Fractionated head and neck irradiation impacts taste progenitors, differentiated taste cells, and Wnt/β-catenin signaling in adult mice

Head and neck cancer patients receiving conventional repeated, low dose radiotherapy (fractionated IR) suffer from taste dysfunction that can persist for months and often years after treatment. To understand the mechanisms underlying functional taste loss, we established a fractionated IR mouse model to characterize how taste buds are affected. Following fractionated IR, we found as in our previous study using single dose IR, taste progenitor proliferation was reduced and progenitor cell number declined, leading to interruption in the supply of new taste receptor cells to taste buds. However, in contrast to a single dose of IR, we did not encounter increased progenitor cell death in response to fractionated IR. Instead, fractionated IR induced death of cells within taste buds. Overall, taste buds were smaller and fewer following fractionated IR, and contained fewer differentiated cells. In response to fractionated IR, expression of Wnt pathway genes, Ctnnb1, Tcf7, Lef1 and Lgr5 were reduced concomitantly with reduced progenitor proliferation. However, recovery of Wnt signaling post-IR lagged behind proliferative recovery. Overall, our data suggest carefully timed, local activation of Wnt/β-catenin signaling may mitigate radiation injury and/or speed recovery of taste cell renewal following fractionated IR.

Effect of Radiation on Sucrose Detection Thresholds of Mice

Radiotherapy is one of the most common treatments for head and neck cancers, with an almost obligate side effect of altered taste (Conger AD. 1973. Loss and recovery of taste acuity in patients irradiated to the oral cavity. Radiat Res. 53:338-347.). In mice, targeted irradiation of the head and neck causes transient repression of proliferation of basal epithelial cells responsible for taste cell replacement, leading to a temporary depletion of taste sensory cells within taste buds, including Type II taste cells involved in detection of sweet stimuli (Nguyen HM, Reyland ME, Barlow LA. 2012. Mechanisms of taste bud cell loss after head and neck irradiation. J Neurosci. 32:3474-3484.). These findings suggest that irradiation may elevate sucrose detection thresholds, peaking at 7 days postirradiation when loss of Type II cells is greatest. To test this hypothesis, sucrose detection thresholds (concentration detected in 50% of presentations) were measured in mice for 15 days after treatment of: 1) irradiation while anesthetized, 2) anesthetic alone, or 3) saline. Mice were trained to distinguish water from several concentrations of sucrose. Mice were irradiated with one 8 Gy dose (RADSOURCE-2000 X-ray Irradiator) to the nose and mouth while under 2,2,2-tribromethanol anesthesia (Avertin). Unexpectedly, mice given anesthesia showed a small elevation in sucrose thresholds compared to saline-injected mice, but irradiated mice show significantly elevated sucrose thresholds compared to either control group, an effect that peaked at 6-8 days postirradiation. The timing of loss and recovery of sucrose sensitivity generally coincides with the reported maximal reduction and recovery of Type II taste cells (Nguyen HM, Reyland ME, Barlow LA. 2012. Mechanisms of taste bud cell loss after head and neck irradiation. J Neurosci. 32:3474-3484.). Thus, even a single dose of irradiation can significantly alter detection of carbohydrates, an important consideration for patients undergoing radiotherapy.

Taste Loss and Recovery Following Radiation Therapy

Previous investigators have reported deficits in taste acuity in patients following radiation therapy for oropharyngeal cancer. In the present longitudinal study, 13 patients (mean age = 51.6 yrs) received conventional or hyperfractionated radiotherapy (63–76.8 Gy) for primary tumors of the oropharynx. One or both parotid glands and at least two-thirds of the tongue were included in the radiation field. Smell recognition and taste detection thresholds were determined at baseline, 1 month, 6 months, and 1 year post-radiation. Differences for smell recognition and the 4 taste qualities were assessed (independently) at the 4 time intervals, with a one-way ANOVA. Smell recognition was unaffected by radiation. There were significant elevations in thresholds for sweet (p < 0.005), salty (p < 0.005), bitter (p < 0.005), and sour (p< 0.001) during radiation therapy that were restored to baseline levels at 6 months and 1 year after radiation. This study demonstrated that radiation-induced taste deficits can be recovered by 6 months.

