Purpose/Objective(s) For head and neck (H&N) cancer radiotherapy, mouthbites play a vital role in tongue immobilization and positioning oral tissues for tissue preservation. However, the most effective commercially available mouthbite remains uncertain, leading to a gap in the literature. Additionally, there's a concerning 21% failure rate for patients requiring mouthbite in our center. This pilot study aims to compare the tolerability, ease of fabrication, and effectiveness of 2 other commercially available mouthbite devices (BL, BF) with the in-house fabricated mouthbite (RW) used in our center for H&N patients. Materials/Methods This prospective randomized controlled pilot study considered 30 H&N patients undergoing radiotherapy and required a mouthbite for it. There are 10 patients in each of the 3 arms. The time taken to fabricate or utilize the mouthbite for patients was recorded. At 4 different intervals, (i) day of Computed Tomography (CT) simulation, (ii) first day of treatment, (iii) midcourse of treatment, (iv) last day of treatment, patient's pain score regarding the mouthbite was recorded. Setup reproducibility for the treatment, tongue, and mouthbite position, at time intervals (ii), (iii) and (iv) were collected. These data were compared across the 3 different mouthbite groups to determine the best suitable one for use. Results The mean fabrication or utilization time for BL, BF, and RW varied at 8.2, 2, and 16.3 minutes respectively. The mean pain score on CT day for BL, BF, and RW were 1, 0, and 0, on day 1 of treatment were 0.4, 0, and 0, on the mid-treatment course were 2.3, 1.4, and 1.4, and on last day of treatment were 2.5, 2.3, 1.4 respectively. All patients in the 3 different mouthbite groups completed treatment 100%. The setup reproducibility group mean for treatment, tongue and mouthbite displacement are shown in Table 1 below: Conclusion Other than the shorter utilization mouthbite time by BF, there are no statistical significances found between the mouthbites groups for the tolerability of mouthbite based on mean pain score and number of treatment fractions completed, as well as the reproducibility of mouthbite based on treatment delivery, tongue and mouthbite displacement. Based on the findings of this study, there is no evidence to suggest that any alternative mouthbite is superior to the current RW mouthbite. Further investigation is warranted in this area.

Detectable plasma Epstein-Barr virus (EBV) DNA post-RT implies a poor prognosis, but Hui et al. reported a model that could sub-stratify these patients by an EBV DNA cut-off of 500 copies/mL. Detection limits however vary between different EBV DNA assays, which could lead to false positives at low EBV DNA levels. We investigated the EBV DNA kinetics and survival in patients harboring a detectable, but non-quantifiable EBV DNA post-RT (≤265 copies/mL; termed as MRD).

Herein, we developed and validated an immune-based prognostic GC for NPC. Our findings underscore the importance of the immune landscape in EBV-positive NPC.

LA-NPC can be subtyped by ascending (A; T3-4N0-1), descending (D; T1-2N2-3) and ascending-descending (AD; T3-4N2-3) at diagnosis, depending on the extent of tumor spread. These phenotypes differ by prognoses, but germline and somatic molecular drivers underpinning their tumorigenesis are unknown. We aimed to validate the A and AD subtypes of LA-NPC and investigate for germline variants that are associated with them. We utilized a cohort of 255 patients with biopsy-proven, non-metastatic, T3-4 NPC (AJCC/UICC 8th edition). Association of clinical covariates were tested by Cox regression. Germline profiling was conducted by whole exome sequencing (100x; Illumina NovaSeq) and variants were shortlisted based on known/predicted pathogenicity. The differential prevalence of variants was tested using Fisher’s exact test. Median follow-up duration of the cohort was 79 (IQR: 66-90) mo; median age was 49.4 (43.2-58.1) y. We identified 108 (42.3%) A- and 147 (57.6%) AD-subtype in our cohort. 55 (50.9%) and 35 (32.4%) of the A-subtype patients compared to 64 (43.5%) and 75 (51.0%) in the AD-subgroup received chemoradiotherapy (CRT) alone and CRT+induction/adjuvant chemotherapy, respectively. High EBV DNA titer of >4000 copies were more frequent in the AD- than A-subgroup (50.0% vs 31.2%, P = 0.0141). 5-y DFS differed between the A and AD subtypes (85.1% [95% CI: 78.2-92.7] vs 67.0% [59.2-75.8%], P <0.001); the AD-subtype was significantly associated with worse DFS (HR 3.10 [1.54-6.23], P = 0.00147) after adjustment for age, EBV DNA and T4-status. Next, we observed germline variants in hallmark-of-cancer genes (FAT1 [N=46; 18.0%] and NOTCH1 [N=13; 5.1%]), DNA repair genes (SRSF6 [N=13; 5.1%] and POLD1 [N=14; 5.5%]) and genes with known association to NPC (MST1R [N=13; 5.1%] and SYNE1[N=50; 19.6%]). Of them, TGFBR2 variants were significantly associated with the unfavorable AD-subtype (OR 3.68 [1.06-15.3], P = 0.041). We have shown that the AD-subtype in patients with LA-NPC is associated with an inferior DFS. The TGFBR2germline variants may be associated with the susceptibility of this unfavorable phenotype.

