Neck Radiotherapy Research Articles

Dental Care for Cancer Patients in the Prevention of Complications of Chemotherapy and Head and Neck Radiation Therapy

Oncological diseases occupy one of the first places in the structure of disability and mortality of the population. The main methods of treating patients with malignant tumors in the maxillofacial area are surgical method, radiation therapy and chemotherapy. Treatment with only one of the listed methods It is rarely performed, mainly at the stage of cancer in situ or stage I of the disease. The treatment depends on the clinical and morphological characteristics of the tumor and requires the use of all methods simultaneously or in a certain sequence. Radiation and chemotherapy treatments not only have systemic side effects, but also side effects in the treatment area. Against the background of antitumor treatment, there is an exacerbation of concomitant chronic diseases, including odontogenic ones. Pathological changes appear on the mucous membrane oral cavity, on the skin, in the subcutaneous tissue, in the salivary glands and in the bone marrow of the jaw bones. The degree of damage to these structures during tumor treatment depends on their initial condition. At the same time, the initial condition of the oral cavity affects the quality of antitumor treatment. Poor oral hygiene and chronic odontogenic lesions can cause the development of episodic fevers and other general complications. All this requires stopping or changes in the tactics of antitumor treatment, which reduces its radicalism. It becomes obvious that sanitation of the oral cavity, carried out before treatment by an oncologist, will avoid or reduce the frequency complications in the maxillofacial area, improve the quality of life of an oncology patient. Dental care for such a patient has features and requires an individual approach. The purpose of this study was to review the literature on the main oral tissue complications arising from chemotherapy and radiation therapy in the head and neck region. In Google Scholar, Medline, Scopus, Web of Sciences, PubMed a systematic review was conducted. Search keywords terms included head and neck cancer, dental care, prevention of complications of cancer, oral tissue lesions manifestationin, chemotherapy, head and neck radiation therapy. Conducted a preliminary search and reviewed 132 titles and abstracts in this literary review included 48 article. This article analyzes the main complications of oral tissues resulting from chemotherapy and radiation therapy in the head and neck area and provides practical recommendations for the management and prevention of complications in this category of patients.

Knowledge-based quality assurance of a comprehensive set of organ at risk contours for head and neck radiotherapy.

Manual review of organ at risk (OAR) contours is crucial for creating safe radiotherapy plans but can be time-consuming and error prone. Statistical and deep learning models show the potential to automatically detect improper contours by identifying outliers using large sets of acceptable data (knowledge-based outlier detection) and may be able to assist human reviewers during review of OAR contours. This study developed an automated knowledge-based outlier detection method and assessed its ability to detect erroneous contours for all common head and neck (HN) OAR types used clinically at our institution. We utilized 490 accurate CT-based HN structure sets from unique patients, each with forty-two HN OAR contours when anatomically present. The structure sets were distributed as 80% for training, 10% for validation, and 10% for testing. In addition, 190 and 37 simulated contours containing errors were added to the validation and test sets, respectively. Single-contour features, including location, shape, orientation, volume, and CT number, were used to train three single-contour feature models (z-score, Mahalanobis distance [MD], and autoencoder [AE]). Additionally, a novel contour-to-contour relationship (CCR) model was trained using the minimum distance and volumetric overlap between pairs of OAR contours to quantify overlap and separation. Inferences from single-contour feature models were combined with the CCR model inferences and inferences evaluating the number of disconnected parts in a single contour and then compared. In the test dataset, before combination with the CCR model, the area under the curve values were 0.922/0.939/0.939 for the z-score, MD, and AE models respectively for all contours. After combination with CCR model inferences, the z-score, MD, and AE had sensitivities of 0.838/0.892/0.865, specificities of 0.922/0.907/0.887, and balanced accuracies (BA) of 0.880/0.900/0.876 respectively. In the validation dataset, with similar overall performance and no signs of overfitting, model performance for individual OAR types was assessed. The combined AE model demonstrated minimum, median, and maximum BAs of 0.729, 0.908, and 0.980 across OAR types. Our novel knowledge-based method combines models utilizing single-contour and CCR features to effectively detect erroneous OAR contours across a comprehensive set of 42 clinically used OAR types for HN radiotherapy.

