Correlation and colocalization of HIF-1a and pimonidazole staining for hypoxia in laryngeal squamous cell carcinomas:A digital, single-cell-based analysis

OBJECTIVE: Tumor hypoxia results in worse local control and patient survival. We performed a digital, single-cell-based analysis to compare two biomarkers for hypoxia (hypoxia-inducible factor 1-alpha [HIF-1α] and pimonidazole [PIMO]) and their effect on outcome in laryngeal cancer patients treated with accelerated radiotherapy with or without carbogen breathing and nicotinamide (AR versus ARCON). MATERIALS AND METHODS: Immunohistochemical staining was performed for HIF-1α and PIMO in consecutive sections of 44 laryngeal cancer patients randomized between AR and ARCON. HIF-1α expression and PIMO-binding were correlated using digital image analysis in QuPath. High-density areas for each biomarker were automatically annotated and staining overlap was analyzed. Kaplan-Meier survival analyses for local control, regional control and disease-free survival were performed to predict a response benefit of ARCON over AR alone for each biomarker. RESULTS: 106 Tissue fragments of 44 patients were analyzed. A weak, significant positive correlation was observed between HIF-1α and PIMO positivity on fragment level, but not on patient level. A moderate strength correlation (r = 0.705, p < 0.001) was observed between the number of high-density staining areas for both biomarkers. Staining overlap was poor. HIF-1α expression, PIMO-binding or a combination could not predict a response benefit of ARCON over AR. CONCLUSION: Digital image analysis to compare positive cell fractions and staining overlap between two hypoxia biomarkers using open-source software is feasible. Our results highlight that there are distinct differences between HIF-1α and PIMO as hypoxia biomarkers and therefore suggest co-existence of different forms of hypoxia within a single tumor

Development and external validation of a prediction model for tube feeding dependency for at least four weeks during chemoradiotherapy for head and neck cancer

Background & aims: Patients who receive chemoradiotherapy or bioradiotherapy (CRT/BRT) for locally advanced head and neck squamous cell carcinoma (LAHNSCC) often experience high toxicity rates interfering with oral intake, causing tube feeding (TF) dependency. International guidelines recommend gastrostomy insertion when the expected use of TF exceeds 4 weeks. We aimed to develop and externally validate a prediction model to identify patients who need TF ≥ 4 weeks and would benefit from prophylactic gastrostomy insertion. Methods: A retrospective multicenter cohort study was performed in four tertiary head and neck cancer centers in the Netherlands. The prediction model was developed using data from University Medical Center Utrecht and the Netherlands Cancer Institute and externally validated using data from Maastricht University Medical Center and Radboud University Medical Center. The primary endpoint was TF dependency ≥4 weeks initiated during CRT/BRT or within 30 days after CRT/BRT completion. Potential predictors were extracted from electronic health records and radiotherapy dose–volume parameters were calculated. Results: The developmental and validation cohort included 409 and 334 patients respectively. Multivariable analysis showed predictive value for pretreatment weight change, texture modified diet at baseline, ECOG performance status, tumor site, N classification, mean radiation dose to the contralateral parotid gland and oral cavity. The area under the receiver operating characteristics curve for this model was 0.73 and after external validation 0.62. Positive and negative predictive value for a risk of 90% or higher for TF dependency ≥4 weeks were 81.8% and 42.3% respectively. Conclusions: We developed and externally validated a prediction model to estimate TF-dependency ≥4 weeks in LAHNSCC patients treated with CRT/BRT. This model can be used to guide personalized decision-making on prophylactic gastrostomy insertion in clinical practice

18F-FDG-PET/CT-guided radiotherapy of cervical lymph nodes in head and neck squamous cell carcinoma

The use of positron emission tomography with fluor-18-fluorodeoxyglucose (FDG-PET) in clinical practice for patients with head and neck squamous cell carcinoma (HNSCC) has expanded rapidly, with implications for diagnostic staging, radiotherapy planning, adaptive radiotherapy, and post-therapy evaluation. The implementation of FDG-PET/CT in radiation treatment planning not only has consequences for target volume definition and dose prescription but is also associated with an increased overall survival in patients with HNSCC. FDG-PET/CT-guided gradient dose prescription provides a window of opportunity for treatment de-intensification of the neck in order to decrease treatment-related toxicity without compromising oncological outcome. Further, interim FDG-PET/CT during radiotherapy can be useful to assess metabolic tumor response and enables opportunities for adaptive treatment strategies. The goals are to increase treatment effectivity in poor responders and reduce unnecessary toxicity in patients with good early tumor response. Further prospective trials investigating adaptive radiotherapy based on interim PET-evaluation are needed, especially regarding human papilloma virus-negative HNSCC and patients treated with primary radiotherapy

