Correlation between plan quality improvements and reduced acute dysphagia and xerostomia in the definitive treatment of oropharyngeal squamous cell carcinoma

Evaluation of recurrence, mortality and treatment complications of oral squamous cell carcinoma in public health centers in Shiraz during 2010 to 2020

INTRODUCTION

Oral Squamous cell Carcinoma (OSCC) is the most common oral cancer and is treated with surgery, radiotherapy and chemotherapy. Various complications of treatment include xerostomia, mucositis, and trismus, which affect patients' quality of life. The aim of this study is to evaluate the mortality, recurrence rate and prevalence of oral complications in treated patients.

METHOD AND MATERIALS

This cross-sectional study reviewed 326 cases of patients with OSCC who were referred to public health centers in Shiraz (Khalili Hospital and Dental School) from 2010 to 2020. All patients were contacted, and the survivors were called and examined by an oral physician. A medical record was created for them, including demographic information, location of the lesion, type of treatment, history of recurrence, metastasis and oral complications.

RESULTS

53.5% of patients were male and 46.5% were female. The mean age of patients was 58.68 years. Mortality and recurrence rate was respectively 49.8% and 17.8%. The most common location of the lesion was tongue (64%). Surgery was done for all patients. 97.4% of patients complained of xerostomia, 46.2% of mucositis and 44.3% of trismus.

CONCLUSION

The most common complications of treatment are xerostomia, mucositis, and trismus, respectively. Frequent and regular follow-ups and supportive therapies reduce these complications and improve patients' quality of life.

Skin/mucosa avoidance radiotherapy (SMART) versus conventional volumetric arc-based radiotherapy (VMAT) for the treatment of head and neck cancer: Dosimetric feasibility study

BACKGROUND

Intensity modulated radiotherapy (IMRT) for head and neck cancer has led to a reduction in radiotherapy doses to normal tissues, like the salivary glands, while maintaining high rates of local control. Oral mucosal and skin toxicity is still a major source of treatment-related morbidity, occurring in most patients.

PURPOSE

We conducted a dosimetric feasibility study with the goal of creating a methodology that could theoretically reduce the dose of radiation to skin and oral mucosa, while maintaining comparable avoidance of other organs at risk, and planning target volume (PTV) coverage.

METHODS

The clinical plans of patients treated previously were replanned using coplanar VMAT arcs on a TrueBeam STx using the photon optimizer (PO) version 15.6 and the Acuros XB dose calculation algorithm. Comparisons were made between three methodologies: "Conventional," "Skin Sparing" and a skin/mucosa avoiding ("SMART") technique, with dose metrics being compared using analysis of variance, with a Bonferroni correction to account for multiple pairwise comparisons. The maximum grade of mucositis and radiation dermatitis during treatment was correlated to different dose-volume metrics to predict what could be clinically meaningful.

RESULTS

Sixteen patients met the study criteria and were replanned using the skin sparing and SMART techniques. Maximum doses to the skin sparing structure were reduced from 64.2 Gy to 56.6 and 55.9 Gy, in the skin sparing and SMART plans (p < 0.0001), and mean doses reduced from 26.7 Gy to 20.0 and 20.2 Gy, respectively (p < 0.0001). Maximum doses to the oral cavity structure were not reduced by either technique, however mean dose to the oral cavity structure was reduced from 39.03 Gy to 33.5 Gy by the SMART technique (p < 0.0001). There was a slight reduction in PTV_High coverage by the V95% in the SMART plans (99.52% vs. 98.79%, p = 0.0073), and a similar slight reduction in PTV_Low coverage by the V95% by both the skin sparing and SMART plans (99.74% vs. 97.89% vs. 97.42%, p < 0.0001). Maximum doses to organs at risk were not statistically different between techniques. Dose to oral cavity and maximum grade experienced during radiotherapy correlated. The Spearman correlation coefficient for dose to 20%, 50%, and 80% of the volume of oral cavity was 0.5 (p = 0.048), 0.64 (p = 0.007), and 0.62 (p = 0.010), respectively. Skin toxicity grade was only found to be correlated with the D20% of the skin sparing structure (Spearman correlation coefficient of 0.58, p = 0.0177).

