose

To evaluate the predictive potency of a novel index combining the pan-immune-inflammatory index and hemoglobin levels (PIV/Hb) for the prevalence of radiation-induced trismus (RIT) in patients with locally advanced nasopharyngeal cancer (LA-NPC) receiving concurrent chemoradiotherapy (CCRT).

Methods

Data from 228 LA-NPC patients were retrospectively examined. Maximum mouth openings (MMO) were measured to confirm the presence of RIT, defined as MMOs ≤35 mm. Complete blood test results from the first day of CCRT were used to calculate PIV/Hb levels. A potential relationship between pretreatment PIV/Hb and the RIT status was evaluated using receiver operating characteristic (ROC) curve analysis.

Results

Post-CCRT RIT was diagnosed in 20.2% of the patients. The ROC curve analysis determined 68.4 g/dL as the ideal PIV/Hb cutoff that effectively divided patients into two distinct groups (area under the curve: 94.7%; specificity: 86.4%; sensitivity: 87.4%). RIT was significantly more prevalent in the PIV/Hb > 68 group than in the PIV/Hb < 68 group (58.8% vs. 3.8%; P < 0.001). Multivariate logistic regression analysis showed that a pre-CCRT PIV > 68 was independently associated with significantly higher rates of RIT.

Conclusion

Higher pretreatment levels of the novel PIV/Hb index predict increased RIT rates following definitive CCRT for LA-NPCs.

Case report: Low-dose radiation-induced meningioma with a short latency period

Patients with radiation-induced meningioma (RIM), most of whom had received head radiation therapy or had been exposed to ionizing radiation during childhood or adolescence, are at risk of developing cranial meningiomas throughout their lifetimes because of the long latency period. Although intermediate-to-high-dose ionizing radiation exposure is an established risk factor for RIM, risk factors for low-dose RIM remain incompletely defined. This study presents the case of a 56-year-old woman diagnosed with radiation-induced giant meningioma 2.5 years after undergoing an interventional embolization procedure for a brain aneurysm. This is the first report of RIM attributable to a brain intervention with an extremely short latency period. The total radiation dose received by the patient during the operation was 1367.3 mGy, representing a low dose. Our case report strengthens the evidence that even low radiation doses can increase the risk of RIM. These findings provide a realistic basis for the theoretical study of RIM and suggest some new ideas for RIM treatment. The need for caution in the use of radioactive treatments and optimization of interventional procedures is highlighted.

Late Changes in Renal Volume and Function after Proton Beam Therapy in Pediatric and Adult Patients: Children Show Significant Renal Atrophy but Deterioration of Renal Function Is Minimal in the Long-Term in Both Groups

To compare late renal effects in pediatric and adult patients with malignancies after PBT involving part of the kidney. A retrospective study was conducted to assess changes in renal volume and function in 24 patients, including 12 children (1-14 years old) and 12 adults (51-80 years old). Kidney volumes were measured from CT or MRI images during follow-up. Dose-volume histograms were calculated using a treatment planning system. In children, the median volume changes for the irradiated and control kidneys were -5.58 (-94.95 to +4.79) and +14.92 (-19.45 to +53.89) mL, respectively, with a relative volume change of -28.38 (-119.45 to -3.87) mL for the irradiated kidneys. For adults, these volume changes were -22.43 (-68.7 to -3.48) and -21.56 (-57.26 to -0.16) mL, respectively, with a relative volume change of -5.83 (-28.85 to +30.92) mL. Control kidneys in children exhibited a marked increase in size, while those in adults showed slight volumetric loss. The percentage of irradiated volume receiving 10 Gy (RBE) (V10) and 20 Gy (RBE) (V20) were significantly negatively associated with the relative volume change per year, especially in children. The CKD stage based on eGFR for all patients ranged from 1 to 3 and no cases with severe renal dysfunction were found before or after PBT. Late effects on the kidneys after PBT vary among age groups. Children are more susceptible than adults to significant renal atrophy after PBT. V10 and V20 might serve as predictors of the degree of renal atrophy after PBT, especially in children. PBT has a minimal impact on deterioration of renal function in both children and adults.

