Simulated effects of tidal inundation and light reduction on Zostera muelleri flowering in seagrass nurseries

Zostera muelleri is an abundant seagrass species distributed through intertidal and shallow subtidal waters on the subtropical coasts of Australia. The vertical distribution of Zostera is likely defined by tidal influences, particularly desiccation and light reduction stresses. These stresses were expected to affect the flowering of Z. muelleri; however, it is difficult to quantify the effects of tidal inundation with field studies due to multiple confounding environmental factors affecting flowering (e.g., water temperature, herbivory, nutrients). A laboratory aquarium experiment compared the effects of two levels of tidal height (intertidal and subtidal) and light intensity (shaded and unshaded) on flowering timing, abundance, the ratio between flowering shoots and vegetative shoots, the morphology and duration of flower development. The earliest and greatest flowering intensity was recorded in the subtidal-unshaded group, with no flowers observed in the intertidal-shaded group. Notably, the peak flowering time was the same across shaded and unshaded treatments. Shading prolonged the timing of the first flowering and reduced the density of flowering shoots and spathes, while tidal inundation had a more significant effect on the density of flowering shoots and the density of spathes. Results showed that Z. muelleri could flower under low light conditions or tidal stress but not when exposed to both stresses simultaneously in a laboratory 'nursery setting'. Therefore, applying subtidal-unshaded conditions appears to be beneficial for seagrass nurseries aimed at improved flower abundance despite the plants previously being collected from and adapted to intertidal meadows. Further studies that explore the suitable conditions for triggering and optimising the flowering will be beneficial in designing cost-effective seagrass nurseries.

Exploring the risks and benefits of flexibility in biodiversity offset location in a case study of migratory shorebirds

Biodiversity offsets aim to counterbalance the residual impacts of development on species and ecosystems. Guidance documents explicitly recommend that biodiversity offset actions be located close to the location of impact because of higher potential for similar ecological conditions, but allowing greater spatial flexibility has been proposed. We examined the circumstances under which offsets distant from the impact location could be more likely to achieve no net loss or provide better ecological outcomes than offsets close to the impact area. We applied a graphical model for migratory shorebirds in the East Asian-Australasian Flyway as a case study to explore the problems that arise when incorporating spatial flexibility into offset planning. Spatially flexible offsets may alleviate impacts more effectively than local offsets; however, the risks involved can be substantial. For our case study, there were inadequate data to make robust conclusions about the effectiveness and equivalence of distant habitat-based offsets for migratory shorebirds. Decisions around offset placement should be driven by the potential to achieve equivalent ecological outcomes; however, when considering more distant offsets, there is a need to evaluate the likely increased risks alongside the potential benefits. Although spatially flexible offsets have the potential to provide more cost-effective biodiversity outcomes and more cobenefits, our case study showed the difficulty of demonstrating these benefits in practice and the potential risks that need to be considered to ensure effective offset placement.

Greater Consideration of Animals Will Enhance Coastal Restoration Outcomes

As efforts to restore coastal habitats accelerate, it is critical that investments are targeted to most effectively mitigate and reverse habitat loss and its impacts on biodiversity. One likely but largely overlooked impediment to effective restoration of habitat-forming organisms is failing to explicitly consider non-habitat-forming animals in restoration planning, implementation, and monitoring. These animals can greatly enhance or degrade ecosystem function, persistence, and resilience. Bivalves, for instance, can reduce sulfide stress in seagrass habitats and increase drought tolerance of saltmarsh vegetation, whereas megaherbivores can detrimentally overgraze seagrass or improve seagrass seed germination, depending on the context. Therefore, understanding when, why, and how to directly manipulate or support animals can enhance coastal restoration outcomes. In support of this expanded restoration approach, we provide a conceptual framework, incorporating lessons from structured decision-making, and describe potential actions that could lead to better restoration outcomes using case studies to illustrate practical approaches.

Drivers of global mangrove loss and gain in social-ecological systems

Mangrove forests store high amounts of carbon, protect communities from storms, and support fisheries. Mangroves exist in complex social-ecological systems, hence identifying socioeconomic conditions associated with decreasing losses and increasing gains remains challenging albeit important. The impact of national governance and conservation policies on mangrove conservation at the landscape-scale has not been assessed to date, nor have the interactions with local economic pressures and biophysical drivers. Here, we assess the relationship between socioeconomic and biophysical variables and mangrove change across coastal geomorphic units worldwide from 1996 to 2016. Globally, we find that drivers of loss can also be drivers of gain, and that drivers have changed over 20 years. The association with economic growth appears to have reversed, shifting from negatively impacting mangroves in the first decade to enabling mangrove expansion in the second decade. Importantly, we find that community forestry is promoting mangrove expansion, whereas conversion to agriculture and aquaculture, often occurring in protected areas, results in high loss. Sustainable development, community forestry, and co-management of protected areas are promising strategies to reverse mangrove losses, increasing the capacity of mangroves to support human-livelihoods and combat climate change.

Simulated megaherbivore grazing as a driver of seagrass flowering

Seagrass meadows are an important habitat for Testudines (sea turtles) and Sirenia (dugong and manatee) megaherbivores. Megaherbivores can influence the structuring of seagrass meadows; for example, foraging patterns have been found to relate to seagrass phenological strategy. However, as these observations are derived from uncontrolled field studies, it is unclear whether grazing drives such changes or if the changes are related to other factors (e.g., temperature, tidal depth, light). In the present study, a mesocosm experiment was designed to test the impacts of grazing on metrics of flowering of Zostera muelleri over two consecutive flowering seasons. Prior to each flowering season, plants were cropped to 3 cm and 1 cm lengths to represent turtle and dugong grazing, respectively. This study measured the timing of flowering, the number of flowering shoots, the height of the flowering shoot, and the number of spathes (sheathing bracts containing seeds) per flowering shoot in each replicate (n = 5) weekly. Cropping had no significant influence on the timing of flowering (i.e., number of days to first and peak flowering) indicating that it is not a trigger for flowering. However, cropping significantly reduced the maximum density of flowering shoots and spathes, which was proposed to be due to resource allocation differences between clonal growth and flower production. A reduction in the flowering ratio was observed in both cropped plant groups and the relatively high density and the ratio of flowering observed in the 1 cm group indicate that the plant was adapting to cope with stress. Morphology of flowering (i.e., the maximum height of flowering shoot and the maximum number of spathes per flowering shoot) was not significantly affected by cropping and these two variables were strongly correlated. The results suggest that cropping can influence the overall flowering densities in a season but not the timing of flowering. This study demonstrated that cropping prior to the flowering season can reduce the expected production of spathes in seed nurseries and suggests it may be beneficial to consider megaherbivores in seed-based restoration activities.