Performance evaluation of commercial and non-commercial shear wave elastography implementations for vascular applications

Background: Shear wave elastography (SWE) is mainly used for stiffness estimation of large, homogeneous tissues, such as the liver and breasts. However, little is known about its accuracy and applicability in thin (∼0.5–2 mm) vessel walls. To identify possible performance differences among vendors, we quantified differences in measured wave velocities obtained by commercial SWE implementations of various vendors over different imaging depths in a vessel-mimicking phantom. For reference, we measured SWE values in the cylindrical inclusions and homogeneous background of a commercial SWE phantom. Additionally, we compared the accuracy between a research implementation and the commercially available clinical SWE on an Aixplorer ultrasound system in phantoms and in vivo in patients. Methods: SWE measurements were performed over varying depths (0–35 mm) using three ultrasound machines with four ultrasound probes in the homogeneous 20 kPa background and cylindrical targets of 10, 40, and 60 kPa of a multi-purpose phantom (CIRS-040GSE) and in the anterior and posterior wall of a homogeneous polyvinyl alcohol vessel-mimicking phantom. These phantom data, along with in vivo SWE data of carotid arteries in 23 patients with a (prior) head and neck neoplasm, were also acquired in the research and clinical mode of the Aixplorer ultrasound machine. Machine-specific estimated phantom stiffness values (CIRS phantom) or wave velocities (vessel phantom) over all depths were visualized, and the relative error to the reference values and inter-frame variability (interquartile range/median) were calculated. Correlations between SWE values and target/vessel wall depth were explored in phantoms and in vivo using Spearman's correlations. Differences in wave velocities between the anterior and posterior arterial wall were assessed with Wilcoxon signed-rank tests. Intra-class correlation coefficients were calculated for a sample of ten patients as a measure of intra- and interobserver reproducibility of SWE analyses in research and clinical mode. Results: There was a high variability in obtained SWE values among ultrasound machines, probes, and, in some cases, with depth. Compared to the homogeneous CIRS-background, this variation was more pronounced for the inclusions and the vessel-mimicking phantom. Furthermore, higher stiffnesses were generally underestimated. In the vessel-mimicking phantom, anterior wave velocities were (incorrectly) higher than posterior wave velocities (3.4–5.6 m/s versus 2.9–5.9 m/s, p ≤ 0.005 for 3/4 probes) and remarkably correlated with measurement depth for most machines (Spearman's ρ = -0.873–0.969, p &lt; 0.001 for 3/4 probes). In the Aixplorer's research mode, this difference was smaller (3.3–3.9 m/s versus 3.2–3.6 m/s, p = 0.005) and values did not correlate with measurement depth (Spearman's ρ = 0.039–0.659, p ≥ 0.002). In vivo, wave velocities were higher in the posterior than the anterior vessel wall in research (left p = 0.001, right p &lt; 0.001) but not in clinical mode (left: p = 0.114, right: p = 0.483). Yet, wave velocities correlated with vessel wall depth in clinical (Spearman's ρ = 0.574–0.698, p &lt; 0.001) but not in research mode (Spearman's ρ = -0.080–0.466, p ≥ 0.003). Conclusions: We observed more variation in SWE values among ultrasound machines and probes in tissue with high stiffness and thin-walled geometry than in low stiffness, homogeneous tissue. Together with a depth-correlation in some machines, where carotid arteries have a fixed location, this calls for caution in interpreting SWE results in clinical practice for vascular applications.</p

Expression of EGFR under tumor hypoxia: identification of a subpopulation of tumor cells responsible for aggressiveness and treatment resistance

Item does not contain fulltextPURPOSE: Overexpression of epidermal growth factor receptor (EGFR) and tumor hypoxia have been shown to correlate with worse outcome in several types of cancer including head-and-neck squamous cell carcinoma. Little is known about the combination and possible interactions between the two phenomena. METHODS AND MATERIALS: In this study, 45 cases of histologically confirmed squamous cell carcinomas of the head and neck were analyzed. All patients received intravenous infusions of the exogenous hypoxia marker pimonidazole prior to biopsy. Presence of EGFR, pimonidazole binding, and colocalization between EGFR and tumor hypoxia were examined using immunohistochemistry. RESULTS: Of all biopsies examined, respectively, 91% and 60% demonstrated EGFR- and pimonidazole-positive areas. A weak but significant association was found between the hypoxic fractions of pimonidazole (HFpimo) and EGFR fractions (F-EGFR) and between F-EGFR and relative vascular area. Various degrees of colocalization between hypoxia and EGFR were found, increasing with distance from the vasculature. A high fraction of EGFR was correlated with better disease-free and metastasis-free survival, whereas a high degree of colocalization correlated with poor outcome. CONCLUSIONS: Colocalization of hypoxia and EGFR was demonstrated in head-and-neck squamous cell carcinomas, predominantly at longer distances from vessels. A large amount of colocalization was associated with poor outcome, which points to a survival advantage of hypoxic cells that are also able to express EGFR. This subpopulation of tumor cells might be indicative of tumor aggressiveness and be partly responsible for treatment resistance

