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Nenclares P, Larkeryd A, Manodoro F, Lee JY, Lalondrelle S, Gilbert DC, Punta M, O’Leary B, Rullan A, Sadanandam A, Chain B, Melcher A, Harrington KJ, Bhide SA. T-cell receptor determinants of response to chemoradiation in locally-advanced HPV16-driven malignancies. Front Oncol 2024; 13:1296948. [PMID: 38234396 PMCID: PMC10791873 DOI: 10.3389/fonc.2023.1296948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/28/2023] [Indexed: 01/19/2024] Open
Abstract
Background The effect of chemoradiation on the anti-cancer immune response is being increasingly acknowledged; however, its clinical implications in treatment responses are yet to be fully understood. Human papillomavirus (HPV)-driven malignancies express viral oncogenic proteins which may serve as tumor-specific antigens and represent ideal candidates for monitoring the peripheral T-cell receptor (TCR) changes secondary to chemoradiotherapy (CRT). Methods We performed intra-tumoral and pre- and post-treatment peripheral TCR sequencing in a cohort of patients with locally-advanced HPV16-positive cancers treated with CRT. An in silico computational pipeline was used to cluster TCR repertoire based on epitope-specificity and to predict affinity between these clusters and HPV16-derived epitopes. Results Intra-tumoral repertoire diversity, intra-tumoral and post-treatment peripheral CDR3β similarity clustering were predictive of response. In responders, CRT triggered an increase peripheral TCR clonality and clonal relatedness. Post-treatment expansion of baseline peripheral dominant TCRs was associated with response. Responders showed more baseline clustered structures of TCRs maintained post-treatment and displayed significantly more maintained clustered structures. When applying clustering by TCR-specificity methods, responders displayed a higher proportion of intra-tumoral TCRs predicted to recognise HPV16 peptides. Conclusions Baseline TCR characteristics and changes in the peripheral T-cell clones triggered by CRT are associated with treatment outcome. Maintenance and boosting of pre-existing clonotypes are key elements of an effective anti-cancer immune response driven by CRT, supporting a paradigm in which the immune system plays a central role in the success of CRT in current standard-of-care protocols.
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Affiliation(s)
- Pablo Nenclares
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
- Head and Neck Unit, The Royal Marsden Hospital, London, United Kingdom
| | - Adrian Larkeryd
- Bioinformatics Unit, The Centre for Translational Immunotherapy, The Institute of Cancer Research, London, United Kingdom
| | - Floriana Manodoro
- Genomics Facility, The Institute of Cancer Research, London, United Kingdom
| | - Jen Y. Lee
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
| | - Susan Lalondrelle
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
| | - Duncan C. Gilbert
- Sussex Cancer Centre, University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
| | - Marco Punta
- Unit of Immunogenetic, Leukemia Genomics and Immunobiology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ben O’Leary
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
- Head and Neck Unit, The Royal Marsden Hospital, London, United Kingdom
| | - Antonio Rullan
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
- Head and Neck Unit, The Royal Marsden Hospital, London, United Kingdom
| | - Anguraj Sadanandam
- Systems and Precision Cancer Medicine Team, The Institute of Cancer Research, London, United Kingdom
| | - Benny Chain
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Alan Melcher
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
| | - Kevin J. Harrington
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
- Head and Neck Unit, The Royal Marsden Hospital, London, United Kingdom
| | - Shreerang A. Bhide
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, United Kingdom
- Head and Neck Unit, The Royal Marsden Hospital, London, United Kingdom
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Bryan SJ, Lee J, Gunu R, Jones A, Olaitan A, Rosenthal AN, Cutts RJ, Garcia-Murillas I, Turner N, Lalondrelle S, Bhide SA. Circulating HPV DNA as a Biomarker for Pre-Invasive and Early Invasive Cervical Cancer: A Feasibility Study. Cancers (Basel) 2023; 15:cancers15092590. [PMID: 37174056 PMCID: PMC10177194 DOI: 10.3390/cancers15092590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND High-risk HPV infection is responsible for >99% of cervix cancers (CC). In persistent infections that lead to cancer, the tumour breaches the basement membrane, releasing HPV-DNA into the bloodstream (cHPV-DNA). A next-generation sequencing assay (NGS) for detection of plasma HPV circulating DNA (cHPV-DNA) has demonstrated high sensitivity and specificity in patients with locally advanced cervix cancers. We hypothesised that cHPV-DNA is detectable in early invasive cervical cancers but not in pre-invasive lesions (CIN). METHODS Blood samples were collected from patients with CIN (n = 52) and FIGO stage 1A-1B CC (n = 12) prior to treatment and at follow-up. DNA extraction from plasma, followed by NGS, was used for the detection of cHPV-DNA. RESULTS None of the patients with pre-invasive lesions were positive for CHPV-DNA. In invasive tumours, plasma from one patient (10%) reached the threshold of positivity for cHPV-DNA in plasma. CONCLUSION Low detection of cHPV-DNA in early CC may be explained by small tumour size, poorer access to lymphatics and circulation, and therefore little shedding of cHPV-DNA in plasma at detectable levels. The detection rate of cHPV-DNA in patients with early invasive cervix cancer using even the most sensitive of currently available technologies lacks adequate sensitivity for clinical utility.
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Affiliation(s)
- Stacey J Bryan
- UCL Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, University College London, Medical School Building, 74 Huntley Street, London WC1E 6AU, UK
| | - Jen Lee
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Richard Gunu
- Translational Research Lab, Department of Women's Cancer, IfWH, Ground Floor POGB, 72 Huntley Street, London WC1E 6DD, UK
| | - Allison Jones
- Translational Research Lab, Department of Women's Cancer, IfWH, Ground Floor POGB, 72 Huntley Street, London WC1E 6DD, UK
| | - Adeola Olaitan
- UCL Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, University College London, Medical School Building, 74 Huntley Street, London WC1E 6AU, UK
| | - Adam N Rosenthal
- UCL Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, University College London, Medical School Building, 74 Huntley Street, London WC1E 6AU, UK
| | - Ros J Cutts
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Isaac Garcia-Murillas
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Nick Turner
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | | | - Shreerang A Bhide
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
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Lalondrelle S, Lee J, Cutts RJ, Garcia Murillas I, Matthews N, Turner N, Harrington K, Vroobel K, Moretti E, Bhide SA. Predicting Response to Radical Chemoradiotherapy with Circulating HPV DNA (cHPV-DNA) in Locally Advanced Uterine Cervix Cancer. Cancers (Basel) 2023; 15:1387. [PMID: 36900180 PMCID: PMC10000151 DOI: 10.3390/cancers15051387] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The majority of locally advanced cervical cancers (LaCC) are causally related to HPV. We sought to investigate the utility of an ultra-sensitive HPV-DNA next generation sequencing (NGS) assay-panHPV-detect-in LaCC treated with chemoradiotherapy, as a marker of treatment response and persistent disease. METHOD Serial blood samples were collected from 22 patients with LaCC before, during and after chemoradiation. The presence of circulating HPV-DNA was correlated with clinical and radiological outcomes. RESULTS The panHPV-detect test demonstrated a sensitivity and specificity of 88% (95% CI-70-99%) and 100% (95% CI-30-100%), respectively, and correctly identified the HPV-subtype (16, 18, 45, 58). After a median follow up of 16 months, and three relapses all had detectable cHPV-DNA at 3 months post-CRT despite complete response on imaging. Another four patients with radiological partial or equivocal response and undetectable cHPV-DNA at the 3-month time point did not go on to develop relapse. All patients with radiological CR and undetectable cHPV-DNA at 3-months remained disease free. CONCLUSIONS These results demonstrate that the panHPV-detect test shows high sensitivity and specificity for detecting cHPV-DNA in plasma. The test has potential applications in assessment of the response to CRT and in monitoring for relapse, and these initial findings warrant validation in a larger cohort.
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Affiliation(s)
- Susan Lalondrelle
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- The Royal Marsden Hospital, Downs Road, Sutton SM2 5PT, UK
| | - Jen Lee
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
| | | | | | - Nik Matthews
- Imperial College London, South Kengsington Campus, SW7 2AZ, UK
| | - Nicholas Turner
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- The Royal Marsden Hospital, Downs Road, Sutton SM2 5PT, UK
| | - Kevin Harrington
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- The Royal Marsden Hospital, Downs Road, Sutton SM2 5PT, UK
| | - Katherine Vroobel
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- The Royal Marsden Hospital, Downs Road, Sutton SM2 5PT, UK
| | - Emily Moretti
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- The Royal Marsden Hospital, Downs Road, Sutton SM2 5PT, UK
| | - Shreerang A. Bhide
- The Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
- The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- The Royal Marsden Hospital, Downs Road, Sutton SM2 5PT, UK
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Nutting CM, Griffin CL, Sanghera P, Foran B, Beasley M, Bernstein D, Cosgrove V, Fisher S, West CM, Sibtain A, Palaniappan N, Urbano TG, Sen M, Soe W, Rizwanullah M, Wood K, Ramkumar S, Junor E, Cook A, Roques T, Scrase C, Bhide SA, Gujral D, Harrington KJ, Mehanna H, Miah A, Emson M, Gardiner D, Morden JP, Hall E. Dose-escalated intensity-modulated radiotherapy in patients with locally advanced laryngeal and hypopharyngeal cancers: ART DECO, a phase III randomised controlled trial. Eur J Cancer 2021; 153:242-256. [PMID: 34256319 DOI: 10.1016/j.ejca.2021.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/30/2021] [Accepted: 05/09/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Radical (chemo)radiotherapy offers potentially curative treatment for patients with locally advanced laryngeal or hypopharyngeal cancer. We aimed to show that dose-escalated intensity-modulated radiotherapy (DE-IMRT) improved locoregional control. METHODS We performed a phase III open-label randomised controlled trial in patients with laryngeal or hypopharyngeal cancer (AJCC III-IVa/b, TNM 7). Patients were randomised (1:1) to DE-IMRT or standard dose IMRT (ST-IMRT) using a minimisation algorithm, balancing for centre, tumour site, nodal status and chemotherapy use. DE-IMRT was 67.2 gray (Gy) in 28 fractions (f) to the primary tumour and 56Gy/28f to at-risk nodes; ST-IMRT was 65Gy/30f to primary tumour and 54Gy/30f to at-risk nodes. Suitable patients received 2 cycles of concomitant cisplatin and up to 3 cycles of platinum-based induction chemotherapy. The primary end-point was time to locoregional failure analysed by intention-to-treat analysis using competing risk methodology. FINDINGS Between February 2011 and October 2015, 276 patients (138 ST-IMRT; 138 DE-IMRT) were randomised. A preplanned interim futility analysis met the criterion for early closure. After a median follow-up of 47.9 months (interquartile range 37.5-60.5), there were locoregional failures in 38 of 138 (27.5%) ST-IMRT patients and 42 of 138 (30.4%) DE-IMRT patients; an adjusted subhazard ratio of 1.16 (95% confidence interval: 0.74-1.83, p = 0.519) indicated no evidence of benefit with DE-IMRT. Acute grade 2 pharyngeal mucositis was reported more frequently with DE-IMRT than with ST-IMRT (42% vs. 32%). No differences in grade ≥3 acute or late toxicity rates were seen. CONCLUSION DE-IMRT did not improve locoregional control in patients with laryngeal or hypopharyngeal cancer. The trial is registered: ISRCTN01483375.
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Affiliation(s)
| | | | | | | | | | - David Bernstein
- Department of Physics, The Royal Marsden Hospital, London, UK
| | | | | | | | | | | | | | | | | | | | - Katie Wood
- Royal Surrey County Hospital, Guildford, UK
| | | | | | | | - Tom Roques
- Norfolk and Norwich University Hospital, UK
| | | | | | | | | | - Hisham Mehanna
- The Institute for Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | | | - Marie Emson
- The Institute of Cancer Research, London, UK
| | | | | | - Emma Hall
- The Institute of Cancer Research, London, UK
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Nenclares P, Gunn L, Soliman H, Bover M, Trinh A, Leslie I, Wong KH, Melcher A, Newbold K, Nutting CM, Ap Dafydd D, Bhide SA, Harrington K. On-treatment immune prognostic score for patients with relapsed and/or metastatic head and neck squamous cell carcinoma treated with immunotherapy. J Immunother Cancer 2021; 9:e002718. [PMID: 34103355 PMCID: PMC8190047 DOI: 10.1136/jitc-2021-002718] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Previous studies have suggested that inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), lactate dehydrogenase (LDH) and fibrinogen) are prognostic biomarkers in patients with a variety of solid cancers, including those treated with immune checkpoint inhibitors (ICIs). We aimed to develop a model that predicts response and survival in patients with relapsed and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) treated with immunotherapy. METHODS Analysis of 100 consecutive patients with unresectable R/M HNSCC who were treated with ICI. Baseline and on-treatment (day 28) NLR, fibrinogen and LDH were calculated and correlated with response, progression-free survival (PFS) and overall survival (OS) using univariate and multivariate analyses. The optimal cut-off values were derived using maximally selected log-rank statistics. RESULTS Low baseline NLR and fibrinogen levels were associated with response. There was a statistically significant correlation between on-treatment NLR and fibrinogen and best overall response. On-treatment high NLR and raised fibrinogen were significantly associated with poorer outcome. In multivariate analysis, on-treatment NLR (≥4) and on-treatment fibrinogen (≥4 ng/mL) showed a significant negative correlation with OS and PFS. Using these cut-off points, we generated an on-treatment score for OS and PFS (0-2 points). The derived scoring system shows appropriate discrimination and suitability for OS (HR 2.4, 95% CI 1.7 to 3.4, p<0.0001, Harrell's C 0.67) and PFS (HR 1.8, 95% CI 1.4 to 2.3, p<0.0001, Harrell's C 0.68). In the absence of an external validation cohort, results of fivefold cross-validation of the score and evaluation of median OS and PFS on the Kaplan-Meier survival distribution between trained and test data exhibited appropriate accuracy and concordance of the model. CONCLUSIONS NLR and fibrinogen levels are simple, inexpensive and readily available biomarkers that could be incorporated into an on-treatment scoring system and used to help predict survival and response to ICI in patients with R/M HNSCC.