High-resolution mapping of losses and gains of Earth's tidal wetlands

Tidal wetlands are expected to respond dynamically to global environmental change, but the extent to which wetland losses have been offset by gains remains poorly understood. We developed a global analysis of satellite data to simultaneously monitor change in three highly interconnected intertidal ecosystem types-tidal flats, tidal marshes, and mangroves-from 1999 to 2019. Globally, 13,700 square kilometers of tidal wetlands have been lost, but these have been substantially offset by gains of 9700 km², leading to a net change of -4000 km² over two decades. We found that 27% of these losses and gains were associated with direct human activities such as conversion to agriculture and restoration of lost wetlands. All other changes were attributed to indirect drivers, including the effects of coastal processes and climate change.

Connecting targets for catchment sediment loads to ecological outcomes for seagrass using multiple lines of evidence

Catchment impacts on downstream ecosystems are difficult to quantify, but important for setting management targets. Here we compared 12 years of monitoring data of seagrass area and biomass in Cleveland Bay, northeast Australia, with discharge and associated sediment loads from nearby rivers. Seagrass biomass and area exhibited different trajectories in response to river inputs. River discharge was a slightly better predictor of seagrass indicators than total suspended solid (TSS) loads, indicating that catchment effects on seagrass are not restricted to sediment. Linear relationships between Burdekin River TSS loads delivered over 1-4 years and seagrass condition in Cleveland Bay generated Ecologically Relevant Targets (ERT) for catchment sediment inputs. Our predicted ERTs were comparable to those previously estimated using mechanistic models. This study highlights the challenges of linking catchment inputs to condition of downstream ecosystems, and the importance of integrating a variety of metrics and approaches to increase confidence in ERTs.

Synthesising wave attenuation for seagrass: Drag coefficient as a unifying indicator

An estimated 100 million people inhabit coastal areas at risk from flooding and erosion due to climate change. Seagrass meadows, like other coastal ecosystems, attenuate waves. Due to inconsistencies in how wave attenuation is measured results cannot be directly compared. We synthesised data from laboratory and field experiments of seagrass-wave attenuation by converting measurements to drag coefficients (C_D). Drag coefficients varied from 0.02-5.12 with C_D¯ = 0.74 for studies conducted in turbulent flow in non-storm conditions. A statistical model suggested that seagrass species affects C_D although the exact mechanism remains unclear. A wave model using the estimated C_D¯ as an input parameter demonstrated that wave attenuation increased with meadow length, shoot density, shoot width and canopy height. Findings can be used to estimate wave attenuation by seagrass, in any given set of conditions.

Simple rules can guide whether land- or ocean-based conservation will best benefit marine ecosystems

Coastal marine ecosystems can be managed by actions undertaken both on the land and in the ocean. Quantifying and comparing the costs and benefits of actions in both realms is therefore necessary for efficient management. Here, we quantify the link between terrestrial sediment runoff and a downstream coastal marine ecosystem and contrast the cost-effectiveness of marine- and land-based conservation actions. We use a dynamic land- and sea-scape model to determine whether limited funds should be directed to 1 of 4 alternative conservation actions—protection on land, protection in the ocean, restoration on land, or restoration in the ocean—to maximise the extent of light-dependent marine benthic habitats across decadal timescales. We apply the model to a case study for a seagrass meadow in Australia. We find that marine restoration is the most cost-effective action over decadal timescales in this system, based on a conservative estimate of the rate at which seagrass can expand into a new habitat. The optimal decision will vary in different social–ecological contexts, but some basic information can guide optimal investments to counteract land- and ocean-based stressors: (1) marine restoration should be prioritised if the rates of marine ecosystem decline and expansion are similar and low; (2) marine protection should take precedence if the rate of marine ecosystem decline is high or if the adjacent catchment is relatively intact and has a low rate of vegetation decline; (3) land-based actions are optimal when the ratio of marine ecosystem expansion to decline is greater than 1:1.4, with terrestrial restoration typically the most cost-effective action; and (4) land protection should be prioritised if the catchment is relatively intact but the rate of vegetation decline is high. These rules of thumb illustrate how cost-effective conservation outcomes for connected land–ocean systems can proceed without complex modelling.

Many coastal marine ecosystems are threatened by anthropogenic activities, but often, the best way to restore and protect these important ecosystems is unclear. Conventional wisdom suggests that the 2 most effective conservation actions to benefit coastal marine ecosystems are implementation of marine protected areas or, alternatively, reduction of land-based threats. Active marine restoration is typically considered a low-priority option, in part due to high costs and low success rates. But does this conventional wisdom hold up to closer scrutiny? We developed a model to ask: should we restore or protect, on either the land or in the ocean, to maximise the extent of coastal marine ecosystems? We based the model on seagrass meadows and adjacent catchments in Queensland, Australia. Surprisingly, we found that direct, active marine restoration can be the most cost-effective approach to maximising extent of marine ecosystems over longer (decades-long) timescales. There is, however, substantial uncertainty in our understanding of the dynamics of complex linked land–sea ecosystems. Further, geomorphological and ecological conditions vary geographically. Therefore, we also used the model to investigate how uncertainty in key parameters affects decision-making outcomes. Our results can be used to guide investment into coastal marine conservation in the absence of complex, region-specific modelling.

