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Nuyts S, Bollen H, Eisbruch A, Strojan P, Mendenhall WM, Ng SP, Ferlito A. Adaptive radiotherapy for head and neck cancer: Pitfalls and possibilities from the radiation oncologist's point of view. Cancer Med 2024; 13:e7192. [PMID: 38650546 PMCID: PMC11036082 DOI: 10.1002/cam4.7192] [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: 01/11/2024] [Revised: 03/19/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Patients with head and neck cancer (HNC) may experience substantial anatomical changes during the course of radiotherapy treatment. The implementation of adaptive radiotherapy (ART) proves effective in managing the consequent impact on the planned dose distribution. METHODS This narrative literature review comprehensively discusses the diverse strategies of ART in HNC and the documented dosimetric and clinical advantages associated with these approaches, while also addressing the current challenges for integration of ART into clinical practice. RESULTS AND CONCLUSION Although based on mainly non-randomized and retrospective trials, there is accumulating evidence that ART has the potential to reduce toxicity and improve quality of life and tumor control in HNC patients treated with RT. However, several questions remain regarding accurate patient selection, the ideal frequency and timing of replanning, and the appropriate way for image registration and dose calculation. Well-designed randomized prospective trials, with a predetermined protocol for both image registration and dose summation, are urgently needed to further investigate the dosimetric and clinical benefits of ART.
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Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of OncologyKU LeuvenLeuvenBelgium
- Department of Radiation OncologyLeuven Cancer Institute, University Hospitals LeuvenLeuvenBelgium
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of OncologyKU LeuvenLeuvenBelgium
- Department of Radiation OncologyLeuven Cancer Institute, University Hospitals LeuvenLeuvenBelgium
| | - Avrahram Eisbruch
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Primoz Strojan
- Department of Radiation Oncology Institute of OncologyUniversity of LjubljanaLjubljanaSlovenia
| | - William M. Mendenhall
- Department of Radiation OncologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Sweet Ping Ng
- Department of Radiation OncologyOlivia Newton‐John Cancer and Wellness Centre, Austin HealthMelbourneAustralia
| | - Alfio Ferlito
- Coordinator International Head and Neck Scientific GroupUdineItaly
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Gobbo M, Joy J, Guedes H, Shazib MA, Anderson C, Abdalla-Aslan R, Peechatanan K, Lajolo C, Nasir KS, Gueiros LA, Nagarajan N, Hafezi Motlagh K, Kandwal A, Rupe C, Xu Y, Ehrenpreis ED, Tonkaboni A, Epstein JB, Bossi P, Wardill HR, Graff SL. Emerging pharmacotherapy trends in preventing and managing oral mucositis induced by chemoradiotherapy and targeted agents. Expert Opin Pharmacother 2024; 25:727-742. [PMID: 38808634 DOI: 10.1080/14656566.2024.2354451] [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: 02/19/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
INTRODUCTION The introduction of targeted therapy and immunotherapy has tremendously changed the clinical outcomes and prognosis of cancer patients. Despite innovative pharmacological therapies and improved radiotherapy (RT) techniques, patients continue to suffer from side effects, of which oral mucositis (OM) is still the most impactful, especially for quality of life. AREAS COVERED We provide an overview of current advances in cancer pharmacotherapy and RT, in relation to their potential to cause OM, and of the less explored and more recent literature reports related to the best management of OM. We have analyzed natural/antioxidant agents, probiotics, mucosal protectants and healing coadjuvants, pharmacotherapies, immunomodulatory and anticancer agents, photobiomodulation and the impact of technology. EXPERT OPINION The discovery of more precise pathophysiologic mechanisms of CT and RT-induced OM has outlined that OM has a multifactorial origin, including direct effects, oxidative damage, upregulation of immunologic factors, and effects on oral flora. A persistent upregulated immune response, associated with factors related to patients' characteristics, may contribute to more severe and long-lasting OM. The goal is strategies to conjugate individual patient, disease, and therapy-related factors to guide OM prevention or treatment. Despite further high-quality research is warranted, the issue of prevention is paramount in future strategies.
