Risk factors for late dysphagia after (chemo)radiotherapy for head and neck cancer: A systematic methodological review

Beyond complete remission: A comparative analysis of long-term laryngeal function in patients with hypopharyngeal and laryngeal cancer following radiotherapy and concurrent chemoradiation

BACKGROUND

This study evaluates functional larynx preservation in patients with hypopharyngeal cancer (HPC) and laryngeal cancer (LC) who achieved complete remission following radiotherapy (RT) or concurrent chemoradiation (CCRT).

METHODS

HPC and LC patients treated with RT/CCRT from 1999 to 2017 were retrospectively analyzed. Severe late dysphagia and tracheostomy cases were assessed to determine laryngeal function. Long-term preservation rate of functional larynx and associated factors were evaluated.

RESULTS

Of 152 patients (55 HPC, 97 LC), nine developed severe dysphagia, occurring on average 58.2 months post-treatment. HPC and cervical node metastasis significantly increased the risk of laryngeal function impairment (p < 0.001 and p = 0.014, respectively), presenting a continued decline in functional larynx preservation rate beyond 10 years.

CONCLUSIONS

Patients with HPC and cervical node metastasis demonstrate an increased risk for long-term laryngeal function impairment despite successful oncologic outcomes. This risk extends beyond 10 years, underscoring the need for prolonged monitoring and comprehensive support.

Oral diet management for carcinoma at the base of tongue with radiotherapy and chemotherapy associated dysphagia: a case report

Introduction

Tongue cancer is one of the common malignancy of the head and neck, and directly impacts chewing, swallowing, and other eating activities. Based on the evidence-based guidelines and clinical management, this paper presents nutrition management experience of a patient with tongue cancer who had a dysphagia and feeding reflux while undergoing radiotherapy and chemotherapy.

Methods

Nutritional risk screening and comprehensive nutritional assessment were performed based on the patient's medical history, and personalized nutritional programs were developed under the guidance of the clinical pharmaceutical consensus of parenteral nutrition and nutritional treatment guidelines for patients with tumors during radiotherapy. For the management of oral feeding, the patient's swallowing function was evaluated to manage oral feeding. Thickening powders were used to improve the consistency of the patient's food, which successfully achieved oral feeding of the patient.

Results

The patient finally ate five meals a day by mouth, and energy requirements were met using industrialized nutritional supplements, and homogenized food was added in between the meals. The energy provided by enteral nutrition can reached approximately 60-75%. The patient's weight and albumin levels had increased significantly at the time of discharge.

Discussion

The nutritional management of patients with dysphagia should be jointly managed by clinicians, nurses, nutritionists, and family members to effectively improve the quality of life (QOL) and nutritional status of patients. To ensure adequate nutritional supply, appropriate swallowing training may delay the deterioration of the chewing function and improve the eating experience of such patients.

Impact of Dynamic Tongue Reconstruction on Sequential Changes of Swallowing Function in Patients Undergoing Total or Near-Total Glossectomy

PURPOSE

This study aimed to compare the effects of motor-innervated free flap on sequential changes of swallowing function in patients undergoing total or near-total glossectomy with laryngeal preservation.

MATERIALS AND METHODS

The medical charts of 21 patients who underwent tongue reconstruction after total or near-total glossectomy between April 2015 and December 2020 were retrospectively reviewed. Patients were divided into groups by reconstruction type: conventional, reconstruction using an anterolateral thigh free flap (n = 11), and dynamic, reconstruction using an anterolateral thigh with innervated vastus lateralis flap (n = 10). Demographics, surgical details, and survival outcomes were investigated. A videofluoroscopic penetration-aspiration scale and functional outcome swallowing scale were analyzed according to postoperative time courses, classified as within 6 months, 6 to 12 months, and after 12 months postoperative. A time-to-event analysis was performed for gastrostomy tube status.

RESULTS

The dynamic group showed improved swallowing outcomes at 6 to 12 months postoperative (dynamic vs conventional group, penetration-aspiration scale: 3 ± 1.51 vs 6 ± 1.63, P = 0.024; functional outcome swallowing scale: 1.89 ± 1.36 vs 4 ± 1.41, P = 0.009). In the multivariate analysis, the dynamic group showed a decreased probability of decompensated swallowing function at 6 to 12 months postoperative (odds ratio, 0.062; 95% confidence interval, 0.004-1.084; P = 0.057). A time-to-event analysis revealed no significant difference in gastrostomy tube status between the dynamic and the conventional group.