CONCLUSION

The SMART technique appears to be able to reduce maximum and mean skin dose, as well as mean oral cavity doses, while only slightly reducing PTV coverage, with acceptable OAR doses. We feel the improvements warrant investigation in a clinical trial.

Quality of Life and Patient-Reported Outcomes Following Proton Therapy for Oropharyngeal Carcinoma: A Systematic Review

BACKGROUND

Complex anatomy surrounding the oropharynx makes proton therapy (PT), especially intensity-modulated PT (IMPT), a potentially attractive option due to its ability to reduce the volume of irradiated healthy tissues. Dosimetric improvement may not translate to clinically relevant benefits. As outcome data are emerging, we aimed to evaluate the evidence of the quality of life (QOL) and patient-reported outcomes (PROs) following PT for oropharyngeal carcinoma (OC).

MATERIALS AND METHODS

We searched PubMed and Scopus electronic databases (date: 15 February 2023) to identify original studies on QOL and PROs following PT for OC. We employed a fluid strategy in the search strategy by tracking citations of the initially selected studies. Reports were extracted for information on demographics, main results, and clinical and dose factor correlates. Quality assessment was performed using the NIH's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The PRISMA guidelines were followed in the preparation of this report.

RESULTS

Seven reports were selected, including one from a recently published paper captured from citation tracking. Five compared PT and photon-based therapy, although none were randomized controlled trials. Most endpoints with significant differences favored PT, including xerostomia, cough, need for nutritional supplements, dysgeusia, food taste, appetite, and general symptoms. However, some endpoints favored photon-based therapy (sexual symptoms) or showed no significant difference (e.g., fatigue, pain, sleep, mouth sores). The PROs and QOL improve following PT but do not appear to return to baseline.

CONCLUSION

Evidence suggests that PT causes less QOL and PRO deterioration than photon-based therapy. Biases due to the non-randomized study design remain obstacles to a firm conclusion. Whether or not PT is cost-effective should be the subject of further investigation.

Diagnosis, Prevention, and Treatment of Radiotherapy-Induced Xerostomia: A Review

In patients with head and neck cancer, irradiation (IR)-sensitive salivary gland (SG) tissue is highly prone to damage during radiotherapy (RT). This leads to SG hypofunction and xerostomia. Xerostomia is defined as the subjective complaint of dry mouth, which can cause other symptoms and adversely affect the quality of life. In recent years, diagnostic techniques have constantly improved with the emergence of more reliable and valid questionnaires as well as more accurate equipment for saliva flow rate measurement and imaging methods. Preventive measures such as the antioxidant MitoTEMPO, botulinum toxin (BoNT), and growth factors have been successfully applied in animal experiments, resulting in positive outcomes. Interventions, such as the new delivery methods of pilocarpine, edible saliva substitutes, acupuncture and electrical stimulation, gene transfer, and stem cell transplantation, have shown potential to alleviate or restore xerostomia in patients. The review summarizes the existing and new diagnostic methods for xerostomia, along with current and potential strategies for reducing IR-induced damage to SG function. We also aim to provide guidance on the advantages and disadvantages of the diagnostic methods. Additionally, most prevention and treatment methods remain in the stage of animal experiments, suggesting a need for further clinical research, among which we believe that antioxidants, gene transfer, and stem cell transplantation have broad prospects.

Dosimetric Benefits of Omitting Primary Tumor Beds in Postoperative Radiotherapy After Transoral Robotic Surgery Using the Auto-Planning Technique

Introduction: It has been suggested that post-transoral robotic surgery (post-TORS) radiotherapy (RT) might reduce the dose to organs at risk (OARs) adjacent to the primary tumor bed; however, the evidence supporting this has yet to be sufficient. This study examined the radiation dose reduction to OARs by omitting the primary tumor bed through the use of an Auto-Planning (AP)-based workflow.

Methods: Twelve patients were identified who underwent post-TORS RT to the primary tumor bed and the unilateral/bilateral neck lymph nodes. In each patient, two treatment plans were designed: a Comprehensive (Comp)-plan treating the original planning target volume (PTV) including both the primary tumor bed and the lymph nodes, and a Neck-plan treating only the lymph nodes and omitting the primary tumor bed. Both plans were optimized using AP to ensure plan quality consistency. We compared the doses received by 95% of the primary tumor beds and lymph nodes (D95%) and our institutional dose constraints for the OARs between the Comp- and Neck-plans. Statistical analysis was performed using R Statistical Software (R Foundation for Statistical Computing, Vienna, Austria) with a two-tailed paired Wilcoxon signed-rank test.

