Late effects of radiation therapy in the head and neck region

Long-term Effectiveness and Safety of Mesenchymal Stromal Cell Therapy for Radiation-Induced Hyposalivation in Head and Neck Cancer Survivors: A Randomized Phase II Trial

PURPOSE

The long-term effect of adipose-derived mesenchymal stromal cells (ASC) on restoring radiation-induced salivary gland hypofunction in patients with previous head and neck cancer has not been validated in larger settings.

PATIENTS AND METHODS

The study was a 12-month follow-up of a randomized trial, including patients with hyposalivation. Patients were randomized to receive allogeneic ASC or placebo in the submandibular glands. The primary endpoint was unstimulated whole saliva (UWS) followed by stimulated whole saliva, patient-reported outcomes (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, Head and Neck Module, and the xerostomia questionnaire), and safety.

RESULTS

Of the 120 enrolled patients, 117 (97.5%) were assessed at 12 months. Treatment with ASC did not increase UWS compared with placebo: Increase in UWS was 0.02 mL/minute [95% confidence interval (CI), 0.01-0.04] in the ASC group and 0.02 mL/minute (95% CI, 0-0.03) in the placebo group (P = 0.56). ASC reduced the symptom burden for dry mouth with -10.07 units (95% CI, -13.39 to -6.75) compared with -4.15 units (95% CI, -7.46 to -0.84) in the placebo group (P = 0.01). Compared with placebo, ASC did not improve sticky saliva (-9.27 vs. -4.55 units; P = 0.13), swallowing (-4.50 vs. 3.49 units; P = 0.5), or xerostomia (-3.12 vs. -2.74 units; P = 0.82). Treatment was safe and associated with a transient immune response.

CONCLUSIONS

Intraglandular ACS therapy in the submandibular glands significantly relieved subjective dry mouth symptoms. Both ASC and placebo increased UWS, but ASC did not prove superior to placebo in restoring salivary gland function, based on the salivary flow rate.

Study of the Role of Narrow Band Imaging in Detection of Recurrent/ Residual Lesion in Post Chemo/Radiotherapy of Hypopharyngeal and Laryngeal Malignancies

NBI as a screening tool to detect recurrent/residual lesions in Post CT/RT patients of Hypopharyngeal and Laryngeal malignancies. To evaluate the effectiveness of Narrow Band Imaging (NBI) in detecting residual or recurrent tumors in the larynx and hypopharynx of patients previously treated with radiotherapy or chemoradiotherapy. 30 patients previously treated by employing RT or CRT with curative intent for laryngeal and hypopharyngeal malignancies were enrolled in the study and were followed up for at least 3 visits that are 1-3months, 3-6 months, and above 6 months respectively with white light endoscopy/video laryngoscopy and transnasal flexible videoendoscopy with NBI mode. The sensitivity of VLS was 40% and specificity was 100%, while the positive and negative predictive values were 100% and 76% respectively. The sensitivity of NBI was 100% and specificity was 90%, while the positive and negative predictive values were 83% and 100% respectively. The accuracy of NBI was found to be 93.3%. The study showed that transnasal videoendoscopy with NBI is an excellent method for follow-up in patients with laryngeal and hypopharyngeal carcinomas treated with RT or CRT. NBI mode improves cancer detection and helps in precise biopsy.

Radiation-induced rhinosinusitis: Mechanism research and clinical progress review

Objectives

Radiation-induced rhinosinusitis is a vital dose-limiting reaction in patients with head and neck malignancy. Unlike oral mucositis during or after radiotherapy, radiation-induced sinusitis is easily overlooked in clinical practice and rarely included in experimental studies. Herein, we review the literature to date on radiation-induced rhinosinusitis.

Methods

Relevant studies published between 1995 and 2022 were determined through a detailed search using open keywords from PubMed, with manual search of the reference list of the identified articles. Keywords searched were "ionizing radiation," "radiotherapy," "intensity-modulated radiotherapy," "head and neck tumor," "nasopharyngeal carcinoma," "nasal epithelium," "radiation damage," and "radiation-induced rhinosinusitis." Full-text articles that clearly stated the pathogenesis, clinical manifestation, predictors, treatment, and prognosis of radiation-induced rhinosinusitis were included.

Results

Radiation-induced rhinosinusitis occurs during radiotherapy and can last for months or even years after radiotherapy. A mixture of cellular outcomes caused by ionizing radiation and persistent damage of the epithelial and submucosal tissues after the treatment result from the radiotherapy itself. Endoscopic sinus surgery improves symptoms but can be accompanied by intraoperative and postoperative complications. Nasal irrigation, steroids, and antibiotics appear to reduce inflammation and relieve symptoms to a certain extent. Studies on other potentially useful drugs are underway and in the exploration stage, without clinical application.

Conclusions

Despite its high incidence, radiation-induced rhinosinusitis is a type of dose-limiting toxicity that theoretically does not produce fatal effects at controlled doses and with adequate follow-up care. In moderate-to-severe cases, toxicity may be present. Currently, radiation-induced rhinosinusitis has potential prevention and treatment strategies. However, no unified management protocol has shown significant improvement in radiation-induced rhinosinusitis. Further research is necessary.