FLASH radiotherapy: A new milestone in the field of cancer radiotherapy

Radiotherapy plays a pivotal role in the control and eradication of tumors, but it can also induce radiation injury to surrounding normal tissues while targeting tumor cells. In recent years, FLASH-Radiotherapy (FLASH-RT) has emerged as a cutting-edge research focus in the field of radiation therapy. By delivering high radiation doses to the treatment target in an ultra-short time, FLASH-RT produces the FLASH effect, which reduces the toxicity to normal tissues while achieving comparable tumor control efficacy to conventional radiotherapy. This review provides a brief overview of the development history of FLASH-RT and its impact on tumor control. Additionally, it focuses on introducing the protective effects and molecular mechanisms of this technology on various normal tissues, as well as exploring its synergistic effects when combined with other tumor therapies. Importantly, this review discusses the challenges faced in translating FLASH-RT into clinical practice and outlines its promising future applications.

Posttreatment Head and Neck Cancer Imaging: Anatomic Considerations Based on Cancer Subsites

Posttreatment imaging surveillance of head and neck cancer is challenging owing to complex anatomic subsites and diverse treatment modalities. Early detection of residual disease or recurrence through surveillance imaging is crucial for devising optimal treatment strategies. Posttreatment imaging surveillance is performed using CT, fluorine 18-fluorodeoxyglucose PET/CT, and MRI. Radiologists should be familiar with postoperative imaging findings that can vary depending on surgical procedures and reconstruction methods that are used, which is dictated by the primary subsite and extent of the tumor. Morphologic changes in normal structures or denervation of muscles within the musculocutaneous flap may mimic recurrent tumors. Recurrence is more likely to occur at the resection margin, margin of the reconstructed flap, and deep sites that are difficult to access surgically. Radiation therapy also has a varying dose distribution depending on the primary site, resulting in various posttreatment changes. Normal tissues are affected by radiation, with edema and inflammation occurring in the early stages and fibrosis in the late stages. Distinguishing scar tissue from residual tumor becomes necessary, as radiation therapy may leave behind residual scar tissue. Local recurrence should be carefully evaluated within areas where these postradiation changes occur. Head and Neck Imaging Reporting and Data System (NI-RADS) is a standardized reporting and risk classification system with guidance for subsequent management. Familiarity with NI-RADS has implications for establishing surveillance protocols, interpreting posttreatment images, and management decisions. Knowledge of posttreatment imaging characteristics of each subsite of head and neck cancers and the areas prone to recurrence empowers radiologists to detect recurrences at early stages. ©RSNA, 2024 Test Your Knowledge questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

An Investigation of the Role of Phase Angle in Malnutrition Risk Evaluation and Clinical Outcomes in Patients with Head and Neck or Brain Tumors Undergoing Radiotherapy

This cross-sectional study aimed to investigate the role of bioelectrical impedance analysis (BIA) and phase angle measurement in assessing malnutrition in head and neck (n = 37) and brain (n = 63) tumor patients received radiotherapy. Common nutritional screening and assessment tests were used to identify malnutrition in the patients. Each patient underwent these tests once, along with phase angle measurement. Additionally, inflammation parameters, including neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), and systemic inflammatory index (SII), were calculated. All study results were correlated with the phase angle cutoff point of 5.72°. The phase angle demonstrated significant correlations with subjective global assessment (SGA), mini nutritional assessment (MNA) scores, BIA parameters, nutritional index, NLR, and SII (p < 0.05). Moreover, in head and neck tumor patients, those with higher standardized phase angle values exhibited significantly better two-year overall survival (32.1% vs. 87.5%, p = 0.006). The phase angle measurement is a convenient, noninvasive, and reproducible method that can complement existing tools for assessing malnutrition risk in radiotherapy patients. The significant correlations observed between the phase angle and various nutritional, inflammation markers and prognosis highlight its potential utility. Further studies incorporating a larger patient cohort will be beneficial in establishing a standard phase angle reference value for cancer patients.

Imaging of the Posttreatment Head and Neck: Expected Findings and Potential Complications

Interpretation of posttreatment imaging findings in patients with head and neck cancer can pose a substantial challenge. Malignancies in this region are often managed through surgery, radiation therapy, chemotherapy, and newer approaches like immunotherapy. After treatment, patients may experience various expected changes, including mucositis, soft-tissue inflammation, laryngeal edema, and salivary gland inflammation. Imaging techniques such as CT, MRI, and PET scans help differentiate these changes from tumor recurrence. Complications such as osteoradionecrosis, chondroradionecrosis, and radiation-induced vasculopathy can arise because of radiation effects. Radiation-induced malignancies may occur in the delayed setting. This review article emphasizes the importance of posttreatment surveillance imaging to ensure proper care of patients with head and neck cancer and highlights the complexities in distinguishing between expected treatment effects and potential complications. Keywords: CT, MR Imaging, Radiation Therapy, Ear/Nose/Throat, Head/Neck, Nervous-Peripheral, Bone Marrow, Calvarium, Carotid Arteries, Jaw, Face, Larynx © RSNA, 2024.