Functional changes of the gustatory organ caused by local radiation exposure during radiotherapy of the head-and-neck region

PURPOSE

The aim of this prospective study was to investigate how often and at which dose levels gustatory disturbances appear during radiotherapy of the tongue and to which extent permanent gustatory deficiencies occur.

PATIENTS AND METHODS

The study included 44 patients treated by definitive irradiation for malignant head-and-neck tumors. In 22 patients the posterior two thirds of the tongue (group 1), and in the other 22 patients the entire tongue (group 2) were exposed to radiation. The control group comprised 30 patients with non-small cell lung cancer receiving definitive radiation therapy (group 3). The dose distribution in the tongue area was calculated using CT-based three-dimensional planning. Before, during and after irradiation the gustatory function was determined by means of gustometry and correlated with the corresponding results of enoral inspection and the patients' subjective statements on gustatory function.

RESULTS

The gustatory ability of the control group was not affected, whereas patients in the locally irradiated groups in parallel with enoral mucositis suffered from loss of gustatory function after a total dose of 20 Gy with a maximum between 40 and 60 Gy. Supportive measures had little influence on acute side effects. The gustatory disturbances regressed within 8 weeks after radiotherapy in patients with partial-tongue irradiation and almost completely after 6 months in patients with entire-tongue irradiation.

CONCLUSION

The severity of gustatory disturbances and the longer recovery time in patients with entire-tongue irradiation suggest an influence of the volume exposed. Therefore, reduction of the highly exposed tongue volume by intensity-modulated radiotherapy opens up possibilities for a reduction of this undesirable side effect.

Studies on the relationship between electrogustometry and sour taste perception

OBJECTIVE

Electrogustometry is used as a measurement of taste perception. The prevailing theory is that the anodal current delivered to the tongue mucosa stimulates the sour taste receptors, but this is not universally accepted. Our aim was to evaluate to what extent electrogustometry relates to an ability to detect sour taste--rather than sweet, salt, or bitter.

METHODS

We compared automated electrogustometric thresholds with visual analogue scale (VAS) ratings of various tastant solutions in 114 subjects. The whole mouth, and each side of the tongue were tested separately. VAS scores from the strongest set of solutions, and the lowest electrogustometry thresholds for each location were used for statistics.

RESULTS

There was a significant correlation between electrogustometry threshold and the whole mouth perception of the salt taste solution. Electrogustometry correlated significantly but weakly for all taste qualities when testing was confined to left and right oral tongue. The positive predictive values of electrogustometry were no better in relation to sour taste perception than to the other taste qualities.

CONCLUSIONS

Our results do not support the theory that electrogustometry is mediated by sour taste receptors or even that it reflects the sour taste quality. We postulate that electrogustometry measures a function of taste perception, which is different from that induced by chemical stimuli.

Confocal microscopy of the peripheral gustatory system: comparison between healthy subjects and patients suffering from taste disorders during radiochemotherapy

OBJECTIVES

Laser-scanning microscopy (LSM) was used to compare taste buds and epithelia of fungiform papillae of healthy subjects with those of patients suffering from taste disorders during/after radiochemotherapy (RCT). Aim of the study was to investigate effects responsible for taste loss at a microscopic level.

STUDY DESIGN

Prospective study.

METHODS

Data from 12 healthy subjects (mean age 52.4, SD 9.5 years) were compared with those of 12 patients (mean age 54.7, SD 8.5 years) with head and neck cancer suffering from taste disorders during RCT. Four parameters from LSM were selected for analysis: 1) distance between the pore of the taste buds of fungiform papillae and the crest of the papillary vessels; 2) epithelial cells of each taste bud at 34 mum; 3), cell density, and 4) area of the taste pore at 4 mum. These data were correlated to measures of gustatory sensitivity obtained with both the validated "taste strips" test kit and electrogustometry.