Breathing-Swallowing discoordination after definitive chemoradiotherapy for head and neck cancers is associated with aspiration pneumonia

PURPOSE

Swallowing dysfunction and the risk of aspiration pneumonia are frequent clinical problems in the treatment of head and neck squamous cell carcinomas (HNSCCs). Breathing-swallowing coordination is an important factor in evaluating the risk of aspiration pneumonia. To investigate breathing-swallowing discoordination after chemoradiotherapy (CRT), we monitored respiration and swallowing activity before and after CRT in patients with HNSCCs.

METHODS

Non-invasive swallowing monitoring was prospectively performed in 25 patients with HNSCCs treated with CRT and grade 1 or lower radiation-induced dermatitis. Videoendoscopy, videofluoroscopy, Food Intake LEVEL Scale, and patient-reported swallowing difficulties were assessed.

RESULTS

Of the 25 patients selected for this study, four dropped out due to radiation-induced dermatitis. The remaining 21 patients were analyzed using a monitoring system before and after CRT. For each of the 21 patients, 405 swallows were analyzed. Swallowing latency and pause duration after the CRT were significantly extended compared to those before the CRT. In the analysis of each swallowing pattern, swallowing immediately followed by inspiration (SW-I pattern), reflecting breathing-swallowing discoordination, was observed more frequently after CRT (p = 0.0001). In 11 patients, the SW-I pattern was observed more frequently compared to that before the CRT (p = 0.00139). One patient developed aspiration pneumonia at 12 and 23 months after the CRT.

CONCLUSION

The results of this preliminary study indicate that breathing-swallowing discoordination tends to increase after CRT and could be involved in aspiration pneumonia. This non-invasive method may be useful for screening swallowing dysfunction and its potential risks.

Patterns and Trends in Adjuvant Therapy for Major Salivary Gland Cancer

OBJECTIVE

To investigate adjuvant therapy indications, utilization, and associated survival disparities in major salivary gland cancer (MSGC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2017 National Cancer Database.

METHODS

Patients with surgically resected MSGC were included (N = 11,398). pT3-4 classification, pN2-3 classification, lymphovascular invasion, pathologic extranodal extension (pENE), and positive surgical margin (PSM) were considered indications for adjuvant radiotherapy (aRT). pENE and PSM were considered possible indications for adjuvant chemotherapy. Multivariable logistic and Cox regression models were implemented.

RESULTS

Among 6694 patients with≥ $\ge $ 1 indication for aRT, 1906 (28.5%) received no further treatment and missed aRT. Age, race, comorbidity status, facility type, and distance to reporting facility were associated with missed aRT (P < .025). Among 4003 patients with ≥1 possible indication for adjuvant chemoradiotherapy (aCRT), 914 (22.8%) received aCRT. Patients with pENE only (38.5%) and both pENE and PSM (44.0%) received aCRT more frequently than those with PSM only (17.0%) (P < .001). Academic facility was associated with aCRT utilization (P < .05). aCRT utilization increased between 2006 and 2017 in both academic (14.8% vs 23.9%) and nonacademic (8.8% vs 13.5%) facilities (P < .05). Among 2691 patients with ≥1 indication for aRT alone, missed aRT portended poorer OS (hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.28-2.03, P < .001). Among 4003 patients with ≥1 possible indication for aCRT, aRT alone (HR: 1.02, 95% CI: 0.89-1.18, P = .780) and aCRT were associated with similar OS.

CONCLUSION

Missed aRT in MSGC occurs frequently and portends poorer OS. Further studies clarifying indications for aCRT are required.

Iterative Patient Testing of a Stimuli-Responsive Swallowing Activity Sensor to Promote Extended User Engagement During the First Year After Radiation: Multiphase Remote and In-Person Observational Cohort Study

BACKGROUND

Frequent sensor-assisted monitoring of changes in swallowing function may help improve detection of radiation-associated dysphagia before it becomes permanent. While our group has prototyped an epidermal strain/surface electromyography sensor that can detect minute changes in swallowing muscle movement, it is unknown whether patients with head and neck cancer would be willing to wear such a device at home after radiation for several months.

OBJECTIVE

We iteratively assessed patients' design preferences and perceived barriers to long-term use of the prototype sensor.

METHODS

In study 1 (questionnaire only), survivors of pharyngeal cancer who were 3-5 years post treatment and part of a larger prospective study were asked their design preferences for a hypothetical throat sensor and rated their willingness to use the sensor at home during the first year after radiation. In studies 2 and 3 (iterative user testing), patients with and survivors of head and neck cancer attending visits at MD Anderson's Head and Neck Cancer Center were recruited for two rounds of on-throat testing with prototype sensors while completing a series of swallowing tasks. Afterward, participants were asked about their willingness to use the sensor during the first year post radiation. In study 2, patients also rated the sensor's ease of use and comfort, whereas in study 3, preferences were elicited regarding haptic feedback.

RESULTS

The majority of respondents in study 1 (116/138, 84%) were willing to wear the sensor 9 months after radiation, and participant willingness rates were similar in studies 2 (10/14, 71.4%) and 3 (12/14, 85.7%). The most prevalent reasons for participants' unwillingness to wear the sensor were 9 months being excessive, unwanted increase in responsibility, and feeling self-conscious. Across all three studies, the sensor's ability to detect developing dysphagia increased willingness the most compared to its appearance and ability to increase adherence to preventive speech pathology exercises. Direct haptic signaling was also rated highly, especially to indicate correct sensor placement and swallowing exercise performance.

