Prognostic value of maximum standardized uptake value measured by pretreatment 18F-FDG PET/CT in locally advanced head and neck squamous cell carcinoma

PURPOSE/OBJECTIVES

To evaluate the prognostic impact of maximum standardized uptake value (SUV_max) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) undergoing pretreatment [F-18] fluoro-D-glucose-positron emission tomography/computed tomography (FDG PET/CT) imaging.

MATERIALS/METHODS

Fifty-eight patients undergoing FDG PET/CT before radical treatment with definitive radiotherapy (±concomitant chemotherapy) or surgery + postoperative (chemo)radiation were analyzed. The effects of clinicopathological factors (age, gender, tumor location, stage, Karnofsky Performance Status (KPS), and treatment strategy) including primary tumor SUV_max and nodal SUV_max on overall survival (OS), disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) were evaluated. Kaplan-Meier survival curves were generated and compared with the log-rank test.

RESULTS

Median follow-up for the whole population was 31 months (range 2.3-53.5). Two-year OS, LRC, DFS and DMFS, for the entire cohort were 62.1, 78.3, 55.2 and 67.2%, respectively. Median pretreatment SUV_max for the primary tumor and lymph nodes was 11.85 and 5.4, respectively. According to univariate analysis, patients with KPS < 80% (p < 0.001), AJCC stage IVa or IVb vs III (p = 0.037) and patients undergoing radiotherapy vs surgery (p = 0.042) were significantly associated with worse OS. Patients with KPS < 80% (p = 0.003) or age ≥65 years (p = 0.007) had worse LRC. The KPS < 80% was the only factor associated with decreased DFS (p = 0.001). SUV_max of the primary tumor or the lymph nodes were not associated with OS, DFS or LRC. The KPS < 80% (p = 0.002), tumor location (p = 0.047) and AJCC stage (p = 0.025) were associated with worse cancer-specific survival (CSS). According to Cox regression analysis, on multivariate analysis KPS < 80% was the only independent parameter determining worse OS, DFS, CSS. Regarding LRC only patients with IK < 80% (p = 0.01) and ≥65 years (p = 0.01) remained statistically significant. Nodal SUV_max was the only factor associated with decreased DMFS. Patients with a nodal SUV_max > 5.4 presented an increased risk for distant metastases (HR, 3.3; 95% CI 1.17-9.25; p = 0.023).

CONCLUSIONS

The pretreatment nodal SUV_max in patients with locally advanced HNSCC is prognostic for DMFS. However, according to our results primary tumor SUV_max and nodal SUV_max were not significantly related to OS, DFS or LRC. Patients presenting KPS < 80% had worse OS, DFS, CSS and LRC.

A prospective analysis of inter- and intrafractional errors to calculate CTV to PTV margins in head and neck patients

PURPOSE

To evaluate an institute-specific CTV-PTV margin for head and neck (HN) patients according to a 3-mm action level protocol.

METHODS/PATIENTS

Twenty-three HN patients were prospectively analysed. Patients were immobilized with a thermoplastic mask. Inter- and intrafractional set-up errors (in the three dimensions) were assessed from portal images (PI) registration. Digitally reconstructed radiographs (DRRs) were compared with two orthogonal PI by matching bone anatomy landmarks. The isocenter was verified during the first five consecutive days of treatment: if the mean error detected was greater than 2 mm the isocenter position was corrected for the rest of the treatment. Isocenter was checked weekly thereafter. Set-up images were obtained before and after treatment administration on 10, 20 and 30 fractions to quantify the intrafractional displacement. For the set-up errors, systematic (Σ), random (σ), overall standard deviations, and the overall mean displacement (M), were determined. CTV to PTV margin was calculated considering both inter- and intrafractional errors.

RESULTS

A total of 396 portal images was analysed in 23 patients. Systematic interfractional (Σ(inter)) set-up errors ranged between 0.77 and 1.42 mm in the three directions, whereas the random (σ (inter)) errors were around 1-1.31 mm. Systematic intrafractional (Σ(intra)) errors ranged between 0.65 and 1.11 mm, whereas the random (σ (intra)) errors were around 1.13-1.16 mm.

CONCLUSIONS

A verification protocol (3-mm action level) provided by EPIDs improves the set-up accuracy. Intrafractional error is not negligible and contributes to create a larger CTV-PTV margin. The appropriate CTV-PTV margin for our institute is between 3 and 4.5 mm considering both inter- and intrafractional errors.

Preliminary analysis of the resources in brachytherapy in Europe and its variability of use

PURPOSE

The main objective of the program <<Patterns of Care for Brachytherapy in Europe (PCBE)>> is to establish a group with detailed information on brachytherapy throughout Europe.

