Radiotherapy and Oncology 66 (2003) 71–74

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Short Communication

Influence of haemoglobin Concentration and peripheral muscle pO2 on

tumour oxygenation in advanced head and neck tumours q
Bernardino Clavo a,1,*, Juan L. Pérez b,1, Laura López a,1, Gerardo Suárez a,1, Marta Lloret a,1,
Jesús Morera c,1, David Macı́as b,1, José C. Martı́nez d,1, Maite Santana a, Marı́a A. Hernández a,1,
Francisco Robaina c,1, Martina Günderoth e
a
Department of Radiation Oncology and Research Unit, Dr. Negrı́n Hospital, C/Barranco la Ballena s/n, 35020 Las Palmas (Canary Islands), Spain
b
Department of Medical Physics, Dr. Negrı́n Hospital, Las Palmas (Canary Islands), Spain
c
Department of Functional and Stereotactic Neurosurgery, Dr. Negrı́n Hospital, Las Palmas (Canary Islands), Spain
d
Department of Radiation Oncology, N aS a de la Candelaria Hospital, Tenerife (Canary Islands), Spain
e
Helzel Medical Systems, Kaltenkirchen, Germany
Received 11 November 2001; received in revised form 15 September 2002; accepted 4 October 2002

Abstract
Haemoglobin concentrations and tumour-pO2 were evaluated pre-therapy in 30 patients with head and neck cancers. Anterior tibialis
muscle-pO2 was additionally measured in 16 of these patients. Tumour-pO2 was lower in the most anaemic patients (P ¼ 0:032) and
correlated with muscle-pO2 (r ¼ 0:809, P , 0:001). These results suggest that haemoglobin concentration influences tumour-oxygenation.
q 2002 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Hemoglobin; Hypoxia; Muscle oxygenation; Oxygen measurement; Polarographic probe; Tumor oxygenation

1. Introduction linear correlation between tumour oxygenation and haemo-

Anaemia [3,16] and tumour hypoxia [7] are known
factors for radio-resistance. Studies with polarographic
probes have shown a significant correlation between tumour
oxygenation and local control in head and neck cancer
[2,5,15]. However, it is not clear whether a direct correlation
between anaemia and tumour oxygenation exists. Initial
studies in head and neck tumours [2,4,5,15] or in breast
cancers [18] did not show a correlation between tumour
oxygenation and haemoglobin concentration (Hb).
However, in 1997 Vaupel et al. [19] reported that cervical
cancers tended to have a lower oxygenation in their most
anaemic patients (Hb , 10 g/dl) than in non-anaemic
patients (Hb . 14 g/dl). Höckel et al. [10] described a
correlation between cervical tumour oxygenation and regio-
nal normal subcutaneous fatty tissue oxygenation. In head
and neck cancers, Becker et al. [1] recently described a non-
q
Presented at the XI Congress of the Spanish Association of Radiation
Oncology (AERO), Murcia, Spain, 2001; partially presented at the 38th
Annual Congress of the American Society of Clinical Oncology (ASCO),
Orlando, FL, USA, 2002.
* Corresponding author.
1
Canary Institute for Cancer Research (ICIC).
0167-8140/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved.
doi:10.1016/S0 167-8140(02)00 391-2
globin concentration in their most anaemic patients
(Hb , 11 g/dl). They did not find any correlation between
normal tissue and tumour oxygenation or haemoglobin
concentration in patients with additional measurement of
sternocleidomastoid muscle oxygenation.
In this study, assessment of normal tissue was carried out
in the anterior tibialis muscle. The pre-tibial area is
frequently affected by ischemic disorders and, as such,
was chosen to give some measure of the oxygen-vascular
status of each individual patient. Preliminary data concern-
ing tumour oxygenation in head and neck tumours and
haemoglobin concentration and oxygenation in the anterior
tibialis muscle are presented here.
2. Material and methods
Hb concentrations and tissue oxygenation were measured
prior to therapy in 30 patients with metastases or advanced
tumours in head and neck as part of clinical studies inves-
tigating modulation of hypoxia during radiotherapy: 29
males and one female, mean age 61 ^ 10 years (range:
36–91 years). The studies were approved by the Regional
Ethics Committee and informed consent was obtained from
72 B. Clavo et al. / Radiotherapy and Oncology 66 (2003) 71–74