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Affiliation(s)
- Pablo Nenclares
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Lucinda Gunn
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Heba Soliman
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Mateo Bover
- Head and Neck Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Amy Trinh
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Isla Leslie
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Kee Howe Wong
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Alan Melcher
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kate Newbold
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Chris M Nutting
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Derfel Ap Dafydd
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Shreerang A Bhide
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kevin Harrington
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
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Wong KH, Panek R, Dunlop A, Mcquaid D, Riddell A, Welsh LC, Murray I, Koh DM, Leach MO, Bhide SA, Nutting CM, Oyen WJ, Harrington KJ, Newbold KL. Changes in multimodality functional imaging parameters early during chemoradiation predict treatment response in patients with locally advanced head and neck cancer. Eur J Nucl Med Mol Imaging 2018; 45:759-767. [PMID: 29164301 PMCID: PMC5978912 DOI: 10.1007/s00259-017-3890-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/13/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess the optimal timing and predictive value of early intra-treatment changes in multimodality functional and molecular imaging (FMI) parameters as biomarkers for clinical remission in patients receiving chemoradiation for head and neck squamous cell carcinoma (HNSCC). METHODS Thirty-five patients with stage III-IVb (AJCC 7th edition) HNSCC prospectively underwent 18F-FDG-PET/CT, and diffusion-weighted (DW), dynamic contrast-enhanced (DCE) and susceptibility-weighted MRI at baseline, week 1 and week 2 of chemoradiation. Patients with evidence of persistent or recurrent disease during follow-up were classed as non-responders. Changes in FMI parameters at week 1 and week 2 were compared between responders and non-responders with the Mann-Whitney U test. The significance threshold was set at a p value of <0.05. RESULTS There were 27 responders and 8 non-responders. Responders showed a greater reduction in PET-derived tumor total lesion glycolysis (TLG40%; p = 0.007) and maximum standardized uptake value (SUVmax; p = 0.034) after week 1 than non-responders but these differences were absent by week 2. In contrast, it was not until week 2 that MRI-derived parameters were able to discriminate between the two groups: larger fractional increases in primary tumor apparent diffusion coefficient (ADC; p < 0.001), volume transfer constant (Ktrans; p = 0.012) and interstitial space volume fraction (Ve; p = 0.047) were observed in responders versus non-responders. ADC was the most powerful predictor (∆ >17%, AUC 0.937). CONCLUSION Early intra-treatment changes in FDG-PET, DW and DCE MRI-derived parameters are predictive of ultimate response to chemoradiation in HNSCC. However, the optimal timing for assessment with FDG-PET parameters (week 1) differed from MRI parameters (week 2). This highlighted the importance of scanning time points for the design of FMI risk-stratified interventional studies.
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Affiliation(s)
- Kee H Wong
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK.
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK.
| | - Rafal Panek
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Alex Dunlop
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Dualta Mcquaid
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
| | - Angela Riddell
- Clinical Radiology, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Liam C Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Iain Murray
- Nuclear Medicine, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Dow-Mu Koh
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
- Clinical Radiology, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Martin O Leach
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
- CRUK Cancer Imaging Centre, The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, UK
| | - Shreerang A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Christopher M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Wim J Oyen
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
- Nuclear Medicine, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Kevin J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Kate L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
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Gurney-Champion OJ, McQuaid D, Dunlop A, Wong KH, Welsh LC, Riddell AM, Koh DM, Oelfke U, Leach MO, Nutting CM, Bhide SA, Harrington KJ, Panek R, Newbold KL. MRI-based Assessment of 3D Intrafractional Motion of Head and Neck Cancer for Radiation Therapy. Int J Radiat Oncol Biol Phys 2018; 100:306-316. [PMID: 29229323 PMCID: PMC5777665 DOI: 10.1016/j.ijrobp.2017.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/14/2017] [Accepted: 10/03/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE To determine the 3-dimensional (3D) intrafractional motion of head and neck squamous cell carcinoma (HNSCC). METHODS AND MATERIALS Dynamic contrast-enhanced magnetic resonance images from 56 patients with HNSCC in the treatment position were analyzed. Dynamic contrast-enhanced magnetic resonance imaging consisted of 3D images acquired every 2.9 seconds for 4 minutes 50 seconds. Intrafractional tumor motion was studied in the 3 minutes 43 seconds of images obtained after initial contrast enhancement. To assess tumor motion, rigid registration (translations only) was performed using a region of interest (ROI) mask around the tumor. The results were compared with bulk body motion from registration to all voxels. Motion was split into systematic motion and random motion. Correlations between the tumor site and random motion were tested. The within-subject coefficient of variation was determined from 8 patients with repeated baseline measures. Random motion was also assessed at the end of the first week (38 patients) and second week (25 patients) of radiation therapy to investigate trends of motion. RESULTS Tumors showed irregular occasional rapid motion (eg, swallowing or coughing), periodic intermediate motion (respiration), and slower systematic drifts throughout treatment. For 95% of the patients, displacements due to systematic and random motion were <1.4 mm and <2.1 mm, respectively, 95% of the time. The motion without an ROI mask was significantly (P<.0001, Wilcoxon signed rank test) less than the motion with an ROI mask, indicating that tumors can move independently from the bony anatomy. Tumor motion was significantly (P=.005, Mann-Whitney U test) larger in the hypopharynx and larynx than in the oropharynx. The within-subject coefficient of variation for random motion was 0.33. The average random tumor motion did not increase notably during the first 2 weeks of treatment. CONCLUSIONS The 3D intrafractional tumor motion of HNSCC is small, with systematic motion <1.4 mm and random motion <2.1 mm 95% of the time.
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Affiliation(s)
- Oliver J Gurney-Champion
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Dualta McQuaid
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Alex Dunlop
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Kee H Wong
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Liam C Welsh
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Angela M Riddell
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Dow-Mu Koh
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Martin O Leach
- CR UK Cancer Imaging Centre, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Christopher M Nutting
- Joint Department of Radiotherapy, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Shreerang A Bhide
- Joint Department of Radiotherapy, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Kevin J Harrington
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Rafal Panek
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kate L Newbold
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
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Panek R, Welsh L, Baker LCJ, Schmidt MA, Wong KH, Riddell AM, Koh DM, Dunlop A, Mcquaid D, d'Arcy JA, Bhide SA, Harrington KJ, Nutting CM, Hopkinson G, Richardson C, Box C, Eccles SA, Leach MO, Robinson SP, Newbold KL. Noninvasive Imaging of Cycling Hypoxia in Head and Neck Cancer Using Intrinsic Susceptibility MRI. Clin Cancer Res 2017; 23:4233-4241. [PMID: 28314789 PMCID: PMC5516915 DOI: 10.1158/1078-0432.ccr-16-1209] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/19/2016] [Accepted: 03/03/2017] [Indexed: 01/13/2023]
Abstract
Purpose: To evaluate intrinsic susceptibility (IS) MRI for the identification of cycling hypoxia, and the assessment of its extent and spatial distribution, in head and neck squamous cell carcinoma (HNSCC) xenografts and patients.Experimental Design: Quantitation of the transverse relaxation rate, R2*, which is sensitive to paramagnetic deoxyhemoglobin, using serial IS-MRI acquisitions, was used to monitor temporal oscillations in levels of paramagnetic deoxyhemoglobin in human CALR xenografts and patients with HNSCC at 3T. Autocovariance and power spectrum analysis of variations in R2* was performed for each imaged voxel, to assess statistical significance and frequencies of cycling changes in tumor blood oxygenation. Pathologic correlates with tumor perfusion (Hoechst 33342), hypoxia (pimonidazole), and vascular density (CD31) were sought in the xenografts, and dynamic contrast-enhanced (DCE) MRI was used to assess patient tumor vascularization. The prevalence of fluctuations within patient tumors, DCE parameters, and treatment outcome were reported.Results: Spontaneous R2* fluctuations with a median periodicity of 15 minutes were detected in both xenografts and patient tumors. Spatially, these fluctuations were predominantly associated with regions of heterogeneous perfusion and hypoxia in the CALR xenografts. In patients, R2* fluctuations spatially correlated with regions of lymph nodes with low Ktrans values, typically in the vicinity of necrotic cores.Conclusions: IS-MRI can be used to monitor variations in levels of paramagnetic deoxyhemoglobin, associated with cycling hypoxia. The presence of such fluctuations may be linked with impaired tumor vasculature, the presence of which may impact treatment outcome. Clin Cancer Res; 23(15); 4233-41. ©2017 AACR.
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Affiliation(s)
- Rafal Panek
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Liam Welsh
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Lauren C J Baker
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
| | - Maria A Schmidt
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Kee H Wong
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Angela M Riddell
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Dow-Mu Koh
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Alex Dunlop
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Dualta Mcquaid
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - James A d'Arcy
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Shreerang A Bhide
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Kevin J Harrington
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | | | | | | | - Carol Box
- Institute of Cancer Research, London, United Kingdom
| | | | - Martin O Leach
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom.
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Simon P Robinson
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
| | - Kate L Newbold
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
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Wong KH, Panek R, Bhide SA, Nutting CM, Harrington KJ, Newbold KL. The emerging potential of magnetic resonance imaging in personalizing radiotherapy for head and neck cancer: an oncologist's perspective. Br J Radiol 2017; 90:20160768. [PMID: 28256151 DOI: 10.1259/bjr.20160768] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Head and neck cancer (HNC) is a challenging tumour site for radiotherapy delivery owing to its complex anatomy and proximity to organs at risk (OARs) such as the spinal cord and optic apparatus. Despite significant advances in radiotherapy planning techniques, radiation-induced morbidities remain substantial. Further improvement would require high-quality imaging and tailored radiotherapy based on intratreatment response. For these reasons, the use of MRI in radiotherapy planning for HNC is rapidly gaining popularity. MRI provides superior soft-tissue contrast in comparison with CT, allowing better definition of the tumour and OARs. The lack of additional radiation exposure is another attractive feature for intratreatment monitoring. In addition, advanced MRI techniques such as diffusion-weighted, dynamic contrast-enhanced and intrinsic susceptibility-weighted MRI techniques are capable of characterizing tumour biology further by providing quantitative functional parameters such as tissue cellularity, vascular permeability/perfusion and hypoxia. These functional parameters are known to have radiobiological relevance, which potentially could guide treatment adaptation based on their changes prior to or during radiotherapy. In this article, we first present an overview of the applications of anatomical MRI sequences in head and neck radiotherapy, followed by the potentials and limitations of functional MRI sequences in personalizing therapy.
