Prospective comparison of acute severe toxicities between smokers and non-smokers during radiotherapy for head and neck cancers

BACKGROUND AND PURPOSE

The association between smoking and acute radiation toxicities of head and neck cancer (HNC) is currently unproven. The aim of the study was to compare the occurrence of acute severe toxicity between active and non-active smokers treated for HNC by radiotherapy.

MATERIALS AND METHODS

A prospective monocentric cohort study included patients treated by (chemo)radiotherapy for HNC from January 2021 to January 2023. Smoking status was recorded. Patients underwent a medical exam weekly during the radiotherapy to report acute toxicities according to the Common Terminology Criteria for Adverse Effects system version 5.0. Primary endpoint was the occurrence of at least one grade ≥ 3 acute toxicity among mucositis, dysphagia and dermatitis.

RESULTS

Among the 102 patients included, 27.4 % were active smokers, 58.8 % were former smokers and 13.7 % had never smoked. Regarding toxicity, 23.5 % (n = 24) patients experienced severe mucositis, 37.2 % (n = 38) severe dysphagia, 13.7 % (n = 14) severe dermatitis and 54.9 % (n = 56) experienced at least one of them. Occurrence of severe acute toxicity was not statistically associated with smoking during radiotherapy (64.3 % among active smokers versus 51.3 % among non-active smokers; p = 0.24). On multivariate analysis, concurrent chemotherapy (87.5 % vs 65.2 %; OR = 5.04 [1.64-15.52]; p = 0.004) and 2.12 Gy versus 2 Gy fractionation schedule (64.3 % vs 41.3 %; OR = 2.53 [1.09-5.90]; p = 0.03) were significantly associated with severe acute toxicity.

CONCLUSION

This study did not find an association between smoking during radiotherapy for HNC and occurrence of severe acute toxicities.

Efficacy of Protontherapy in Atypical Meningiomas

PURPOSE/OBJECTIVE(S)

To assess the efficacy and safety of complementary radiotherapy (RT) [by proton beams alone (PT) or in combination with photon beams (Ph)] to surgery in the local treatment of atypical meningiomas.

MATERIALS/METHODS

One hundred one consecutive patients with atypical (WHO grade II) meningiomas were treated with PT +/- Ph at our institution between Nov 1996 to Sep 2022. The total median dose was 59.4 Gy RBE (range 59.4- 68.4) with Proton component alone (n = 76) or PT + Ph (n = 25). The median age at RT was 57.2 years old (range 22.0-79.6). Localization was supratentorial in 62 patients (61.4%), skull base in 29 patients (28.7%), and infratentorial in 10 patients (9.9%). Gross tumor resection was reported in 20 cases (19.8%) and subtotal in 81 (80.2%), 34 patients underwent multiples (2-4) surgeries before RT. Overall survival (OS), meningioma related survival (MRS), Progression Free Survival (PFS), Time to Local progression (TLP), and 3, 5 and 10-year survival rates were evaluated using Kaplan-Meier method. All post-PT clinical toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE v 5.0).

RESULTS

During follow-up after PT (median 47.8 months), local progression was reported in 26 patients (25.7%) and 24 patients died (including 13 meningioma-related deaths). Median TLP was 34.3 months (IC 95% 1.9-128.1), OS was 163 months (IC95% 93.9-232.2), MRS was 34.3 (IC 95% 1.9-128.1) and PFS was 41.4 (IC 95% 1.5-217.8). Actuarial 3, 5 and 9-year OS was 83%, 78% and 66%, while MRS was 89%, 83% and 71% respectively. Patients treated with PT alone presented better OS with 9 deaths (6 meningioma-related deaths) and median of 163.0 months [IC95% (93.9-232.2)], 3y-95%, 5y-93%, 10y-65%, respectively. However, the Patients treated with PT+Ph presented 15 deaths (7 meningioma-related deaths) and median of 51.9 months [IC 95% (7.0-96.8); 2y-75%, 5y-50%, 10y-50%) (p = 0.018). Median TLR was 36.4 months (26.6-46.2) after PT alone and 11.9 months (10.3-13.5) after PT+Ph. However, well-controlled radionecrosis ≤ Grade2 was more frequent after PT alone 20 cases vs 3 cases after PT+Ph. Long-term symptoms was observed during the last visit in 45 patients (44.6%) treated with PT vs. 8 (38.1%) treated with PT+Ph.