CONCLUSIONS

Patients and survivors were receptive to the idea of wearing a personalized risk sensor for an extended period during the first year after radiation, although this may have been limited to well-educated non-Hispanic participants. A significant minority of patients expressed concern with various aspects of the sensor's burden and its appearance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03010150; https://clinicaltrials.gov/study/NCT03010150.

Utilizing a Second Flap to Address the Effect of Postradiotherapy Soft Tissue Fibrosis in Head and Neck Malignancy

Background  Late effects of adjuvant radiation therapy (RT) on soft tissues can lead to hair loss, pigmentary changes, loss of tissue volume, and fibrosis, which appear months to years after the treatment. These changes are often progressive and are because of tissue hypoxia due to radiation-induced capillary endothelial damage. Tissue hypoxia may be compounded by subclinical infection following minor trauma, exposed hardware, or associated osteoradionecrosis. The combined effect of these factors causes significant deformities in soft tissue, affecting both function and appearance. Such changes are also seen in primarily transferred flaps, which have been radiated, resulting in severe, progressive soft tissue fibrosis, compromising function and aesthetics. In selected cases, a second flap may be needed to restore function and volume. Methods  Data of patients who underwent secondary soft tissue transfers for postradiotherapy-related soft tissue changes were collected from the hospital electronic medical records, from January 2019 to 2023. Details regarding the primary surgery, dose, duration of adjuvant RT, time interval between adjuvant RT and secondary soft tissue transfer, indications, and the choice of the second flap were analyzed. Results  Twenty-one patients had undergone secondary soft tissue transfer for extensive soft tissue fibrosis. In addition, associated compounding features like exposed implant and volume loss were observed. Two patients with osteoradionecrosis also had associated extensive soft tissue fibrosis necessitating replacement. Out of these 21 patients, 13 had undergone free tissue transfers, while 7 locoregional tissue transfers. Conclusion  Late sequelae of adjuvant RT changes usually present from 6 months onwards. The radiated hypoxic tissue, due to capillary damage, leads to a chronic progressive fibrotic stage, causing loss of soft tissue volume and fibrosis. Replacing this tissue with a vascularized flap helps to restore volume and correct these secondary changes, improving overall quality of life.

Radiation-induced xerostomia and cariogenic dietary habits

PURPOSE

Despite the availability of various prevention methods, dental caries continue to be diagnosed in patients receiving head and neck radiotherapy (RT). Since conventional approaches do not evaluate posttreatment alterations in dietary behaviors, we aimed to assess the influence of radiation-induced xerostomia on post-RT cariogenic dietary habits in patients.

METHODS

Fifty-seven patients completed the Xerostomia Questionnaire (XQ) and answered questions regarding daily cariogenic food and beverage (CFB) intake, daily tooth brushing, fluoride application, and subjective total taste acuity (STTA). They also underwent evaluations to determine the Simplified Oral Hygiene Index (OHI-S) score, Saxon test score, number of decayed-missing-filled teeth (DMFT), and proportion of DMFT to the test teeth (DMFT rate). Clinical records were searched for information regarding RT modalities, including the median of the mean dose to the parotid glands, days after the completion of RT, submandibular gland resection, whole-neck irradiation, and the DMFT value and rate before RT. The patients were divided into low and high XQ score groups based on the median XQ score of 47.5 for the two sample tests. Univariable and multivariable regression analyses were used to identify independent factors for frequent CFB intake.

RESULTS

Higher XQ scores were associated with a significantly greater frequency of CFB intake (p = 0.028*). Regression analysis also identified a higher XQ score (p = 0.017*) as an independent risk factor for frequent CFB intake.

CONCLUSION

Radiation-induced xerostomia increased the frequency of CFB intake.

Evaluation and management of dry mouth and its complications in rheumatology practice

INTRODUCTION

The symptom of dry mouth has multiple potential etiologies and can be a diagnostic clue to the presence of common systemic diseases encountered in rheumatology practice. The presence of decreased saliva flow (i.e. salivary hypofunction) defines a subset of dry mouth patients in whom there may be reversible drug effects, an iatrogenic insult such as head and neck irradiation, or a disease that directly involves the salivary glands (e.g. Sjögren's disease). The assessment of salivary hypofunction includes sialometry, salivary gland imaging, salivary gland biopsy, and an assessment for relevant systemic diseases. Optimal management of dry mouth requires accurate definition of its cause, followed by general measures that serve to alleviate its symptoms and prevent its complications.

AREAS COVERED

Through a literature search on xerostomia and salivary hypofunction, we provide an overview of the causes of dry mouth, highlight the potential impact of salivary hypofunction on oral and systemic health, detail routine evaluation methods and treatment strategies, and emphasize the importance of collaboration with oral health care providers.

EXPERT OPINION

Our Expert Opinion is provided on unmet needs in the management of dry mouth and relevant research progress in the field.