CONCLUSIONS

Considering higher mortality in patients subjected to total or near-total glossectomy, dynamic reconstruction with motor-innervated free flap is worth to perform in terms of enhancing the swallowing function within 1-year postoperative period, thereby improving the quality of life.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

OBJECTIVE

To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.

METHODS

Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.

RESULTS

The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.

CONCLUSION

Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Intra and interobserver agreement of the Dynamic Imaging Grade of Swallowing Toxicity Scale (DIGEST) in fiberoptic endoscopic evaluation of swallowing (FEES): the importance of observer-tailored training

PURPOSE

The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) is a scale to quantify the severity of pharyngeal dysphagia in head and neck cancer (HNC) patients. This study (1) described the training process of the observers for DIGEST in fiberoptic endoscopic evaluation of swallowing (FEES), (2) determined observer agreement on the DIGEST in FEES, (3) explored the effect of bolus consistency on observer agreement, and 4) explored criterion validity of the DIGEST in FEES.

METHODS

Twenty-seven dysphagic HNC patients were enrolled. Two observers completed a training program for DIGEST in FEES. Observer agreement on the Penetration-Aspiration Scale (PAS), percentage of pharyngeal residue (PPR), and DIGEST grades was determined using linearly weighted Cohen's kappa coefficient (κ).

RESULTS

Due to insufficient observer agreement after the first measurement attempt, additional training was organized using an elaborated manual with descriptions of the visuoperceptual variables, thereby improving observer agreement. Intraobserver agreement was almost perfect on the PAS (κ = 0.86-0.88) and PPR (κ = 0.84-0.86). Interobserver agreement was substantial on the PAS (κ = 0.78), almost perfect on the PPR (κ = 0.82), substantial on the safety grade (κ = 0.64), almost perfect on the efficiency grade (κ = 0.85), and substantial on the summary grade (κ = 0.71). Bolus consistency had an effect on observer agreement. A significant correlation was found between DIGEST efficiency grade and EAT-10.

CONCLUSION

The DIGEST showed to be a reproducible measurement for FEES in terms of observer agreement. However, agreement between novice observers on the DIGEST was only reached after specific observer-tailored training. Observer agreement should be analyzed by taking bolus consistency into account during training, as this might affect the interpretation of the outcome. A manual with well-defined descriptions can optimize the reproducibility of DIGEST measurements.

Research progress in the risk factors and screening assessment of dysphagia in the elderly

With the aging of the population, the incidence of dysphagia has gradually increased and become a major clinical and public health issue. Early screening of dysphagia in high-risk populations is crucial to identify the risk factors of dysphagia and carry out effective interventions and health management in advance. In this study, the current epidemiology, hazards, risk factors, preventive, and therapeutic measures of dysphagia were comprehensively reviewed, and a literature review of screening instruments commonly used globally was conducted, focusing on their intended populations, main indicators, descriptions, and characteristics. According to analysis and research in the current study, previous studies of dysphagia were predominantly conducted in inpatients, and there are few investigations and screenings on the incidence and influencing factors of dysphagia in the community-dwelling elderly and of dysphagia developing in the natural aging process. Moreover, there are no unified, simple, economical, practical, safe, and easy-to-administer screening tools and evaluation standards for dysphagia in the elderly. It is imperative to focus on dysphagia in the community-dwelling elderly, develop unified screening and assessment tools, and establish an early warning model of risks and a dietary structure model for dysphagia in the community-dwelling elderly.

Clinical Value Screening, Prognostic Significance, and Key Gene Identification of TrkB in Laryngeal Carcinoma

Purpose

Using human gene chip expression profiling technology to screen out downstream genes related to TrkB regulation in laryngeal cancer cells.

Methods

Using the Hep-2 TrkB shRNA cell line, divide it into an experimental group (shNTRK2) and a control group (PLKO1), and use the human gene expression microarray to screen out the differential genes. Then, select 10 upregulated genes and 10 downregulated genes from the differential genes, and use RT-PCR to verify whether the screening results of human gene expression microarray profiles are reliable. Use GO, KEGG, and miRNA enrichment analyses, PPI network diagram, etc., to analyze the differential genes and further screen out the key genes.