CONCLUSION

PT alone or PT+Ph were effective and well-tolerated treatment in WHO grade II meningioma and PT alone appeared to be better for the local control and survival.

[Radiotherapy and targeted therapy for the management of breast cancer: A review]

The purpose of this study was to review the current knowledge regarding combinations of the most commonly used targeted therapies or those under development for the management of breast cancer with radiation therapy. Several studies have shown that the combination of radiation therapy and tamoxifen increased the risk of radiation-induced lung toxicity; therefore, the two modalities are generally not given concurrently. The combination of HER2 inhibitors (trastuzumab, pertuzumab) and radiation therapy appeared to be safe. However, trastuzumab emtansine (T-DM1) should not be given concomitantly with brain radiation therapy because this combination may increase the risk of brain radionecrosis. The combination of radiation therapy with other new targeted therapies such as new selective estrogen receptor modulators (SERDs), lapatinib, cell cycle inhibitors, immune checkpoint inhibitors, or molecules acting on DNA damage repair seems feasible but has been mainly evaluated on retrospective or prospective studies with small numbers of patients. Moreover, there is a great heterogeneity between these studies regarding the dose and fractionation used in radiotherapy, the dosage of systemic treatments and the sequence of treatments used. Therefore, the combination of these new molecules with radiotherapy should be proposed sparingly, under close monitoring, pending the ongoing prospective studies cited in this review.

[Limits of dose constraint definition for organs at risk specific to stereotactic radiotherapy]

Stereotactic radiotherapy is a very hypofractionated radiotherapy (>7.5Gy per fraction), and therefore is more likely to induce late toxicities than conventional normofractionated irradiations. The present study examines four frequent and potentially serious late toxicities: brain radionecrosis, radiation pneumonitis, radiation myelitis, and radiation-induced pelvic toxicities. The critical review focuses on the toxicity scales, the definition of the dose constrained volume, the dosimetric parameters, and the non-dosimetric risk factors. The most commonly used toxicity scales remain: RTOG/EORTC or common terminology criteria for adverse events (CTCAE). The definition of organ-at-risk volume requiring protection is often controversial, which limits the comparability of studies and the possibility of accurate dose constraints. Nevertheless, for the brain, whatever the indication (arteriovenous malformation, benign tumor, metastasis of solid tumors...), the association between the volume of brain receiving 12Gy (V12Gy) and the risk of cerebral radionecrosis is well established for both single and multi-fraction stereotactic irradiation. For the lung, the average dose received by both lungs and the V20 seem to correlate well with the risk of radiation-induced pneumonitis. For the spinal cord, the maximum dose is the most consensual parameter. Clinical trial protocols are useful for nonconsensual dose constraints. Non-dosimetric risk factors should be considered when validating the treatment plan.

[Biological, preclinical and clinical aspects of the association between radiation therapy and CDK4/6 inhibitors]

Several clinical studies have shown that CDK4/6 inhibitors (CDK4/6i) improve survival in patients with metastatic or locally advanced HR-positive, HER-2-negative breast cancer (BC). The aim of this review was to synthesize the biological, preclinical and clinical aspects of the treatment of BC with CDK4/6i, with a focus on the combination of CDK4/6i and radiotherapy. The DNA damage induced after exposure of cells to ionizing radiation activates control pathways that inhibit cell progression in the G1 and G2 phases and induce a transient delay in progression in the S phase. These checkpoints are in particular mediated by cyclin-dependent kinases (CDK) 4/6 activated by cyclin D1. Several preclinical studies have shown that CDK4/6i could be used as radiosensitizers in non-small cell lung cancer, medulloblastoma, brainstem glioma and breast cancer. CDK4/6 inhibition also protected against radiation-induced intestinal toxicities by inducing redistribution of quiescent intestinal progenitor cells, making them less radiosensitive. Clinical data on the combination of CDK inhibitors and radiotherapy for both locoregional and metastatic irradiation are based on retrospective data. Nevertheless, the most optimal therapeutic sequence would be radiotherapy followed by palbociclib. Pending prospective clinical trials, the concomitant combination of the two treatments should be done under close supervision.