The cost and feasibility of marine coastal restoration

Land-use change in the coastal zone has led to worldwide degradation of marine coastal ecosystems and a loss of the goods and services they provide. Restoration is the process of assisting the recovery of an ecosystem that has been degraded, damaged, or destroyed and is critical for habitats where natural recovery is hindered. Uncertainties about restoration cost and feasibility can impede decisions on whether, what, how, where, and how much to restore. Here, we perform a synthesis of 235 studies with 954 observations from restoration or rehabilitation projects of coral reefs, seagrass, mangroves, salt-marshes, and oyster reefs worldwide, and evaluate cost, survival of restored organisms, project duration, area, and techniques applied. Findings showed that while the median and average reported costs for restoration of one hectare of marine coastal habitat were around US$80000 (2010) and US$1600000 (2010), respectively, the real total costs (median) are likely to be two to four times higher. Coral reefs and seagrass were among the most expensive ecosystems to restore. Mangrove restoration projects were typically the largest and the least expensive per hectare. Most marine coastal restoration projects were conducted in Australia, Europe, and USA, while total restoration costs were significantly (up to 30 times) cheaper in countries with developing economies. Community- or volunteer-based marine restoration projects usually have lower costs. Median survival of restored marine and coastal organisms, often assessed only within the first one to two years after restoration, was highest for saltmarshes (64.8%) and coral reefs (64.5%) and lowest for seagrass (38.0%). However, success rates reported in the scientific literature could be biased towards publishing successes rather than failures. The majority of restoration projects were short-lived and seldom reported monitoring costs. Restoration success depended primarily on the ecosystem, site selection, and techniques applied rather than on money spent. We need enhanced investment in both improving restoration practices and large-scale restoration.

The cost and feasibility of marine coastal restoration

Land-use change in the coastal zone has led to worldwide degradation of marine coastal ecosystems and a loss of the goods and services they provide. Restoration is the process of assisting the recovery of an ecosystem that has been degraded, damaged, or destroyed and is critical for habitats where natural recovery is hindered. Uncertainties about restoration cost and feasibility can impede decisions on whether, what, how, where, and how much to restore. Here, we perform a synthesis of 235 studies with 954 observations from restoration or rehabilitation projects of coral reefs, seagrass, mangroves, salt-marshes, and oyster reefs worldwide, and evaluate cost, survival of restored organisms, project duration, area, and techniques applied. Findings showed that while the median and average reported costs for restoration of one hectare of marine coastal habitat were around US$80000 (2010) and US$1600000 (2010), respectively, the real total costs (median) are likely to be two to four times higher. Coral reefs and seagrass were among the most expensive ecosystems to restore. Mangrove restoration projects were typically the largest and the least expensive per hectare. Most marine coastal restoration projects were conducted in Australia, Europe, and USA, while total restoration costs were significantly (up to 30 times) cheaper in countries with developing economies. Community- or volunteer-based marine restoration projects usually have lower costs. Median survival of restored marine and coastal organisms, often assessed only within the first one to two years after restoration, was highest for saltmarshes (64.8%) and coral reefs (64.5%) and lowest for seagrass (38.0%). However, success rates reported in the scientific literature could be biased towards publishing successes rather than failures. The majority of restoration projects were short-lived and seldom reported monitoring costs. Restoration success depended primarily on the ecosystem, site selection, and techniques applied rather than on money spent. We need enhanced investment in both improving restoration practices and large-scale restoration.

Anticipative management for coral reef ecosystem services in the 21st century

Under projections of global climate change and other stressors, significant changes in the ecology, structure and function of coral reefs are predicted. Current management strategies tend to look to the past to set goals, focusing on halting declines and restoring baseline conditions. Here, we explore a complementary approach to decision making that is based on the anticipation of future changes in ecosystem state, function and services. Reviewing the existing literature and utilizing a scenario planning approach, we explore how the structure of coral reef communities might change in the future in response to global climate change and overfishing. We incorporate uncertainties in our predictions by considering heterogeneity in reef types in relation to structural complexity and primary productivity. We examine 14 ecosystem services provided by reefs, and rate their sensitivity to a range of future scenarios and management options. Our predictions suggest that the efficacy of management is highly dependent on biophysical characteristics and reef state. Reserves are currently widely used and are predicted to remain effective for reefs with high structural complexity. However, when complexity is lost, maximizing service provision requires a broader portfolio of management approaches, including the provision of artificial complexity, coral restoration, fish aggregation devices and herbivore management. Increased use of such management tools will require capacity building and technique refinement and we therefore conclude that diversification of our management toolbox should be considered urgently to prepare for the challenges of managing reefs into the 21st century.

Transforming management of tropical coastal seas to cope with challenges of the 21st century

Over 1.3 billion people live on tropical coasts, primarily in developing countries. Many depend on adjacent coastal seas for food, and livelihoods. We show how trends in demography and in several local and global anthropogenic stressors are progressively degrading capacity of coastal waters to sustain these people. Far more effective approaches to environmental management are needed if the loss in provision of ecosystem goods and services is to be stemmed. We propose expanded use of marine spatial planning as a framework for more effective, pragmatic management based on ocean zones to accommodate conflicting uses. This would force the holistic, regional-scale reconciliation of food security, livelihoods, and conservation that is needed. Transforming how countries manage coastal resources will require major change in policy and politics, implemented with sufficient flexibility to accommodate societal variations. Achieving this change is a major challenge - one that affects the lives of one fifth of humanity.

Impact of sea-level rise and coral mortality on the wave dynamics and wave forces on barrier reefs

A one-dimensional wave model was used to investigate the reef top wave dynamics across a large suite of idealized reef-lagoon profiles, representing barrier coral reef systems under different sea-level rise (SLR) scenarios. The modeling shows that the impacts of SLR vary spatially and are strongly influenced by the bathymetry of the reef and coral type. A complex response occurs for the wave orbital velocity and forces on corals, such that the changes in the wave dynamics vary reef by reef. Different wave loading regimes on massive and branching corals also leads to contrasting impacts from SLR. For many reef bathymetries, wave orbital velocities increase with SLR and cyclonic wave forces are reduced for certain coral species. These changes may be beneficial to coral health and colony resilience and imply that predicting SLR impacts on coral reefs requires careful consideration of the reef bathymetry and the mix of coral species.