all patients prior to measurements. Oxygenation of the ante-
rior tibialis muscle was assessed in 16 patients who showed
no clinical signs of lower limb ischemia.
Tumour and muscle oxygenation was measured by a
polarographic probe system ‘pO2 Histograph’ (Eppendorf
AG, Hamburg, Germany). The details of this technique
have been described previously [18]. For each set of
measurements obtained from either tumour and muscle
200 single pO2 values were recorded using at least six differ-
ent electrode tracks. To determine tumour and muscle
oxygenation, median pO2 and the percentage of pO2 values
# 10 mmHg, # 5 mmHg and # 2:5 mmHg were obtained
from the pooled data for each individual.
Haemoglobin concentrations from the same patients were
measured in venous blood samples. Anaemia was defined as
Hb , 13 g/dl in males and Hb , 12 g/dl in females. A sub-
group of four patients with Hb , 11:5 g/dl was defined as
the most anaemic group of patients.
The two-sided unpaired t-test was used to compare
tumour pO2 between anaemic and non-anaemic patients.
Results are expressed as mean ^ SD. Linear correlation
was assessed by Pearson’s r-test. Correlations between
more than two variables were assessed by linear regression.
Differences were considered as significant at the P , 0:05
level.
evident. This was also the case when the corresponding
muscle pO2 and tumour pO2 were compared using percen-
tages of values # 10 mmHg (r ¼ 0:760, P , 0:001), # 5
mmHg (r ¼ 0:700, P ¼ 0:003), and # 2:5 mmHg
(r ¼ 0:845, P , 0:001), respectively (Fig. 2). By linear
correlation analysis there was no significant relationship
between Hb concentration and median tumour oxygenation
(r ¼ 0:421, P ¼ 0:104), or percentages of values # 10, 5 or
2.5 mmHg in these 16 patients. Compared with non-anae-
mic patients, tumour pO2 was lower in the anaemic and in
the most anaemic patients (31.1 ^ 24.8 mmHg, 11.5 ^ 13.3
mmHg (P ¼ 0:080), and 2.7 ^ 2.7 mmHg (P ¼ 0:047),
respectively). The percentage of values # 10 mmHg was
32.5 ^ 32.3% in non-anaemic, 51.8 ^ 27.5% in anaemic
(not significant), and 69.3 ^ 12.1% in the most anaemic
patients (P ¼ 0:053) (Fig. 1).
Using multiple linear regression analysis in the group
with muscle pO2 measurements (n ¼ 16), median tumour
oxygenation tended to correlate (r ¼ 0:887) with median
muscle pO2 (P , 0:001) and Hb concentration (P ¼ 0:014).

