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Salivary Parameters As Predictive Markers for Radiation-Induced Treatment Response in Head and Neck Cancers: an Investigational Study

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Salivary Parameters As Predictive Markers for Radiation-Induced Treatment Response in Head and Neck Cancers: an Investigational Study Original Article Middle East Journal of Cancer; April 2018; 9(2): 133-142 Salivary Parameters as Predictive Markers for Radiation-induced Treatment Response in Head and Neck Cancers: An Investigational Study Dipika Jayachander*, Arnadi Ramachandrayya Shivashankara**, Mamidipudi Srinivasa Vidyasagar***, Raees Tonse****, Sarita Pais*****, Ashwin DL Lobo** Sanath Kumar Hegde******, Suresh Rao******, Manjeshwar Shrinath Baliga******♦ *Department of Radiation Oncology, Apollo Hospital, Bengaluru, Karnataka, India **Department of Biochemistry, Father Miller Medical College, Kankanady, Mangalore, India ***Department of Radiotherapy, Kasturba Medical College, Manipal University, Manipal, Karnataka, India ****Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India *****Department of Radiation Oncology, Narayana Hrudayalaya, Bengaluru, Karnataka, India ******Department of Radiation Oncology, Mangalore Institute of Oncology, Pumpwell, Mangalore, Karnataka, India Abstract Background: This study evaluates the predictive significance of salivary amylase, glutathione, lipid peroxides, and lactate dehydrogenase in the treatment of head and neck cancer patients who undergo curative radiotherapy/chemoradiotherapy. Methods: The volunteers for the study included head and neck cancer patients that required curative radiotherapy/chemoradiotherapy. Patients provided saliva and blood samples before the start of radiation treatment and 24 hours after the first radiation fraction of 2 Gy (before the start of the second fraction). Samples were assessed for the levels of blood and salivary amylase, glutathione, lipid peroxides, and lactate dehydrogenase by standard laboratory methods. Clinical tumor radioresponse was assessed one month after the completion of treatment as complete responders, partial responders, and nonresponders. Results: The results indicated a significant increase in the levels of amylase, ♦Corresponding Author: lactate dehydrogenase, and lipid peroxides; and a concomitant decrease in the levels Manjeshwar Shrinath Baliga, of glutathione <0.05 - <0.0001 in saliva and blood. The correlation between the PhD P P Senior Radiobiologist differences in each biochemical parameter with that of the treatment response showed Incharge Head of Research- a significant correlation only for the salivary lactate dehydrogenase (R2=0.25; P<0.02). Mangalore Institute of The results indicate that salivary lactate dehydrogenase can be a Oncology, Pumpwell, Conclusion: Mangalore, Karnataka, India useful predictive marker to ascertain radiation-induced tumor regression in head and Tel: 91-9945422961 neck cancers. Email: [email protected] Keywords: Salivary amylase, Glutathione, Lipid peroxides, Lactate dehydrogenase, Tumor response, Predictive assay Received: June 3, 2017; Accepted: September 13, 2017 Dipika Jayachander et al. Introduction is not effective for advanced cancers (T3 or T4) Head and neck cancers are the leading cause and doses that range from 75 to 80 Gy or more of cancer related deaths in many parts of the may be needed to obtain meaningful results.5-7 world.1 Surgery and/or radiotherapy and/or Additionally, radiation is also combined with chemotherapy is used for cancer control and small doses of chemotherapy (chemoradiation) to possible cure depending on the patient's general enhance the therapeutic effects. Concurrent health, stage, and localization of the tumor.2,3 Of platinum-based (cisplatin, carboplatin) these, radiotherapy is especially useful in the chemoradiation is shown to be effective in treatment of inoperable tumors and estimates are increasing absolute survival.8,9 However the use that approximately 70% of all patients receive of chemoradiation is shown to compromise quality radiation therapy at some point during the course of life by increasing non-hematological side effects of their disease for either curative or palliative that include mucositis, dysphagia, and purposes.4 xerostomia.5,6 With respect to cancer of the head and neck, From clinical perspective, though radiation when radiation therapy is employed for curative treatment protocol is almost same for all head intent, a total dose of 65-70 Gy in 6-7 weeks can and neck cancers, the inter-individual differences produce local control rates of 80%-90% in the in the tumor intrinsic factors (like as DNA early stages (T1 and T2 lesions).5-7 However, this aneuploidy; S-phase fraction and proliferation Figure 1. Flow chart of the study emphasizing the death and loss of follow up during the course of treatment and during the follow up. 134 Middle East J Cancer 2018; 9(2): 133-142 Saliva as a Predictive Marker for Radiation Response in Head & Neck Cancers Table 1. Details on the criteria used for selection of the study patients. Inclusion criteria Exclusion criteria 1. Age >18 years 1. Patients unwilling to be a part of the study. 