Neck management in metastatic cutaneous squamous cell carcinoma of the head and neck.

Optimal neck management remains unclear in head and neck cutaneous squamous cell carcinoma (HNcSCC) with parotid metastasis. Our goal was to compare the impact of different cervical treatments on HNcSCC with parotid metastasis. Patients were retrospectively included. The primary outcome variables were regional control (RC) and disease-specific survival (DSS). The impacts of observation, elective neck irradiation (ENI), and elective neck dissection (END) were analyzed using the Cox model and presented as hazard ratios (HRs) and 95% confidence intervals (CIs). In total, 268 patients were enrolled. In the Cox model for RC, compared with ENI, observation was associated with a significantly higher risk of regional recurrence (p = 0.001, HR = 2.50, 95%CI = 1.45-4.30). However, END showed a comparable influence on regional recurrence (p = 0.246, HR = 0.70, 95%CI = 0.38-1.28). In the Cox model for DSS, END demonstrated a similar HR of 0.62 (95%CI = 0.30-1.26) compared to ENI (p = 0.184). However, patients who underwent observation were associated with an additional nearly twofold risk of cancer-related mortality (HR = 2.85, 95%CI = 1.55-5.23). Subgroup analysis showed that ENI predicted comparable RC (p = 0.389) and DSS (p = 0.346) in patients with one or two metastatic parotid lymph nodes, but worse RC (p = 0.007) and DSS (p = 0.024) in patients with more than three positive lymph nodes. In HNcSCC with parotid metastasis, elective treatment of neck lymph nodes with END or ENI should always be performed.

Ocular surface changes in patients who have undergone head and neck radiation therapy.

Dry eye syndrome (DES) is a familiar sequelae of radiation therapy (RT) for head and neck cancers (HNC). Ocular surface changes such as DES occur due to injury to the conjunctival epithelium, goblet cells, corneal surface, lacrimal glands, and meibomian glands. This study aimed at the evaluation and early detection of changes in ocular surface parameters in patients receiving RT for extraocular HNC. Forty-two eyes of 21 patients undergoing HNC RT were evaluated. Radiation technique and dose of radiation to the lens and eye were recorded. Subjects were evaluated for meibomian gland changes by meiboscore grading, ocular surface disease index (OSDI) questionnaire, Schirmer's test, tear film break-up time (TBUT), and slit-lamp examination before RT, immediately post RT, and 6 weeks post RT. A comparison of the ipsilateral eye on the irradiated side to the contralateral eye was done. A significant reduction in TBUT was seen immediately post RT and 6 weeks post RT ( P < 0.001 and 0.008, respectively), with an increase in meiboscore at both visits ( P < 0.001). An OSDI score of >13 was seen in 23.80% of patients post RT, with a significant difference from baseline ( P < 0.001). On comparing ipsilateral and contralateral eye groups, a significant difference from baseline was seen in TBUT ( P < 0.001 and 0.033, respectively) and meiboscore ( P < 0.001 for both eyes). A significant change of >1 second in TBUT and >1.7 in meiboscore was seen with a mean dose of around 8 Gy to the lens. All patients undergoing HNC RT should be followed up for ocular surface and meibomian gland changes. The contralateral eye should also be evaluated. Patients receiving lower doses to the ocular structures should also be kept under follow-up.