Results

A total of 318 differential genes (87 upregulated genes and 231 downregulated genes) were screened in laryngeal cancer cells. Use RT-PCR for the 10 upregulated differential genes (DMKN, FHL1, FOXN4, GGNBP1, HOXB9, ABCB1, TNFAI, RGS2, LINC01133, and FGG) and 10 downregulated differential genes (CHI3L1, FMOD, IGFBP1, IRF5, SPARC, NPAS4, TRPS1, TRAP, COL8A1, and DNER), and the results are consistent with the chip results, confirming the accuracy of the chip results; GO analysis results show that the downstream differential genes (DEGs) regulated by TrkB are mainly involved in biological processes such as retinol metabolic process, diterpenoid metabolic process, and regulation of cell-substrate adhesion. DEGs mainly affect cytoskeletal protein binding, serotonin-activated cation-selective channel activity, and sphingosine molecular functions. DEGs are mainly enriched in the cell periphery, secretory granule, cytoplasmic membrane-bounded vesicle lumen, blood microparticle, and other molecular components. The results of disease enrichment analysis show that the downstream differential genes regulated by TrkB are mainly involved in atypical hemolytic uremic syndrome, hematologic disease, meningococcal disease, lung cancer, susceptibility, asthma, and other diseases. The PPI network diagram results showed 7 hub genes, and then, we used GO analysis and KEGG enrichment analysis to see the biological process, cell component, molecular functions, and biological pathways.

Conclusion

Gene chip technology was used to screen out the differential genes of TrkB epigenetic modification in the Hep-2 cell line, and seven key genes (ALDH1A1, SDR16C5, PIK3R1, PLCG2, IL2RG, PIK3CD, and SPARC) were further screened using bioinformatics technology.

Sequential Evaluation of Swallowing Function During Chemoradiotherapy for Head and Neck Cancer

Background

Many studies have addressed chronic dysphagia resulting from chemoradiotherapy for head and neck cancer (HNC) because of its severity, but changes in the swallowing function during chemoradiotherapy has been rarely reported. This study aimed to elucidate the changes in the swallowing function during chemoradiotherapy for HNC.

Methods

From April 2018 to July 2020, 20 patients who underwent definitive or postoperative chemoradiotherapy at our hospital for head and neck squamous cell carcinoma were evaluated by flexible endoscopy with the Hyodo scoring system for swallowing, the Penetration-Aspiration Scale (PAS), and the Functional Outcomes Swallowing Scale (FOSS).

Results

Assessments at the start of treatment, at 40 Gy, and at the end of treatment yielded these mean values: Hyodo score-0.39, 1.22, and 2.56; PAS-1.00, 1.05, and 1.5; FOSS-0.2, 0.55, and 1.1, respectively. The Dunn multiple comparison test was used for analysis to determine significance (P < 0.05). The Hyodo score and FOSS were significantly increased at the end of treatment versus initial evaluation; however, score was maintained at a tolerable level for oral intake. PAS did not show a significant increase.

Conclusion

In conclusion, changes in the swallowing function during chemoradiotherapy for HNC were mild, and swallowing function was maintained at a tolerable level for oral intake.

Clinical Swallowing Profile Change in HNC Patients Treated with C/RT

OBJECTIVES/HYPOTHESIS

To demonstrate utility of the Mann Assessment of Swallowing Ability-Cancer (MASA-C) to describe change in swallowing ability in a cohort of HNC patients from pre-C/RT to post-C/RT to follow up at 3 months post-C/RT. An exploratory analysis compared patients treated with radiotherapy (RT) only to patients treated with chemoradiation (CRT).

STUDY DESIGN

Prospective Cohort.

METHODS

The MASA-C and Functional Oral Intake Scale (FOIS) were completed on 85 HNC patients within the first 5 days of CRT initiation, at the completion of C/RT (6 weeks), and 3 months after completion of C/RT. MASA-C total scores and clinical profiles were used to describe change in swallowing performance at each time point.

RESULTS

MASA-C and FOIS scores were significantly lower at 6 weeks and 3 months compared to baseline. Patients treated with CRT demonstrated more frequent and more severe dysphagia. Post C/RT items demonstrating the most deterioration included taste, diet level, oral mucosa, saliva, weight loss, and pharyngeal functions. Significant recovery was observed between 6 weeks and 3 months on both the MASA-C and FOIS. MASA-C items revealing the greatest recovery included taste, diet level, oral mucosa, tongue movement, weight loss, oral transit, voice, and pharyngeal phase. Few significant differences were noted between RT and CRT cases at 3 months.

CONCLUSIONS

Swallowing functions deteriorate significantly following C/RT with incomplete recovery at 3 months. Few differences were noted between RT and CRT treated patients at 3 months. Clinical profiling with the MASA-C provides a standard, simple method to document swallow function change over time in these patients.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:E1873-E1880, 2021.