RESULTS

Patients complaining from taste disorders during RCT exhibited a significant decrease of taste function assessed with both natural and electric stimuli. In these patients, we found thicker epithelia and smaller areas of the taste pores compared with healthy subjects. In 30% of those patients, no taste pores were detectable; in deeper sections, however, normal taste buds were present.

CONCLUSIONS

In conclusion, in RCT patients with taste disorders, LSM indicates changes of epithelia of fungiform papilla but no changes of the taste bud structure. Damage of the chorda tympani nerve by scattered rays, direct or indirect mucotoxic effects of chemotherapeutic agents, and covering of taste pores by epithelial cells are likely reasons for taste loss during RCT.

Taste dysfunction in patients receiving radiotherapy

BACKGROUND

Taste loss is a major cause of morbidity in patients undergoing head and neck irradiation.

METHODS

In a prospective study, 51 patients undergoing radical head and neck irradiation at the Tokyo University Hospital were assessed for taste loss. Taste ability was measured by the taste threshold for the four basic tastes (sweet, sour, salt, and bitter qualities) plus another taste of "umami" quality using a filter-paper-disc method in patients before, during, and after radiotherapy (RT).

RESULTS

All tastes declined on the fifth week after the start of RT and improved on the 11th week. Anatomic pathologic analyses in rats revealed that taste buds diminished completely on the sixth day after irradiation of 15 Gy in a single fraction, and the appearance of taste buds returned almost to the preirradiation state on the 28th day.

CONCLUSIONS

The main cause of taste disorder resulting from RT was believed to be a disappearance of taste buds and not damage to the taste nerves.

[Changes of taste bud and fungiform papillae after 60Co radiation in rat]

OBJECTIVE

To observe the morphological changes and the regenerating ability of the fungiform papillae and taste buds after 60Co radiation with clinical doses in rats.

METHODS

The heads, faces and necks of 30 SD rats were radiated with a large dose and one time of 60Co in the clinical radiation. The general living condition and the number and shape of the fungiform papillae and taste buds of the tongues were observed after the radiation in rats.

RESULTS

In the group of 60Co radiation, the animals had wilting, decreasing appetite, losing weight. The heads, faces and necks of animals appeared redness, peeling of hair, increasing of secretions in 5 days after the 60Co radiation. The changes reached the summit in 10 days and the general living condition of the animals recovered in 60 days. The fungiform papillae and taste buds of the animals appeared degeneration, atrophy and collapsing in 5 days after the 60Co radiation. The injuries reached the summit in 10-20 days and the fungiform papillae and taste buds regenerated partially, and the some atrophied fungiform papillae and taste buds were not regenerated in 60 days.

CONCLUSION

The damage to fungiform papillae and taste buds of tongue following the 60Co radiation with the clinical doses was very serious. The damaged fungiform papillae and taste buds can regenerate partially, but not completely.

Taste dysfunction in irradiated patients with head and neck cancer

Taste disorders caused by radiation therapy for head and neck cancer are common. This prospective study of 40 patients with head and neck cancer assessed changes in taste sensations during radiation therapy. The relationship between the time course and the degree of taste disorder was studied. The taste recognition threshold and supra-threshold taste intensity performance for the four basic tastes were measured using the whole-mouth taste method before, during, and after radiation therapy. Bitter taste was affected most. An increase in threshold for sweet taste depended upon whether the tip of tongue was included within the radiation field. The slope of the taste intensity performance did not change during or after radiotherapy. The pattern of salivary dysfunction was different from that of taste dysfunction. The main cause of taste disorders during radiation support the hypothesis that taste dysfunction is due to damage to the taste buds in the radiation field.