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Affiliation(s)
- Kee H Wong
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Rafal Panek
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Christopher M Nutting
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Katie L Newbold
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
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10
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Dean JA, Welsh LC, Wong KH, Aleksic A, Dunne E, Islam MR, Patel A, Patel P, Petkar I, Phillips I, Sham J, Schick U, Newbold KL, Bhide SA, Harrington KJ, Nutting CM, Gulliford SL. Normal Tissue Complication Probability (NTCP) Modelling of Severe Acute Mucositis using a Novel Oral Mucosal Surface Organ at Risk. Clin Oncol (R Coll Radiol) 2017; 29:263-273. [PMID: 28057404 PMCID: PMC6175048 DOI: 10.1016/j.clon.2016.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/20/2016] [Accepted: 11/01/2016] [Indexed: 12/23/2022]
Abstract
AIMS A normal tissue complication probability (NTCP) model of severe acute mucositis would be highly useful to guide clinical decision making and inform radiotherapy planning. We aimed to improve upon our previous model by using a novel oral mucosal surface organ at risk (OAR) in place of an oral cavity OAR. MATERIALS AND METHODS Predictive models of severe acute mucositis were generated using radiotherapy dose to the oral cavity OAR or mucosal surface OAR and clinical data. Penalised logistic regression and random forest classification (RFC) models were generated for both OARs and compared. Internal validation was carried out with 100-iteration stratified shuffle split cross-validation, using multiple metrics to assess different aspects of model performance. Associations between treatment covariates and severe mucositis were explored using RFC feature importance. RESULTS Penalised logistic regression and RFC models using the oral cavity OAR performed at least as well as the models using mucosal surface OAR. Associations between dose metrics and severe mucositis were similar between the mucosal surface and oral cavity models. The volumes of oral cavity or mucosal surface receiving intermediate and high doses were most strongly associated with severe mucositis. CONCLUSIONS The simpler oral cavity OAR should be preferred over the mucosal surface OAR for NTCP modelling of severe mucositis. We recommend minimising the volume of mucosa receiving intermediate and high doses, where possible.
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Affiliation(s)
- J A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - L C Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - K H Wong
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - A Aleksic
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - E Dunne
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - M R Islam
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - A Patel
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - P Patel
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - I Petkar
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - I Phillips
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - J Sham
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - U Schick
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - K L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - S A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - K J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - C M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - S L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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11
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Dillon MT, Barker HE, Pedersen M, Hafsi H, Bhide SA, Newbold KL, Nutting CM, McLaughlin M, Harrington KJ. Radiosensitization by the ATR Inhibitor AZD6738 through Generation of Acentric Micronuclei. Mol Cancer Ther 2017; 16:25-34. [PMID: 28062704 PMCID: PMC5302142 DOI: 10.1158/1535-7163.mct-16-0239] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 10/21/2016] [Accepted: 11/01/2016] [Indexed: 11/16/2022]
Abstract
AZD6738 is an orally active ATR inhibitor (ATRi) currently in phase I clinical trials. We found in vitro growth inhibitory activity of this ATRi in a panel of human cancer cell lines. We demonstrated radiosensitization by AZD6738 to single radiation fractions in multiple cancer cell lines independent of both p53 and BRCA2 status by the clonogenic assay. Radiosensitization by AZD6738 to clinically relevant doses of fractionated radiation was demonstrated in vitro using a 3D tumor spheroid model and, in vivo, AZD6738 radiosensitized by abrogating the radiation-induced G2 cell-cycle checkpoint and inhibiting homologous recombination. Mitosis with damaged DNA resulted in mitotic catastrophe as measured by micronucleus formation by live-cell fluorescent-ubiquitination cell-cycle imaging of cell-cycle progression and nuclear morphology. Induction of micronuclei was significantly more prominent for AZD6738 compared with inhibition of the downstream kinase CHK1 alone at isoeffective doses. Micronuclei were characterized as acentric chromosomal fragments, which displayed characteristics of increased DNA damage and cell-cycle dyssynchrony when compared with the primary nucleus. Mol Cancer Ther; 16(1); 25-34. ©2016 AACR.
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Affiliation(s)
- Magnus T. Dillon
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Holly E. Barker
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Malin Pedersen
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Hind Hafsi
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | | | | | | | - Martin McLaughlin
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kevin J. Harrington
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- The Royal Marsden Hospital, London, UK
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12
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Panek R, Schmidt MA, Borri M, Koh DM, Riddell A, Welsh L, Dunlop A, Powell C, Bhide SA, Nutting CM, Harrington KJ, Newbold KL, Leach MO. Time-resolved angiography with stochastic trajectories for dynamic contrast-enhanced MRI in head and neck cancer: Are pharmacokinetic parameters affected? Med Phys 2016; 43:6024. [PMID: 27806585 DOI: 10.1118/1.4964795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/26/2016] [Accepted: 09/30/2016] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To investigate the effects of different time-resolved angiography with stochastic trajectories (TWIST) k-space undersampling schemes on calculated pharmacokinetic dynamic contrast-enhanced (DCE) vascular parameters. METHODS A digital perfusion phantom was employed to simulate effects of TWIST on characteristics of signal changes in DCE. Furthermore, DCE-MRI was acquired without undersampling in a group of patients with head and neck squamous cell carcinoma and used to simulate a range of TWIST schemes. Errors were calculated as differences between reference and TWIST-simulated DCE parameters. Parametrical error maps were used to display the averaged results from all tumors. RESULTS For a relatively wide range of undersampling schemes, errors in pharmacokinetic parameters due to TWIST were under 10% for the volume transfer constant, Ktrans, and total extracellular extravascular space volume, Ve. TWIST induced errors in the total blood plasma volume, Vp, were the largest observed, and these were inversely dependent on the area of the fully sampled k-space. The magnitudes of errors were not correlated with Ktrans, Vp and weakly correlated with Ve. CONCLUSIONS The authors demonstrated methods to validate and optimize k-space view-sharing techniques for pharmacokinetic DCE studies using a range of clinically relevant spatial and temporal patient derived data. The authors found a range of undersampling patterns for which the TWIST sequence can be reliably used in pharmacokinetic DCE-MRI. The parameter maps created in the study can help to make a decision between temporal and spatial resolution demands and the quality of enhancement curve characterization.
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Affiliation(s)
- Rafal Panek
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Maria A Schmidt
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Marco Borri
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Dow-Mu Koh
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Angela Riddell
- The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Liam Welsh
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Alex Dunlop
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Ceri Powell
- The Institute of Cancer Research, London SM2 5PT, United Kingdom
| | - Shreerang A Bhide
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Christopher M Nutting
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Kevin J Harrington
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Kate L Newbold
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Martin O Leach
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
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13
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Petkar I, Rooney K, Roe JWG, Patterson JM, Bernstein D, Tyler JM, Emson MA, Morden JP, Mertens K, Miles E, Beasley M, Roques T, Bhide SA, Newbold KL, Harrington KJ, Hall E, Nutting CM. DARS: a phase III randomised multicentre study of dysphagia- optimised intensity- modulated radiotherapy (Do-IMRT) versus standard intensity- modulated radiotherapy (S-IMRT) in head and neck cancer. BMC Cancer 2016; 16:770. [PMID: 27716125 PMCID: PMC5052945 DOI: 10.1186/s12885-016-2813-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Persistent dysphagia following primary chemoradiation (CRT) for head and neck cancers can have a devastating impact on patients' quality of life. Single arm studies have shown that the dosimetric sparing of critical swallowing structures such as the pharyngeal constrictor muscle and supraglottic larynx can translate to better functional outcomes. However, there are no current randomised studies to confirm the benefits of such swallow sparing strategies. The aim of Dysphagia/Aspiration at risk structures (DARS) trial is to determine whether reducing the dose to the pharyngeal constrictors with dysphagia-optimised intensity- modulated radiotherapy (Do-IMRT) will lead to an improvement in long- term swallowing function without having any detrimental impact on disease-specific survival outcomes. METHODS/DESIGN The DARS trial (CRUK/14/014) is a phase III multicentre randomised controlled trial (RCT) for patients undergoing primary (chemo) radiotherapy for T1-4, N0-3, M0 pharyngeal cancers. Patients will be randomised (1:1 ratio) to either standard IMRT (S-IMRT) or Do-IMRT. Radiotherapy doses will be the same in both groups; however in patients allocated to Do-IMRT, irradiation of the pharyngeal musculature will be reduced by delivering IMRT identifying the pharyngeal muscles as organs at risk. The primary endpoint of the trial is the difference in the mean MD Anderson Dysphagia Inventory (MDADI) composite score, a patient-reported outcome, measured at 12 months post radiotherapy. Secondary endpoints include prospective and longitudinal evaluation of swallow outcomes incorporating a range of subjective and objective assessments, quality of life measures, loco-regional control and overall survival. Patients and speech and language therapists (SLTs) will both be blinded to treatment allocation arm to minimise outcome-reporting bias. DISCUSSION DARS is the first RCT investigating the effect of swallow sparing strategies on improving long-term swallowing outcomes in pharyngeal cancers. An integral part of the study is the multidimensional approach to swallowing assessment, providing robust data for the standardisation of future swallow outcome measures. A translational sub- study, which may lead to the development of future predictive and prognostic biomarkers, is also planned. TRIAL REGISTRATION This study is registered with the International Standard Randomised Controlled Trial register, ISRCTN25458988 (04/01/2016).
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Affiliation(s)
- Imran Petkar
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Keith Rooney
- Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB UK
| | - Justin W. G. Roe
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Joanne M. Patterson
- Speech and Language Therapy Department, Sunderland City Hospitals NHS Foundation Trust, Kayll Road, Sunderland, SR4 7TP UK
- Institute of Health and Society, University of Newcastle, Newcastle upon Tyne, NE1 7RU UK
| | - David Bernstein
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Justine M. Tyler
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Marie A. Emson
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - James P. Morden
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Kathrin Mertens
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Elizabeth Miles
- Mount Vernon Hospital, Rickmansworth Road, Northwood, HA6 2RN UK
| | - Matthew Beasley
- University Hospitals Bristol, Horfield Road, Bristol, BS2 8ED UK
| | - Tom Roques
- Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY UK
| | - Shreerang A. Bhide
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Kate L. Newbold
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Kevin J. Harrington
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Emma Hall
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
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14
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Miah AB, Gulliford SL, Morden J, Newbold KL, Bhide SA, Zaidi SH, Hall E, Harrington KJ, Nutting CM. Recovery of Salivary Function: Contralateral Parotid-sparing Intensity-modulated Radiotherapy versus Bilateral Superficial Lobe Parotid-sparing Intensity-modulated Radiotherapy. Clin Oncol (R Coll Radiol) 2016; 28:e69-e76. [PMID: 26994893 PMCID: PMC4979532 DOI: 10.1016/j.clon.2016.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 02/06/2016] [Accepted: 02/09/2016] [Indexed: 11/23/2022]
Abstract
AIMS To establish whether there is a difference in recovery of salivary function with bilateral superficial lobe parotid-sparing intensity-modulated radiotherapy (BSLPS-IMRT) versus contralateral parotid-sparing IMRT (CLPS-IMRT) in patients with locally advanced head and neck squamous cell cancers. MATERIALS AND METHODS A dosimetric analysis was carried out on data from two studies in which patients received BSLPS-IMRT (PARSPORT II) or CLPS-IMRT (PARSPORT). Acute (National Cancer Institute, Common Terminology Criteria for adverse events - NCI CTCAEv3.0) and late (Late Effects of Normal Tissue- subjective, objective, management analytical - LENTSOMA and Radiation Therapy Oncology Group) xerostomia scores were dichotomised: recovery (grade 0-1) versus no recovery (≥grade 2). Incidence of recovery of salivary function was compared between the two techniques and dose-response relationships were determined by fitting dose-response curves to the data using non-linear logistic regression analysis. RESULTS Seventy-one patients received BSLPS-IMRT and 35 received CLPS-IMRT. Patients received 65 Gy in 30 fractions to the primary site and involved nodal levels and 54 Gy in 30 fractions to elective nodal levels. There were significant differences in mean doses to contralateral parotid gland (29.4 Gy versus 24.9 Gy, P < 0.005) and superficial lobes (26.8 Gy versus 30.5 Gy, P = 0.02) for BSLPS and CLPS-IMRT, respectively. Lower risk of long-term ≥grade 2 subjective xerostomia (LENTSOMA) was reported with BSLPS-IMRT (odds ratio 0.50; 95% confidence interval 0.29-0.86; P = 0.012). The percentage of patients who reported recovery of parotid saliva flow at 1 year was higher with BSLPS-IMRT compared with CLPS-IMRT techniques (67.1% versus 52.8%), but the difference was not statistically significant (P = 0.12). For the whole parotid gland, the tolerance doses, D50, were 25.6 Gy (95% confidence interval 20.6-30.5), k = 2.7 (0.9-4.5) (CLPS-IMRT) and 28.9 Gy (26.1-31.9), k = 2.4 (1.4-3.4) (BSLPS-IMRT). For the superficial lobe, D50 were similar: BSLPS-IMRT 23.5 Gy (19.3-27.6), k = 1.9 (0.5-3.8); CLPS-IMRT 24.0 Gy (17.7-30.1), k = 2.1 (0.1-4.1). CONCLUSION BSLPS-IMRT reduces the risk of developing high-grade subjective xerostomia compared with CLPS-IMRT. The D50 of the superficial lobe may be a more reliable predictor of recovery of parotid function than the whole gland mean dose.