Radiomics aims to extract novel information on biology from radiological images for phenotypic profiling of tumors. However, there has been little correlation between radiomics features and molecular phenotypes in tumors. Here, we investigated for a radiomics signature to predict for radioresistance in nasopharynx cancer (NPC). We further determined the intratumoral spatial heterogeneity of the radiomics features, and the association with tumor transcriptome. We utilized imaging datasets (CT and MRI T2-weighted) of 641 NPC patients from two academic institutions (314 [NCCS] and 327 [SYSUCC]). Two radiomics pipelines – Pyradiomics (v2.1.2) and Moddicom (v.0.51) were employed for analyses. Segmentation of the primary gross tumor volume (GTVp) was performed by consensus agreement between three radiation oncologists; for intratumoral spatial analysis, subregions were autosegmented by creating an internal margin of 5 mm (Velocity v4.0) to derive a tumor core (TC) and periphery (TP) for each patient. Gene expression profiling was performed in 80 cases using Illumina Truseq (min 3.0 x107 reads). Primary clinical endpoint was local regional recurrence-free survival (LRFS). Hierarchical clustering and correlation analyses revealed significant inter-pipeline and inter-institutional correlation in extracted radiomics features for CT images, but not for MRI. 79.1% (53 of 67 common between Pyradiomics and Moddicom) of CT features and 33.0% (23 of 70 common between Pyradiomics and Moddicom) of MRI features were correlated between pipelines (Spearman R≥0.9 and FDR-corrected P ≤0.05). Between institutions, >90% of the CT features showed similar clusters across the different radiomics modules, but not for MRI. Following feature reduction by stepwise exclusion of features that were correlated or had a tight interpatient variance, five CT features were associated with LRFS, adjusted for clinical covariates; this corresponded to an AUC of 0.82 (95% CI 0.81-0.83) for locoregional recurrence with the combinatorial clinico-radiomics model. Interestingly, these features demonstrated significant intratumoral spatial heterogeneity between TC and TP. Notably, GLNU expression was higher in TC than TP, which was correlated with elevated hypoxia scores by the Ratnan and West signatures (P <0.001); Entrophy was linked to TP, and was associated with several immune signatures (P <0.001 for all). Using novel biostatistical and bioinformatics approaches, we herein demonstrate the reliability and accuracy of radiomics from independent datasets to identify novel biology relating to radioresistance in NPC. Likewise to molecular genetics, we highlight the intratumoral spatial heterogeneity for radiomics features that could be linked to known molecular drivers of radioresistance. A pan-cancer analysis ought to be undertaken to derive robust biomarker signatures that would inform on precision therapies.

BACKGROUND:The aim of this study was to investigate the effect of treatment with the saliva biomimetic, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and SnF2 /NaF compared with SnF2 /NaF alone on coronal surface caries progression in head-and-neck cancer patients undergoing radiotherapy.METHODS:Twenty-four participants were randomized into two groups. Both groups used 0.4% SnF2 gel and a 0.32% NaF toothpaste; the test group also applied a crème containing 10% CPP-ACP three times daily while the control group used an identical crème without CPP-ACP (placebo). Resting saliva flow rate and saliva fluoride concentrations were determined. Caries status was assessed using ICDASII at baseline and 12-weeks postradiotherapy. Data were statistically analysed using a linear mixed effects model.RESULTS:Both groups showed significantly reduced resting saliva flow rate (P < 0.001) postradiotherapy. There were no significant differences in flow rates and fluoride concentration between groups. The CPP-ACP group exhibited a significant (P < 0.05) 51% reduction in coronal surface caries progression compared with the placebo group.CONCLUSION:Resting salivary flow rate was significantly reduced in head-and-neck cancer patients following radiotherapy and use of CPP-ACP with SnF2 /NaF significantly lowered caries progression compared with SnF2 /NaF alone.