METHODS

The data was compiled by the general coordinator, the ESTRO, and the <<National Cancer Services Analysis>> through a website.

RESULTS

A total of 32 countries reported data from at least 50% of their centres (criteria of inclusion). Countries were grouped in three categories based on the time of incorporation to the European Union. The majority of treatments belonged to gynaecological tumours. A large spread was found regarding workload of specialists depending on centre and group.

CONCLUSION

Collection of information by a website is a feasible methodology. An increase in brachytherapy treatment was observed in all 3 groups by a rate of more than 20% (year 2002 versus year 1997). These results advocate for the continuation of the PCBE study to demonstrate the development in the field, such as an increase or decrease of patient numbers per tumour category.

L-2-Oxothiazolidine-4-carboxylate reverses the tumour growth-promoting effect of interleukin-2 and improves the anti-tumour efficacy of biochemotherapy in mice bearing B16 melanoma liver metastases

The efficacy of sequential chemoimmunotherapy involving interleukin-2 (IL2) in metastatic melanoma is limited, in part, by the severe toxicity associated with most therapeutic regimens. Glutathione (GSH), the most prevalent intracellular non-protein thiol, plays an important role in protecting against cellular injury caused by various anticancer agents. GSH is also involved in the IL2-induced proliferative activity of immune system cells and some melanoma cells expressing IL2 receptors, such as B16 melanoma cells. The present study investigated the effect of selective manipulation of GSH using the cysteine prodrug l-2-oxothiazolidine-4-carboxylate (OTZ) on the response of B16 melanoma to sequential biochemotherapy with cyclophosphamide (CY) and IL2. We found that OTZ, by depressing GSH levels, abrogates the in vitro growth-promoting effects of IL2 on B16 melanoma cells. The combination of OTZ plus IL2 in vivo also showed antitumour activity in mice bearing B16 melanoma liver metastases, significantly increasing their life span. Schedule dependency between both compounds was found; OTZ given intermittently in combination with daily IL2 administration was found to be the best therapeutic schedule. We also observed that whereas IL2 or OTZ alone added to CY resulted in a lower or non-significant improvement in the life span of the mice compared with tolerated doses of CY alone, the addition of both OTZ and IL2 to CY produced a significantly greater increase in survival than CY alone, and markedly protected mice against CY-induced toxicity, which allowed the administration of otherwise lethal doses of CY, with the CY activity/toxicity ratio being increased by four-fold.

Tunicamycin treatment reduces intracellular glutathione levels: effect on the metastatic potential of the rhabdomyosarcoma cell line S4MH

Highly metastatic cells are known to overexpress certain Asn-linked oligosaccharides in the plasmatic membrane. Another phenotypic characteristic of malignant cells consists in the expression of high levels of intracellular glutathione (GSH). The aim of the present work was to demonstrate that the inhibition of N-glycosylation induces changes in intracellular GSH levels, and in turn participates in the inhibition of the metastatic potential of tumor cells by tunicamycin treatment. Firstly, we demonstrated that in comparison to the poorly metastatic cell line F21, the highly metastatic cells S4MH express a higher number of Asn-linked beta1-6 branched oligosaccharides and sialic acid (SA) and/or chitobiose oligosaccharides in glycoproteins involved in the regulation of the adhesion efficiency of tumor cells on endothelial cells and extracellular matrix. Our results showed that the decrease in S4MH cell adhesion efficiency on endothelial cells and extracellular matrix after the inhibition of N-glycan processing by tunicamycin treatment was caused by: (1) inhibition of the expression of N-glycan structures recognized by endothelial endogenous lectins, including beta1-6 branched oligosaccharides and SA and/or chitobiose oligosaccharides, and (2) redistribution of cell surface glycoproteins with beta1-6 branched oligosaccharides and/or SA and/or chitobiose oligosaccharides in their structures, caused by the depletion of intracellular GSH levels. The latter condition prevents the organization of these glycoproteins in the plasmatic membrane of S4MH cells necessary for anchoring to the substratum.