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Affiliation(s)
- Margherita Gobbo
- Unit of Oral and Maxillofacial Surgery, Ca' Foncello Hospital, Piazzale Ospedale, Treviso, Italy
| | - Jamie Joy
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Helena Guedes
- Medical Oncology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto, Portugal
| | - Muhammad Ali Shazib
- Workman School of Dental Medicine, High Point University, High Point, NC, USA
| | - Carryn Anderson
- Department of Radiation Oncology, University of Iowa Hospitals & Clinics, Iowa City, USA
| | - Ragda Abdalla-Aslan
- Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Khunthong Peechatanan
- Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia
- Department of Medicine, Division of Medical Oncology, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Carlo Lajolo
- Head and Neck Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Khawaja Shehryar Nasir
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Luiz Alcino Gueiros
- Department of Clinic and Preventive Dentistry & Oral Medicine Unit, Health Sciences Center, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Nivethitha Nagarajan
- Department of Orofacial Sciences, School of Dentistry, University of California San Francisco, California, USA
| | - Kimia Hafezi Motlagh
- Department of Oral Medicine, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Abhishek Kandwal
- Himalayan Institute of Medical Sciences Cancer Research Institute Swami Rama Himalayan University, Uttarakhand, India
| | - Cosimo Rupe
- Head and Neck Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yuanming Xu
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Eli D Ehrenpreis
- Department of Medicine, Advocate Lutheran General Hospital, Park Ridge, IL, USA
- E2Bio Life Sciences, Skokie, IL, USA
| | - Arghavan Tonkaboni
- Oral Medicine Department, School of Dentistry, Tehran University of Medical Science, Tehran, Iran
| | - Joel B Epstein
- Department of Surgery, City of Hope National Cancer Center, Duarte, CA, USA
| | - Paolo Bossi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano (Milan), Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Hannah R Wardill
- School of Biomedicine, The University of Adelaide, Adelaide, Australia
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Stephanie L Graff
- Lifespan Cancer Institute, Providence, RI, USA
- Legorreta Cancer Center, Brown University, Providence, RI, USA
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Castelli J, Thariat J, Benezery K, Hasbini A, Gery B, Berger A, Liem X, Guihard S, Chapet S, Thureau S, Auberdiac P, Pommier P, Ruffier A, Perrier L, Devillers A, Campillo-Gimenez B, de Crevoisier R. Weekly Adaptive Radiotherapy vs Standard Intensity-Modulated Radiotherapy for Improving Salivary Function in Patients With Head and Neck Cancer: A Phase 3 Randomized Clinical Trial. JAMA Oncol 2023; 9:1056-1064. [PMID: 37261806 PMCID: PMC10236337 DOI: 10.1001/jamaoncol.2023.1352] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/08/2023] [Indexed: 06/02/2023]
Abstract
Importance Xerostomia is a major toxic effect associated with intensity-modulated radiotherapy (IMRT) for oropharyngeal cancers. Objective To assess whether adaptive radiotherapy (ART) improves salivary function compared with IMRT in patients with head and neck cancer. Design, Setting, and Participants This phase 3 randomized clinical trial was conducted in 11 French centers. Patients aged 18 to 75 years with stage III-IVB squamous cell oropharyngeal cancer treated with chemoradiotherapy were enrolled between July 5, 2013, and October 1, 2018. Data were analyzed from November 2021 to May 2022. Interventions The patients were randomly assigned (1:1) to receive standard IMRT (without replanning) or ART (systematic weekly replanning). Main Outcomes and Measures The primary end point was the frequency of xerostomia, measured by stimulating salivary flow with paraffin. Secondary end points included salivary gland excretory function measured using technetium-99m pertechnetate scintigraphy, patient-reported outcomes (Eisbruch xerostomia-specific questionnaire and the MD Anderson Symptom Inventory for Head and Neck Cancer questionnaire), early and late toxic effects, disease control, and overall and cancer-specific survival. Results A total of 132 patients were randomized, and after 1 exclusion in the ART arm, 131 were analyzed: 66 in the ART arm (mean [SD] age at inclusion, 60 [8] years; 57 [86.4%] male) and 65 in the standard IMRT arm (mean [SD] age at inclusion, 60 [8] years; 57 [87.7%] male). The median follow-up was 26.4 months (IQR, 1.2-31.3 months). The mean (SD) salivary flow (paraffin) at 12 months was 630 (450) mg/min in the ART arm and 584 (464) mg/min in the standard arm (P = .64). The mean (SD) excretory function of the parotid gland at 12 months, measured by scintigraphy, improved in the ART arm (48% [17%]) compared with the standard arm (41% [17%]) (P = .02). The 2-year-overall survival was 76.9% (95% CI, 64.7%-85.4%) in both arms. Conclusions and Relevance This randomized clinical trial did not demonstrate a benefit of ART in decreasing xerostomia compared with standard IMRT. No significant differences were found in secondary end points except for parotid gland excretory function, as assessed by scintigraphy, or in survival rates. Trial Registration ClinicalTrials.gov Identifier: NCT01874587.