Modern standards of precision radiotherapy, primarily driven by the technological advances of intensity modulation and image guidance, have led to increased versatility in radiotherapy planning and delivery. The ability to shape doses around critical normal organs, while simultaneously "painting" boost doses to the tumor have translated to substantial therapeutic gains in head and neck cancer patients. Recently, dose adaptation (or adaptive radiotherapy) has been proposed as a novel concept to enhance the therapeutic ratio of head and neck radiotherapy, facilitated in part by the onset of molecular and functional imaging. These contemporary imaging techniques have enabled visualisation of the spatial molecular architecture of the tumor. Daily cone-beam imaging, besides improving treatment accuracy, offers another unique angle to explore radiomics - a novel high throughput feature extraction and selection workflow, for adapting radiotherapy based on real-time tumor changes. Here, we review the existing evidence of molecular and functional imaging in head and neck cancers, as well as the current application of adaptive radiotherapy in the treatment of this tumor type. We propose that adaptive radiotherapy can be further exploited through a systematic application of molecular and functional imaging, including radiomics, at the different phases of planning and treatment. (C) 2018 Societe francaise de radiotherapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.

Aim/Background: We reported that induction gemcitabine, carboplatin and paclitaxel (GCP) failed to improve overall, disease free and distant metastasis free survival in patients with advanced nasopharyngeal carcinoma (NPC) treated with concurrent weekly cisplatin and IMRT. We next examined if pre-treatment plasma neutrophil-lymphocyte ratio (NLR) and EBV DNA predicted for patients who benefit from induction GCP. Methods: Patients with biopsy-proven UICC/AJCC stage III, IVA/B NPC were eligible. Patients received IMRT (69.96 and 60 Gy to GTV and CTV, respectively) with weekly cisplatin (40 mg/m2). Induction GCP comprised of gemcitabine, 1 gm/m2, carboplatin, AUC 2.5, paclitaxel, 70 mg/m2, given on days 1 and 8 3-weekly for 3 cycles. Plasma EBV DNA was quantified using real-time quantitative PCR. NLR was computed as a ratio of absolute neutrophil to lymphocyte counts. Results: 108 of 172 patients in the randomised trial had EBV DNA measurements at baseline. 53 and 55 patients were randomised to GCP and control arms, respectively. Median follow-up duration was 2.3 years (range = 0.11-3.92). 103 were alive at the time of analysis, 24 (22%) experienced disease progression, 15 (14%) had distant metastases and 12 (11%) had local relapses. Uppermost thirtile of EBV DNA titre was 6000 copies/ml and median NLR was 3.0. Patients with EBV DNA ≥6000 copies/ml (EBVhigh) and NLR ≥3.0 (NLRhigh) had a higher likelihood of disease progression and distant metastasis (HR 1.6, 95% CI = 0.7-3.83, DFS; 2.2, 0.77-6.11, DMFS). Likelihood of disease free and distant metastasis free survival was improved with induction GCP regardless of EBV DNA threshold (HR 0.40, EBVhigh vs 0.50, DFS; 0.30, EBVhigh vs 0.50, DMFS). Induction GCP led to significantly improved DFS and DMFS in the NLRhigh subgroup (HR 0.30, 0.07-0.92, p = 0.02, DFS; 0.10, 0.01-0.92, p = 0.01, DMFS), while outcomes did not differ between treatment arms in patients with NLR <3.0 (HR 0.90, 0.25-3.00, DFS; 1.7, 0.31-9.26, DMFS). Conclusions: Elevated EBV DNA and NLR portend for an unfavourable prognosis in patients with advanced NPC. While the role of induction chemotherapy in an unselected patient cohort is uncertain, NLR may be a useful biomarker to select patients a priori for this treatment. Clinical trial identification: NCT00997906 Disclosure: All authors have declared no conflicts of interest.