Coastal retreat and improved water quality mitigate losses of seagrass from sea level rise

The distribution and abundance of seagrass ecosystems could change significantly over the coming century due to sea level rise (SLR). Coastal managers require mechanistic understanding of the processes affecting seagrass response to SLR to maximize their conservation and associated provision of ecosystem services. In Moreton Bay, Queensland, Australia, vast seagrass meadows supporting populations of sea turtles and dugongs are juxtaposed with the multiple stressors associated with a large and rapidly expanding human population. Here, the interactive effects of predicted SLR, changes in water clarity, and land use on future distributions of seagrass in Moreton Bay were quantified. A habitat distribution model of present day seagrass in relation to benthic irradiance and wave height was developed which correctly classified habitats in 83% of cases. Spatial predictions of seagrass and presence derived from the model and bathymetric data were used to initiate a SLR inundation model. Bathymetry was iteratively modified based on SLR and sedimentary accretion in seagrass to simulate potential seagrass habitat at 10 year time steps until 2100. The area of seagrass habitat was predicted to decline by 17% by 2100 under a scenario of SLR of 1.1 m. A scenario including the removal of impervious surfaces, such as roads and houses, from newly inundated regions, demonstrated that managed retreat of the shoreline could potentially reduce the overall decline in seagrass habitat to just 5%. The predicted reduction in area of seagrass habitat could be offset by an improvement in water clarity of 30%. Greater improvements in water clarity would be necessary for larger magnitudes of SLR. Management to improve water quality will provide present and future benefits to seagrasses under climate change and should be a priority for managers seeking to compensate for the effects of global change on these valuable habitats.

Managing for interactions between local and global stressors of ecosystems

Global stressors, including climate change, are a major threat to ecosystems, but they cannot be halted by local actions. Ecosystem management is thus attempting to compensate for the impacts of global stressors by reducing local stressors, such as overfishing. This approach assumes that stressors interact additively or synergistically, whereby the combined effect of two stressors is at least the sum of their isolated effects. It is not clear, however, how management should proceed for antagonistic interactions among stressors, where multiple stressors do not have an additive or greater impact. Research to date has focussed on identifying synergisms among stressors, but antagonisms may be just as common. We examined the effectiveness of management when faced with different types of interactions in two systems--seagrass and fish communities--where the global stressor was climate change but the local stressors were different. When there were synergisms, mitigating local stressors delivered greater gains, whereas when there were antagonisms, management of local stressors was ineffective or even degraded ecosystems. These results suggest that reducing a local stressor can compensate for climate change impacts if there is a synergistic interaction. Conversely, if there is an antagonistic interaction, management of local stressors will have the greatest benefits in areas of refuge from climate change. A balanced research agenda, investigating both antagonistic and synergistic interaction types, is needed to inform management priorities.

Fussy feeders: phyllosoma larvae of the Western Rocklobster (Panulirus cygnus) demonstrate prey preference

The Western Rocklobster (Panulirus cygnus) is the most valuable single species fishery in Australia and the largest single country spiny lobster fishery in the world. In recent years a well-known relationship between oceanographic conditions and lobster recruitment has become uncoupled, with significantly lower recruitment than expected, generating interest in the factors influencing survival and development of the planktonic larval stages. The nutritional requirements and wild prey of the planktotrophic larval stage (phyllosoma) of P. cygnus were previously unknown, hampering both management and aquaculture efforts for this species. Ship-board feeding trials of wild-caught mid-late stage P. cygnus phyllosoma in the eastern Indian Ocean, off the coast of Western Australia, were conducted in July 2010 and August-September 2011. In a series of experiments, phyllosoma were fed single and mixed species diets of relatively abundant potential prey items (chaetognaths, salps, and krill). Chaetognaths were consumed in 2-8 times higher numbers than the other prey, and the rate of consumption of chaetognaths increased with increasing concentration of prey. The highly variable lipid content of the phyllosoma, and the fatty acid profiles of the phyllosoma and chaetognaths, indicated they were from an oligotrophic oceanic food chain where food resources for macrozooplankton were likely to be constrained. Phyllosoma fed chaetognaths over 6 days showed significant changes in some fatty acids and tended to accumulate lipid, indicating an improvement in overall nutritional condition. The discovery of a preferred prey for P. cygnus will provide a basis for future oceanographic, management and aquaculture research for this economically and ecologically valuable species.

Phase Ib trial of radiotherapy in combination with combretastatin-A4-phosphate in patients with non-small-cell lung cancer, prostate adenocarcinoma, and squamous cell carcinoma of the head and neck

BACKGROUND

The vascular disrupting agent combretastatin-A4-phosphate (CA4P) demonstrated antitumour activity in preclinical studies when combined with radiation.

METHODS

Patients with non-small-cell lung cancer (NSCLC), prostate adenocarcinoma, and squamous cell carcinoma of the head and neck (SCCHN) received 27 Gy in 6 fractions treating twice weekly over 3 weeks, 55 Gy in 20 fractions over 4 weeks, and 66 Gy in 33 fractions over 6 weeks respectively. CA4P was escalated from 50 mg/m2 to 63 mg/m2. CA4P exposure was further increased from one to three to six doses. Patients with SCCHN received cetuximab in addition.

RESULTS

Thirty-nine patients received 121 doses of CA4P. Dose-limiting toxic effects (DLTs) of reversible ataxia and oculomotor nerve palsy occurred in two patients with prostate cancer receiving weekly CA4P at 63 mg/m2. DLT of cardiac ischaemia occurred in two patients with SCCHN at a weekly dose of 50 mg/m2 in combination with cetuximab. Three patients developed grade 3 hypertension. Responses were seen in 7 of 18 patients with NSCLC. At 3 years, 3 of 18 patients with prostate cancer had prostate-specific antigen relapse.

CONCLUSIONS

Radiotherapy with CA4P appears well tolerated in most patients. The combination of CA4P, cetuximab, and radiotherapy needs further scrutiny before it can be recommended for clinical studies.

Positron emission tomography in oncology: a review

Positron emission tomography is an evolving imaging tool that is becoming increasingly available for use in clinical practice. This overview will look at the current evidence for the use of positron emission tomography in imaging different tumour types and the different radiotracers that are either available or being evaluated in an investigational setting.

Pre-treatment Haemoglobin Concentration in Accelerated and Conventional Radiotherapy for Non-small Cell Lung Carcinoma

Serum haemoglobin has been shown to be an independent prognostic factor for a number of cancers including head and neck, bladder, cervix and anal cancers. This study has investigated the prognostic significance of pre-treatment haemoglobin in 164 consecutive patients receiving radical radiotherapy for non-small cell lung cancer. Forty-six received conventional fractionation to 60 Gy in 30 fractions and the remainder received accelerated fractionation, either CHART, 54 Gy in 36 fractions over 12 days (27 patients) or CHARTWEL, 60 Gy in 40 fractions over 18 days (76 patients). Patients were divided into three equal groups by haemoglobin concentration. The median overall survival in each of the three groups from lowest to highest haemoglobin was 17.5 months (95% CI 7.9 25), 18.4 months (95% CI 15.0 25.9) and 16.3 months (95% CI 13.0-19.6). No significant effect of pre-treatment haemoglobin concentration was seen in predicting overall, local disease free or metastases free survival.