Feasibility and Intermediate Results of Transcarotid Revascularization with a Prosthetic Conduit

IntroductionTranscarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet anatomic criteria and therefore are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy via the adoption of a prosthetic arterial conduit. MethodsA single center retrospective study of patients with critical carotid artery stenosis who underwent TCAR via a prosthetic conduit between June 2019 and October 2021 was performed. All patients in the study were considered high-risk for carotid endarterectomy (CEA) based on anatomic features, such as restenosis post-CEA and neck radiation. Unfavorable CCA anatomy was defined as a clavicle to carotid bifurcation distance < 5 cm, a CCA diameter < 6 mm, and/or significant atherosclerotic disease at the intended arterial access site. The primary outcome of interest was technical success. Secondary outcomes included perioperative complications, intermediate and long-term patency, intermediate and long-term stroke and/or mortality and in-hospital length of stay. Follow-up ranged from 1-29 months. ResultsEight patients underwent ten TCAR procedures via a prosthetic conduit. A total of two procedures (20%) were performed on female patients and eight procedures (75%) were performed on male patients. The mean age was 65 years old (standard deviation (SD) 11 years). Technical success was 100%. The 30-day ipsilateral stroke rate was 0%. The 30-day patency was 90%. There was no re-exploration for hemorrhage and 30 day mortality was 0%. ConclusionsTCAR is an excellent option for carotid artery revascularization. Unfavorable CCA anatomy has limited its applicability. TCAR via a prosthetic conduit has the potential to expand eligibility for this promising therapy.

Update on olfactory neuroblastoma.

Olfactory neuroblastomas are uncommon malignancies that arise from olfactory receptor cells located high in the nasal cavity. Accurate diagnosis plays a crucial role in determining clinical results and guiding treatment decisions. Diagnosis can be a major challenge for pathologists, especially when dealing with tumours with poor differentiation. The discovery of several molecular and immunohistochemical markers would help to overcome classification difficulties. Due to the paucity of large-scale studies, standardisation of diagnosis, treatment and prediction of outcome remains a challenge. Surgical resection by endoscopic techniques with the addition of postoperative irradiation is the treatment of choice. In addition, it is advisable to consider elective neck irradiation to minimise the risk of nodal recurrence. Molecular characterisation will help not only to make more accurate diagnoses but also to identify specific molecular targets that can be used to develop personalised treatment options tailored to each patient. The present review aims to summarise the current state of knowledge on histopathological diagnosis, the molecular biology and management of this disease.

An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis

BackgroundOsteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications.MethodsA 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary—CUP) was admitted with a right-sided epi—/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction.ResultsDue to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient’s airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief.ConclusionsThe present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.

Cochlear Implantation After Head and Neck Radiation: A Case Series, Systematic Review, and Meta-analysis.

To determine if cochlear implant (CI) is safe and effective in patients with radiation therapy (XRT)-induced sensorineural hearing loss and to discuss considerations in this population through a retrospective cohort review, systematic review, and meta-analysis. PubMed, Cochrane Library, and Embase. We retrospectively reviewed all CI cases after head and neck (HN) XRT at our institution, noting intraoperative findings, postoperative complications, and hearing outcomes. Change in speech discrimination scores (SDSs) was the primary outcome measure. Systematic review was performed to identify all cases of CI after HNXRT. A meta-analysis was performed to assess SDS change. The retrospective cohort review identified 12 patients who underwent CI after HNXRT. One patient with HN cancer (HNC) and one with central nervous system pathology (CNSP) received bilateral implants. Six had HNC, three had CNSP, and one had Langerhans cell histiocytosis. Eleven had abnormal findings during CI. There were no postoperative complications. Twenty articles with an additional 97 patients were suitable for systematic review inclusion. Of the 109 patients, 67 (61.5%) had HNC and 18 (16.5%) had CNSP. Abnormal intraoperative findings were common (30.3%), most frequently in the mastoid (66.7%). Postoperative complications, including wound dehiscence and infection with some requiring explantation, occurred in 10.1% of patients. Sixty-six patients were included in the meta-analysis. All demonstrated SDS improvement (mean increase, 56.2%). Patients with prior HNXRT benefit from CI. Paying careful attention to surgical planning and technique, postoperative care, and patient expectations is imperative, as complications are not uncommon.