Distant metastasis represents a significant source of treatment failure in patients with locally advanced nasopharyngeal carcinoma (NPC) who are treated with concurrent cisplatin and radiation therapy (RT). A recent randomized trial investigating the efficacy of adding induction chemotherapy (gemcitabine, carboplatin, and paclitaxel, GCP) to the current standard regime of concurrent cisplatin and RT, failed to indicate further improvement in survival outcomes with the experimental strategy. In this secondary analysis, we test the hypothesis that raised plasma EBV DNA levels measured pre-treatment predicts for a therapeutic benefit with induction GCP. Patients with biopsy-proven stage 3/4 NPC with no evidence of distant metastasis were eligible. All patients underwent intensity modulated RT, delivered to a dose of 69.96 and 60 Gy in 33 fractions to the gross tumor and high risk subclinical and nodal regions, respectively. Cisplatin, at a dose of 40 mg/m2, was administered concurrently once a week with RT. In the experimental arm, the 3-weekly GCP combination regime comprised of gemcitabine, 1 gm/m2, carboplatin, AUC 2.5, paclitaxel, 70 mg/m2, given at days 1 and 8 for a total of 3 cycles. Plasma EBV DNA levels were quantified using real-time quantitative polymerase chain reaction assay. A total of 172 patients were accrued for the primary randomized study. Median follow-up of all patients was 3.25 (range, 1.07-8.42) and 2.69 years (range, 0.11 - 8.32) in the GCP and control arms, respectively. Overall survival (OS), disease-free survival (DFS), and distant metastasis-free survival (DMFS) were comparable between both treatment arms (HR: OS = 1.05, 95% CI = 0.44-2.53, p = 0.915; DFS = 0.77, 95% CI = 0.44-1.35, p = 0.362; DMFS = 0.81, 95% CI = 0.39-1.71, p = 0.585). One hundred twelve patients had EBV DNA analysis pre-treatment (N = 56, GCP and control). Of this group of patients, 37 (66.1%) and 41 (73.2%) in the control and GCP arms, respectively, had detectable levels of EBV DNA pre-treatment. For patients with detectable EBV DNA levels, induction GCP seems to confer a favorable DFS and DMFS (HR: DFS = 0.39, 95% CI = 0.14-1.11, p = 0.056; DMFS = 0.45, 95% CI = 0.13-1.49, p = 0.166). In contrast, DFS and DMFS were comparable between both treatment arms in patients with undetectable EBV DNA levels at baseline (HR: DFS = 0.74, 95% CI = 0.18-2.97, p = 0.617; DMFS = 0.80, 95% CI = 0.11-5.69, p = 0.864). Local regional failure rates were comparable between both arms, independent of baseline EBV DNA levels. The addition of induction chemotherapy to concurrent chemoradiation therapy in locally advanced NPC remains controversial. Nonetheless, patients with detectable EBV DNA levels pre-treatment appear to benefit from induction GCP, both in terms of DFS and DMFS. Baseline EBV DNA level potentially has a role as a predictive marker in stratifying patients with stage 3/4 NPC for induction chemotherapy.

The efficacy of parenteral (intramuscular) or intramammary (IMM) benzylpenicillin treatment for clinical mastitis caused by gram-positive bacteria susceptible to penicillin in vitro was investigated. Cows with clinical mastitis in 1 udder quarter were randomly placed into 2 treatment groups. The preliminary bacteriological diagnosis of intramammary infection (IMI) was based on on-farm culturing, and the bacteriological diagnoses were later confirmed by a quantitative PCR assay. Clinical mastitis caused by gram-positive bacteria susceptible to benzylpenicillin was treated with penicillin via either the parenteral route (20 mg/kg) or IMM route (600 mg) once per day for 5 d. The outcome of the treatment was evaluated 3 to 4 wk after the onset of the treatment. The affected quarter was examined to assess the clinical cure, and milk samples were collected from the affected quarter to determine the bacteriological cure and milk N-acetyl-β-d-glucosaminidase activity. The survival and the composite milk somatic cell counts of the treated cows were followed up for 6 and 3 mo after treatment, respectively. A total of 140 cows with clinical mastitis were included in the study, 61 being treated with benzylpenicillin parenterally and 79 via the IMM route. From all quarters treated, 108 of 140 (77.1%) were cured clinically and 77 of 140 (55.0%) were cured bacteriologically. The route of treatment did not significantly affect the outcome of the treatment; 80.3% of the quarters with parenteral treatment and 74.7% of the quarters with IMM treatment showed a clinical cure, and 54.1 and 55.7% a bacteriological cure, respectively. The milk N-acetyl-β-d-glucosaminidase activity was significantly lower in the quarters with a clinical or bacteriological cure than in the quarters with no cure. The 6-mo survival and the proportion of cows with composite milk somatic cell counts <200,000/mL among the treated cows during the 3-mo follow-up period did not significantly differ between the treatment groups. In conclusion, the outcome of either parenteral or IMM benzylpenicillin treatment of clinical mastitis caused by penicillin-susceptible bacteria was similar.