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Affiliation(s)
- Joël Castelli
- University of Rennes, CLCC Eugène Marquis, Inserm, LTSI–UMR 1099, Rennes, France
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Laboratoire de Physique Corpusculaire, Normandie Universite, Caen, France
| | - Karen Benezery
- Department of Radiotherapy, Centre Antoine Lacassagne, Nice, France
| | - Ali Hasbini
- Radiotherapy, Clinique Pasteur-Lanroze, Brest, France
| | - Bernard Gery
- Department of Radiation Oncology, Centre François Baclesse, Laboratoire de Physique Corpusculaire, Normandie Universite, Caen, France
| | - Antoine Berger
- Department of Radiotherapy, CHU Poitiers, Poitiers, France
| | - Xavier Liem
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Center, Lille, France
| | - Sébastien Guihard
- Department of Radiotherapy, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | - Sophie Chapet
- Department of Radiotherapy, CHU Tours, Tours, France
| | | | | | - Pascal Pommier
- Department of Radiotherapy, Centre Léon Bérard, Lyon, France
| | | | - Lionel Perrier
- University Lyon, Léon Bérard Cancer Centre, Lyon, France
| | - Anne Devillers
- Department of Nuclear Medicine, Centre Eugène Marquis, Rennes, France
| | | | - Renaud de Crevoisier
- University of Rennes, CLCC Eugène Marquis, Inserm, LTSI–UMR 1099, Rennes, France
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Dai D, Tian Q, Shui Y, Li J, Wei Q. The impact of radiation induced lymphopenia in the prognosis of head and neck cancer: A systematic review and meta-analysis. Radiother Oncol 2022; 168:28-36. [PMID: 35017020 DOI: 10.1016/j.radonc.2022.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Radiotherapy is a key part of head and neck cancer (HNC) treatment. Radiation induced lymphopenia (RIL) is a severe complication of radiotherapy. The aim of this study was to evaluate the prognostic role of RIL in HNC patients. METHOD We conducted a PRISMA guideline based systemic review and meta-analysis. The studies were identified on the PubMed, Embase and Cochrane Library from 2007 to October 2021. The quality of each study was assessed by Newcastle-Ottawa Quality Assessment Form for Cohort Studies (NOS). RESULTS There were 8 studies with 2,733 samples finally included in current study. The meta-analysis showed that the odds ratio of developing grade 3-4 RIL was 13.49 (95%CI = 7.03-25.89, I2 = 94%). The incidence rate of grade 3-4 RIL ranged from 73%-88%. Multivariate meta-analysis found that the RIL significantly decreased the overall survival (HR = 2.94, 95%CI = 1.83-4.74, I2 = 0%) and distant metastasis free survival of HNC (HR = 3.79, 95%CI = 2.06-6.97, I2 = 0%). After sensitivity analysis and excluding a potential study that caused heterogeneity, the new pooled multivariate meta-analysis showed RIL was a risk factor to the progression free survival of HNC patients (HR = 3.16, 95%CI = 1.77-5.63, I2 = 0%). CONCLUSION This is the first meta-analysis which showed severe RIL decreased the overall survival and promoted the progression of HNC patients. Future large-scale prospective studies are required to evaluate the association between severe RIL and the prognosis of HNC.
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Affiliation(s)
- Dongjun Dai
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiaoying Tian
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongjie Shui
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinfan Li
- Department of Pathology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Qichun Wei
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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