Multidisciplinary management and role of reirradiation in the treatment of a breast cancer patient with four locoregional recurrences

Breast cancer is a frequent and sometimes fatal disease. The risk of locoregional recurrence has considerably decreased since the introduction of adjuvant treatments (radiotherapy, chemotherapy, hormone therapy). Nevertheless, some patients present a risk of multiple local recurrences. We report here the case of a patient who had four locoregional breast cancer recurrences. There is currently no validated biomarker that allows the prediction of recurrence. Salvage surgery, most often mastectomy, remains the recommended treatment for the management of these recurrences in the irradiated field. However, increasingly, depending on the patient's wishes and the technical possibilities of multiple surgeries, the question of a second conservative treatment and reirradiation arises. This type of management must in all cases be multidisciplinary and in specialized centers. Reirradiation must in any case try to give maximum priority to the protection of healthy tissue already irradiated.

Is cancer a prognostic factor for severe COVID-19, especially for breast cancer patients?

The coronavirus disease 2019 (COVID-19) pandemic has caused a global upheaval in our health care system. Our hospital facilities have been subjected to a major influx of patients and the prevention of cross-contamination has been a key issue in the spread of the virus. New recommendations for good hygiene practice and new recommendations for disease management have emerged to limit the spread of the virus and reorganize the provision of care in key services. Many studies have attempted to identify factors that contribute to poor prognosis for COVID-19 infection. Among them, cancer patients, were considered more at risk of developing severe forms of COVID-19. In this article, we provide an overview of the current state of the pandemic as well as new recommendations for disease management that have emerged in oncology and radiation therapy in particular. In this article, we will try to provide some answers through a review of the literature to the question: is cancer a prognostic factor for severe COVID-19?

Assessment of Side Effects of Radiation Therapy in Patients With COVID-19 Treated for Early-Stage Breast Cancer

Purpose/Objective(s)

The Covid-19 caused by the SARS-COV-2 coronavirus is at the origin of a global pandemic. This pandemic has prompted the current health system to reorganize and rethink the care offered by health establishments. We report the early and late toxicity in patients infected with COVID-19 treated at the same time for early-stage breast cancer (BC) toxicity.

Materials/Methods

This is a monocentric prospective study of patients treated in our hospital between March and June 2020. The monocentric registry was created for all cancer patients who were diagnosed with COVID 19 infection. The inclusion criteria of the patients evaluated were to be irradiated for early-stage breast cancer and to have a positive COVID diagnosis on a PCR test and / or a lung computed tomography (CT) scan and / or suggestive clinical symptoms. All of them needed 6 months follow up clinic after the end of the radiotherapy with clinical examination, mammogram, as well as CT scan to evaluate the lung status. Radiotherapy (RT) consisted of 50 Gy to the breast or chest wall with or without lymph node irradiation, as well as hypofractionated schemes adapted to pandemic situation. The treatment-related toxicity was graded according to the CTCAE (version 4.03).

Results

Three hundred fifty patients (pts) have been treated for early-stage BC in our Department between 03/2017 and 06/2020. Of them, 16 were presented with clinical symptoms of COVID 19 infection and of them 12 had clinical, CT scan and PCR confirmation. This entire cohort of 12 pts with median age of 56 (42-72) underwent their RT. All patients were invited to realize CT scan 6 months after the end of RT and to come in the hospital for clinical and radiological evaluation. During the radiotherapy, there were 9 pts presented radio dermatitis, of the 8 (66%): grade 1 and one (8%) grade 2. Two patients treated to the regional lymph nodes presented esophagitis de grade 2. The late toxicity as well as the lung radiological evaluation was realized 6 months after the end of the radiotherapy and there was no RT or COVID lung sequel on the CT scans. There was one patient who presented COVID related dyspnea, and 2 patients with post treatment fibrosis.

Conclusion

The half-year follow-up of prospective COVID19+ cohort, treated for early-stage BC demonstrated an acceptable toxicity profile with few low-grade adverse events. It seems that the COVID 19 infection does not appear to increase the side effects of RT. Therefore, the RT should not be delayed.