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Affiliation(s)
- A B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S L Gulliford
- Joint Department of Physics, The Institute of Cancer Research, Surrey, UK
| | - J Morden
- The Institute of Cancer Research, Clinical Trials and Statistic Unit, London, UK
| | - K L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S H Zaidi
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - E Hall
- The Institute of Cancer Research, Clinical Trials and Statistic Unit, London, UK
| | - K J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK.
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15
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Dean JA, Wong KH, Gay H, Welsh LC, Jones AB, Schick U, Oh JH, Apte A, Newbold KL, Bhide SA, Harrington KJ, Deasy JO, Nutting CM, Gulliford SL. Functional Data Analysis Applied to Modeling of Severe Acute Mucositis and Dysphagia Resulting From Head and Neck Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 96:820-831. [PMID: 27788955 PMCID: PMC5653218 DOI: 10.1016/j.ijrobp.2016.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/29/2016] [Accepted: 08/12/2016] [Indexed: 11/05/2022]
Abstract
Purpose Current normal tissue complication probability modeling using logistic regression suffers from bias and high uncertainty in the presence of highly correlated radiation therapy (RT) dose data. This hinders robust estimates of dose-response associations and, hence, optimal normal tissue—sparing strategies from being elucidated. Using functional data analysis (FDA) to reduce the dimensionality of the dose data could overcome this limitation. Methods and Materials FDA was applied to modeling of severe acute mucositis and dysphagia resulting from head and neck RT. Functional partial least squares regression (FPLS) and functional principal component analysis were used for dimensionality reduction of the dose-volume histogram data. The reduced dose data were input into functional logistic regression models (functional partial least squares—logistic regression [FPLS-LR] and functional principal component—logistic regression [FPC-LR]) along with clinical data. This approach was compared with penalized logistic regression (PLR) in terms of predictive performance and the significance of treatment covariate—response associations, assessed using bootstrapping. Results The area under the receiver operating characteristic curve for the PLR, FPC-LR, and FPLS-LR models was 0.65, 0.69, and 0.67, respectively, for mucositis (internal validation) and 0.81, 0.83, and 0.83, respectively, for dysphagia (external validation). The calibration slopes/intercepts for the PLR, FPC-LR, and FPLS-LR models were 1.6/−0.67, 0.45/0.47, and 0.40/0.49, respectively, for mucositis (internal validation) and 2.5/−0.96, 0.79/−0.04, and 0.79/0.00, respectively, for dysphagia (external validation). The bootstrapped odds ratios indicated significant associations between RT dose and severe toxicity in the mucositis and dysphagia FDA models. Cisplatin was significantly associated with severe dysphagia in the FDA models. None of the covariates was significantly associated with severe toxicity in the PLR models. Dose levels greater than approximately 1.0 Gy/fraction were most strongly associated with severe acute mucositis and dysphagia in the FDA models. Conclusions FPLS and functional principal component analysis marginally improved predictive performance compared with PLR and provided robust dose-response associations. FDA is recommended for use in normal tissue complication probability modeling.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Kee H Wong
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Hiram Gay
- Department of Radiation Oncology, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Liam C Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ann-Britt Jones
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ulrike Schick
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kate L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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McQuaid D, Dunlop A, Nill S, Franzese C, Nutting CM, Harrington KJ, Newbold KL, Bhide SA. Evaluation of radiotherapy techniques for radical treatment of lateralised oropharyngeal cancers : Dosimetry and NTCP. Strahlenther Onkol 2016; 192:516-25. [PMID: 27295511 DOI: 10.1007/s00066-016-0980-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/12/2016] [Indexed: 12/22/2022]
Abstract
AIM The aim of this study was to investigate potential advantages and disadvantages of three-dimensional conformal radiotherapy (3DCRT), multiple fixed-field intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) in terms of dose to the planning target volume (PTV), organs at risk (OARs) and normal tissue complication probability (NTCP) for delivering ipsilateral radiotherapy. MATERIALS AND METHODS 3DCRT, IMRT and VMAT were compared in patients with well-lateralised primary tonsillar cancers who underwent primary radical ipsilateral radiotherapy. The following parameters were compared: conformity index (CI); homogeneity index (HI); dose-volume histograms (DVHs) of PTVs and OARs; NTCP, risk of radiation-induced cancer and dose accumulation during treatment. RESULTS IMRT and VMAT were superior to 3DCRT in terms of CI, HI and dose to the target volumes, as well as mandible and dose accumulation robustness. The techniques were equivalent in terms of dose and NTCP for the contralateral oral cavity, contralateral submandibular gland and mandible, when specific dose constraint objectives were used on the oral cavity volume. Although the volume of normal tissue exposed to low-dose radiation was significantly higher with IMRT and VMAT, the risk of radiation-induced secondary malignancy was dependant on the mathematical model used. CONCLUSION This study demonstrates the superiority of IMRT/VMAT techniques over 3DCRT in terms of dose homogeneity, conformity and consistent dose delivery to the PTV throughout the course of treatment in patients with lateralised oropharyngeal cancers. Dosimetry and NTCP calculations show that these techniques are equivalent to 3DCRT with regard to the risk of acute mucositis when specific dose constraint objectives were used on the contralateral oral cavity OAR.
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Affiliation(s)
- D McQuaid
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - A Dunlop
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - S Nill
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - C Franzese
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
| | - C M Nutting
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - K J Harrington
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - K L Newbold
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - S A Bhide
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK.
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK.
- The Institute of Cancer Research, SW3 6JB, London, UK.
- The Institute of Cancer Research, SM2 5NG, Sutton, UK.
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17
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Wong KH, Kuciejewska A, Sharabiani MTA, Ng-Cheng-Hin B, Hoy S, Hurley T, Rydon J, Grove L, Santos A, Ryugenji M, Bhide SA, Nutting CM, Harrington KJ, Newbold KL. A randomised controlled trial of Caphosol mouthwash in management of radiation-induced mucositis in head and neck cancer. Radiother Oncol 2016; 122:207-211. [PMID: 27393218 DOI: 10.1016/j.radonc.2016.06.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/25/2016] [Accepted: 06/26/2016] [Indexed: 01/02/2023]
Abstract
PURPOSE This phase III, non-blinded, parallel-group, randomised controlled study evaluated the efficacy of Caphosol mouthwash in the management of radiation-induced oral mucositis (OM) in patients with head and neck cancer (HNC) undergoing radical (chemo)radiotherapy. PATIENTS AND METHODS Eligible patients were randomised at 1:1 to Caphosol plus standard oral care (intervention) or standard oral care alone (control), stratified by radiotherapy technique and use of concomitant chemotherapy. Patients in the intervention arm used Caphosol for 7weeks: 6weeks during and 1-week post-radiotherapy. The primary endpoint was the incidence of severe OM (CTCAE ⩾grade 3) during and up to week 8 post-radiotherapy. Secondary endpoints include pharyngeal mucositis, dysphagia, pain and quality of life. RESULTS The intervention (n=108) and control (n=107) arms were well balanced in terms of patient demographics and treatment characteristics. Following exclusion of patients with missing data, 210 patients were available for analysis. The incidence of severe OM did not differ between the intervention and control arms (64.1% versus 65.4%, p=0.839). Similarly, no significant benefit was observed for other secondary endpoints. Overall, compliance with the recommended frequency of Caphosol was low. CONCLUSION Caphosol did not reduce the incidence or duration of severe OM during and after radiotherapy in HNC.
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Affiliation(s)
- Kee H Wong
- Head and Neck Oncology Unit, Royal Marsden Hospital, Sutton, UK; The Institute of Cancer Research, London, UK.
| | | | | | | | - Sonja Hoy
- Head and Neck Oncology Unit, Royal Marsden Hospital, Sutton, UK
| | - Tara Hurley
- Head and Neck Oncology Unit, Royal Marsden Hospital, Sutton, UK
| | - Joanna Rydon
- Head and Neck Oncology Unit, Royal Marsden Hospital, Sutton, UK
| | - Lorna Grove
- Head and Neck Oncology Unit, Royal Marsden Hospital, London, UK
| | - Ana Santos
- Head and Neck Oncology Unit, Royal Marsden Hospital, London, UK
| | - Motoko Ryugenji
- Head and Neck Oncology Unit, Royal Marsden Hospital, London, UK
| | - Shreerang A Bhide
- Head and Neck Oncology Unit, Royal Marsden Hospital, Sutton, UK; The Institute of Cancer Research, London, UK
| | - Chris M Nutting
- Head and Neck Oncology Unit, Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- Head and Neck Oncology Unit, Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - Kate L Newbold
- Head and Neck Oncology Unit, Royal Marsden Hospital, Sutton, UK; The Institute of Cancer Research, London, UK.
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18
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Dean JA, Wong KH, Welsh LC, Jones AB, Schick U, Newbold KL, Bhide SA, Harrington KJ, Nutting CM, Gulliford SL. Normal tissue complication probability (NTCP) modelling using spatial dose metrics and machine learning methods for severe acute oral mucositis resulting from head and neck radiotherapy. Radiother Oncol 2016; 120:21-7. [PMID: 27240717 PMCID: PMC5021201 DOI: 10.1016/j.radonc.2016.05.015] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Severe acute mucositis commonly results from head and neck (chemo)radiotherapy. A predictive model of mucositis could guide clinical decision-making and inform treatment planning. We aimed to generate such a model using spatial dose metrics and machine learning. MATERIALS AND METHODS Predictive models of severe acute mucositis were generated using radiotherapy dose (dose-volume and spatial dose metrics) and clinical data. Penalised logistic regression, support vector classification and random forest classification (RFC) models were generated and compared. Internal validation was performed (with 100-iteration cross-validation), using multiple metrics, including area under the receiver operating characteristic curve (AUC) and calibration slope, to assess performance. Associations between covariates and severe mucositis were explored using the models. RESULTS The dose-volume-based models (standard) performed equally to those incorporating spatial information. Discrimination was similar between models, but the RFCstandard had the best calibration. The mean AUC and calibration slope for this model were 0.71 (s.d.=0.09) and 3.9 (s.d.=2.2), respectively. The volumes of oral cavity receiving intermediate and high doses were associated with severe mucositis. CONCLUSIONS The RFCstandard model performance is modest-to-good, but should be improved, and requires external validation. Reducing the volumes of oral cavity receiving intermediate and high doses may reduce mucositis incidence.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Kee H Wong
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Liam C Welsh
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Kate L Newbold
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Christopher M Nutting
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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19
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Panek R, Welsh L, Dunlop A, Wong KH, Riddell AM, Koh DM, Schmidt MA, Doran S, Mcquaid D, Hopkinson G, Richardson C, Nutting CM, Bhide SA, Harrington KJ, Robinson SP, Newbold KL, Leach MO. Repeatability and sensitivity of T2* measurements in patients with head and neck squamous cell carcinoma at 3T. J Magn Reson Imaging 2016; 44:72-80. [PMID: 26800280 PMCID: PMC4915498 DOI: 10.1002/jmri.25134] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 12/02/2015] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To determine whether quantitation of T2* is sufficiently repeatable and sensitive to detect clinically relevant oxygenation levels in head and neck squamous cell carcinoma (HNSCC) at 3T. MATERIALS AND METHODS Ten patients with newly diagnosed locally advanced HNSCC underwent two magnetic resonance imaging (MRI) scans between 24 and 168 hours apart prior to chemoradiotherapy treatment. A multiple gradient echo sequence was used to calculate T2* maps. A quadratic function was used to model the blood transverse relaxation rate as a function of blood oxygenation. A set of published coefficients measured at 3T were incorporated to account for tissue hematocrit levels and used to plot the dependence of fractional blood oxygenation (Y) on T2* values, together with the corresponding repeatability range. Repeatability of T2* using Bland-Altman analysis, and calculation of limits of agreement (LoA), was used to assess the sensitivity, defined as the minimum difference in fractional blood oxygenation that can be confidently detected. RESULTS T2* LoA for 22 outlined tumor volumes were 13%. The T2* dependence of fractional blood oxygenation increases monotonically, resulting in increasing sensitivity of the method with increasing blood oxygenation. For fractional blood oxygenation values above 0.11, changes in T2* were sufficient to detect differences in blood oxygenation greater than 10% (Δ T2* > LoA for ΔY > 0.1). CONCLUSION Quantitation of T2* at 3T can detect clinically relevant changes in tumor oxygenation within a wide range of blood volumes and oxygen tensions, including levels reported in HNSCC. J. Magn. Reson. Imaging 2016;44:72-80.