Oral Tissue Lesions Manifestation in Cancer Patients Following Chemotherapy and Head and Neck Radiation Therapy

Background: As is known, cancer therapy includes a complex of therapeutic measures: chemotherapy, radiotherapy and radical. The purpose of this study was to review the literature on the main oral tissue complications arising from chemotherapy and radiation therapy in the head and neck region. Methods: In Google Scholar, Medline, Scopus, Web of Sciences, PubMed a systematic review was conducted. Search keywords terms included: Cancer patients, oral tissue lesions, head and neck, chemotherapy, radiation therapy. Conducted a preliminary search and reviewed 134 titles and abstracts in this literary review included 58. Cancer patients in the oral cavity exhibit a variety of oral tissue lesions during and shortly after radiation therapy to the head and neck. Results: Our search showed that cancer patients following chemotherapy and head and neck radiation therapy often experience oral manifestations. Among these lesions, increased susceptibility to dental caries, periodontal disease, oral mucositis, tissue fibrosis, salivary gland dysfunction, o pportunistic infections of the mucous membranes, and neurosensory disorders are often encountered. These manifestations represent a serious problem for patients and require special strategies from treating physicians to mitigate the harmful effects of radiation therapy on vital functions and improve the quality of life of these patients. Complications in the oral cavity, chemotherapy and head and neck radiation therapy creates many social problems and difficulties for cancer patients. Arguments for an interdisciplinary approach to the management of these patients are recommended in many studies. Conclusion: This review will help dental practitioners manage the risks of dental interventions and prevent potential complications in patients with cancer requiring dental care. Prevention, supportive care, and symptom management by health care providers are important for patients with oral problems related to cancer treatment and can help the patient cope with cancer and its complications.

Neoplasia-related and treatment-induced lymphopenia: impact on the outcome of chemoradiotherapy in laryngeal cancer

Introduction The role of the immune system in the efficacy of radiotherapy (RT) has been well established. We examined the role of neoplasia-related and treatment-induced lymphopenia in the outcome of RT or chemoradiotherapy (CRT) in squamous cell laryngeal cancer. Materials and Methods We retrospectively analyzed a series of 135 laryngeal carcinomas treated with radical or postoperative RT/CRT. Six lymphocyte-related variables were defined and examined: i. lymphocyte counts (LCs) before a brief course of induction chemotherapy, ii. pre-RT LCs, iii. post-RT LCs, iv. pre-RT neutrophil/lymphocyte ratio (N/L), v. pre-RT monocyte/lymphocyte ratio (M/L), and vi. pre-RT platelet/lymphocyte ratio (Pt/L). Results RT and CRT resulted in a significant decrease of LCs at the end of therapy, and this was significantly more prominent in patients treated with radical intent and neck irradiation (median LC nadir 810/μl vs. 1250/μl; p = .0003). Induction chemotherapy did not intensify the lymphotoxic effect of RT. LCs lower than the 33rd percentile before RT (<1718/μl) and after RT (<720/μl) were significantly linked to poor locoregional progression-free survival (LRFS; p = .02 and p = .08, respectively) and disease-specific overall survival (OS; p = .02 and p = .03, respectively). This was also confirmed multivariate analysis (LRFS: p = .006/HR = 2.41 and p = .08/HR = 1.76, respectively; OS: p = .001/HR = 3.06 and p = .02/HR = 2.07, respectively). High pre-RT N/L, M/L, and Pt/L ratios were also of ominous prognostic relevance. Conclusions Both neoplasia-related and RT-induced lymphopenia define the outcome of RT in terms of locoregional failure, incidence of metastasis, and, finally, disease-specific survival of patients with laryngeal cancer. Restoration of pre-RT lymphopenia and protection of peripheral lymphocytes during RT emerge as critical issues that demand therapeutic interventions to maximize the efficacy of RT/CRT in patients with laryngeal cancer.