3. Results and discussion

Mean tumour pO2 was 25.6 ^ 19.5 mmHg in 19 non-

anaemic patients, 14.3 ^ 13.5 mmHg in 11 anaemic patients
(P ¼ 0:103), and 2.7 ^ 2.7 mmHg in the four most anaemic
patients (P ¼ 0:032). The percentage of values # 10 mmHg
was 33.8 ^ 25.5% in non-anaemic compared with
46.8 ^ 25.1% in anaemic patients (not significant), and
69.3 ^ 12.1% in the most anaemic patients (P ¼ 0:014).
The percentage of values # 5 mmHg was higher in the
sub-group of the most anaemic patients compared with
non-anaemic patients (56 ^ 22.1% and 25.4 ^ 26.6%,
respectively; P ¼ 0:045). Differences in the percentage of
values # 2:5 mmHg were not statistically significant (Fig.
1). Using linear correlation analysis there was a tendency
that for Hb concentration and median tumour pO2
(r ¼ 0:335, P ¼ 0:071) or the percentage of values # 10
mmHg, respectively (r ¼ 20:351, P ¼ 0:057) correlated.
The anterior tibialis muscle oxygenation was measured in
16 patients. Mean muscle pO2 of all patients was
25.3 ^ 13.5 mmHg, thus lying within the range of normal
Fig. 1. Median pO2 (upper panel) and percentage of values # 10 mmHg
muscle oxygenation of healthy volunteers (range: 16.2–27.2 (lower panel) of head and neck tumours and the anterior tibialis muscle.
mmHg) as reported by other authors [9,11]. As described ’Tumour (n ¼ 30)’ shows the analysis of all patients. ’Tumour (n ¼ 16)’
earlier by Jung et al. [11], no dependency of muscle pO2 on and ’Muscle (n ¼ 16)’ show the data in the sub-group of patients under-
haemoglobin concentration and/or age of patients was going simultaneous tumour and muscle pO2 measurements. Tumours in the
most anaemic patients showed lower median pO2 and higher percentage of
found.
values # 10 mmHg than in non-anaemic patients in both groups ‘Tumour
In the 16 patients additionally undergoing muscle pO2 (n ¼ 30)’ and ‘Tumour (n ¼ 16)’ (*P , 0:05). Differences in muscle
measurements, a significant correlation between medians oxygenation were not significant. Error bars show the 95% confidence
of muscle and tumour pO2 (r ¼ 0:809, P , 0:001) was interval.
 B. Clavo et al. / Radiotherapy and Oncology 66 (2003) 71–74
Fig. 2. Correlation of muscle and tumour pO2 in 16 patients with head and
neck tumours (r ¼ 0:809, P , 0:001). p , Non-anaemic patients; W, anae-
mic patients; K, most anaemic patients.
The preliminary data in head and neck cancers described
here suggest a relationship between tumour and anterior
tibialis muscle oxygenation. Due to anatomical and func-
tional abnormalities [17], tumours are considered to have
less self-regulatory properties and may be more sensitive to
the influence of extrinsic factors such as lung, cardiac or
vascular function, the oxygen-carrying capacity of the
blood, and even patient’s smoking habits. Indeed, a trend
towards a lower tumour oxygenation has been seen in
smokers as compared to non-smokers [1] and it is known
that cigarette smoking during radiotherapy decreases local
control probability in head and neck tumours [16]. The
narrow correlation between anterior tibialis muscle pO2
and tumour oxygenation in our study supports these findings
and suggests that factors modulating oxygenation capacity
in this sensitive muscle could also influence tumour oxyge-
nation. Höckel et al. [10] described a correlation between
cervical tumour oxygenation and regional normal subcuta-
neous fatty tissue oxygenation. However, other studies have
failed to see such a correlation between tumour oxygenation
and regional normal tissue oxygenation, as was the case in
the study of Becker et al. [1] who performed oxygenation
measurements in head and neck tumours and sternocleido-
mastoid muscle. The reasons for these contradictory find-
ings from different studies remains unexplained. However,
measurements may be influenced by the self-regulating
capacity of the tissues investigated. For example, the pre-
tibial area is one of the most frequently affected by ischemic
disorders and, as such, the anterior tibialis muscle may be a
normal tissue which is more sensitive to structural and func-
tional changes in tumour patients than other normal tissues.
Such factors may have some influence on tumour oxygena-
tion.
73
The aim of this study was to assess to what extent Hb
concentrations might influence oxygenation in head and
neck tumours. The best curve fit was a non-linear regression
(’S’ model: r ¼ 0:420, P ¼ 0:029), which is in accordance
with theoretical models describing the relationship between
Hb concentrations and tumour oxygenation [8] as well as
with other clinical data [1]. This type of correlation could
explain why several studies did not find a correlation
between Hb concentration and tumour pO2. However, we
have shown the linear correlation for the subsequent multi-
ple linear regression study. This analysis showed that the
relationship between Hb and tumour pO2 became more
significant when it was analysed with the effect of a muscle
pO2 and tumour pO2 association.
These findings may be of clinical relevance as Hb
concentrations can be easily determined and modulated by
blood transfusion or erythropoietin (rhEPO) administration.
It is generally accepted that tumours with extended hypoxic
or even anoxic areas are less sensitive to sparsely ionizing
radiation thus having a poorer prognosis with respect to
therapy outcome [7]. Clinical studies and meta-analyses
[6,14] investigating the relationship between anaemia and
response to radiotherapy found that low Hb is an indicator of
poor prognosis. Recent studies showed that the administra-
tion of rhEPO is a safe concept for the correction of anaemia
in cancer patients [13,20]. In animal models, tumour oxyge-
nation in the anaemia group significantly improved after
rhEPO. However, tumour pO2 did not recover completely
following the restoration of normal Hb levels, and the effect
of rhEPO was less pronounced in larger tumours [12].
Further investigations are therefore necessary to show the
effectiveness of blood transfusion or rhEPO in increasing
both tumour oxygenation and subsequently radiosensitivity
in our patients with head and neck cancers, and to evaluate
other parameters which might have an influence on tumour
oxygenation even when haemoglobin levels have been
corrected to the normal level. The association between
tumour and tibialis anterior muscle oxygenation needs
further validation.
Acknowledgements
We acknowledge the assistance of Dr. Debra Kelleher
(Institute of Physiology, University of Mainz, Germany)
in the preparation of the manuscript. The ’Eppendorf pO2
Histograph 6650’ device was purchased by a grant
(#FUNCIS PI: 31-98) from the Health and Research Foun-
dation of the Autonomous Government of the Canary
Islands (Spain).
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