Effects of L-2-oxothiazolidine-4-carboxylate on the cytotoxic activity and toxicity of cyclophosphamide in mice bearing B16F10 melanoma liver metastases

Glutathione (GSH) is the major non-protein thiol in cells that plays a critical role against damage from electrophilic agents such as alkylating drugs. Selective therapeutic GSH elevation in normal but not in tumour cells has been suggested as a means of protecting host tissues against more intense doses of chemotherapy. The present study investigated the response of B16 melanoma to treatment with the cysteine pro-drug L-2-oxothiazolidine-4-carboxylate (OTZ), alone and in combination with cyclophosphamide (CY). We found that OTZ decreased the GSH levels and proliferation rate of B16 melanoma cells in vitro, sensitizing them to the cytotoxic action of the activated metabolite of CY, acrolein (AC). In contrast to OTZ, the cysteine deliverer N-acetylcysteine (NAC) enhanced B16 melanoma cell proliferation by increasing GSH levels, and markedly decreased the sensitivity of these tumour cells to AC. In vivo studies showed the antitumoral activity of OTZ in B16 melanoma liver metastasis-induced mice, increasing their life span. We also observed that, whereas with CY treatment the GSH levels in peripheral blood mononuclear cells (PBMCs) were reduced and a dose-dependent leukopenia was produced, OTZ significantly increased PBMC GSH content, reducing toxicity and enhancing the survival of mice bearing established melanoma liver metastases treated with lethal dose CY. These results suggest a critical role for OTZ in protecting against alkylator agent-induced immunosuppression, which may allow the dose escalation of these cytostatic drugs to improve their therapeutic benefit in the treatment of malignant melanoma.

In vitro and in vivo comparison between the effects of treatment with adenosine triphosphate and treatment with buthionine sulfoximine on chemosensitization and tumour growth of B16 melanoma

In this study we compare the effects of treatment with external sodium adenosine 5'-triphosphate (ATP) with the effects of L-buthionine-SR-sulfoximine (BSO) on B16 melanoma growth and on the modulation of the cytotoxic antimelanoma activity of cyclophosphamide (CY). We evaluated the in vitro effects of treatment with ATP or BSO on intracellular glutathione (GSH) levels, mitochondrial membrane potential (delta psi(m)) and the proliferation rate of the B16F10 melanoma cell line. Compared with untreated cells, delta psi(m) and GSH levels were already significantly decreased (25% and 57% reduction, respectively) after the first hour of incubation in culture cells exposed to 3 mM ATP. After 24 and 48 h a major reduction was observed in delta psi(m) (nearly 30%). GSH levels were also maximally depleted at 24 h (approximately 75%) and partially recovered (up to 37% of levels of control) after ATP was removed from the medium. At 24 and 48 h, the proliferation rate was decreased 1.4- and 1.7-fold, respectively, compared with control cells. Treatment with 50 microM BSO produced a time-dependent decrease in GSH levels (0.5, 21, 48 and 97.3% reduction at 1, 4, 8 and 24 h, respectively), but up to 54% of the levels of control cells was recovered after BSO was removed from the medium. In contrast to ATP, neither delta psi(m) nor proliferation rate was significantly modified in the first 24 h with BSO treatment. At 48 h, delta psi(m) was reduced by nearly 27%, and cell proliferation decreased 1.2-fold compared with controls. When the in vitro cytotoxic effect of low dose acrolein (an active metabolite of CY) in combination with BSO or ATP was analysed, a synergistic effect was found between BSO and acrolein, with a dose modification factor (DMF) of 1.98, but the antiproliferative effects of acrolein plus ATP were only approximately additive (DMF = 1.05). In addition, in in vivo studies differential effects were found between ATP and BSO. Specifically, whereas BSO alone significantly increased the survival time of mice bearing B16 melanoma liver metastases, and enhanced the cytotoxic effect of CY on this tumour model, no therapeutic benefits could be observed with ATP treatment, either alone or in combination with diethyl maleate (a GSH-depleting agent) and CY. In conclusion, our findings show that in our experimental system, both extracellular ATP and BSO have growth-inhibitory properties against B16 melanoma in vitro. In vivo, however, only BSO produces a chemosensitizing effect, whereas ATP has not proved useful as a biological modifier of chemotherapy.

Interleukin-2 increases intracellular glutathione levels and reverses the growth inhibiting effects of cyclophosphamide on B16 melanoma cells