Quantitative dynamic contrast-enhanced magnetic resonance imaging in head and neck cancer: A systematic comparison of different modelling approaches

Background and purpose

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) describes tissue microvasculature and has prognostic and predictive potential in radiotherapy for head and neck cancer (HNC). However, lack in standardization of DCE-MRI hinders comparison of studies and clinical implementation. This study investigated the accuracy and robustness of the population arterial input function (AIF), correlations between pharmacokinetic parameters and their association to T stage and human papillomavirus (HPV) status for HNC.

Materials and methods

DCE-MRI was acquired for 44 HNC patients. Population AIFs were calculated with six different approaches. DCE-MRI was analysed in primary and lymph node tumours using Tofts model (TM) with population AIFs and individual AIFs, extended TM (ETM) with individual AIFs, Brix model (BM), and areas under the curve (AUCs). Intraclass correlation, concordance correlation, Pearson correlation and Whitney Mann U test helped examining the robustness and accuracy of population AIF, correlations between DCE-MRI parameters and their association to T stage and HPV status, respectively.

Results

The population AIF was robust but differed from individual AIFs. There was significant correlation between KtransTM/ETM and ve, TM/ETM, and KtransTM/ETM and Kep, TM/ETM. ABrix and AUCs correlated for lymph nodes. Kep, Brix correlated with ABrix, KtransTM/ETM and Kep, TM/ETM for primary tumours. Kep, TM significantly decreased with increasing T stage. Both the correlations and the parameters' association to T stage were stronger for HPV negative lesions.

Conclusions

Individual AIF was preferred for accurate pharmacokinetic modelling of DCE-MRI. DCE-MRI parameters and their correlations were affected by the lesion type, HPV status and T staging.

Implications of oral dysbiosis and HPV infection in head and neck cancer: from molecular and cellular mechanisms to early diagnosis and therapy

Head and neck cancer (HNC) is the sixth most common type of cancer, with more than half a million new cases annually. This review focuses on the role of oral dysbiosis and HPV infection in HNCs, presenting the involved taxons, molecular effectors and pathways, as well as the HPV-associated particularities of genetic and epigenetic changes and of the tumor microenvironment occurred in different stages of tumor development. Oral dysbiosis is associated with the evolution of HNCs, through multiple mechanisms such as inflammation, genotoxins release, modulation of the innate and acquired immune response, carcinogens and anticarcinogens production, generation of oxidative stress, induction of mutations. Thus, novel microbiome-derived biomarkers and interventions could significantly contribute to achieving the desideratum of personalized management of oncologic patients, regarding both early diagnosis and treatment. The results reported by different studies are not always congruent regarding the variations in the abundance of different taxons in HNCs. However, there is a consistent reporting of a higher abundance of Gram-negative species such as Fusobacterium, Leptotrichia, Treponema, Porphyromonas gingivalis, Prevotella, Bacteroidetes, Haemophilus, Veillonella, Pseudomonas, Enterobacterales, which are probably responsible of chronic inflammation and modulation of tumor microenvironment. Candida albicans is the dominant fungi found in oral carcinoma being also associated with shorter survival rate. Specific microbial signatures (e.g., F. nucleatum, Bacteroidetes and Peptostreptococcus) have been associated with later stages and larger tumor, suggesting their potential to be used as biomarkers for tumor stratification and prognosis. On the other hand, increased abundance of Corynebacterium, Kingella, Abiotrophia is associated with a reduced risk of HNC. Microbiome could also provide biomarkers for differentiating between oropharyngeal and hypopharyngeal cancers as well as between HPV-positive and HPV-negative tumors. Ongoing clinical trials aim to validate non-invasive tests for microbiome-derived biomarkers detection in oral and throat cancers, especially within high-risk populations. Oro-pharyngeal dysbiosis could also impact the HNCs therapy and associated side-effects of radiotherapy, chemotherapy, and immunotherapy. HPV-positive tumors harbor fewer mutations, as well as different DNA methylation pattern and tumor microenvironment. Therefore, elucidation of the molecular mechanisms by which oral microbiota and HPV infection influence the HNC initiation and progression, screening for HPV infection and vaccination against HPV, adopting a good oral hygiene, and preventing oral dysbiosis are important tools for advancing in the battle with this public health global challenge.