Neck management in cutaneous squamous cell carcinoma with parotid metastasis.

Our objective is to assess the oncologic outcomes of observation, elective neck dissection (END), and elective neck irradiation (ENI) in the neck management of head and neck cutaneous squamous cell carcinoma (HNcSCC) with parotid metastasis (P+) and to evaluate the quality of life (QoL) of patients who received END or ENI. Patients with P+ HNcSCC were retrospectively enrolled. The impact of observation, END, and ENI on regional control (RC) and overall survival (OS) was analyzed using Cox proportional hazards model with presentation via hazard ratio (HR) with a 95% confidence interval (CI). QoL was evaluated using the University of Washington Quality of Life questionnaire. A total of 134 patients were included in our analysis. In the Cox model for RC, both END and ENI had decreased HRs of 0.27 (95% CI: 0.15-0.69) and 0.34 (95% CI: 0.18-0.86), respectively, in comparison with observation. In the Cox model for OS, both END (p = 0.001, HR: 0.22, 95% CI: 0.10-0.72) and ENI (p = 0.006, HR: 0.30, 95% CI: 0.17-0.83) were superior to observation. In patients with three or more positive parotid lymph nodes, END resulted in significantly better RC (p < 0.001) and OS (p = 0.001) compared with ENI. The two groups were found to be comparable in all 12 domains of the University of Washington Quality of Life questionnaire. In the neck management of P+ HNcSCC, observation is not recommended. END is the preferred option, but ENI is an alternative method without compromise to survival or QoL, except in cases with three or more metastatic parotid lymph nodes.

Heavily Calcified Symptomatic Carotid Stenosis Treated With Off-Label Use of Lithotripsy Balloon Plus Stenting: 2-Dimensional Operative Video.

Severe symptomatic carotid artery stenosis poses a significant risk for recurrent strokes. Best treatment options depend on multiple factors, including patient medical conditions and lesion characteristics.1 Despite treatment options such as carotid endarterectomy, conventional carotid angioplasty/stent, and transcervical carotid revascularization, certain patients are not ideal candidates for any of these modalities. Novel technical advances such as intravascular lithotripsy (Shockwave Medical Inc.) have emerged as a potential treatment modality to treat patients with severely calcified plaques, a well-described limitation for carotid stent expansion and apposition.2-4 The safety and efficacy of intravascular lithotripsy have been demonstrated through select case series and coronary artery disease I-II-III studies, culminating in its Food and Drug Administration approval for the management of novo, calcified, stenotic coronary arteries before stent placement.2,5 This technical video presents an illustrative case of a patient with symptomatic severely calcified carotid plaque with previous neck radiation precluding endarterectomy, treated with off-label use of balloon lithotripsy plus stent.6 The patient consented to the procedure.

Chinese guildeline on diagnosis and treatment of basal cell carcinoma (2023 edition)

Basal cell carcinoma (BCC) is the most common skin malignancy, with a higher prevalence in Caucasians than in East Asians. Although there is a lack of epidemiological data in China, it is generally believed that the incidence of BCC in China is increasing due to the aging population. A variety of risk factors are related to the occurrence of BCC, among which ultraviolet rays and gene mutations play a major role, especially the abnormal activation of Hedgehog (Hh) signaling pathway, which is considered to be the most important pathogenesis of BCC. The clinical manifestations of BCC are highly specific, and most experienced doctors can make a preliminary diagnosis by clinical manifestations. Dermoscopy and other imaging methods can greatly improve the accuracy of diagnosis, but there are still some atypical or rare types of BCC that need further confirmation through histopathological examination. This guideline is initiated by the National Clinical Research Center for Skin and Immune Diseases (based on Peking University First Hospital). It has invited a panel of experts consisting of 24 senior dermatologists specializing in dermatologic surgery from the Dermatologic Surgery Group of the Chinese Medical Doctor Association of Dermatology, the Dermatologic Surgery Group of the Dermatology & Venereology Committee, Chinese Association of Integration Medicine, and the Dermatologic Surgery and Cosmetic Branch of Clina Leprosy Association. In addition, experts from the Burn and Plastic Surgery (Maxillofacial), Ophthalmology, Otolaryngology, Head and Neck Surgery, Radiation Therapy, and Pathology were also invited to participate. This panel forms the "Chinese Guideline for the Diagnosis and Treatment of Basal Cell Carcinoma" expert group. Based on the latest domestic and international research findings, the guideline was developed through four rounds of discussions by the expert group and revised to provide valuable references for clinical healthcare providers in the diagnosis and treatment of BCC.