Unusual severe radiation-induced toxicity in a patient with discoid lupus erythematosus: A case report and critical review of the literature

Data on the incidence and severity of radiation-induced toxicity in patients with systemic and/or cutaneous lupus erythematosus (SLE/CLE) are very limited. After reporting the case of a patient who experienced major toxicity and CLE flare in the irradiated area following breast irradiation, we conducted a comprehensive literature review of available data in this setting. The few retrospectives studies which have evaluated both the risk of toxicity in SLE/CLE patients and/or the potential induction or reactivation of SLE/CLE with radiotherapy have not shown differences between SLE/CLE patients and controls. Several other factors such as concurrent chemotherapy, a particular genetic background, or lupus treatments (essentially hydroxychloroquine) can explain severe radiation-induced toxicity. Therefore, patients with SLE/CLE should be irradiated like patients without SLE/CLE, with close monitoring during radiotherapy if other risk factors exist. Further studies examining a larger number of patients would probably allow a better understanding of the radiosensitivity of these patients.

Clinical practice of breast cancer protontherapy: A single-centre experience from selection to treatment

PURPOSE

Breast protontherapy efficiently limits cardiac, lung and contralateral breast exposure, which may clinically translate into better late tolerance profile compared with classic photon techniques. While breast protontherapy is already implemented in the United States and in some European countries, clinical experience of breast cancer protontherapy is currently limited in France. The aim of this study is to evaluate the clinical practice of breast cancer protontherapy at the Institut Curie in order to implement this technique at a larger scale.

MATERIALS AND METHODS

Data from all breast cancer patients that have been addressed to the protontherapy centre of Orsay (CPO, Institut Curie) for adjuvant breast protontherapy were retrieved. We analysed why these patients were ultimately treated with protontherapy or not.

RESULTS

Between November 2019 and November 2020, eleven breast cancer patients have been evaluated for adjuvant protontherapy at the CPO. Two of them were ultimately treated with proton beams; adjuvant breast protontherapy therapy was well tolerated. The nine other patients were not treated with protontherapy due to lack of availability of protontherapy treatment rooms in acceptable time limits, at the time of patient evaluation.

CONCLUSION

Despite dosimetric advantages and excellent clinical tolerance, lack of availability of protontherapy machines currently limits wider implementation of breast protontherapy.

[Proton therapy for head and neck squamous cell carcinomas: From physics to clinic]

Intensity-modulated radiation therapy (IMRT) is presently the recommended technique for the treatment of locally advanced head and neck carcinomas. Proton therapy would allow to reduce the volume of irradiated normal tissue and, thus, to decrease the risk of late dysphagia, xerostomia, dysgeusia and hypothyroidism. An exhaustive research was performed with the search engine PubMed by focusing on the papers about the physical difficulties that slow down use of proton therapy for head and neck carcinomas. Range uncertainties in proton therapy (±3 %) paradoxically limit the use of the steep dose gradient in distality. Calibration uncertainties can be important in the treatment of head and neck cancer in the presence of materials of uncertain stoichiometric composition (such as with metal implants, dental filling, etc.) and complex heterogeneities. Dental management for example may be different with IMRT or proton therapy. Some uncertainties can be somewhat minimized at the time of optimization. Inter- and intrafractional variations and uncertainties in Hounsfield units/stopping power can be integrated in a robust optimization process. Additional changes in patient's anatomy (tumour shrinkage, changes in skin folds in the beam patch, large weight loss or gain) require rescanning. Dosimetric and small clinical studies comparing photon and proton therapy have well shown the interest of proton therapy for head and neck cancers. Intensity-modulated proton therapy is a promising treatment as it can reduce the substantial toxicity burden of patients with head and neck squamous cell carcinoma compared to IMRT. Robust optimization will allow to perform an optimal treatment and to use proton therapy in current clinical practice.

[Ascaridiasis zoonoses: visceral larva migrans syndromes]

The syndrome of Visceral Larva Migrans is a zoonotic disease due to the migration in human of nematodes larval, specially ascarid. Since the larvae fail to complete their migrating cycle in humans, the diagnosis of Toxocariasis infection remains only serologic. We have been able to demonstrate by the technique of agar diffusion and the Western-blotting method that the etiology due to Toxocara canis was twice as much frequent as the one due to Toxocara cati in the syndrome of Visceral and Ocular Larva Migrans. The use of numerous antigens from adult nematodes, mainly Ascaris suum, has shown, than in France, in the syndrome of VLM at least 12% of the cases were certainly due to other nematodes. Nippostrongylus brasiliensis (or another similar nematode) of the rat might be responsible. The existence of numerous clinical and biological cases found negative in serology, allow us to suggest that some other larval nematodes, may be from wild animals, might play an etiological role.