Fibrin hydrogels fortified with FGF-7/10 and laminin-1 peptides promote regeneration of irradiated salivary glands

Ionizing radiation, commonly used for head and neck cancer treatment, typically damages the salivary glands, resulting in hyposalivation. The development of treatments to restore this lost function is crucial for improving the quality of life for patients suffering from this condition. To address this clinical need, we have developed an innovative hydrogel by chemically conjugating laminin-1 peptides (A99 and YIGSR) and growth factors, FGF-7 and FGF-10, to fibrin hydrogels. Our results demonstrate that FGF-7/10 and laminin-1 peptides fortified fibrin hydrogel [enhanced laminin-1 peptides fibrin hydrogel (Ep-FH)] promotes salivary gland regeneration and functionality by improving epithelial tissue organization, establishing a healthy network of blood vessels and nerves, while reducing fibrosis in a head and neck irradiated mouse model. These results indicate that fibrin hydrogel-based implantable scaffolds containing pro-regenerative signals promote sustained secretory function of irradiated salivary glands, offering a potential alternative treatment for hyposalivation in head and neck cancer patients undergoing radiation treatment. These unique findings emphasize the potential of fibrin hydrogel-based implantable scaffolds enriched with pro-regenerative signals in sustaining the secretory function of irradiated salivary glands and offer a promising alternative treatment for addressing hyposalivation in head and neck cancer patients undergoing radiation therapy. STATEMENT OF SIGNIFICANCE: Radiation therapies used to treat head and neck cancers often result in damaged salivary gland, leading to severe dryness of the oral cavity. In this study, we engineered FGF-7 and FGF-10 and immobilized them into L1p-FH. The resulting hydrogel, Ep-FH, restored irradiated salivary gland functionality by enhancing epithelial tissue organization, promoting the development of a healthy network of blood vessels and nerves as well as reduction of fibrosis.

Dietary Interventions in Cancer Treatment and Response: A Comprehensive Review

Simple Summary

Chemotherapy and radiotherapy are essential components to the management of most solid malignancies. These modalities exert their effects primarily by mediating the DNA damage of malignant cells; however, healthy cells are also damaged by the same mechanisms and can incur acute and late side effects resulting in both morbidity and mortality. Dietary interventions have been shown to reduce cancer growth, progression, and metastasis in many different solid tumor models and they show promise for improving cancer outcomes in early phase clinical studies. Here, we review preclinical and clinical studies that examine how dietary interventions can impact cancer treatment toxicity and efficacy in patients who were undergoing chemotherapy and/or radiotherapy. This information can help clinicians tailor the dietary regimens to patients based on their treatment methods and promote larger clinical trials to test the dietary effects on cancer treatment safety and efficacy.

Abstract

Chemotherapy and radiotherapy are first-line treatments in the management of advanced solid tumors. Whereas these treatments are directed at eliminating cancer cells, they cause significant adverse effects that can be detrimental to a patient’s quality of life and even life-threatening. Diet is a modifiable risk factor that has been shown to affect cancer risk, recurrence, and treatment toxicity, but little information is known how diet interacts with cancer treatment modalities. Although dietary interventions, such as intermittent fasting and ketogenic diets, have shown promise in pre-clinical studies by reducing the toxicity and increasing the efficacy of chemotherapeutics, there remains a limited number of clinical studies in this space. This review surveys the impact of dietary interventions (caloric restriction, intermittent and short-term fasting, and ketogenic diet) on cancer treatment outcomes in both pre-clinical and clinical studies. Early studies support a complementary role for these dietary interventions in improving patient quality of life across multiple cancer types by reducing toxicity and perhaps a benefit in treatment efficacy. Larger, phase III, randomized clinical trials are ultimately necessary to evaluate the efficacy of these dietary interventions in improving oncologic or quality of life outcomes for patients that are undergoing chemotherapy or radiotherapy.