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Affiliation(s)
- Rafal Panek
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Liam Welsh
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Alex Dunlop
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Kee H Wong
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Angela M Riddell
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Dow-Mu Koh
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Maria A Schmidt
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Simon Doran
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Dualta Mcquaid
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | | | | | | | - Shreerang A Bhide
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Kevin J Harrington
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Simon P Robinson
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
| | - Kate L Newbold
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Martin O Leach
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
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20
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Dean JA, Welsh LC, McQuaid D, Wong KH, Aleksic A, Dunne E, Islam MR, Patel A, Patel P, Petkar I, Phillips I, Sham J, Newbold KL, Bhide SA, Harrington KJ, Gulliford SL, Nutting CM. Assessment of fully-automated atlas-based segmentation of novel oral mucosal surface organ-at-risk. Radiother Oncol 2016; 119:166-71. [PMID: 26970676 DOI: 10.1016/j.radonc.2016.02.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/05/2016] [Accepted: 02/09/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Current oral mucositis normal tissue complication probability models, based on the dose distribution to the oral cavity volume, have suboptimal predictive power. Improving the delineation of the oral mucosa is likely to improve these models, but is resource intensive. We developed and evaluated fully-automated atlas-based segmentation (ABS) of a novel delineation technique for the oral mucosal surfaces. MATERIAL AND METHODS An atlas of mucosal surface contours (MSC) consisting of 46 patients was developed. It was applied to an independent test cohort of 10 patients for whom manual segmentation of MSC structures, by three different clinicians, and conventional outlining of oral cavity contours (OCC), by an additional clinician, were also performed. Geometric comparisons were made using the dice similarity coefficient (DSC), validation index (VI) and Hausdorff distance (HD). Dosimetric comparisons were carried out using dose-volume histograms. RESULTS The median difference, in the DSC and HD, between automated-manual comparisons and manual-manual comparisons were small and non-significant (-0.024; p=0.33 and -0.5; p=0.88, respectively). The median VI was 0.086. The maximum normalised volume difference between automated and manual MSC structures across all of the dose levels, averaged over the test cohort, was 8%. This difference reached approximately 28% when comparing automated MSC and OCC structures. CONCLUSIONS Fully-automated ABS of MSC is suitable for use in radiotherapy dose-response modelling.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Liam C Welsh
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Dualta McQuaid
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Kee H Wong
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Emma Dunne
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | - Imran Petkar
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Jackie Sham
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Kate L Newbold
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Christopher M Nutting
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
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Miah AB, Bhide SA, Del Rosario L, Matthews J, Nicol R, Tanay MA, Gupta S, Zaidi SH, Newbold KL, Harrington KJ, Nutting CM. Induction Chemotherapy Followed by Chemo-intensity-modulated Radiotherapy for Locally Advanced Nasopharyngeal Cancer. Clin Oncol (R Coll Radiol) 2016; 28:e61-7. [PMID: 26876458 DOI: 10.1016/j.clon.2016.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 12/01/2015] [Accepted: 12/30/2015] [Indexed: 11/16/2022]
Abstract
AIMS To determine the toxicity and tumour control rates after chemo-intensity-modulated radiotherapy (chemo-IMRT) for locally advanced nasopharyngeal cancers (LA-NPC). MATERIALS AND METHODS Patients with LA-NPC were enrolled in a trial to receive induction chemotherapy followed by parotid-sparing chemo-IMRT. The primary site and involved nodal levels received 65 Gy in 30 fractions and at risk nodal levels received 54 Gy in 30 fractions. Incidence of ≥grade 2 subjective xerostomia was the primary end point. Secondary end points included incidences of acute and late toxicities and survival outcomes. RESULTS Forty-two patients with American Joint Committee on Cancer stages II (12%), III (26%) and IV (62%) (World Health Organization subtype: I [5%]; II [40%]; III [55%]) completed treatment between January 2006 and April 2010 with a median follow-up of 32 months. Incidences of ≥grade 2 acute toxicities were: dysphagia 83%; xerostomia 76%; mucositis 97%; pain 76%; fatigue 99% and ototoxicity 12%. At 12 months, ≥grade 2 subjective xerostomia was observed in 31%, ototoxicitiy in 13% and dysphagia in 4%. Two year locoregional control was 86.2% (95% confidence interval: 70.0-94.0) with 2 year progression-free survival at 78.4% (61.4-88.6) and 2 year overall survival at 85.9% (69.3-93.9). CONCLUSIONS Chemo-IMRT for LA-NPC is feasible with good survival outcomes. At 1 year, 31% experience ≥grade 2 subjective xerostomia.
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Affiliation(s)
- A B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - S A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - L Del Rosario
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - J Matthews
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - R Nicol
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - M A Tanay
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S Gupta
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S H Zaidi
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - K L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - K J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C M Nutting
- The Institute of Cancer Research, London, UK.
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22
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Borri M, Schmidt MA, Powell C, Koh DM, Riddell AM, Partridge M, Bhide SA, Nutting CM, Harrington KJ, Newbold KL, Leach MO. Characterizing Heterogeneity within Head and Neck Lesions Using Cluster Analysis of Multi-Parametric MRI Data. PLoS One 2015; 10:e0138545. [PMID: 26398888 PMCID: PMC4580650 DOI: 10.1371/journal.pone.0138545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 09/01/2015] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To describe a methodology, based on cluster analysis, to partition multi-parametric functional imaging data into groups (or clusters) of similar functional characteristics, with the aim of characterizing functional heterogeneity within head and neck tumour volumes. To evaluate the performance of the proposed approach on a set of longitudinal MRI data, analysing the evolution of the obtained sub-sets with treatment. MATERIAL AND METHODS The cluster analysis workflow was applied to a combination of dynamic contrast-enhanced and diffusion-weighted imaging MRI data from a cohort of squamous cell carcinoma of the head and neck patients. Cumulative distributions of voxels, containing pre and post-treatment data and including both primary tumours and lymph nodes, were partitioned into k clusters (k = 2, 3 or 4). Principal component analysis and cluster validation were employed to investigate data composition and to independently determine the optimal number of clusters. The evolution of the resulting sub-regions with induction chemotherapy treatment was assessed relative to the number of clusters. RESULTS The clustering algorithm was able to separate clusters which significantly reduced in voxel number following induction chemotherapy from clusters with a non-significant reduction. Partitioning with the optimal number of clusters (k = 4), determined with cluster validation, produced the best separation between reducing and non-reducing clusters. CONCLUSION The proposed methodology was able to identify tumour sub-regions with distinct functional properties, independently separating clusters which were affected differently by treatment. This work demonstrates that unsupervised cluster analysis, with no prior knowledge of the data, can be employed to provide a multi-parametric characterization of functional heterogeneity within tumour volumes.
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Affiliation(s)
- Marco Borri
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Maria A. Schmidt
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Ceri Powell
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Dow-Mu Koh
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
- Radiology Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Angela M. Riddell
- Radiology Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Mike Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Shreerang A. Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Kevin J. Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Katie L. Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Martin O. Leach
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
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Miah AB, Gulliford SL, Clark CH, Bhide SA, Zaidi SH, Newbold KL, Harrington KJ, Nutting CM. Dose-response analysis of parotid gland function: what is the best measure of xerostomia? Radiother Oncol 2013; 106:341-5. [PMID: 23566529 DOI: 10.1016/j.radonc.2013.03.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 02/12/2013] [Accepted: 03/06/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE To describe the dose-response relationships for the different measures of salivary gland recovery following radical radiotherapy for locally advanced head and neck squamous cell cancers (LA-HNSCC). METHODS AND MATERIALS Dosimetric analysis of data from the PARSPORT trial, a Phase III study of conventional RT (RT) and intensity modulated radiotherapy (IMRT) for LA-HNSCC was undertaken to determine the relationship between parotid gland mean dose and toxicity endpoints: high-grade subjective and objective xerostomia and xerostomia-related quality of life scores. LKB-NTCP parameters (TD50, m and n) were generated and tolerance doses (D50) reported using non-linear logistic regression analysis. RESULTS Data were available on 63 patients from the PARSPORT trial. Parotid saliva flow rate provided the strongest association between mean dose and recovery, D50=23.4 Gy (20.6-26.2) and k=3.2 (1.9-4.5), R(2)=0.85. Corresponding LKB parameters were TD50=26.3 Gy (95% CI: 24.0-30.1), m=0.25 (0.18-1.0 and n=1). LENTSOMA subjective xerostomia also demonstrated a strong association D50=33.3 Gy (26.7-39.8), k=2.8 (91.4-4.4), R(2)=0.77). CONCLUSION We recommend using the LENT SOMA subjective xerostomia score to predict recovery of salivation due to its strong association with dosimetry and ease of recording.
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Affiliation(s)
- Aisha B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
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Miah AB, Gulliford SL, Bhide SA, Zaidi SH, Newbold KL, Harrington KJ, Nutting CM. The effect of concomitant chemotherapy on parotid gland function following head and neck IMRT. Radiother Oncol 2013; 106:346-51. [PMID: 23540553 DOI: 10.1016/j.radonc.2013.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 02/17/2013] [Accepted: 03/04/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine whether concomitant chemotherapy increases the incidence of high grade xerostomia following parotid-sparing intensity-modulated radiotherapy (IMRT) in patients with locally advanced head and neck squamous cell cancer. MATERIALS AND METHODS The incidence of high grade (≥G2) acute (CTCAEv3.0) and late (LENTSOMA and RTOG) xerostomia was compared between patients treated with either IMRT or concomitant chemo-IMRT (c-IMRT) in 2 prospective studies. Parotid gland mean tolerance doses (D₅₀) were reported using non-linear logistic regression analysis. RESULTS Thirty-six patients received IMRT alone and 60 patients received c-IMRT. Patients received 65 Gy in 30 daily fractions to the primary site and involved nodal groups and 54 Gy in 30 fractions to elective nodal groups, mean doses to the parotid glands were comparable. Concomitant cisplatin 100mg/m(2) was administered on days 1 and 29 of IMRT. The incidence of ≥G2 subjective xerostomia was similar in both groups; acute-64.7% (IMRT) versus 60.3% (c-IMRT), p=0.83; late-43% (IMRT) versus 34% (c-IMRT), p=0.51. Recovery of parotid salivary flow at 1 year was higher with IMRT (64% vs 50%), but not statistically significant (p=0.15). D₅₀ for absence of parotid saliva flow at 1 year was 23.2 Gy (95% CI: 17.7-28.7) for IMRT and 21.1 Gy (11.8-30.3) for c-IMRT. CONCLUSION Concomitant c-IMRT does not increase the incidence of acute or late xerostomia relative to IMRT alone.
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Affiliation(s)
- Aisha B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Surrey, UK
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25
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Wilkins AC, Rosenfelder N, Schick U, Gupta S, Thway K, Nutting CM, Harrington KJ, Newbold K, Bhide SA. Equivalence of cisplatin and carboplatin-based chemoradiation for locally advanced squamous cell carcinoma of the head and neck: a matched-pair analysis. Oral Oncol 2013; 49:615-9. [PMID: 23485743 DOI: 10.1016/j.oraloncology.2013.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/07/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carboplatin can be substituted for cisplatin in concomitant chemoradiation (CRT) for locally advanced squamous cell carcinoma of the head and neck (LASCCHN) when the latter is contraindicated. This matched-pair study aimed to compare the efficacy and acute toxicity of carboplatin and cisplatin. METHODS Patients treated with 2 cycles of concomitant carboplatin-based CRT were matched to patients treated with 2 cycles of cisplatin. Matching criteria included age, tumour site, stage, smoking status and use of induction chemotherapy. Radiation was delivered using conformal techniques. Data on weekly acute toxicity throughout CRT was compared using the chi-squared test for proportions. Kaplan Meier statistics described time to local relapse, distant relapse and overall survival, the log-rank test was used to compare 3-year survival outcomes. RESULTS Sixty-five patients who received carboplatin were matched to 65 who received cisplatin. Significant differences in toxicity included increased emesis with cisplatin and more anaemia and thrombocytopenia with carboplatin. There was no significant difference in 3-year locoregional control (87% vs. 79%, p=0.54), freedom from distant metastases (88% vs. 85%, p=0.79) and overall survival (59% vs. 68%, p=0.24) between the carboplatin and cisplatin cohorts, respectively. CONCLUSIONS When cisplatin is contraindicated, carboplatin-based CRT yields equivalent treatment outcomes in patients with LASCCHN.