Psychosocial needs of post-radiotherapy cancer survivors and their direct caregivers - a systematic review

Radiotherapy is an important modality for cancer treatment. About 50% of cancer patients receive radiotherapy, and one-third of radiotherapy recipients were identified as having unmet psychosocial needs. The unmet psychosocial needs worsen the patient's quality of life and treatment effectiveness. This review aims to identify the psychosocial needs of post-radiotherapy cancer survivors and their direct caregivers. Systematic research of Embase, Scopus and PubMed was done and 17 studies were selected for analysis. The results show that patients encounter distress and fear due to treatment immobilization and unfamiliarity with procedures respectively. Information provision is a common need raised by patients and caregivers. Patients and caregivers report relationship problems due to affected sexual functions. To facilitate future studies, solutions to each identified psychosocial need are proposed in the discussion based on the 17 selected papers and other supporting literature. This review proposes art therapy to alleviate psychological distress, and pre-treatment information sessions to reinforce information delivery. Creative interventions such as a sexual rehabilitation program are recommended. Future studies are warranted to examine the interventions and thus improve the patients' and caregivers' well-being.

Cytokine Levels in Saliva Are Associated with Salivary Gland Fibrosis and Hyposalivation in Mice after Fractionated Radiotherapy of the Head and Neck

Cytokines are mediators of inflammation that could lead to fibrosis. The aim was to monitor cytokine levels in saliva and serum after locally fractionated radiotherapy of the head and neck in mice and investigate associations with salivary gland fibrosis and hyposalivation. C57BL/6 mice were randomized to sham or X-ray irradiation of 66 Gy in 10 fractions over 5 days. Blood and saliva were collected on days -7, 5, 35, 80, and 105 following cytokine analysis. The harvested submandibular salivary gland was assessed for the presence of fibrosis. Decision tree regression analysis was used to investigate whether cytokine levels could predict late endpoints in terms of hyposalivation or fibrosis. Significant formation of fibrosis in gland tissue and reduced saliva production was found after irradiation. The pro-inflammatory cytokines IL-1α, TNF, TIMP1, G-CSF, KC, and MIP-1α showed increased levels in saliva in irradiated mice and a strong correlation with late endpoints. The decision tree analysis largely separated controls from irradiated animals, with IL-1α being the strongest predictor. Pro-inflammatory cytokines in saliva, but not in serum, were associated with late endpoints. This indicates that cytokine expression in saliva is a good biomarker for local salivary gland damage with IL-1α as the strongest single predictor.

Mathematical modeling of radiotherapy: impact of model selection on estimating minimum radiation dose for tumor control

Introduction

Radiation therapy (RT) is one of the most common anticancer therapies. Yet, current radiation oncology practice does not adapt RT dose for individual patients, despite wide interpatient variability in radiosensitivity and accompanying treatment response. We have previously shown that mechanistic mathematical modeling of tumor volume dynamics can simulate volumetric response to RT for individual patients and estimation personalized RT dose for optimal tumor volume reduction. However, understanding the implications of the choice of the underlying RT response model is critical when calculating personalized RT dose.

Methods

In this study, we evaluate the mathematical implications and biological effects of 2 models of RT response on dose personalization: (1) cytotoxicity to cancer cells that lead to direct tumor volume reduction (DVR) and (2) radiation responses to the tumor microenvironment that lead to tumor carrying capacity reduction (CCR) and subsequent tumor shrinkage. Tumor growth was simulated as logistic growth with pre-treatment dynamics being described in the proliferation saturation index (PSI). The effect of RT was simulated according to each respective model for a standard schedule of fractionated RT with 2 Gy weekday fractions. Parameter sweeps were evaluated for the intrinsic tumor growth rate and the radiosensitivity parameter for both models to observe the qualitative impact of each model parameter. We then calculated the minimum RT dose required for locoregional tumor control (LRC) across all combinations of the full range of radiosensitvity and proliferation saturation values.

Results

Both models estimate that patients with higher radiosensitivity will require a lower RT dose to achieve LRC. However, the two models make opposite estimates on the impact of PSI on the minimum RT dose for LRC: the DVR model estimates that tumors with higher PSI values will require a higher RT dose to achieve LRC, while the CCR model estimates that higher PSI values will require a lower RT dose to achieve LRC.

Discussion

Ultimately, these results show the importance of understanding which model best describes tumor growth and treatment response in a particular setting, before using any such model to make estimates for personalized treatment recommendations.

Nasal Cytology Changes in Head and Neck Cancer Treatment: A Systemic Review

Nasal cytology is a non-invasive, low-cost exam that can help physicians in the diagnosis of allergic and nonallergic rhinitis, discriminating between different nasal disorders. The aim of this review is to summarize and analyze the current knowledge about nasal cytological examination in head and neck cancer, with a specific focus on the effects of different treatments. Indeed, nasal cytology is important to choose the best treatment for nasal complaints in each patient. A review of the English literature (PubMed, Scopus, Cochrane) was performed (5404 records screened). The inclusion criteria were clinical trials, cohort studies, case-control studies, case series, and case reports regarding nasal cytology in head and neck cancer treatment. Exclusion criteria were as follows: non-human studies, non-English literature, non-cytological evaluations. Two independent reviewers, working separately, extracted the data from all the eligible studies, which were subsequently cross-checked. Five studies were included in qualitative synthesis: three assessed mucosal disorders after radiation therapy and two after total laryngectomy. Radiotherapy can determine mucous or squamous cell metaplasia and neutrophil inflammation. Laryngectomees show hyperplasia of the basal zone cells and mucous cell metaplasia, and they do not develop inflammatory changes. The main limitation of this review is the low number and heterogeneity of studies present in the literature. In conclusion, nasal cytology is useful and allows for identifying mucosal disorders of the nasal cavities after surgery and/or radiotherapy for head and neck cancer. This can help physicians to better treat the nasal complaints of such patients.