Results: All plans met target dose coverage requirements with at least 95% of the PTVs covered with the corresponding prescription doses. The primary tumor bed in the Neck-plans was spared with a significantly lower mean D95% (25.9 Gy vs. 60.0 Gy; p < 0.01; Wilcoxon test). The mean dose to the oral cavity (20.9 Gy vs. 28.1 Gy; p < 0.01) and the supraglottis (36.9 Gy vs. 28.2 Gy; p < 0.01) was significantly lower in the Neck-plans.

Conclusion: This study suggests that sparing the primary tumor bed during post-TORS RT offers dosimetric benefits to nearby OARs with significant dose reductions to the oral cavity and supraglottis. Further study of the clinical risks and benefits afforded by this strategy is needed.

A nomogram for predicting late radiation-induced xerostomia among locoregionally advanced nasopharyngeal carcinoma in intensity modulated radiation therapy era

Background: Dry mouth sensation cannot be improved completely even though parotids are spared correctly. Our purpose is to develop a nomogram to predict the moderate-to-severe late radiation xerostomia for patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC) in intensity modulated radiation therapy (IMRT) / volumetric modulated arc radiotherapy (VMAT) era.

Methods: A dataset of 311 patients was retrospectively collected between January 2010 and February 2013. The binary logistic regression was to estimate each factor’s prognostic value for development of moderate-to-severe patient-reported xerostomia at least 2 years (Xer2y) after completion of radiotherapy. Therefore, we can develop a nomogram according to binary logistic regression coefficients. This novel model was validated by bootstrapping analyses.

Results: Contralateral Parotid mean dose (coMD<24.4Gy), VMAT (yes), and platinum-based concurrent chemoradiotherapy (no) were significantly related to patient-reported xerostomia at least 2 years (Xer2y) (all p < 0.001), and were included in the nomogram. Receiver operating characteristic (ROC) analysis revealed AUC (area under the ROC curve) with the value of 0.811 (0.710-0.912) of the nomogram, which was significantly higher than coMD 0.698 (0.560-0.840) from QUANTEC2010 (p<0.001). Calibration plots illustrated that the predicted Xer2y was close to the actual observation, and decision curve analyses (DCA) indicated valid positive net benefits.

Conclusion: We developed a feasible nomogram to predict patient-rated Xer2y based on comprehensive individual data in patients with LA-NPC in the real world. The proposed model is able to facilitate the development of treatment plan and quality of life improvement.

A Comparison of Behavior of Transitional-State Foods Under Varying Oral Conditions

Transitional foods are under-utilized in the adult population as they may provide an opportunity to optimize eating pleasure and nutrition for individuals on a modified texture diet. Yet, little is known about the behavioral properties of transitional foods and no research to date has explored the dissolution of known transitional foods in adults. This study aimed to understand the extent of dissolution of five transitional snacks items in relationship to time, tongue pressure, and amount of saliva. Thirty individuals ages 50 to 88 participated in this study (10 with diagnosed xerostomia). The foods tested included shrimp chips, Baby Mum Mums, the EAT bar, and the Savorease cracker with and without dip. Each test food was placed in the mouth for 5 s or 12 s with or without tongue pressure and then expectorated. Benchtop preparation via the International Dysphagia Diet Standardisation Initiative (IDDSI) protocol was also completed. An IDDSI fork pressure test was then performed on all samples. Significant differences between snacks were found in degree of dissolution, with Savorease crackers dissolving more consistently than all others and Baby Mum Mums dissolving least frequently than all others. Tongue pressure positively influenced the dissolution of some foods, particularly those with decreased rates of dissolution. Differences also existed between testing conditions. Overall, there was a wide variability in degree and speed of dissolution across different transitional foods and testing methods. These findings support the need for individual testing to explore post-oral processing consistency when determining the clinical utility of transitional foods.