A phase I/II study of CHARTWEL with concurrent chemotherapy in locally advanced, inoperable carcinoma of the oesophagus

AIM

To evaluate the feasibility, efficacy and toxicity of concurrent chemotherapy and continuous, hyperfractionated, accelerated radiotherapy weekend less (CHARTWEL) in the treatment of locally advanced, inoperable oesophageal cancer.

METHODS

A prospective study of 19 patients with histologically confirmed, locally advanced, inoperable carcinoma of the oesophagus. CHARTWEL was prescribed from day 1 to doses of 40.5 Gy (three patients), 42 Gy (five patients), 45 Gy (four patients), 46.5 Gy (three patients) and 49.5 Gy (four patients). Cisplatin 75 mg/m2 was administered on day 1 of radiotherapy, followed by 5-fluorouracil (5-FU) 1000 mg daily for 4 days.

RESULTS

All patients completed radiotherapy, with two requiring modification of their chemotherapy dose. Acute toxicity was acceptable, with no interruptions to treatment. The median dysphagia free time was 9.6 months with 38% of patients being dysphagia free at 42 months. The median time to locoregional relapse was 13.2 months with 50% being free at 1 year and 35% at 3.5 years. There was a trend towards greater control when the higher doses (45-49.5 Gy) were compared with the lower doses (40.5-42 Gy), P = 0.07. The median survival time was 10.7 months with 1- and 2-year survival rates of 50 and 26%, respectively. Strictures developed in seven out of 18 patients (38%), but five were found on biopsy to be due to recurrent disease. There was no other long-term toxicity and no treatment-related death occurred.

CONCLUSIONS

CHARTWEL with concomitant cisplatin/5-FU chemotherapy is a feasible treatment option in these patients. It is well tolerated, achieves a high rate of local control and effectively palliates the symptoms of dysphagia, all with relatively rapid resolution of treatment-related toxicity. The results warrant continued dose escalation to 51 Gy.

Dose-escalation with CHARTWEL (continuous hyperfractionated accelerated radiotherapy week-end less) combined with neo-adjuvant chemotherapy in the treatment of locally advanced non-small cell lung cancer

PURPOSE

a radiation-dose-escalation study was undertaken to assess the therapeutic benefit of combining accelerated hyperfractionated radiotherapy (RT) with neo-adjuvant chemotherapy (CT) in non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

One hundred and thirteen patients with locally advanced NSCLC were entered into a phase II trial of CHARTWEL (CHART Week-End-Less) 54 Gy or 60 Gy with or without three cycles of CT. Acute oesophageal reactions and analgesia were scored for up to 8 weeks after the start of RT. Pneumonitis, lung fibrosis, spinal cord and oesophageal strictures, were assessed using clinical and radiological criteria from 3 months onwards and throughout the study. Haematological and gastrointestinal toxicity was monitored in those patients undergoing CT. Endpoints for treatment outcome were overall survival, disease-free survival and loco-regional control.

RESULTS

Chemotherapy enhanced the incidence and duration of acute dysphagia,but the increase was transient. Healing occurred in all cases and there has been no evidence of long-term oesophageal complications. Clinically, almost 25% of those receiving CT+RT had Grade 2 pneumonitis, higher than seen with RT alone. However, the 1 patient with severe Grade 3 pneumonitis was in the RT 60 Gy alone group. An incidence of 17% Grade 2 pulmonary fibrosis at 2 years was seen with CT, slightly lower than with RT alone. To date, there is no evidence of Grade 3 lung fibrosis. There was a higher scoring of lung damage with the radiological endpoint, which gave no indication that CT increased pulmonary toxicity over that of RT alone. Loco-regional control at 2 years was 37% and 55% for CHARTWEL 54 Gy and 60 Gy alone compared with 72% in those treated with 60 Gy and neo-adjuvant CT However, this did not translate into a survival advantage.

CONCLUSIONS

This study of CHARTWEL combined with induction chemotherapy, has shown that the strategy is feasible and that a possible therapeutic benefit may be obtained by the addition of CT. Although neo-adjuvant treatment increased acute mucosal reactions and slight-to-moderate pneumonitis seen with CHARTWEL 60 Gy, the clinical management and quality of life of these patients is similar to those treated with radiotherapy alone.

From CHART to CHARTWEL in non-small cell lung cancer: clinical radiobiological modelling of the expected change in outcome

CHART (Continuous Hyperfractionated Accelerated Radiotherapy) has been shown to improve the tumour control probability and survival relative to conventional radiotherapy in patients with inoperable non-small cell lung cancer (NSCLC). CHARTWEL (CHART Weekend-less) is a further development of this schedule escalating the physical dose to 60 Gy while maintaining the low dose per fraction of 1.5 Gy. In this schedule, three fractions, with a minimum interval of 6 h between fractions, are delivered 5 days per week. This extends overall treatment time from the 12 days of CHART to 18 days. Radiobiological modelling is used to estimate the expected tumour control and normal tissue morbidity after CHARTWEL relative to CHART. The estimations are based on the outcome of the CHART trial and published values for dose-fractionation and dose-response parameters for human tissues and tumours. Two new estimates of quantitative radiobiological parameters for early normal-tissue morbidity after chest irradiation are reported here. For radiation pneumonitis, the dose recovered per day is estimated at 0.44 Gy/day with 95% confidence limits 0.07 Gy/day and 0.80 Gy/day. For oesophagitis, the normalized dose-response gradient, gamma50, is estimated at 2.1 with 95% confidence limits 1.4 and 3.6. With regard to normal tissue effects, the increase in total dose when going from CHART to CHARTWEL is moderated by the slightly longer overall treatment time in case of early morbidity while the introduction of the weekend gaps may moderate the effect for late-responding normal tissues with a long repair halftime. Tumour control at 3 years is expected to increase by some 7-14 percentage points (from 19% to 26-33%) whereas the incidence of moderate and severe early oesophagitis and pneumonitis is expected to increase by about 2 percentage points. The incidence of late morbidity, lung fibrosis and oesophageal strictures, is expected to increase by 3-4 percentage points. The analyses conclude that CHARTWEL is likely to improve the therapeutic ratio relative to CHART.