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Affiliation(s)
- A C Wilkins
- Head and Neck Unit, Royal Marsden Hospital, London and Surrey, United Kingdom
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26
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Powell C, Schmidt M, Borri M, Koh DM, Partridge M, Riddell A, Cook G, Bhide SA, Nutting CM, Harrington KJ, Newbold KL. Changes in functional imaging parameters following induction chemotherapy have important implications for individualised patient-based treatment regimens for advanced head and neck cancer. Radiother Oncol 2013; 106:112-7. [PMID: 23089306 DOI: 10.1016/j.radonc.2012.09.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 07/09/2012] [Accepted: 09/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND When induction chemotherapy (IC) is used prior to chemoradiotherapy (CRT) in head and neck cancer (HNC), functional imaging (FI) may inform adaptation of treatment plans with the aim of optimising outcomes. Understanding the impact of IC on FI parameters is, therefore, essential. PURPOSE To prospectively evaluate the feasibility of acquiring serial FI ((18)F-FDG-PET, diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) MRI) and its role in defining individualised treatment regimens following IC in HNC. METHODS AND MATERIALS Ten patients with stage III and IV HNC underwent conventional (CT and MRI) and functional (DW, DCE-MRI and (18)F-FDG-PET/CT) imaging at baseline and following two cycles of IC prior to definitive CRT. RESULTS One patient withdrew due to claustrophobia. Seven out of nine patients had a complete metabolic response to IC on (18)F-FDG-PET imaging. DCE-MRI showed a significant fall in transfer constant (K(trans)) (0.209 vs 0.129 min(-1)P<0.01) and integrated area under gadolinium curve at 60s (IAUGC6O) (18.4 vs 11.9 mmol/min, P<0.01) and DW-MRI a rise in ADC (0.89 vs 1.06 × 10(-3) mm(2)/s, P<0.01) following IC. CONCLUSIONS Acquiring FI sequences is feasible in HNC. There are marked changes in FI parameters following IC which may guide adaptation of individualised treatment regimens.
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Affiliation(s)
- Ceri Powell
- The Royal Marsden NHS Trust, Surrey, United Kingdom
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Bhide SA, Newbold KL, Harrington KJ, Nutting CM. Clinical evaluation of intensity-modulated radiotherapy for head and neck cancers. Br J Radiol 2012; 85:487-94. [PMID: 22556403 DOI: 10.1259/bjr/85942136] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy and surgery are the principal curative modalities in treatment of head and neck cancer. Conventional two-dimensional and three-dimensional conformal radiotherapy result in significant side effects and altered quality of life. Intensity-modulated radiotherapy (IMRT) can spare the normal tissues, while delivering a curative dose to the tumour-bearing tissues. This article reviews the current role of IMRT in head and neck cancer from the point of view of normal tissue sparing, and also reviews the current published literature by individual head and neck cancer subsites. In addition, we briefly discuss the role of image guidance in head and neck IMRT, and future directions in this area.
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Affiliation(s)
- S A Bhide
- Head and Neck Unit, Royal Marsden Hospital, Sutton, Surrey, UK
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Zaidi S, McLaughlin M, Bhide SA, Eccles SA, Workman P, Nutting CM, Huddart RA, Harrington KJ. The HSP90 inhibitor NVP-AUY922 radiosensitizes by abrogation of homologous recombination resulting in mitotic entry with unresolved DNA damage. PLoS One 2012; 7:e35436. [PMID: 22523597 PMCID: PMC3327673 DOI: 10.1371/journal.pone.0035436] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 03/16/2012] [Indexed: 12/27/2022] Open
Abstract
Background Heat shock protein 90 (HSP90) is a molecular chaperone responsible for the conformational maintenance of a number of client proteins that play key roles in cell cycle arrest, DNA damage repair and apoptosis following radiation. HSP90 inhibitors exhibit antitumor activity by modulating the stabilisation and activation of HSP90 client proteins. We sought to evaluate NVP-AUY922, the most potent HSP90 inhibitor yet reported, in preclinical radiosensitization studies. Principal Findings NVP-AUY922 potently radiosensitized cells in vitro at low nanomolar concentrations with a concurrent depletion of radioresistance-linked client proteins. Radiosensitization by NVP-AUY922 was verified for the first time in vivo in a human head and neck squamous cell carcinoma xenograft model in athymic mice, as measured by delayed tumor growth and increased surrogate end-point survival (p = <0.0001). NVP-AUY922 was shown to ubiquitously inhibit resolution of dsDNA damage repair correlating to delayed Rad51 foci formation in all cell lines tested. Additionally, NVP-AUY922 induced a stalled mitotic phenotype, in a cell line-dependent manner, in HeLa and HN5 cell lines irrespective of radiation exposure. Cell cycle analysis indicated that NVP-AUY922 induced aberrant mitotic entry in all cell lines tested in the presence of radiation-induced DNA damage due to ubiquitous CHK1 depletion, but resultant downstream cell cycle effects were cell line dependent. Conclusions These results identify NVP-AUY922 as the most potent HSP90-mediated radiosensitizer yet reported in vitro, and for the first time validate it in a clinically relevant in vivo model. Mechanistic analysis at clinically achievable concentrations demonstrated that radiosensitization is mediated by the combinatorial inhibition of cell growth and survival pathways, ubiquitous delay in Rad51-mediated homologous recombination and CHK1-mediated G2/M arrest, but that the contribution of cell cycle perturbation to radiosensitization may be cell line specific.
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Affiliation(s)
- Shane Zaidi
- Targeted Therapy Team, Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom
| | - Martin McLaughlin
- Targeted Therapy Team, Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom
- * E-mail:
| | - Shreerang A. Bhide
- Targeted Therapy Team, Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom
| | - Suzanne A. Eccles
- Tumour Biology and Metastasis Team, Cancer Research UK Cancer Therapeutics Unit, The Institute of Cancer Research, Haddow Laboratories, Sutton, Surrey, United Kingdom
| | - Paul Workman
- Signal Transduction and Molecular Pharmacology Team, Cancer Research UK Cancer Therapeutics Unit, The Institute of Cancer Research, Haddow Laboratories, Sutton, Surrey, United Kingdom
| | | | | | - Kevin J. Harrington
- Targeted Therapy Team, Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom
- The Royal Marsden Hospital, London, United Kingdom
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Bhide SA, Gulliford S, Schick U, Miah A, Zaidi S, Newbold K, Nutting CM, Harrington KJ. Dose-response analysis of acute oral mucositis and pharyngeal dysphagia in patients receiving induction chemotherapy followed by concomitant chemo-IMRT for head and neck cancer. Radiother Oncol 2012; 103:88-91. [PMID: 22280809 DOI: 10.1016/j.radonc.2011.12.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 12/14/2011] [Accepted: 12/28/2011] [Indexed: 01/24/2023]
Abstract
Dose-response curves (DRCs) and the quantitative parameters describing these curves were generated for grade 3 oral mucositis and dysphagia in 144 patients using individual patient DVHs. Curve fits to the oral mucositis clinical data yielded parameter values of mean dose in 2 Gy equivalent, MD(50) = 51 Gy (95% CI 40-61), slope of the curve, k = 1(95% CI 0.6-1.5). R(2) value for the goodness of fit was 0.80. Fits to the grade 3 dysphagia clinical data yielded parameter values of MD(50) = 44.5 Gy (95% CI 36-53), k = 2.6 (95% CI 0.8-4.5). R(2) value for the goodness of fit was 0.65. This is the first study to derive DRCs in patients receiving induction chemotherapy followed by chemo-radiation (IC-C-IMRT) for head and neck cancer. The dose-response model described in this study could be useful for comparing acute mucositis rates for different dose-fractionation schedules when using IMRT for head and neck cancer.
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Miah AB, Bhide SA, Guerrero-Urbano MT, Clark C, Bidmead AM, St Rose S, Barbachano Y, A'hern R, Tanay M, Hickey J, Nicol R, Newbold KL, Harrington KJ, Nutting CM. Dose-escalated intensity-modulated radiotherapy is feasible and may improve locoregional control and laryngeal preservation in laryngo-hypopharyngeal cancers. Int J Radiat Oncol Biol Phys 2012; 82:539-47. [PMID: 21236602 DOI: 10.1016/j.ijrobp.2010.09.055] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 08/30/2010] [Accepted: 09/03/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE To determine the safety and outcomes of induction chemotherapy followed by dose-escalated intensity-modulated radiotherapy (IMRT) with concomitant chemotherapy in locally advanced squamous cell cancer of the larynx and hypopharynx (LA-SCCL/H). METHODS AND MATERIALS A sequential cohort Phase I/II trial design was used to evaluate moderate acceleration and dose escalation. Patients with LA-SCCL/H received IMRT at two dose levels (DL): DL1, 63 Gy/28 fractions (Fx) to planning target volume 1 (PTV1) and 51.8 Gy/28 Fx to PTV2; DL2, 67.2 Gy/28 Fx and 56 Gy/28 Fx to PTV1 and PTV2, respectively. Patients received induction cisplatin/5-fluorouracil and concomitant cisplatin. Acute and late toxicities and tumor control rates were recorded. RESULTS Between September 2002 and January 2008, 60 patients (29 DL1, 31 DL2) with Stage III (41% DL1, 52% DL2) and Stage IV (52% DL1, 48% DL2) disease were recruited. Median (range) follow-up for DL1 was 51.2 (12.1-77.3) months and for DL2 was 36.2 (4.2-63.3) months. Acute Grade 3 (G3) dysphagia was higher in DL2 (87% DL2 vs. 59% DL1), but other toxicities were equivalent. One patient in DL1 required dilatation of a pharyngeal stricture (G3 dysphagia). In DL2, 2 patients developed benign pharyngeal strictures at 1 year. One underwent a laryngo-pharyngectomy and the other a dilatation. No other G3/G4 toxicities were reported. Overall complete response was 79% (DL1) and 84% (DL2). Two-year locoregional progression-free survival rates were 64.2% (95% confidence interval, 43.5-78.9%) in DL1 and 78.4% (58.1-89.7%) in DL2. Two-year laryngeal preservation rates were 88.7% (68.5-96.3%) in DL1 and 96.4% (77.7-99.5%) in DL2. CONCLUSIONS At a mean follow-up of 36 months, dose-escalated chemotherapy-IMRT at DL2 has so far been safe to deliver. In this study, DL2 delivered high rates of locoregional control, progression-free survival, and organ preservation and has been selected as the experimental arm in a Cancer Research UK Phase III study.
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Affiliation(s)
- Aisha B Miah
- Head and Neck Unit, The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
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Abstract
It is increasingly being recognized that oral cavity cancer incidences are rising globally. Furthermore, these tumors represent a high risk group of tumors comparative to other head and neck tumor sub-sites and have a high preponderance of occult nodal metastases. Surgery alone leads to excellent outcomes in early stage disease. Advanced tumors require adjuvant radiotherapy with or without concomitant chemotherapy. Irradiation using 3D conformal radiotherapy results in high incidence of late radiation side-effects. Xersostomia and mandibular osteoradionecrosis result in most significant effects on patients' quality of life. Intensity modulated radiotherapy (IMRT) is an advanced approach to 3-D treatment planning and conformal therapy (3D-CRT). It optimizes the delivery of irradiation to irregularly-shaped volumes and has the ability to produce concavities in radiation treatment volumes and hence enables sparing of normal tissue while delivering adequate doses to the tumor volumes. In this manuscript, we discuss the advantages of IMRT based on review of published peer reviewed literature.
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Affiliation(s)
- S A Bhide
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ London, United Kingdom.
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Nutting CM, Morden JP, Harrington KJ, Urbano TG, Bhide SA, Clark C, Miles EA, Miah AB, Newbold K, Tanay M, Adab F, Jefferies SJ, Scrase C, Yap BK, A'Hern RP, Sydenham MA, Emson M, Hall E. Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial. Lancet Oncol 2011; 12:127-36. [PMID: 21236730 PMCID: PMC3033533 DOI: 10.1016/s1470-2045(10)70290-4] [Citation(s) in RCA: 1154] [Impact Index Per Article: 88.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Xerostomia is the most common late side-effect of radiotherapy to the head and neck. Compared with conventional radiotherapy, intensity-modulated radiotherapy (IMRT) can reduce irradiation of the parotid glands. We assessed the hypothesis that parotid-sparing IMRT reduces the incidence of severe xerostomia. Methods We undertook a randomised controlled trial between Jan 21, 2003, and Dec 7, 2007, that compared conventional radiotherapy (control) with parotid-sparing IMRT. We randomly assigned patients with histologically confirmed pharyngeal squamous-cell carcinoma (T1–4, N0–3, M0) at six UK radiotherapy centres between the two radiotherapy techniques (1:1 ratio). A dose of 60 or 65 Gy was prescribed in 30 daily fractions given Monday to Friday. Treatment was not masked. Randomisation was by computer-generated permuted blocks and was stratified by centre and tumour site. Our primary endpoint was the proportion of patients with grade 2 or worse xerostomia at 12 months, as assessed by the Late Effects of Normal Tissue (LENT SOMA) scale. Analyses were done on an intention-to-treat basis, with all patients who had assessments included. Long-term follow-up of patients is ongoing. This study is registered with the International Standard Randomised Controlled Trial register, number ISRCTN48243537. Findings 47 patients were assigned to each treatment arm. Median follow-up was 44·0 months (IQR 30·0–59·7). Six patients from each group died before 12 months and seven patients from the conventional radiotherapy and two from the IMRT group were not assessed at 12 months. At 12 months xerostomia side-effects were reported in 73 of 82 alive patients; grade 2 or worse xerostomia at 12 months was significantly lower in the IMRT group than in the conventional radiotherapy group (25 [74%; 95% CI 56–87] of 34 patients given conventional radiotherapy vs 15 [38%; 23–55] of 39 given IMRT, p=0·0027). The only recorded acute adverse event of grade 2 or worse that differed significantly between the treatment groups was fatigue, which was more prevalent in the IMRT group (18 [41%; 99% CI 23–61] of 44 patients given conventional radiotherapy vs 35 [74%; 55–89] of 47 given IMRT, p=0·0015). At 24 months, grade 2 or worse xerostomia was significantly less common with IMRT than with conventional radiotherapy (20 [83%; 95% CI 63–95] of 24 patients given conventional radiotherapy vs nine [29%; 14–48] of 31 given IMRT; p<0·0001). At 12 and 24 months, significant benefits were seen in recovery of saliva secretion with IMRT compared with conventional radiotherapy, as were clinically significant improvements in dry-mouth-specific and global quality of life scores. At 24 months, no significant differences were seen between randomised groups in non-xerostomia late toxicities, locoregional control, or overall survival. Interpretation Sparing the parotid glands with IMRT significantly reduces the incidence of xerostomia and leads to recovery of saliva secretion and improvements in associated quality of life, and thus strongly supports a role for IMRT in squamous-cell carcinoma of the head and neck. Funding Cancer Research UK (CRUK/03/005).