Serial Changes in Parotid Gland Volume and Symptoms After Radiation Therapy in Oropharyngeal Cancer

Objective: To evaluate the serial changes in the volume of the parotid gland and clinical symptoms after a course of radiation therapy (RT) in patients with oropharyngeal cancer. Methods: A total of 33 patients who were diagnosed with oropharyngeal cancer and had been treated with RT or concurrent chemoradiation therapy were evaluated. Parotid gland volumes were measured serially by head and neck computed tomography with contrast-enhanced images before RT, and 6 months, 1 year, and 2 years after RT. Patients also filled out EORTC (European Organization for the Research and Treatment of Cancer) QLQ-C30 questionnaires on the quality of life (QOL) at the same time. This questionnaire included questions about salivary gland function: dry mouth, sticky saliva, and taste disorder. Higher scores on EORTC questionnaire translates to worse QOL. Results: All patients received more than 60 Gy irradiation in total. The mean volume of parotid gland decreased from 23.30 mL before RT to 15.80 mL, 15.93 mL, and 16.67 mL after 6 months, 1 year, and 2 years, respectively (P < 0.001 between pre-RT and all other 3 periods). The scores on the QOL questionnaire were higher (worsened QOL) at all 3 times after radiation than in the pre-RT period. The mean score of QOL increased from pre-RT to 2 years post-RT: "dry mouth" from 1.65 to 2.70, "sticky saliva" from 1.19 to 2.00, and "taste disorder" from 1.12 to 1.94. All 3 of these parameters were correlated with the volume of the parotid gland (P < 0.005 each). Conclusions: The volume of the parotid gland decreases significantly after RT for oropharyngeal cancer and does not recover significantly for at least 2 years. There was a significant correlation between decreased parotid volume and a lower QOL involving salivation.

Clinical outcomes of dental implants in head and neck cancer patients: An overview

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes of dental implants (DIs) in patients with head and neck cancer (HNC) treated with radiotherapy (RT), isolated chemotherapy, or bone modifying agents (BMAs).

STUDY DESIGN

This study was registered in the Prospective Register of Systematic Reviews (CRD42018102772); conducted via the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist; and based on PubMed, Scopus, Embase, Cochrane Library, Web of Science, and gray literature searches. The selection of studies was performed in 2 phases by 2 independent reviewers. The risk of bias (RoB) was assessed by the Measurement Tool to Assess the Methodological Quality of Systematic Reviews 2.

RESULTS

Twenty systematic reviews were included in the qualitative analysis. The majority scored as having high RoB (n = 11). Primary DIs placement in the mandible of patients with HNC subjected to RT doses <50 Gy was associated with better survival rates.

CONCLUSIONS

The placements of DIs could be considered safe in patients with HNC in sites of alveolar bone that received RT (≤5000 Gy); however, no conclusions could be made in patients with cancer managed by chemotherapy or BMAs. Due to the heterogeneity of studies included, the recommendation for DIs placement in patients with cancer should be carefully considered. Future better controlled randomized clinical trials are required to provide enhanced clinical guidelines for best patient care.

Narrow Band Imaging Technology: Role in the Detection of Recurrent Laryngeal and Hypopharyngeal Cancers Post-radiotherapy

To assess the diagnostic accuracy of NBI endoscopy for the diagnosis of early recurrent laryngeal and hypopharyngeal cancers after radiotherapy. The study was conducted over a period of two and a half years from June 2019 to February 2022 and included 123 post-RT patients with laryngeal and hypopharyngeal cancers. The patients were planned for endoscopy with white light and narrow-band imaging. The biopsy was carried out in NBI suspected lesions and sent for histopathological examination. The pathologist was blinded to the outcome of NBI and WLE results to eliminate observer bias. The age group most commonly affected in our study was 40-50 years. Out of the 123 patients, 106 were males and 17 were females. The overall Sensitivity, Specificity, Positive predictive value and Negative predictive value of NBI for malignant lesions were 90.6%, 99%, 95.2% and 98% respectively. NBI Technology is a first-rate diagnostic tool that can help in diagnosing early recurrent cancer lesions, especially after RT, in which the recurrence is otherwise difficult to differentiate from post-radiotherapy oedema. This technology can significantly reduce the rates of failure to detect cancers in early stages.