Implications of improved diagnostic imaging of small nodal metastases in head and neck cancer : Radiotherapy target volume transformation and dose de-escalation

Diagnostic imaging continues to evolve, and now has unprecedented accuracy for detecting small nodal metastasis. This influences the tumor load in elective target volumes and subsequently has consequences for the radiotherapy dose required to control disease in these volumes. Small metastases that used to remain subclinical and were included in elective volumes, will nowadays be detected and included in high-dose volumes. Consequentially, high-dose volumes will more often contain low-volume disease. These target volume transformations lead to changes in the tumor burden in elective and “gross” tumor volumes with implications for the radiotherapy dose prescribed to these volumes. For head and neck tumors, nodal staging has evolved from mere palpation to combinations of high-resolution imaging modalities. A traditional nodal gross tumor volume in the neck typically had a minimum diameter of 10–15 mm, while nowadays much smaller tumor deposits are detected in lymph nodes. However, the current dose levels for elective nodal irradiation were empirically determined in the 1950s, and have not changed since. In this report the radiobiological consequences of target volume transformation caused by modern imaging of the neck are evaluated, and theoretically derived reductions of dose in radiotherapy for head and neck cancer are proposed. The concept of target volume transformation and subsequent strategies for dose adaptation applies to many other tumor types as well. Awareness of this concept may result in new strategies for target definition and selection of dose levels with the aim to provide optimal tumor control with less toxicity

Implications of improved diagnostic imaging of small nodal metastases in head and neck cancer : Radiotherapy target volume transformation and dose de-escalation

Diagnostic imaging continues to evolve, and now has unprecedented accuracy for detecting small nodal metastasis. This influences the tumor load in elective target volumes and subsequently has consequences for the radiotherapy dose required to control disease in these volumes. Small metastases that used to remain subclinical and were included in elective volumes, will nowadays be detected and included in high-dose volumes. Consequentially, high-dose volumes will more often contain low-volume disease. These target volume transformations lead to changes in the tumor burden in elective and “gross” tumor volumes with implications for the radiotherapy dose prescribed to these volumes. For head and neck tumors, nodal staging has evolved from mere palpation to combinations of high-resolution imaging modalities. A traditional nodal gross tumor volume in the neck typically had a minimum diameter of 10–15 mm, while nowadays much smaller tumor deposits are detected in lymph nodes. However, the current dose levels for elective nodal irradiation were empirically determined in the 1950s, and have not changed since. In this report the radiobiological consequences of target volume transformation caused by modern imaging of the neck are evaluated, and theoretically derived reductions of dose in radiotherapy for head and neck cancer are proposed. The concept of target volume transformation and subsequent strategies for dose adaptation applies to many other tumor types as well. Awareness of this concept may result in new strategies for target definition and selection of dose levels with the aim to provide optimal tumor control with less toxicity

Targeting Hypoxia, HIF-1, and Tumor Glucose Metabolism to Improve Radiotherapy Efficacy

Item does not contain fulltextRadiotherapy, an important treatment modality in oncology, kills cells through induction of oxidative stress. However, malignant tumors vary in their response to irradiation as a consequence of resistance mechanisms taking place at the molecular level. It is important to understand these mechanisms of radioresistance, as counteracting them may improve the efficacy of radiotherapy. In this review, we describe how the hypoxia-inducible factor 1 (HIF-1) pathway has a profound effect on the response to radiotherapy. The main focus will be on HIF-1-controlled protection of the vasculature postirradiation and on HIF-1 regulation of glycolysis and the pentose phosphate pathway. This aberrant cellular metabolism increases the antioxidant capacity of tumors, thereby countering the oxidative stress caused by irradiation. From the results of translational studies and the first clinical phase I/II trials, it can be concluded that targeting HIF-1 and tumor glucose metabolism at several levels reduces the antioxidant capacity of tumors, affects the tumor microenvironment, and sensitizes various solid tumors to irradiation. Clin Cancer Res; 18(20); 5585-94. (c)2012 AACR