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Abstract
Intensity-modulated radiotherapy (IMRT) has been a significant technological advance in the field of radiotherapy in recent years. IMRT allows sparing of normal tissue while delivering radical radiation doses to the target volumes. The role of IMRT for parotid salivary gland sparing in head and neck cancer is well established. The utility of IMRT for pharyngeal constrictor muscle and cochlear sparing requires investigation in clinical trials. The current evidence supporting the use of IMRT in various head and neck subsites has been summarized. Sparing of organs at risk allows for dose-escalation to the target volumes, taking advantage of the steep dose-response relationship for squamous cell carcinomas to improve treatment outcomes in advanced head and neck cancers. However, dose-escalation could result in increased radiation toxicity (acute and late), which has to be studied in detail. The future of IMRT in head and neck cancers lies in exploring the use of biological imaging for dose-escalation using targeted dose painting.
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Affiliation(s)
- S A Bhide
- Head and Neck Unit, The Institute of Cancer Research and The Royal Marsden Hospital, London and Surrey, United Kingdom
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Harrington KJ, Hingorani M, Tanay MA, Hickey J, Bhide SA, Clarke PM, Renouf LC, Thway K, Sibtain A, McNeish IA, Newbold KL, Goldsweig H, Coffin R, Nutting CM. Phase I/II study of oncolytic HSV GM-CSF in combination with radiotherapy and cisplatin in untreated stage III/IV squamous cell cancer of the head and neck. Clin Cancer Res 2010; 16:4005-15. [PMID: 20670951 DOI: 10.1158/1078-0432.ccr-10-0196] [Citation(s) in RCA: 191] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE This study sought to define the recommended dose of JS1/34.5-/47-/GM-CSF, an oncolytic herpes simplex type-1 virus (HSV-1) encoding human granulocyte-macrophage colony-stimulating factor (GM-CSF), for future studies in combination with chemoradiotherapy in patients with squamous cell cancer of the head and neck (SCCHN). EXPERIMENTAL DESIGN Patients with stage III/IVA/IVB SCCHN received chemoradiotherapy (70 Gy/35 fractions with concomitant cisplatin 100 mg/m(2) on days 1, 22, and 43) and dose-escalating (10(6), 10(6), 10(6), 10(6) pfu/mL for cohort 1; 10(6), 10(7), 10(7), 10(7) for cohort 2; 10(6), 10(8), 10(8), 10(8) for cohort 3) JS1/34.5-/47-/GM-CSF by intratumoral injection on days 1, 22, 43, and 64. Patients underwent neck dissection 6 to 10 weeks later. Primary end points were safety and recommended dose/schedule for future study. Secondary end points included antitumor activity (radiologic, pathologic). Relapse rates and survival were also monitored. RESULTS Seventeen patients were treated without delays to chemoradiotherapy or dose-limiting toxicity. Fourteen patients (82.3%) showed tumor response by Response Evaluation Criteria in Solid Tumors, and pathologic complete remission was confirmed in 93% of patients at neck dissection. HSV was detected in injected and adjacent uninjected tumors at levels higher than the input dose, indicating viral replication. All patients were seropositive at the end of treatment. No patient developed locoregional recurrence, and disease-specific survival was 82.4% at a median follow-up of 29 months (range, 19-40 months). CONCLUSIONS JS1/34.5-/47-/GM-CSF combined with cisplatin-based chemoradiotherapy is well tolerated in patients with SCCHN. The recommended phase II dose is 10(6), 10(8), 10(8), 10(8). Locoregional control was achieved in all patients, with a 76.5% relapse-free rate so far. Further study of this approach is warranted in locally advanced SCCHN.
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Bhide SA, Gulliford S, Fowler J, Rosenfelder N, Newbold K, Harrington KJ, Nutting CM. Characteristics of response of oral and pharyngeal mucosa in patients receiving chemo-IMRT for head and neck cancer using hypofractionated accelerated radiotherapy. Radiother Oncol 2010; 97:86-91. [PMID: 20826031 DOI: 10.1016/j.radonc.2010.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 08/17/2010] [Accepted: 08/18/2010] [Indexed: 11/24/2022]
Abstract
PURPOSE This study describes the acute response of oral and pharyngeal mucosa to chemo-IMRT schedules using different doses per fraction. MATERIALS AND METHODS Patients, treated in prospective trials of concomitant chemo-IMRT with 2.17 Gy, 2.25 Gy and 2.4 Gy per fraction and identical dose of cisplatin, were included in this study. Acute toxicity was recorded prospectively using the CTCAE v2.0. We describe the incidence and prevalence of grade 3 oral mucositis and dysphagia over time and report the influence of overall treatment time (OTT). The association between the lengths of pharyngeal mucosa receiving 50 Gy (L50) and 60 Gy (L60) and grade 3 dysphagia was tested. RESULTS The incidence and the peak prevalence of grade 3 dysphagia were significantly higher in patients receiving 2.4 Gy per fraction. The peak prevalence of grade 3 dysphagia was higher and the recovery was slower in patients with lower OTT (median 38 days vs. 42 days) treatment. There was a significant correlation between L50, L60 and grade 3 dysphagia. A L50 and L60 greater than 8 cm resulted in greater than 60% and 70% incidence of grade 3 dysphagia, respectively. CONCLUSION The length of pharyngeal mucosa receiving doses close to the prescription dose correlates with grade 3 dysphagia. It was observed that incidence of grade 3 dysphagia was lower and recovery from it was quicker in patients with greater OTT.
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Hingorani M, White CL, Zaidi S, Pandha HS, Melcher AA, Bhide SA, Nutting CM, Syrigos KN, Vile RG, Vassaux G, Harrington KJ. Therapeutic effect of sodium iodide symporter gene therapy combined with external beam radiotherapy and targeted drugs that inhibit DNA repair. Mol Ther 2010; 18:1599-605. [PMID: 20588260 DOI: 10.1038/mt.2010.120] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Adenoviral (AdV) transfer of sodium iodide symporter (NIS) gene has translational potential, but relatively low levels of transduction and subsequent radioisotope uptake limit the efficacy of the approach. In previous studies, we showed that combining NIS gene delivery with external beam radiotherapy (EBRT) and DNA damage repair inhibitors increased viral gene expression and radioiodide uptake. Here, we report the therapeutic efficacy of this strategy. An adenovirus expressing NIS from a telomerase promoter (Ad-hTR-NIS) was cytotoxic combined with relatively high-dose (50 microCi) (131)I therapy and enhanced the efficacy of EBRT combined with low-dose (10 and 25 microCi) (131)I therapy in colorectal and head and neck cancer cells. Combining this approach with ataxia-telangiectasia mutated (ATM) or DNA-dependent protein kinase (DNA-PK) inhibition caused maintenance of double-stranded DNA breaks (DSBs) at 24 hours and increased cytotoxicity on clonogenic assay. When the triplet of NIS-mediated (131)I therapy, EBRT, and DNA-PKi was used in vivo, 90% of mice were tumor-free at 5 weeks. Acute radiation toxicity in the EBRT field was not exacerbated. In contrast, DNA-PKi did not enhance the therapeutic efficacy of EBRT plus adenovirus-mediated HSVtk/ganciclovir (GCV). Therefore, combining NIS gene therapy and EBRT represents an ideal strategy to exploit the therapeutic benefits of novel radiosensitizers.
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Affiliation(s)
- Mohan Hingorani
- Targeted Therapy Team, The Institute of Cancer Research, London, UK
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Abstract
Radiation therapy has come a long way from treatment planning based on orthogonal radiographs with large margins around tumours. Advances in imaging and radiation planning software have led to three-dimensional conformal radiotherapy and, further, to intensity modulated radiotherapy (IMRT). IMRT permits sparing of normal tissues and hence dose-escalation to tumours. IMRT is the current standard in treatment of head and prostate cancer and is being investigated in other tumour sites. Exquisitely sculpted dose distributions (increased geographical miss) with IMRT, plus tumour motion and anatomical changes during radiotherapy make image guided radiotherapy an essential part of modern radiation delivery. Various hardware and software tools are under investigation for optimal IGRT.
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Affiliation(s)
- S A Bhide
- Institute of Cancer Research and Royal Marsden Hospital, Fulham Road, London, UK
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Abstract
Radiotherapy and surgery are the principal curative modalities in treatment of head and neck cancer. Conventional (two dimensional, 2D and three-dimensional conformal radiotherapy, 3DCRT) result in significant side-effects and altered quality of life. Intensity modulated radiotherapy (IMRT) can spare the normal tissues, while delivering a curative dose to the tumour bearing tissues. Technical advances like volumetric intensity modulated arc therapy (VMAT) have helped optimise IMRT further. Image guided radiotherapy (IGRT) can be used to aid target delineation and also help reduce the PTV margins to further enhance the therapeutic ratio. Particle therapy using protons provides significant advantage in terms of normal tissue sparing and is recommended for small cranial tumours and in radiotherapy for paediatric patients.
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Affiliation(s)
- S A Bhide
- Royal Marsden Hospital and Institute of Cancer Research, London, UK
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Harrington KJ, Kazi R, Bhide SA, Newbold K, Nutting CM. Novel therapeutic approaches to squamous cell carcinoma of the head and neck using biologically targeted agents. Indian J Cancer 2010; 47:248-59. [DOI: 10.4103/0019-509x.64711] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Clark CH, Miles EA, Urbano MTG, Bhide SA, Bidmead AM, Harrington KJ, Nutting CM. Pre-trial quality assurance processes for an intensity-modulated radiation therapy (IMRT) trial: PARSPORT, a UK multicentre Phase III trial comparing conventional radiotherapy and parotid-sparing IMRT for locally advanced head and neck cancer. Br J Radiol 2009; 82:585-94. [PMID: 19332518 DOI: 10.1259/bjr/31966505] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The purpose of this study was to compare conventional radiotherapy with parotid gland-sparing intensity-modulated radiation therapy (IMRT) using the PARSPORT trial. The validity of such a trial depends on the radiotherapy planning and delivery meeting a defined standard across all centres. At the outset, many of the centres had little or no experience of delivering IMRT; therefore, quality assurance processes were devised to ensure consistency and standardisation of all processes for comparison within the trial. The pre-trial quality assurance (QA) programme and results are described. Each centre undertook exercises in target volume definition and treatment planning, completed a resource questionnaire and produced a process document. Additionally, the QA team visited each participating centre. Each exercise had to be accepted before patients could be recruited into the trial. 10 centres successfully completed the quality assurance exercises. A range of treatment planning systems, linear accelerators and delivery methods were used for the planning exercises, and all the plans created reached the standard required for participation in this multicentre trial. All 10 participating centres achieved implementation of a comprehensive and robust IMRT programme for treatment of head and neck cancer.
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Affiliation(s)
- C H Clark
- Department of Physics, Royal Marsden NHS Foundation Trust, London and Sutton, Surrey, UK.