Omission of radiotherapy to lymph node level III in patients with cN0 adenoid cystic carcinoma of the major salivary gland: a single center experience.

Due to the rarity of adenoid cystic carcinoma (ACC) of the major salivary gland, there is no consensus on the extent of prophylactic neck irradiation (PNI) for patients with clinically negative lymph nodes (cN0) disease. We conducted a retrospective analysis of all patients with ACC of the major salivary gland who received treatment at our center between January 2010 and April 2020. The primary endpoint was regional failure-free survival(RRFS). Secondary endpoints included overall survival (OS), distant metastasis-free survival (DMFS), local recurrence-free survival (LRFS), and acute toxicity. A total of 139 patients were included in the analysis. For cN0 patients, the 5-year RRFS, OS, DMFS, and LRFS were 93.2%, 90.2%, 75.7%, and 91.4%, respectively. Multivariate analysis revealed that PORT was an independent prognostic factor for RRFS and LRFS. No statistically significant differences were observed between the Level III sparing PNI group and the Standard PNI group in terms of RRFS, OS, DMFS, and LRFS. The doses delivered to the larynx and thyroid in the Level III sparing PNI group were significantly lower than those in the Standard PNI group. In patients with cN0 ACC of the major salivary gland, PNI improves regional control, and the level III nodal region sparing radiotherapy does not increase the risk of level III recurrence, while potentially reducing toxicity.

Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology - Head and Neck Surgery.

Squamous cell carcinoma of the nasal vestibule (NV SCC) is a head and neck malignancy for which there is no established consensus on most aspects of clinical management. The purpose of this document is to give updated recommendations that incorporate recent evidence on its clinical characteristics and the high efficacy of brachytherapy as primary treatment modality. A working group consisting of the members of the Scientific Committee for Oncology and Reconstructive Surgery of the Italian Society of Otorhinolaryngology Head and Neck Surgery and radiation oncologists expert in brachytherapy was formed to achieve a consensus. Consensus was reached on a set of recommendations, proposing a refined anatomical definition of the nasal vestibule, a novel T staging system of the NV SCC, and brachytherapy as standard of care, with a new method for catheter implantation. The Committee emphasises the critical role of an accurate classification in clinical practice and encourages further research to validate the novel staging system and further improve treatment strategies. Where appropriate, it is recommended that patients be referred to centres with specific experience in brachytherapy for NV SCC.

Early experience with baroreflex activation therapy from a vascular surgery perspective