Glutathione (GSH) plays an essential role in the metabolism of melanoma. As changes in intracellular GSH content can modify the processes of cell proliferation and detoxification, this could determine the therapeutic response to some cancer treatment strategies. The purpose of this study was to test the effects of treatment with interleukin-2 (IL-2), alone and in combination with cyclophosphamide (CY), on survival of mice bearing B16 melanoma liver metastases, and to determine the influence of these therapeutic agents on the GSH metabolism of B16 cells. In the in vivo test system, B16 melanoma liver metastases were induced in C57BL/6 mice which were subsequently treated with IL-2, CY and CY plus IL-2. Survival time was used to determine the response to treatment. In the in vitro system, we evaluated the effects of IL-2, acrolein (an active metabolite of CY responsible for GSH depletion) and acrolein plus IL-2 on GSH levels and proliferation of B16 melanoma cells. Results indicated that, in vivo, all treatments increased mouse survival times with respect to control mice. However, the addition of IL-2 to CY therapy decreased survival time compared with treatment with CY alone. In vitro, whereas acrolein produced a GSH depletion and inhibited B16 cell proliferation, IL-2 increased GSH content and cell proliferation rate compared with untreated cells. Moreover, addition of IL-2 to cells preincubated with acrolein increased GSH levels and proliferation with respect to acrolein alone. In summary, the data suggest that GSH plays a critical role in the growth-promoting effects of IL-2 on B16F10 melanoma cells and in the antagonistic effect of IL-2 on CY inhibitory activity on these tumor cells.

Tumor-host interaction in non-random metastatic pattern distribution

In the clinical evolution of malign tumors, prognosis depends on whether metastasis develops or not. Biologically speaking, the formation of metastasis implies the existence of tumor cells capable of successfully performing all the steps in the metastatic process: local invasion, lymphatic or hematogenous dissemination, arrest in the microvascular bed of an organ, extravasation and growth of a secondary colony. Clinical observations have demonstrated that for each primary tumor there is a colonization pattern determined by the characteristics of the microvascular endothelium and the functional environment of the target organ. Moreover, the formation of metastasis depends on at least two additional factors: a) tumor cell-tumor cell and tumor cell-host cell relations modulated by intercellular contact and/or soluble paracrine or autocrine growth factors; b) the antitumor efficiency of the immune system, mediated primarily by the action of NK/LAK cells, macrophages and cytolytic T-lymphocytes, whose activity is in turn regulated by a complex of cytokines, including interferons, tumor necrosis factors and interleukins. In this work, we first review certain aspects of tumor biology that are specifically involved in tumor cell-host cell interactions determining non-random metastatic pattern distribution, and then review the implication of certain cytokines in the regulation of tumor proliferation.

The addition of interleukin-2 to cyclophosphamide therapy can facilitate tumor growth of B16 melanoma

The role of interleukin-2 (IL-2) on tumor growth of B16F10 melanoma cells was assessed in two sets of mice with different immune status: normal (immunocompetent) mice and immunodeficient mice. The two sets of animals were treated with cyclophosphamide (CY) or IL-2 alone or with a combined therapy of CY+IL-2. On days 6 and 10 after tumor cell injection, we evaluated the incidence of hepatic B16 melanoma metastases and the percentage of hepatic volume occupied by metastatic tissue. We observed that the CY alone (300 mg/kg, days 3 and 8 post-tumoral inoculation) significantly reduced tumor growth in all treated mice; however, CY proved more effective in normal recipients than in immunodeficient hosts. On the other hand, whereas administration of IL-2 alone (10(5) IU daily, from day 3 to day 7) in immunocompetent mice significantly reduced tumor growth on days 6 and 10, in immunodeficient mice, no significant differences were observed in tumor growth either on the 6th or on the 10th day, in comparison to control groups. Finally, when the combined CY+IL-2 therapy was administered, an antisynergistic effect between these therapeutic agents was achieved both in normal and in immunodeficient mice. Thus, the addition of low-dose IL-2 (25 x 10(3) IU daily, from day 4 to day 7) to high-dose CY (300 mg/kg, days 3 and 8) significantly increased tumor growth in both the early and later periods, compared to the effect of CY alone. It is concluded that exogenous IL-2 can facilitate tumor growth of B16 melanoma cells in vivo.

[Isotopic radioangiography in hepatic cirrhosis. Changes induced by somatostatin]

The value of first step isotopic angiography (FSIA) with 99-TC in the study of altered liver kidney and spleen circulation in patients with liver cirrhosis and alcoholic hepatitis is analyzed. This technique is used to evaluate the effect of a 250 mcg IV bolus of somatostatin on the activity/time curve at the three circulatory levels. The ratio of basal hepatic artery/portal flow in cirrhotics was 59 + 11/41 + 11% and 39 + 6/61 + 4 in alcoholic hepatitis, significantly different from normal controls (p less than 0.001). In cirrhotics the degree of alteration in FSIA correlated with the severity of liver disease. Somatostatin significantly improved the ratio of basel hepatic artery/portal flow and diminished the pressure at the root of suprahepatic veins (18.5 +/- - v.s. 16 +/- mmHg, p greater than 0.001). Neither the slopes nor the time of maximum isotopic activity of renal and splenic activity/time curves were modified. We concluded highlighting the clinical value of FSIA as a non invasive test in the study of chronic liver diseases.