Therapeutic benefits of factors derived from stem cells from human exfoliated deciduous teeth for radiation-induced mouse xerostomia

Radiation therapy for head and neck cancers is frequently associated with adverse effects on the surrounding normal tissue. Irreversible damage to radiation-sensitive acinar cells in the salivary gland (SG) causes severe radiation-induced xerostomia (RIX). Currently, there are no effective drugs for treating RIX. We investigated the efficacy of treatment with conditioned medium derived from stem cells from human exfoliated deciduous teeth (SHED-CM) in a mouse RIX model. Intravenous administration of SHED-CM, but not fibroblast-CM (Fibro-CM), prevented radiation-induced cutaneous ulcer formation (p < 0.0001) and maintained SG function (p < 0.0001). SHED-CM treatment enhanced the expression of multiple antioxidant genes in mouse RIX and human acinar cells and strongly suppressed radiation-induced oxidative stress. The therapeutic effects of SHED-CM were abolished by the superoxide dismutase inhibitor diethyldithiocarbamate (p < 0.0001). Notably, quantitative liquid chromatography-tandem mass spectrometry shotgun proteomics of SHED-CM and Fibro-CM identified eight proteins activating the endogenous antioxidant system, which were more abundant in SHED-CM than in Fibro-CM (p < 0.0001). Neutralizing antibodies against those activators reduced antioxidant activity of SHED-CM (anti-PDGF-D; p = 0.0001, anti-HGF; p = 0.003). Our results suggest that SHED-CM may provide substantial therapeutic benefits for RIX primarily through the activation of multiple antioxidant enzyme genes in the target tissue.

Affective Symptoms and Oropharyngeal Dysphagia in Head-and-Neck Cancer Patients: A Systematic Review

Oropharyngeal dysphagia (OD) is a high impact morbidity in head-and-neck cancer (HNC) patients. A wide variety of instruments are developed to screen for affective symptoms and OD. The current paper aims to systematically review and appraise the literature to obtain insight into the prevalence, strength, and causal direction of the relationship between affective symptoms and OD in HNC patients. This review was conducted in accordance with the PRISMA statement. A systematic search of the literature was performed using PubMed, PsycINFO, Cochrane, and Embase. All available publications reporting on the relationship between affective conditions and swallowing function in HNC patients were included. Conference papers, tutorials, reviews, and studies with less than 5 patients were excluded. Fifteen studies met the inclusion criteria. The level of evidence and methodological quality were assessed using the ABC-rating scale and QualSyst critical appraisal tool. Eleven studies reported a positive relationship between affective symptoms and OD. The findings of this paper highlight the importance of affective symptom screening in dysphagic HNC patients as clinically relevant affective symptoms and OD seems to be prevalent and coincident in this population. Considering the impact of affective symptoms and OD on patients' daily life, early detection and an integrated interdisciplinary approach are recommended. However, due to the heterogeneity of study designs, outcomes, and outcome measures, the generalization of study results is limited.

Protective effects of hesperidin in cyclophosphamide-induced parotid toxicity in rats

Cyclophosphamide (CYP) is an alkylating agent that is used on a wide range as a treatment of malignancies and autoimmune diseases. Previous studies have shown the promising role of hesperidin (HSP) as an antioxidant agent against various models of toxic agents. The protective effect of the HSP against CYP-induced parotid damage was evaluated in this study. Forty rats (180-200 g) were divided into four equal groups: Group I (received normal saline), Group II (HSP-treated at a dose of 100 mg/kg/day for 7 consecutive days), Group III (CYP-treated at a dose of 200 mg/kg single intraperitoneal injection on the 7th day of the experiment), Group IV (CYP + HSP); HSP-treated at a dose of 100 mg/kg/day for 7 consecutive days and CYP (200 mg/kg) single intraperitoneal injection on the 7th day of the experiment. Afterwards, the oxidative stress and inflammatory markers, the histopathological and immunohistochemical alterations of the parotid tissues in the studied groups were evaluated. CYP intoxication induced a significant parotid tissue injury represented by the elevation in the values of malondialdehyde (MDA), tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) and decrease in the catalase activity and glutathione peroxidase (GPx). Histologically, extensive histopathological alterations e.g., widely spaced serous acini with irregular shapes and congested blood vessels as well as downregulated ki-67 and alpha-smooth muscle actin (α-SMA) immunoexpression were induced by CYP. HSP administration markedly improved the biochemical and the histopathological studies. We can conclude that HSP elicited protective effects against the CYP-induced parotid toxicity.

Diagnostic efficacy of positron emission computerized tomography scans in suspicious laryngeal findings postorgan preservation treatment

BACKGROUND

Larynx preservation protocols (LPP) for glottic primary squamous cell carcinoma has gained popularity worldwide. Direct laryngoscopy (DL) with biopsy is mandated when recurrence is suspected. The efficacy of 18Fluoro-deoxy-glucose positron emission computerized tomography (PET-CT) as alternative first-line diagnostic investigation in suspected recurrence was evaluated.

METHODS

A retrospective study of patients with suspicious fiber-optic findings at more than 12 weeks after LPP. Sensitivity, specificity, and the negative predictive value (NPV) of DL and PET-CT were compared.

RESULTS

Seventy-two patients presenting 105 cases of suspicious events were included in this study. Fifty-two events were initially investigated by DL and 53 events by PET-CT. The sensitivity of DL and PET-CT was 56.25% and 100%, respectively. The NPV was 84% for DL and 100% for PET-CT (p = 0.015).

CONCLUSION

Negative PET scans after LPP are highly accurate in ruling out recurrent/persistent disease and may spare the patient from negative biopsies.