Concurrent chemoradiotherapy is now considered the standard of care for patients with locally advanced nasopharyngeal carcinoma (NPC). However, the benefit of adjuvant chemotherapy remains controversial. To assess if adjuvant chemotherapy might further reduce the risk of developing distant metastases, we performed a retrospective analysis of patients with Stage III or IV NPC who only received 3 cycles of concurrent chemoradiotherapy versus those who received 3 cycles of concurrent chemoradiotherapy followed by 3 cycles of adjuvant chemotherapy. Between 2001 and 2005, 282 patients with Stage III or IV NPC were treated with chemoradiotherapy. Of these, 52 patients received 3 cycles of concurrent chemoradiotherapy but did not receive any adjuvant chemotherapy, whilst 135 patients received an additional 3 cycles of adjuvant chemotherapy. These two groups formed the basis of this report. All patients were treated using standard RT protocols prevailing at that time and the Al-Sarraf chemotherapy regimen. The median follow up of the patients was 27 months (range 2.1–71 months). There was no statistical difference between the two groups (no adjuvant vs. adjuvant chemotherapy) for tumor stage (p = 0.21), nodal stage (p = 0.49), overall stage (p = 0.10) or age (p = 0.55), although the adjuvant chemotherapy group had more Stage IV patients (45.9% versus 28.8%). The 3-year metastases-free survival rate was 84.1% for those who did not receive adjuvant chemotherapy and 87.5% for those who received adjuvant chemotherapy. The adjusted hazard ratio for developing metastases if adjuvant chemotherapy was omitted was 1.23 (95% CI, 0.40–3.81) after adjusting for stage of disease, though this was not statistically significant (p = 0.718). The 3-year overall survival rates were 92% and 96% for no adjuvant and adjuvant, respectively. The adjusted hazard ratio of overall survival if no adjuvant chemotherapy was administered was 4.1 (95% CI, 0.91–19.17, p = 0.066) when adjusted for stage of disease. Despite having a greater proportion of Stage IV patients, the adjuvant group had a slightly lower 3 year metastasis rate, as well as a lower proportional risk of developing metastases. Our retrospective series was unable to demonstrate a statistically significant benefit for adjuvant chemotherapy. However, the number of events was relatively small at the time of analysis. To show a 20% benefit at type I error of 5% and power of 80% would have required 313 events in each arm. We would like to urge other groups to analyze their data and perhaps a combined metanalysis could be performed.

This is a prospective study of wound healing after extractions in patients who had radiation therapy for nasopharyngeal cancer. From 40 patients who fulfilled all the study criteria were extracted a total of 155 teeth. The demographic data were analysed, checking for factors that might affect the healing process after extraction. Wound healing was divided into three groups: normal wound healing, delayed healing and osteoradionecrosis. Logistic regression was used to analyse possible relationships. There was a low complication rate: 5.8% and 1.9% of extractions showed delayed healing and osteoradionecrosis, respectively. The age of the patient at time of extraction was the only significant factor that influenced the occurrence of delayed healing. It was observed that localized radiation absorption was considerably different from the total radiation dose. In conclusion, postradiation extractions have a low risk of complications and the results point to age as a factor that may influence wound healing.

Since the introduction of mammalian cell survival curves, the parameters D0 and N have been used as quantitative measures of inherent radiation sensitivity, as was the shoulder width Dq. These parameters are more generally applicable at high doses. We propose to introduce a measure of tumor radioresponsitivity that is more applicable to the clinical treatment schedules that employ small fractional doses (1–2 Gy), the ratio α/E, derived from the linear quadratic model for cell inactivation as the intercept on the reciprocal-dose plot. For tumor-control experiments this ratio is the reciprocal of the TCD50 when radiation is given in very small fractions or at low dose rates (assuming negligible clonogen proliferation). The rationales for this choice are: (1) α is a measure of the steepness of the initial linear segment of the dose-survival curve. Accordingly, at doses per fraction of 1–2 Gy the observed effect increases with α. (2) E is by definition a positive measure of the clonogen kill required for a specified tumor response, e.g., E = −log (surviving fraction of clonogens at the 50% control level). Therefore it is also a measure of the number of clonogens present at the time of inception of treatment, which for a given dose is a prime determinant of the probability of tumor control. This measure of radioresponsitivity is to be distinguished from the ratio α/β, which is a measure of fractionation sensitivity. A survey of the literature indicates that these do not correlate, except in highly hypoxic tumors (e.g., clamped); such tumors are characterized by low radioresponsitivity as well as low fractionation sensitivity (high α/β ratio). There are at present only limited data for determination of this ratio, however, since reciprocal-dose analysis requires tumor control doses for several different sizes of dose per fraction.