Swallowing exercises for head and neck cancer patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Extensive surgery and chemo/radiation therapy (C/RT) to manage head and neck cancer (HNC) patients affects their ability to swallow food and liquids, risk of aspiration and greatly influences their quality of life (QOL).

OBJECTIVES

Ascertain the effectiveness of swallowing exercises on improving swallowing function, performance status, mouth opening, risk of aspiration/penetration and QOL in HNC patients.

DESIGN

Systematic review and meta-analysis of randomized controlled trials DATA SOURCES: PubMed, Ovid-Medline, Embase, Cochrane Library, CINAHL and Web of Science and included all available RCTs.

REVIEW METHODS

We followed the PRISMA guidelines and standard methods for conducting a systematic review and meta-analysis. Comprehensive Meta-analysis 3.0 using the random effects model was used for data analysis.

RESULTS

In total, 19 RCTs with 1100 participants were identified and included in the current review. Swallowing exercises had significant small effect on swallowing function 0.33 (95%CI = 0.00-0.65) and moderate effect on mouth opening 0.60 (95%CI = 0.21-0.99) immediately after intervention and small effect at 6-month follow-up 0.46 (95%CI = 0.11-0.81). However, non-significant effects were observed on risk of aspiration/penetration, performance status and all domains of QOL.

CONCLUSION

Swallowing exercises demonstrated effectiveness in improving swallowing function and mouth opening in HNC patients undergoing multimodal treatment. This is the first comprehensive systematic review and meta-analysis of RCTs to assess the effect of swallowing exercises in HNC patients undergoing multimodal treatment. Nurses can play an important role in assisting the delivery of oropharyngeal swallowing exercises including jaw exercises, tongue exercises and swallowing maneuvers with assistance and guidance from speech pathologists to help improve HNC complications and QOL for HNC survivors.

[Concurrent chemoradiotherapy for head neck cancers. Should organs at risk dose constraints be revisited ?]

Concurrent chemoradiotherapy improves the outcome of locally advanced head and neck cancers and the current reference chemotherapy is cisplatin. These results are obtained at the cost of increased toxicities. To limit the risk of toxicity, organ at riskdose constraints have been established starting with 2D radiotherapy, then 3D radiotherapy and intensity-modulated radiotherapy. Regarding grade ≥3 acute toxicities, the scientific literature attests that concurrent chemoradiotherapy significantly increases risks of mucositis and dysphagia. Constraints applied to the oral mucosa volume excluding the planning target volume, the pharyngeal constrictor muscles and the larynx limit this adverse impact. Regarding late toxicity, concurrent chemoradiotherapy increases significantly the risk of postoperative neck fibrosis and hearing loss. However, for some organs at risk, concurrent chemotherapy appears to increase late radiation induced effect, even though the results are less marked (brachial plexus, mandible, pharyngeal constrictor muscles, parotid gland). This additional adverse impact of concomitant chemotherapy may be notable only when organs at risk receive less than their usual dose thresholds and this would be vanished when those thresholds are exceeded as seems to be the situation for the parotid glands. Until the availability of more robust data, it seems appropriate to apply the principle of delivering dose to organs at risk as low as reasonably achievable.

Individualized prediction of late-onset dysphagia in head and neck cancer survivors

BACKGROUND

Limited data exist regarding which head and head and neck cancer (HNC) survivors will suffer from long-term dysphagia.

METHODS

From a population-based cohort of 1901 Utah residents with HNC and ≥3 years follow-up, we determined hazard ratio for dysphagia, aspiration pneumonia, or gastrostomy associated with various risk factors. We tested prediction models with combinations of factors and then assessed discrimination of our final model.

RESULTS

Cancer site in the hypopharynx, advanced tumor classification, chemoradiation, preexisting dysphagia, stroke, dementia, esophagitis, esophageal spasm, esophageal stricture, gastroesophageal reflux, thrush, or chronic obstructive pulmonary disease were associated with increased risk of long-term dysphagia. Our final prediction tool gives personalized risk calculation for diagnosis of dysphagia, aspiration pneumonia, or gastrostomy tube placement at 5, 10, and 15 years after HNC based on 18 factors.

CONCLUSION

We developed a clinically useful risk prediction tool to identify HNC survivors most at risk for dysphagia.