Biology of taste buds and the clinical problem of taste loss

Taste buds are the anatomical structures that mediate the sense of taste. They comprise taste cells and nerve fibers within specialized epithelial structures. Taste cells are traditionally described by histologic methods as basal, dark, intermediate, and light cells, with the nerve fibers surrounding and infiltrating the taste buds. By means of immunohistochemical methods, taste cells and gustatory nerve fibers can be classified in functional groups based on the expression of various cell adhesion molecules and other proteins. When taste buds become damaged, the loss of the ability to taste results. This loss is not uncommon and can impact health and quality of life. Patients who receive radiation therapy for head and neck cancer often experience taste loss, which leads to compromised nutritional intake and a worse outcome than patients who do not experience taste loss. The mode of radiation damage to taste cells and nerve fibers has been investigated using cell adhesion molecules, synaptic vesicle proteins, and other cell markers. The light and intermediate cells are preferentially affected by ionizing radiation, whereas the nerve fibers remain structurally intact. Experimental studies of radiation-induced taste loss are performed via a unique animal/human model.

Morphological changes in taste buds of the fungiform papillae after a single dose of x-ray irradiation in rats

The qualitative and quantitative changes occurring in the taste buds of the fungiform papillae of male Sprague-Dawley rats (aged 51-125 days old) after x-ray irradiation were studied. A single dose of 2000 Roentgen (R) was delivered and observations were made at 0, 3, 7, 14, 21 and 30 days after x-ray irradiation. The changes in taste bud morphology were interpreted first as degenerative and then as regenerative at various stages of the study. The degenerative process appeared at about the third day and reached a peak at 7 days. Regeneration then began after a further week and the taste buds appeared mature at about 30 days. While the number of fungiform papillae remained constant throughout the study, there was a marked loss of taste buds on these papillae at 7 days. At 14 days, the number of taste buds increased from this low level, and by 30 days the number approached the control values. Initial taste bud loss could be attributed to a direct irradiation damage leading to taste bud cell desquamation combined with a concomitant mitotic inhibition of the stratum germinativum.

Quantitative radiation dose-response relationships for normal tissues in man. II. Response of the salivary glands during radiotherapy

A quantitative dose-response curve for salivary gland function in patients during radiotherapy is presented. Salivary-function data used in this study were obtained from four previously published reports. All patients were treated with 60Co teletherapy to the head and neck using conventional treatment techniques. Salivary dysfunction was determined at specific dose levels by comparing salivary flow rates before therapy with flow rates at specific dose intervals during radiotherapy up to a total dose of 6000 cGy. Fifty percent salivary dysfunction occurred after 1000 cGy and eighty percent dysfunction was observed by the end of the therapy course (6000 cGy). The salivary-function curve was also compared to the previously published dose-response curve for taste function. Comparisons of the two curves indicate that salivary dysfunction precedes taste loss and that the shapes of the dose-response curves are different. A new term, tissue tolerance ratio, defined as the ratio of responses of two tissues given the same radiation dose, was used to make the comparisons between gustatory and salivary gland tissue effects. Measurements of salivary gland function and analysis of dose-response curves may be useful in evaluating chemical modifiers of radiation response.

Radiation therapy of the oral cavity: sequelae and management, part 1

This is the first article in a two-part series dealing with the effects and manifestations in the oral cavity of radiation therapy of head and neck tumors. In this section, oral mucous membranes, taste buds, edema and trismus, diet, salivary glands, bone, periodontium, teeth, and composition of oral flora are discussed. Dental management of the dentulous patient is then approached; criteria for preradiation extraction are delineated. In the next issue of Head & Neck Surgery, the final article in this series will discuss preradiation and postradiation extractions and will elaborate on the dental management (fluoride treatments, follow-up, and restorative care) of the dentulous patient. Dental management of the edentulous patient will also be presented.

Dental management of the irradiated patient

There is an increasing number of patients receiving radiation therapy for oral malignancies. In many malignant tumors, radiation is often the treatment of choice, while in others it may be used in conjunction with surgery or chemotherapy. There are inherent dental and oral problems associated with radiation therapy. It is the purpose of this paper to deal briefly with the physical principles and the biological basis of radiation therapy. In addition, the specific radiation effects on oral mucous membranes, taste buds, salivary glands, bone, the periodontium and teeth will be discussed. Radiation complications in edentulous patients, and in particular the problems of wearing dentures in such patients will be evaluated. An approach to the problem of dental extractions and other dental treatments in the pre- and post-irradiated patient is suggested.