Failure-specific prognostic factors after continuous hyperfractionated accelerated radiotherapy (CHART) or conventional radiotherapy in locally advanced non-small-cell lung cancer: a competing risks analysis

The aim of this study was to identify possible failure-specific prognostic factors in non-small-cell lung cancer. Clinical outcome was analysed in 549 patients participating in the randomized controlled trial of CHART vs conventional radiotherapy. Local failure and distant failure with or without concurrent local relapse were subjected to a competing risk analysis using an accelerated failure-time model with a log-logistic hazard function. Randomization to CHART (2 P = 0.005), increasing age (2 P = 0.036) and female sex (2 P = 0.09) was all associated with a prolonged interval to failure. Advanced clinical stage was associated with a decreased interval to failure (2 P = 0.004) and a significantly increased risk (2 P = 0.009) of failing in distant rather than in local position. From this model, prognostic indices for local and distant failure were estimated for each individual patient. Competing risk analysis allows identification of patients with different failure patterns, and may provide a means of stratifying patients for intensified local or systemic therapy.

BOLD MRI of human tumor oxygenation during carbogen breathing

An MRI method is described for demonstrating improved oxygenation of human tumors and normal tissues during carbogen inhalation (95% O2, 5% CO2). T2*-weighted gradient-echo imaging was performed before, during, and after carbogen breathing in 47 tumor patients and 13 male volunteers. Analysis of artifacts and signal intensity was performed. Thirty-six successful tumor examinations were obtained. Twenty showed significant whole-tumor signal increases (mean 21.0%, range 6.5-82.4%), and one decreased (-26.5 +/- 8.0%). Patterns of signal change were heterogeneous in responding tumors. Five of 13 normal prostate glands (four volunteers and nine patients with nonprostatic tumors) showed significant enhancement (mean 11.4%, range 8.4-14.0%). An increase in brain signal was seen in 11 of 13 assessable patients (mean 8.0 +/- 3.7%, range 5.0-11.7%). T2*-weighted tumor MRI during carbogen breathing is possible in humans. High failure rates occurred due to respiratory distress. Significant enhancement was seen in 56%, suggesting improved tissue oxygenation and blood flow, which could identify these patients as more likely to benefit from carbogen radiosensitization.

Radiotherapy-related early morbidity in head and neck cancer: quantitative clinical radiobiology as deduced from the CHART trial

BACKGROUND AND PURPOSE

Early reactions after radiotherapy for head and neck cancer may become the limiting factor in current attempts to intensify loco-regional therapy through altered fractionation or combination of radiotherapy with chemotherapy. The aim of the present study was to quantify the dependence of early reactions on the dose-fractionation used in radiotherapy and on patients' age and radiation field size.

PATIENTS AND METHODS

The data analyzed are from the randomized controlled trial of CHART (continuous hyperfractionated accelerated radiotherapy) vs. conventional radiotherapy in head and neck cancer. The trial accrued 918 patients from March 1990 to April 1995. Several early morbidity items were evaluated weekly for the first 8 weeks after the start of treatment. Weekly evaluation was continued in patients with early reactions extending beyond 8 weeks. Linear regression was used to analyze the time with reactions in individual patients. Polychotomous ordinal response regression was used to analyze the peak grade of early reactions in individual patients.

RESULTS

The main findings of this analysis were as follows. (1) The incidence and peak prevalence of confluent mucositis was higher after CHART than after conventional radiotherapy. Therefore, the average time spent with confluent mucositis per patient treated was significantly longer after CHART than after conventional fractionation. (2) In patients who actually developed confluent mucositis, the average duration of this grade of reaction was not significantly different after CHART compared with conventional radiotherapy. (3) Confluent mucositis developed earlier after the start of treatment (2.9 vs. 4.9 weeks) but also started to improve sooner (5.4 vs. 7.5 weeks after the start of treatment) after CHART than after conventional radiotherapy. (4) The dose recovered per 1-day protraction of overall treatment time, D(prolif), was estimated at 0.80 Gy with 95% confidence limits 0.7 and 1.1 Gy/day for human mucosa. (5) For human skin erythema, the estimate of D(prolif) was 0.12 Gy/day with 95% confidence limits -0.12 and 0.22 Gy/day. (6) Highly significant relationships were found between the grade of morphological mucositis on one hand and dysphagia, pain on swallowing and prescribed analgesics on the other. Patients with confluent mucositis had fewer functional problems if this was confined to the larynx as compared with other subsites in the head and neck. (7) Although the incidence of confluent mucositis was higher in the oral cavity and oropharynx than in the hypopharynx and larynx, the radiobiological properties of mucosal reactions did not show significant variation among the various subsites within the head and neck region. (8) For a given dose and overall treatment time, a highly significant increase in incidence and severity of both mucositis and erythema was seen with increasing field size. Thus, a significant dose-volume or dose-area effect exists for both of these tissues. (9) Patients' age had no significant influence on the incidence and severity of mucositis or erythema.

CONCLUSIONS

This study provides quantitative estimates of the dose-time and dose-volume relationships for human skin and normal mucosa in the head and neck region based on an analysis of data from 918 patients entered into a randomized-controlled trial of altered dose fractionation in radiotherapy.

Programming of radiotherapy in the treatment of non-small-cell lung cancer--a way to advance care

Radical radiotherapy, the mainstay of treatment for early inoperable non-small-cell lung cancer, is most commonly given in daily fractions, Monday to Friday, to a total dose of 60-70 Gy over 6-8 weeks. Since the 1980s, novel fractionation schedules have been explored with the aim of improving local tumour control and survival without increasing late morbidity. There have been two main approaches. In hyperfractionated radiotherapy the dose per fraction is reduced and the total dose increased to give improved tumour control without increased late morbidity. Hyperfractionation schedules, with more than one fraction per day have been successfully evaluated, but so far significant benefit has not been achieved when compared with conventional radiotherapy plus chemotherapy. In accelerated radiotherapy the overall duration of radiotherapy is reduced to overcome repopulation of tumour cells during the course of treatment. In all the different regimens of accelerated radiotherapy a common feature is giving two or more fractions on some or all treatment days and, in some cases, a lower dose per fraction is also incorporated. CHART (continuous hyperfractionated accelerated radiotherapy) is the most novel and accelerated schedule tested, and a randomised controlled trial showed a significant survival advantage from CHART compared with conventional radiotherapy. Changes in the fractionation of radiotherapy must be combined with other approaches such as neoadjuvant and concomitant chemotherapy, hypoxic-cell modifiers, and conformal radiotherapy, so that care of patients with non-small-cell lung cancer can be further advanced.