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Nutting CM, van Herpen CML, Miah AB, Bhide SA, Machiels JP, Buter J, Kelly C, de Raucourt D, Harrington KJ. Phase II study of 3-AP Triapine in patients with recurrent or metastatic head and neck squamous cell carcinoma. Ann Oncol 2009; 20:1275-9. [PMID: 19246715 DOI: 10.1093/annonc/mdn775] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment options for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) are limited with response rates to cytotoxic chemotherapy of approximately 30% and median survival of 6 months. PATIENTS AND METHODS In a multicentre phase II study, 32 patients with recurrent or metastatic HNSCC received 3-AP Triapine (3-aminopyridine-2-carboxaldehyde thiosemicarbazone), an inhibitor of ribonucleotide reductase, 96 mg/m2, daily for 4 days every 14 days (one cycle). Eligibility criteria required Eastern Cooperative Oncology Group performance status (ECOG PS) of zero to two with a life expectancy of >3 months; one prior chemotherapy regimen was allowed. RESULTS Thirty patients were assessable for response and toxicity. Median age was 57 years (range 36-79) and median ECOG PS was one (range 0-2). Thirteen patients had previously been treated with chemotherapy. A total of 130 cycles were administered with a median number of cycles of 3.5 (range 1-8). Mild anaemia (40%), nausea (22%) and fatigue (22%) were commonly reported with G3 and G4 neutropenia documented in 22% and 22%, respectively. Overall response rate was 5.9% (95% confidence interval 0.2% to 28.7%). One patient achieved a partial response, eight had stable disease and 21 progressive disease. Median time to disease progression was 3.9 months. CONCLUSIONS 3-AP Triapine as a single agent, at this dose and schedule, is well tolerated but has only minor activity in the treatment of advanced HNSCC.
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Affiliation(s)
- C M Nutting
- Head and Neck Unit, Royal Marsden Hospital and Institute of Cancer Research, London, UK.
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Bhide SA, Ahmed M, Rengarajan V, Powell C, Miah A, Newbold K, Nutting CM, Harrington KJ. Anemia During Sequential Induction Chemotherapy and Chemoradiation for Head and Neck Cancer: The Impact of Blood Transfusion on Treatment Outcome. Int J Radiat Oncol Biol Phys 2009; 73:391-8. [DOI: 10.1016/j.ijrobp.2008.04.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Revised: 04/07/2008] [Accepted: 04/11/2008] [Indexed: 11/30/2022]
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Bhide SA, Ahmed M, Barbachano Y, Newbold K, Harrington KJ, Nutting CM. Sequential induction chemotherapy followed by radical chemo-radiation in the treatment of locoregionally advanced head-and-neck cancer. Br J Cancer 2008; 99:57-62. [PMID: 18560402 PMCID: PMC2453042 DOI: 10.1038/sj.bjc.6604444] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We describe a retrospective series of patients with advanced head-and-neck cancer who were treated with induction chemotherapy followed by radical chemo-radiation. Patients treated with two cycles of induction chemotherapy followed by definitive chemo-radiation for squamous cell carcinoma of the head-and-neck region, from 2001 – 2006 at the Royal Marsden Hospital, formed the basis of this study. Cisplatin (75 mg m−2) on day 1 and 5-FU (1000 mg m−2) day 1 – 4 was the standard regimen used for induction treatment. Cisplatin (100 mg m−2) on day 1 and day 29 was used for concomitant treatment. The radiation was delivered using conformal technique. Tissues containing macroscopic and microscopic disease were treated to doses of 65 Gray (Gy) in 30 fractions and 50 Gy in 25 fractions, respectively. Data on patterns of relapse and acute toxicity (NCICTCv.3.0) were collected. A total of 129 patients were included, median age was 58 (range: 27 – 78). The site of tumour was: oropharynx 70 (54%), larynx 30 (23%), hypopharynx 24 (19%) and other 5 (4%). The median follow-up was 19 months (range: 4 – 58). Local control, disease-specific survival and overall survival at 2 years were 71%, 68% and 63%, respectively. The distant recurrence rate at 2 years was 9%. Ten patients required dose reduction during induction chemotherapy due to toxicity. The dose of 5-FU was reduced in six patients and that of cisplatin in four patients. The incidence of grade 3/4 toxicity was: neutropenia 5%, thrombocytopenia 1%, nausea and vomiting 3%. One cycle of concurrent cisplatin was omitted in 23 patients due to toxicity. Full-dose radiotherapy was administered to 98% of patients. The incidence of grade 3/4 toxicity was: skin 20%, dysphagia 65%, mucositis 60%, neutropenia 3%, anaemia 1%, nausea and vomiting 4%, nephrotoxicity 1%. Induction chemotherapy followed by radical chemo-radiation is a safe and tolerable regimen in the treatment of advanced head-and-neck cancer. Distant recurrence rates are lower with equivalent local control and survival compared to chemo-radiation alone (historical controls).
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Affiliation(s)
- S A Bhide
- Head and Neck Unit, Royal Marsden Hospital, London SW3 6JJ, UK
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Nutting CM, Bhide SA, Harrington KJ. Treatment of head and neck cancer. N Engl J Med 2008; 358:1076-7; author reply 1077-8. [PMID: 18326077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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White CL, Menghistu T, Twigger KR, Searle PF, Bhide SA, Vile RG, Melcher AA, Pandha HS, Harrington KJ. Escherichia coli nitroreductase plus CB1954 enhances the effect of radiotherapy in vitro and in vivo. Gene Ther 2007; 15:424-33. [PMID: 18079753 DOI: 10.1038/sj.gt.3303081] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Escherichia coli nitroreductase (NTR) converts the prodrug CB1954 (5-(aziridin-1-yl)-2,4-dinitrobenzamide) into a bifunctional alkylating agent that causes DNA crosslinks. In this study, the ability of NTR to enhance the combined effects of CB1954 and radiation has been tested in vitro and in vivo. Stably transduced ovarian cancer cells (SKOV3-NTR) that are sensitive to CB1954 (IC(50)=0.35 muM) demonstrated enhanced cytotoxicity when treated with CB1954 and single-fraction irradiation. The NTR-CB1954 system mediated a bystander effect in combination with radiation on transfer of conditioned medium from SKOV3-NTR, but not SKOV3, cells to SW480 target cells. The ability of CB1954 to enhance radiation-induced cytotoxicity in SKOV3-NTR (but not SKOV3) cells was also demonstrated by fluorescence-activated cell sorting (FACS) with dual staining for propidium iodide/fluorescein diacetate, 4',6-diamidino-2-phenylindole dichloride staining of apoptotic cells and measurement of double-stranded DNA breaks by FACS and confocal microscopy for gammaH2AX foci. Adenoviral delivery of NTR, under constitutive cytomegalovirus or tissue-specific CTP1 promoters, increased the in vitro cytotoxicity of CB1954 plus radiation in MTT and clonogenic assays. Finally, adenoviral delivery of NTR plus CB1954 enhanced the effect of fractionated radiotherapy (12 Gy in four fractions) in SW480 xenograft tumours in nude mice.
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Affiliation(s)
- C L White
- Targeted Therapy Laboratory, Cancer Research UK Centre for Cell and Molecular Biology, Chester Beatty Laboratories, The Institute of Cancer Research, London, UK
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Abstract
Radiotherapy is commonly used in the management of malignant parotid gland tumours that have adverse pathological risk factors after surgery. Radiation to the parotid bed is associated with predictable complications. In particular, the close proximity of the auditory apparatus, which receives a significant radiation dose, results in significant toxicity in a proportion of patients. Here we review auditory toxicity after radiation to the parotid bed.
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Affiliation(s)
- S A Bhide
- Head and Neck Unit, Institute of Cancer Research and Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK.
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Bhide SA, Puranik SS. Galanin immunohistochemistry and electron microscopic studies in developing human fetal mammillary bodies. J Chem Neuroanat 2005; 29:289-95. [PMID: 15927790 DOI: 10.1016/j.jchemneu.2005.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2004] [Revised: 11/11/2004] [Accepted: 03/08/2005] [Indexed: 11/25/2022]
Abstract
Development and maturation of nuclear groups in the mammillary complex of second and third trimester human fetal hypothalamus were studied using Nissl stain, galanin immunocytochemistry and transmission electron microscopy. While the identity of the supra and medial mammillary nucleus was established at 24 weeks of gestation (w.g.) in Nissl stained preparation, galanin immunoreactive (Gal-ir) neurons were seen in the supra and medial mammillary nucleus of 27 through 39 w.g. fetuses. Immunoreactive perikarya in the lateral mammillary nucleus appear later at 34 w.g. and show relatively meager population. Gal-ir neurons of the supramammillary nucleus were divisible in dorsal and ventral subgroups. There was a progressive increase in galanin expressing neurons in more and more ventral positions, along the medial margin of either mammillary body so that in term fetal specimens, the ventral subgroup appeared to be continuous with the medial mammillary nucleus. Galanin positive neurons were relatively sparse in the core of the mammillary bodies. Transmission electron micrographs revealed neurons with varying degree of indentation of the nuclear envelope. Vigorous synaptogenesis was seen in the supramammillary region of the mammillary bodies. The height and width of the synaptic complex also showed a progressive increase. Although galanin neurons were reported from the supramammillary nucleus of adult human mammillary complex, no immunoreactivity was detected in the medial and lateral components of the mammillary body. We suggest that expression of galanin in the medial and lateral components may be of transient occurrence and may serve a significant role in the synaptogenesis.
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Affiliation(s)
- S A Bhide
- Department of Zoology, Institute of Science, R.T. Marg, Civil Lines, Nagpur, India.
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Abstract
A forty-three year old female patient with right sided breast cancer was treated with adjuvant radiotherapy and Tamoxifen. She had a relapse in the right supraclavicular fossa after a disease free period of 12 years. She progressed, after a short period of disease stabilization on Idoxifene followed by a further stable period on Anastrazole. At further disease relapse, she was commenced on Exemestane. After a period of disease stabilization and subsequent disease progression in the right supraclavicular fossa, Exemestane was discontinued. Six weeks later there was a marked regression of the right supraclavicular mass. Withdrawal response to Tamoxifen is well documented. To our knowledge a similar response after Exemestane withdrawal has not been reported in the literature.
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Affiliation(s)
- S A Bhide
- Cancer Centre at the Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK.
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Abstract
PP are first visible at approximately 15.5 wk gestation after which there is a rapid spurt in the development and maturation of lymphoid follicles so that at any given point of time new foci of PP development are continuously formed at a rapid rate. Addition of rows of follicles results in the formation of a PP. Immature PP of younger fetuses have a spongy structure in contrast with the compact lymphoid follicles of mature PP of older fetuses. Immunocytochemical studies reveal that there is a subtle gradation in the expression of lymphocyte surface markers with increasing fetal age. Expression of antigenic markers occurs in an ordered sequence viz. HLA - DR, CD19 (B cell population), CD9 (pre-B cells), CD3 T lymphocytes, CD4 helper / inducer lymphocytes, the CD8 suppressor / cytotoxic cells and lastly, the CD57 Natural Killer cells. The antigens are expressed first on lymphocytes of PP and thereafter in those of the appendix. Our findings clearly demonstrate that the approximately 5 wk fetal period from 17.5 wk to 22 wk represents a major growth phase in the development of surface markers of lymphocytes in the mucosal immune system of the gut.
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Affiliation(s)
- S A Bhide
- Department of Zoology, R. T. Marg, Civil Lines, Nagpur, India.
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Morgan DJ, Aboud CJ, McCaffrey IM, Bhide SA, Lamont RF, Taylor-Robinson D. Comparison of Gram-stained smears prepared from blind vaginal swabs with those obtained at speculum examination for the assessment of vaginal flora. Br J Obstet Gynaecol 1996; 103:1105-8. [PMID: 8916997 DOI: 10.1111/j.1471-0528.1996.tb09591.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether Gram-stained smears obtained from blind vaginal swabs could be used reliably for the assessment of the vaginal flora. DESIGN A prospective, blind comparative study. SETTING The antenatal clinic of a district general hospital. PARTICIPANTS Eighty-eight women examined and screened for the presence of bacterial vaginosis during their first antenatal clinic visit. Two smears were obtained for each woman, the first prepared from a vaginal swab taken blindly and the second at speculum examination. The smears were Gram-stained and classified according to the Nugent score: Grade 1 (normal), Grade 2 (intermediate), Grade 3 (bacterial vaginosis). RESULTS Eight of the 88 pregnant women were identified as having bacterial vaginosis on the basis of the smear taken at speculum examination, and these were correctly identified as having bacterial vaginosis by smears prepared from the blindly taken swab. This gives the blind vaginal swab technique for detecting bacterial vaginosis a sensitivity and specificity of 100% when compared with swabbing at speculum examination. The flora of two women were graded as intermediate, and of 75 as normal by both techniques. Only in three cases was there a disparity between the two techniques, a difference that was not statistically significant (kappa = 0.8546, 95% CI 0.6945 to 1.0). CONCLUSIONS Vaginal smears prepared from correctly taken blind vaginal swabs can be used to assess the vaginal flora and screen for bacterial vaginosis. This method could be used in epidemiological studies of bacterial vaginosis in the general population and for screening antenatal populations for abnormal vaginal flora.
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Affiliation(s)
- D J Morgan
- Department of Obstetrics and Gynaecology, Northwick Park and St Mark's NHS Trust, Harrow, UK
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