Baroreflex activation therapy (BAT) is an emerging device-based treatment for patients with heart failure with a reduced ejection fraction refractory to maximally tolerated goal-directed medical therapy. Currently, there is sparse literature on the critical role that vascular surgeons serve in the delivery of this novel therapy. This single-institution series describes the creation of a BAT program and elaborates on the function of vascular surgeons in the multidisciplinary heart failure team. The preoperative evaluation, perioperative care, and postoperative course of patients receiving BAT from March 2022 to August 2023 were retrospectively analyzed. Eleven patients were evaluated by a dedicated heart failure cardiologist for medical eligibility and assessed by a vascular surgeon for technical feasibility. Of the 11 patients, 7 were men (63.6%). The median age was 60.5 years (range, 44-73 years). No patient (0.00%) had existing carotid artery disease, and one patient (9.1%) had undergone previous neck radiation therapy. All 11 patients (100%) had an existing cardiac implantable electronic device, and BAT implantation was performed on the same side as the cardiac implantable electronic device in two patients (18.1%). Four patients (36.4%) required preoperative hospital admission for medical optimization before surgery. The median length of surgery was 82 minutes (range, 58-113 minutes), and the median length of stay in the hospital after surgery was 1 day (range, 0-6 days). No major adverse neurologic or cardiovascular events, cranial nerve injuries, device complications requiring reintervention, or heart failure-related mortality at 6 months occurred. Three patients (27.3%) experienced extraneous stimulations, which affected BAT tolerability. Within 6 months after BAT implantation, no significant improvements were observed for several heart failure disease burden markers compared with 6 months before BAT implantation. Our early results demonstrate that BAT implantation is a safe procedure with rare complications. Vascular surgeons play an important role in the multidisciplinary delivery of this novel device-based therapy. More data are needed to understand whether BAT is beneficial in the treatment of heart failure with a reduced ejection fraction refractory to maximally tolerated goal-directed medical therapy.

Cone-beam computed tomography-guided online adaptive radiotherapy for pharyngeal cancer with whole neck irradiation: dose-volume histogram analysis between adapted and scheduled plans.

The present study aimed to evaluate whether an adapted plan with Ethos™ could be used for pharyngeal cancer. Ten patients with pharyngeal cancer who underwent chemoradiotherapy with available daily cone-beam computed tomography (CBCT) data were included. Simulated treatments were generated on the Ethos™ treatment emulator using CBCTs every four to five fractions for two plans: adapted and scheduled. The simulated treatments were divided into three groups: early (first-second week), middle (third-fourth week), and late (fifth-seventh week) periods. Dose-volume histogram parameters were compared for each period between the adapted and scheduled plans in terms of the planning target volume (PTV) (D98%, D95%, D50% and D2%), spinal cord (Dmax and D1cc), brainstem (Dmax) and ipsilateral and contralateral parotid glands (Dmedian and Dmean). The PTV D98%, D95% and D2% of the adapted plan were significantly higher than those of the scheduled plans in all periods, except for D98% in the late period. The adapted plan significantly reduced the spinal cord Dmax and D1cc compared with the scheduled plan in all periods. Ipsilateral and contralateral parotid glands Dmean of the adapted plan were lower than those of scheduled plan in the late period. In conclusion, the present study revealed that the adapted plans could maintain PTV coverage while reducing the doses to organs at risk in each period compared with scheduled plans.

Embracing Personalized Strategies in Radiotherapy for Nasopharyngeal Carcinoma: Beyond the Conventional Bounds of Fields and Borders.

Radiotherapy is the primary treatment modality for non-metastatic nasopharyngeal carcinoma (NPC) across all TN-stages. Locoregional control rates have been impressive even from the 2D radiotherapy (RT) era, except when the ability to deliver optimal dose coverage to the tumor is compromised. However, short- and long-term complications following head and neck RT are potentially debilitating, and thus, there has been much research investigating technological advances in RT delivery over the past decades, with the primary goal of limiting normal tissue damage. On this note, with a plateau in gains of therapeutic ratio by modern RT techniques, future advances have to be focused on individualization of RT, both in terms of dose prescription and the delineation of target volumes. In this review, we analyzed the guidelines and evidence related to contouring methods, and dose prescription for early and locoregionally advanced (LA-) NPC. Next, with the preference for induction chemotherapy (IC) in patients with LA-NPC, we assessed the evidence concerning radiotherapy adaptations guided by IC response, as well as functional imaging and contour changes during treatment. Finally, we discussed on RT individualization that is guided by EBV DNA assessment, and its importance in the era of combinatorial immune checkpoint blockade therapy with RT.