2. Patients with a definitive diagnosis of head and neck 2. Women who were pregnant. cancer. 3. Patients who had oral surgery within the previous six 3. Patients scheduled to receive radiotherapy (> 60 Gy) or weeks. chemoradiation either as primary treatment or postoperative 4. Received chemotherapy or radiation treatment previously treatment of the head and neck. to the head and neck region. 4. Patients whose general health condition according to 5. Patients who used high doses of non-steroidal anti- Karnofsky's scale was above 80% at the start of the treatment. inflammatory drugs. 6. Patients with co-morbid conditions such as poorly controlled diabetes mellitus and hypertension. 7. Patients with existing mental illnesses like schizophrenia or bipolar disorders. 8. Patients with pre-existing ulceration or open wounds in the treatment area. kinetics; tumor vascularity-related hypoxia; growth) may result in a diverse response to the intracellular low-molecular-weight thiol; and cytotoxic effects of ionizing radiation and negate glutathione (GSH); as well as alterations in the the radiotherapeutic outcome.9,10 This would genes responsible for detoxification, drug necessitate a need for predictive methods to detect resistance, apoptosis, angiogenesis, and cell tumor radioresponse prior to treatment or Figure 2. Graphs show correlation between various differences in the pre post biochemical parameters of blood with treatment response. (CR = Complete; PR = partial response) 135 Middle East J Cancer 2018; 9(2): 133-142 Dipika Jayachander et al. Table 2. Age, gender and habits of the complete and partial responders as ascertained 4 weeks after the completion of the treatment. Complete responders Partial/No responders (n = 14) (n = 16) Age (years) 53.71±4.4 58.31±1.9 Gender Male 11 14 Female 32 Alcohol consumption Male 5 11 Female 00 Beedi smokers Male 11 12 Female 00 Tobacco/betel chewers Male 49 Female 31 immediately after a few fractions. In this regard, radiation cell kill and tumor regression during the development and use of molecular techniques the early stage of cancer treatment is important.9 like microarray that predict clinical outcome on With respect to the evaluation of the radiation the basis of gene expression appear to be useful.11 treatment outcome, the extent of tumor regression However, these techniques are either unavailable is ascertained one month after the completion of in developing countries and, if available, are the last treatment and, depending on the decrease extremely expensive. In lieu of these observations, in tumor size, is categorized as either complete the alternatives that are cost effective and confirm response (CR), partial response (PR), or no Figure 3. Graphs show correlation between various differences in the pre post biochemical parameters of saliva with treatment response. (CR = Complete; PR = partial response) 136 Middle East J Cancer 2018; 9(2): 133-142 Saliva as a Predictive Marker for Radiation Response in Head & Neck Cancers Table 3. Tumor site, tumor node, and metastasis (TNM) grading, age, gender, habits, treatment modality, and previous treatment details of the complete and partial responders. Complete responders Partial responders Site Tongue 54 Buccal mucosa 33 Palate 01 Gingivobuccal sulcus 02 Tonsil 32 Vallecula 12 Floor of mouth 11 Salivary gland 11 Primary T1 21 T2 66 T3 43 T4 05 Tx 21 Regional lymph nodes N0 85 N1 23 N2a 33 N2b 33 N2c 01 N3 10 Nx 01 Distant metastases M0 14 16 Treatment modality Prior surgery 76 Radiotherapy only 34 Chemoradiation 11 12 response (NR).7 When compared to most cancers, Materials and Methods the advantage of most head and neck cancers are The study was conducted from October 2011 its easy access for detailed inspection. Another to May 2013 in the Departments of Radiation recently recognized important aspect is that saliva Oncology and Biochemistry at Father Muller is an important body fluid in the diagnosis and Medical College, Mangalore, Karnataka, India. prediction of the severity of various ailments such The subjects comprised histopathologically as oral cancers.12-17 In lieu of these observations, confirmed adult oral cancer patients scheduled to the present study was undertaken to assess the receive curative radiotherapy or chemoradiother- usefulness of salivary amylase (a vital functional apy. Table 1 lists details of the exclusion and enzyme involved in digestion of carbohydrates), inclusion criteria. The Father Muller Charitable GSH (a major cellular antioxidant and factor for Institutional Ethical Committee approved the radioresistance), lipid peroxides (an end product study. of radiation damage on lipids), and lactate During
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