Organ Function Preservation Failure after (Chemo)Radiotherapy in Head and Neck Cancer: A Retrospective Cohort Analysis

Objective

The aim of the current study was to determine the incidence of organ function preservation failure (OFPF) in patients with head and neck squamous cell carcinoma (HNSCC) treated by (chemo)radiotherapy and to identify its risk factors.

Study Design

Retrospective cohort analysis.

Setting

Tertiary cancer care center.

Subjects and Methods

A single-center retrospective cohort analysis was done (n = 703) in which OFPF after (chemo)radiotherapy was assessed. OFPF was defined as local failure or pure functional failure in the absence of local failure because of major surgical intervention (total laryngectomy, commando resection, permanent tracheostomy) or feeding tube dependence >2 years.

Results

OFPF occurred in 153 patients (21.8%). Reasons for OFPF were local failure in 103 patients (14.6%) and functional failure in 50 patients (7.2%). Evidence of functional failure included need for total laryngectomy (n = 9, 1.3%), commando resection (n = 2, 0.3%), permanent tracheostomy (n = 16, 2.3%), and/or long-term feeding tube for functional reasons (n = 23, 3.3%). In a Cox proportional hazards model, OFPF was worse for patients with T4 tumors (hazard ratio [HR] <0.5 and P < .001 for all other stages), for laryngeal vs oropharyngeal cancer (HR, 1.83; 95% confidence interval [CI], 1.20-2.79, P = .005, hypopharyngeal not significant), and for smokers (HR, 1.68; 95% CI, 1.10-2.56, P = .015). Exploratory multivariate analysis by tumor site showed that T4 tumor and pretreatment tracheostomy were the strongest predictive factors for OFPF in laryngeal and hypopharyngeal carcinoma while T4 tumor and smoking were predictive for poor OFPF in oropharyngeal carcinoma.

Conclusion

This work shows a detrimental effect of smoking on functional outcomes after (chemo-)radiotherapy for HNSCC. Moreover, T4 tumor, laryngeal subsite, and pretreatment tracheostomy are strong predictors of OFPF.

Association Between Pharyngeal Pooling and Aspiration Using Fiberoptic Endoscopic Evaluation of Swallowing in Head and Neck Cancer Patients with Dysphagia

Postswallow pharyngeal pooling may be a risk factor for tracheal aspiration. However, limited literature shows the potential association between pharyngeal pooling and aspiration in head and neck cancer (HNC) patients. This study investigates the relationship between postswallow pharyngeal pooling and aspiration in HNC patients with oropharyngeal dysphagia. Furthermore, the effects of tumor stage, tumor location, and cancer treatment on aspiration were examined. Ninety dysphagic HNC patients underwent a standardized fiberoptic endoscopic evaluation of swallowing (FEES) using thin and thick liquid boluses. For each swallow, three visuoperceptual ordinal variables were scored: postswallow vallecular pooling, postswallow pyriform sinus pooling, and aspiration. Logistic regression analyses with correction for the location of pooling, tumor stage, tumor location, and cancer treatment were performed to explore the association between pooling and aspiration. No significant association was found between postswallow vallecular pooling and aspiration for thin liquid. However, severe versus mild-to-moderate postswallow vallecular pooling of thick liquid was significantly associated to aspiration. Similar results were seen after correction for the presence of pyriform sinus pooling, tumor stage, tumor location, or type of cancer treatment. This study showed a significant association between severe postswallow pyriform sinus pooling of thick liquid and aspiration, independent of the presence of vallecular pooling, tumor stage, tumor location, or cancer treatment. Concluding, location (valleculae versus pyriform sinuses), liquid bolus consistency (thin versus thick liquid), and amount of postswallow pharyngeal pooling (no pooling, mild/moderate pooling, severe pooling) have an influence on the probability of aspiration in dysphagic HNC patients, and they should be carefully considered during FEES, even in the absence of aspiration during the examination.

Highlights from the Second International Symposium on HPV infection in head and neck cancer

The Second International Symposium on HPV Infection in Head and Neck Cancer was held on 3rd-4th November 2016 in Leipzig, Germany. The meeting brought together researchers and clinicians to share the latest knowledge on HPV infection in head and neck cancer and to join active and constructive scientific discussions. This report summarizes the major themes discussed during the symposium.

Effectiveness of primary surgery versus primary radiotherapy on unknown primary head and neck squamous cell carcinoma: a systematic review protocol

REVIEW QUESTION

The review question is: what is the effectiveness of primary surgery versus primary radiotherapy on disease-free survival and quality of life in adults with an unknown primary, head and neck squamous cell carcinoma?

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.