Pharyngeal Constrictor Dose–Volume Histogram Metrics and Patient-Reported Dysphagia in Head and Neck Radiotherapy

AimsHead and neck radiotherapy long-term survival continues to improve and the management of long-term side-effects is moving to the forefront of patient care. Dysphagia is associated with dose to the pharyngeal constrictors and can be measured using patient-reported outcomes to evaluate its effect on quality of life. The aim of the present study was to relate pharyngeal constrictor dose–volume parameters with patient-reported outcomes to identify prognostic dose constraints. Materials and methodsA 64-patient training cohort and a 24-patient testing cohort of oropharynx and nasopharynx cancer patients treated with curative-intent chemoradiotherapy were retrospectively examined. These patients completed the MD Anderson Dysphagia Inventory outcome survey at 12 months post-radiotherapy to evaluate late dysphagia: a composite score lower than 60 indicated dysphagia. The pharyngeal constrictor muscles were subdivided into four substructures: superior, middle, inferior and cricopharyngeal. Dose–volume histogram (DVH) metrics for each of the structure combinations were extracted. A decision tree classifier was run for each DVH metric to identify dose constraints optimising the accuracy and sensitivity of the cohort. A 60% accuracy threshold and feature selection method were used to ensure statistically significant DVH metrics were identified. These dose constraints were then validated on the 24-patient testing cohort. ResultsExisting literature dose constraints only had two dose constraints performing above 60% accuracy and sensitivity when evaluated on our training cohort. We identified two well-performing dose constraints: the pharyngeal constrictor muscle D63% < 55 Gy and the superior–middle pharyngeal constrictor combination structure V31Gy < 100%. Both dose constraints resulted in ≥73% mean accuracy and ≥80% mean sensitivity on the training and testing patient cohorts. In addition, a pharyngeal constrictor muscle mean dose <57 Gy resulted in a mean accuracy ≥74% and mean sensitivity ≥60%. ConclusionMid-dose pharyngeal constrictor muscle and substructure combination dose constraints should be used in the treatment planning process to reduce late patient-reported dysphagia.

Prevention and Care of Oral Manifestations in Cancer Patients Receiving Chemotherapy and Head and Neck Radiation Therapy. Systematic Review

Purpose: The purpose of this systematic review was to evaluate current evidence to prevent and care of oral manifestations chemotherapy and head and neck radiation therapy. Methods: Study selected if they met the following criteria: design - random allocation of participants; participants - anyone with cancer receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral complication. Search keywords terms included head and neck cancer, dental care, prevention of complications of cancer, oral tissue lesions manifestationin, chemotherapy, head and neck radiation therapy, length of hospitalisation, cost and patient quality of life. Results: Conducted a preliminary search and reviewed 132 titles and abstracts in this review and 48 full-text articles were selected of high methodological quality. This systematic review analyzes the main complications of oral tissues resulting from chemotherapy and radiation therapy in the head and neck area and provides practical recommendations for the management and prevention of complications in this category of patients. The main methods of treating patients with malignant tumors in the maxillofacial area are surgical method, radiation therapy and chemotherapy. The treatment depends on the clinical and morphological characteristics of the tumor and requires the use of all methods simultaneously or in a certain sequence. Radiation and chemotherapy treatments not only have systemic side effects, but also side effects in the treatment area. Against the background of antitumor treatment, there is an exacerbation of concomitant chronic diseases, including odontogenic ones. Pathological changes appear on the mucous membrane oral cavity, on the skin, in the subcutaneous tissue, in the salivary glands and in the bone marrow of the jaw bones. Poor oral hygiene and chronic odontogenic lesions can cause the development of episodic fevers and other general complications. All this requires stopping or changes in the tactics of antitumor treatment, which reduces its radicalism. Conclusion: The current systematic review demonstrated that regular extensive oral health education, sanitation of the oral cavity, carried out before treatment by an oncologist, will avoid or reduce the frequency complications in the maxillofacial area, improve the quality of life of an oncology patient. Dental care for such a patient has features and requires an individual approach.