The clinical effect of radiotherapy on pulpal microvasculature: a systematic review

Introduction/objectives Radiotherapy (RT) has a detrimental effect on the histomorphology of oral tissues. Patients undergoing RT are at risk of developing macrovascular and microvascular changes, which can lead to significant clinical consequences. Despite advances in RT delivery systems, radiation injury remains a modern-day clinical problem. The aim of this systematic review is to investigate the available evidence regarding the impact of RT to the dental pulp and the clinical manifestations of these effects.Data and sources A multi-database search (PubMed, Medline, Embase and CINAHL) was performed to identify related papers published from inception until November 2021. An additional manual search was performed to identify further articles. The data extracted from relevant papers were analysed according to the outcomes selected in this review.Study selection The search generated seven articles eligible for analysis with a total of 2,709 teeth included. RT dose exposure ranged from 30-71.2 Gray with a common finding that RT decreases the number of teeth responding to pulp sensibility testing.Conclusions Knowledge related to the impact of RT on dental pulp is limited and based on weak evidence and a low-level quality of studies. Future studies should incorporate exact RT doses to the teeth and use replicable pulpal testing methods. Understanding the pulpal status post-RT remains an important consideration as dental extractions should be avoided in this cohort due to the risk of osteoradionecrosis.

Feasibility and safety of neck level IB-sparing radiotherapy in nasopharyngeal cancer: a long-term single institution analysis

PURPOSE

Nasopharyngeal cancer (NPC) has a higher prevalence of regional nodal metastasis than other head and neck cancers; however, level IB lymph node involvement is rare. We evaluated the safety and feasibility of level IB-sparing radiotherapy (RT) for NPC patients.

MATERIALS AND METHODS

We retrospectively reviewed 236 patients with NPC who underwent definitive intensity-modulated RT with or without chemotherapy between 2004 and 2018. Of them, 212 received IB-sparing RT, and 24 received non-IB-sparing RT. We conducted a propensity score matching analysis to compare treatment outcomes according to IB-sparing status. In addition, dosimetric analysis of the salivary glands was performed to identify the relationship between xerostomia and the IB-sparing RT.

RESULTS

The median follow-up duration was 78 months (range, 7 to 194 months). Local, regional, and distant recurrences were observed in 11.9%, 6.8%, and 16.1% of patients, respectively. Of the 16 patients with regional recurrence, 14 underwent IB-sparing RT. The most common site categorization of regional recurrence was level II (75%), followed by retropharyngeal lymph nodes (43.8%); however, there was no recurrence at level IB. In the matched cohorts, IB-sparing RT was not significantly related to treatment outcomes. However, IB-sparing RT patients received a significantly lower mean ipsilateral and contralateral submandibular glands doses (all, p < 0.001) and had a lower incidence of chronic xerostomia compared with non-IB-sparing RT patients (p = 0.006).

CONCLUSION

Our results demonstrated that IB-sparing RT is sufficiently safe and feasible for treating NPC. To reduce the occurrence of xerostomia, IB-sparing RT should be considered without compromising target coverage.

Long-term functional outcomes and quality of life after partial glossectomy for T2 squamous cell carcinomas

INTRODUCTION

Partial glossectomy and reconstruction strategy for malignant tongue tumors influences speech and swallowing.

OBJECTIVE

The aim of this retrospective study was to evaluate long-term functional outcomes after partial glossectomy for pT2 mobile tongue carcinomas with a maximum dimension between 2 and 3cm. Different reconstruction strategies (with or without pedicled flap) were compared.

METHODS

Twenty-two patients with at least 12 months followup were included. Clinician-based and self-reported instruments were used to analyze tongue motility, speech intelligibility and articulation, swallowing, and quality of life.

RESULTS

Patients with a higher tongue motility had better articulation and lower dysphagia. Avoiding pedicled flap reconstruction seemed to guarantee lower impairment of speech and swallowing. Worse functional outcomes induced a lower quality of life.

CONCLUSION

Partial glossectomy results in tongue motility impairment and consequently alterations of oral functions. Since the type of reconstruction impacts long-term outcomes, it should be adequately planned before surgery.

A model of radiation-induced temporomandibular joint damage in mice

PURPOSE

A small animal radiation research platform (SARRP) equipped with a miniature beam system, an image-guided positioning system, and a dose planning system was used to develop and evaluate a mouse model of radiation-induced temporomandibular damage.

METHODS

Left jaw disks of adult male C57BL/6 mice and C3H mice were targeted using the SARRP for image-guided irradiation. The total radiation dose was 75 Gy. Experiment 1 (Scoping study): Mice in the C57BL/6 mouse test and control groups were sacrificed at 1, 3, 6, 9, 12, 15, and 18 weeks after irradiation, whereas mice in the C3H test and control groups were sacrificed at 1, 3, 6, 9, and 12 weeks after irradiation. Experiment 2 (Full -scale validation study): Mice in the C57BL/6 mouse test and control groups were sacrificed at 1, 3 and 6 weeks after irradiation. Histopathological analysis of the temporomandibular skeletal muscle in each group was performed using hematoxylin and eosin (H&E) and Masson staining; the temporal mandibular bone was examined through H&E staining.

RESULTS

SARRP delivered the rated dose to the temporomandibular joints of C57BL/6 and C3H mice. C3H and C57BL/6 mice in the test group showed different degrees of osteocytic necrosis and osteoporosis at different time points. H&E staining of skeletal muscle tissue showed slight fibrosis in the C57BL/6 test at 3 and 6 weeks time point.