A pilot study of postoperative CHART and CHARTWEL in head and neck cancer

A Phase II pilot study of continuous hyperfractionated accelerated radiotherapy (CHART)/CHART weekend less (CHARTWEL) was carried out in the postoperative treatment of patients with squamous cell carcinoma of the head and neck. Twenty-four patients (17 male, seven female) with a median age of 64 years (range 34-80) were treated with postoperative radiotherapy between 1991 and 1999. All patients presented with primary squamous cell carcinoma, which, at surgery, had shown adverse pathological factors for recurrence. Intermediate risk was determined by the presence of two of the following factors: margins 5 mm, Stage T3/T4, perineural or vascular invasion, poor differentiation, oral primary, multicentric primary, and more than four positive lymph nodes. High-risk factors included the presence of extracapsular spread and/or incomplete resection margins, or the presence of four of the factors defining intermediate risk. The patients were treated using a CHART (n = 11) or a CHARTWEL (n = 13) schedule, administering a dose between 49.5 Gy and 54 Gy. High-risk factors were present in 18/24 patients. Treatment was commenced from a median time of 6.9 weeks (range 4.4-16.6) after radical surgery. All patients completed treatment. A confluent radiation mucositis occurred in 20/23 evaluable patients, which settled in 4-10 weeks after commencing radiotherapy. Moderate dysphagia was observed in 13 patients. Mild subcutaneus oedema was noted in 11 patients from 12 weeks after treatment. No significant late toxicity has been observed. Over a median follow up-period of 17 months, local control has been maintained in 17 patients (71%). Seven patients have relapsed and died of disease. A mean survival of 24 months (range 1-84) has been observed. This pilot study demonstrates acceptable morbidity for CHART/CHARTWEL in the postoperative setting. A prospective multicentre randomized trial using an accelerated schedule of radiotherapy versus conventional fractionation for the radical postoperative treatment of primary head and neck cancer is currently in preparation.

bcl-2 expression in head and neck cancer: an enigmatic prognostic marker

PURPOSE

The role of bcl-2 overexpression in cancer presents a paradox. In some tumor types, it is associated with favorable outcome, whereas in others the reverse is true. The purpose of this study was to explore the influence of bcl-2 in a large series of head and neck cancer patients treated in the CHART randomized trial.

METHODS AND MATERIALS

Histologic material was obtained from 400 patients; bcl-2 expression was assessed by immunohistochemistry as either positive or negative cytoplasmic staining.

RESULTS

Positivity of bcl-2 was recorded in 12.8% (9.5-16.5%, 95% confidence limits) of tumors. There were significant differences in positive tumors within different sites with nasopharynx showing the highest incidence (46.2%). A multivariate logistic regression analysis showed that bcl-2 was strongly associated with histologic dedifferentiation, as well as increasing N stage and female gender. In univariate analyses, bcl-2 positive patients had a lower locoregional relapse rate (RR 0.57, p = 0.02) and improved survival (RR 0.49, p = 0.004) compared to bcl-2 negative patients; this became more significant in multivariate analysis.

CONCLUSION

These data demonstrate that bcl-2 overexpression is a marker of what is considered to be more advanced and aggressive disease yet it is associated with a more favorable outcome irrespective of the treatment schedule.

Non-small cell lung cancer and CHART (continuous hyperfractionated accelerated radiotherapy)--where do we stand?

This paper reviews the use of hyperfractionated and/or accelerated radiation therapy in the curative treatment of non-small cell lung cancer, and explains the scientific rationale behind the development of these regimes. The indications, practicalities and economics of introducing them routinely are addressed. Novel radiotherapy techniques are further discussed in the context of current developments and on-going clinical trials.

Gas exchange parameters in radiotherapy patients during breathing of 2%, 3.5% and 5% carbogen gas mixtures

The gas mixture carbogen may be breathed by patients to enhance the oxygenation level and therefore the radiosensitivity of tumours. However, owing to the high CO2 content, its inhalation is associated with patient intolerance. Our aim was to determine a suitable carbon dioxide and oxygen gas mixture with similar enhancement of arterial oxygenation to 5% carbogen and with improved patient tolerance. 14 patients entered the study; of those 14, 8 were able to tolerate 2%, 3.5% and 5% carbogen mixtures as well as a control gas for sufficient time to allow successful arterial blood gas sampling. Gas exchange parameters were measured using a carbon dioxide monitor and a blood gas analyser. Arterial carbon dioxide tension ranged from 2.9 kPa to 6.82 kPa whilst breathing the carbogen mixtures, and arterial oxygen tension increased at least three-fold from basal values. There were no significant changes in the respiratory rate, heart rate and blood pH. The results suggest that 2% CO2 in O2 enhances arterial oxygen levels to a similar extent as 3.5% and 5% CO2 and that it is well tolerated.

Sweat gland function as a measure of radiation change

BACKGROUND

Radiotherapy may result in dryness of the skin even when no other change can be detected. We describe a system for recording the electrical conductance of skin as a measure of sweat gland function.

PATIENTS AND METHODS

In 22 normal volunteers close agreement was obtained between measurements obtained from comparable sites on both sides of the chest. Measurements were subsequently made in 38 patients treated by radiotherapy to one side of the chest for tumours of the breast or lung using one of five different fractionation schedules. Simultaneous readings were obtained from both sides of the chest with the non irradiated side acting as a control.

RESULTS

A dose response relationship was demonstrated: five patients who received the equivalent total dose of 15 Gy in 2-Gy fractions showed no change in conductance. Sixteen out of 23 who received an equivalent total dose of 42-46 Gy in 2-Gy fractions had a greater than 22% reduction in mean skin conductance compared with that of the control areas despite the skin appearing normal in the large majority. Marked changes in skin conductance were seen after higher total doses. In a prospective study 18 women receiving breast irradiation underwent weekly readings during treatment. A mean reduction of 40% in skin conductance was noted by the end of the second week of treatment prior to any clinical evidence of radiation change. Skin conductance returned to normal in 44% of patients by 6 months. In the remainder, those patients who showed the greatest reduction in skin conductance during treatment demonstrated the least recovery.

CONCLUSIONS

Changes in sweat gland function can be detected and quantified in skin which may otherwise appear normal. Differences may so be demonstrated between areas treated using different fractionation schedules and the method may be applied to the detection during radiotherapy of unusually sensitive patient.

A pilot study of continuous, hyperfractionated, accelerated radiotherapy in rectal adenocarcinoma

This pilot study investigated the feasibility, toxicity and effect of continuous, hyperfractionated, accelerated radiotherapy (CHART) in 19 patients with adenocarcinoma of the rectum who were treated at Mount Vernon Hospital between April 1992 and April 1994. A total dose of 54 Gy was given in 36 fractions over 12 consecutive days; three fractions of 1.5 Gy were employed each day with an interfraction interval of 6 hours. Of these 19 patients, 13 had local pelvic recurrence from rectal carcinoma, four had a primary rectal carcinoma (which was unsuitable for abdominoperineal resection because of patient frailty), and two had large, fixed, unresectable tumours and were given radiotherapy preoperatively to a lower dose of 42 Gy in 28 fractions over 10 days to facilitate surgery. However, none of the 19 patients subsequently underwent surgical resection. Treatment compliance with radiotherapy was 95%. Acute bowel toxicity was assessed by means of a daily bowel chart for 6 weeks and then at 8, 12 and 26 weeks after the completion of radiotherapy. Patients were subsequently scored using the World Health Organization (WHO) grading system. No toxic deaths were observed in this study. There were five grade 3 and one grade 4 toxicities (WHO scale) observed in six patients. There has been minimal acute bladder toxicity in two patients and skin reactions have been surprisingly minimal in all but three patients. Small bowel obstruction and late bowel damage, possibly attributable to radiotherapy, occurred in three patients. Complete pain relief was achieved in recurrent rectal cancer in 100% of patients, at a median of 15 days since commencing radiotherapy (range 7-63 days), and has been maintained for mean and median durations of 19 and 18 months respectively (range 1.5-45 months). Five patients have had a recurrence of pain at 3, 4, 8, 9 and 18 months respectively. All four patients with primary rectal adenocarcinoma achieved a complete response, which has been sustained for 4 months (until death), 54 and 57 months, although one patient relapsed locally at 8 months. In summary, CHART appears to be a feasible treatment for pelvic tumours with regard to toxicity. Patients with pain from a locoregional recurrence achieved rapid complete pain relief, which was sustained for many months.

Repair halftimes estimated from observations of treatment-related morbidity after CHART or conventional radiotherapy in head and neck cancer

BACKGROUND AND PURPOSE

The CHART (Continuous Hyperfractionated Accelerated Radiotherapy) head and neck cancer fractionation schedule delivered 54 Gy in 36 fractions on 12 consecutive days and this was compared in a randomised controlled trial with conventional fractionation delivering 66 Gy in 33 fractions over 6-7 weeks. Patients receiving CHART experienced statistically significantly less treatment-related morbidity after 6 months than patients receiving conventional fractionation. However, this improved tolerance was much less than anticipated from existing knowledge of dose-fractionation effects on late-responding normal tissues. Here, the experience from the CHART study is analysed and repair halftimes for three types of late treatment-related morbidity of human tissues are estimated.

PATIENTS AND METHODS

The CHART trial was open for patient accrual from March 1990 to April 1995 and a total of 918 patients in 11 participating centres were randomised. All patients were followed at regular intervals for a minimum of 5 years or until the time of death. At each follow-up, a number of treatment-related morbidity items were evaluated and scored prospectively. Data for three late endpoints are analysed here: laryngeal oedema, skin telangiectasia and subcutaneous fibrosis. Differences in the incidence of these endpoints in the two trial arms were quantified by means of the ratio of hazard rates in a Cox proportional hazards model. Monte Carlo sampling was performed from distributions of fractionation sensitivity (quantified by the alpha/beta-ratio) and steepness of the dose-response curve (quantified by the normalised dose-response gradient, gamma50) with means and standard deviations derived from the literature. Each pair of values were used to convert a Monte Carlo sampled estimate of the difference in biological effect into an estimate of the repair halftime. From the distribution of 1000 Monte Carlo samples, the mean repair halftime and its 95% confidence interval were estimated.

RESULTS

The estimated repair halftimes, with 95% confidence intervals in parentheses, were 4.9 h (3.2, 6.4) for laryngeal oedema, 3.8 h (2.5, 4.6) for skin telangiectasia and 4.4 h (3.8, 4.9) for subcutaneous fibrosis. Calculations show that these repair halftimes are consistent with the observations from two published randomised controlled trials of altered fractionation in head and neck cancer, the EORTC 22791 and 22851 trials.

CONCLUSIONS

These long repair halftimes for late effects in human normal tissues have to be considered in order to gain the full benefit from fractionation schedules employing multiple fractions per day.

Dynamic contrast enhanced magnetic resonance scanning as a predictor of response to accelerated radiotherapy for advanced head and neck cancer

Tumour perfusion has been assessed in patients with advanced head and neck cancer using dynamic contrast enhanced MRI prior to and at completion of accelerated radiotherapy, and related to local tumour control. Sequential MRI scans, at 3 s intervals after intravenous injection of gadolinium using a dynamic scan sequence through a tumour region of interest (ROI), were performed in 13 patients with advanced head and neck cancer before and on completion of radiotherapy. The scans have been analysed in terms of maximum tumour enhancement (E), slope of the enhancement versus time curve and the time taken to reach maximum tumour enhancement (Tmax), and these parameters related to tumour outcome after radiotherapy. Local tumour control was related to the value of E on a post-radiotherapy scan and the difference in Tmax between a pre- and post-radiotherapy scan. Durable local control was seen in those tumours with a post-radiotherapy value for E of less than 8 and a mean fall in Tmax of 27.3 s. These results imply that tumours with diminished tumour perfusion at the end of radiotherapy are those most sensitive to treatment and that those tumours which show greater tumour enhancement after accelerated radiotherapy are likely to fail locally. This may reflect the persistence of viable perfused tumour at completion of radiotherapy.