CONCLUSION

We established a model of radiation-induced damage in the temporomandibular joint of C57BL/6 mice and demonstrated that the observed physiological and histological changes correspond to radiation damage observed in humans. Furthermore, the SARRP can deliver precise radiation doses.

Genetic susceptibility to patient-reported xerostomia among long-term oropharyngeal cancer survivors

Genetic susceptibility for xerostomia, a common sequela of radiotherapy and chemoradiotherapy for head and neck cancer, is unknown. Therefore, to identify genetic variants associated with moderate to severe xerostomia, we conducted a GWAS of 359 long-term oropharyngeal cancer (OPC) survivors using 579,956 autosomal SNPs. Patient-reported cancer treatment-related xerostomia was assessed using the MD Anderson Symptom Inventory. Patient response was dichotomized as moderate to severe or none to mild symptoms. In our study, 39.2% of OPC survivors reported moderate to severe xerostomia. Our GWAS identified eight SNPs suggestively associated with higher risk of moderate to severe xerostomia in six genomic regions (2p13.3, rs6546481, Minor Allele (MA) = A, ANTXR1, P = 4.3 × 10-7; 5p13.2-p13.1, rs16903936, MA = G, EGFLAM, P = 5.1 × 10-6; 4q21.1, rs10518156, MA = G, SHROOM3, P = 7.1 × 10-6; 19q13.42, rs11882068, MA = G, NLRP9, P = 1.7 × 10-5; 12q24.33, rs4760542, MA = G, GLT1D1, P = 1.8 × 10-5; and 3q27.3, rs11714564, MA = G, RTP1, P = 2.9 × 10-5. Seven SNPs were associated with lower risk of moderate to severe xerostomia, of which only one mapped to specific genomic region (15q21.3, rs4776140, MA = G, LOC105370826, a ncRNA class RNA gene, P = 1.5 × 10-5). Although our small exploratory study did not reach genome-wide statistical significance, our study provides, for the first time, preliminary evidence of genetic susceptibility to xerostomia. Further studies are needed to elucidate the role of genetic susceptibility to xerostomia.

Long-term survival of implant-based oral rehabilitation following maxillofacial reconstruction with vascularized bone flap

Aim

The aim of the study was to assess the 5-year cumulative survival rate of implant-based dental rehabilitation following maxillofacial reconstruction with a vascularized bone flap and to investigate the potential risk factors which might influence the survival rate.

Materials and methods

A retrospective cohort study was designed. Inclusion criteria involved 18 years old or above patients with the availability of clinical and radiological data and a minimum follow-up 1 year following implant placement. The cumulative survival rate was analyzed by Kaplan–Meier curves and the influential risk factors were assessed using univariate log-rank tests and multivariable Cox-regression analysis.

Results

151 implants were assessed in 40 patients with a mean age of 56.43 ± 15.28 years at the time of implantation. The mean number of implants placed per patient was 3.8 ± 1.3 with a follow-up period of 50.0 ± 32.0 months. The cumulative survival at 1-, 2- and 5-years was 96%, 87%, and 81%. Patients with systemic diseases (HR = 3.75, 95% CI 1.65–8.52; p = 0.002), irradiated flap (HR = 2.27, 95% CI 1.00–5.17; p = 0.05) and poor oral hygiene (HR = 11.67; 95% CI 4.56–29.88; p < 0.0001) were at a significantly higher risk of implant failure.

Conclusion

The cumulative implant survival rate was highest at 1st year followed by 2nd and 5th year, indicating that the risk of implant failure increased over time. Risk indicators that seem to be detrimental to long-term survival include poor oral hygiene, irradiated flap and systemic diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40729-022-00413-7.

Two dimensional computational model coupling myoarchitecture-based lingual tissue mechanics with liquid bolus flow during oropharyngeal swallowing

Biomechanical relationships involving lingual myoanatomy, contractility, and bolus movement are fundamental properties of human swallowing. To portray the relationship between lingual deformation and bolus flow during swallowing, a weakly one-way solid-fluid finite element model (FEM) was derived employing an elemental mesh aligned to magnetic resonance diffusional tractography (Q-space MRI, QSI) of the human tongue, an arbitrary Lagrangian-Eulerian (ALE) formulation with remeshing to account for the effects of lingual surface (boundary) deformation, an implementation of patterned fiber shortening, and a computational visualization of liquid bolus flow. Representing lingual tissue deformation in terms of its 2D principal Lagrangian strain in the mid-sagittal plane, we demonstrated that the swallow sequence was characterized by initial superior-anterior expansion directed towards the hard palate, followed by sequential, radially directed, contractions of the genioglossus and verticalis to promote lingual rotation (lateral perspective) and propulsive displacement. We specifically assessed local bolus velocity as a function of viscosity (perfect slip conditions) and observed that a low viscosity bolus (5 cP) exhibited maximal displacement, surface spreading and local velocity compared to medium (110 cP, 300 cP) and high (525 cP) viscosity boluses. Analysis of local nodal velocity revealed that all bolus viscosities exhibited a bi-phasic progression, with the low viscosity bolus being the most heterogeneous and fragmented and the high viscosity bolus being the most homogenous and cohesive. Intraoral bolus cohesion was depicted in terms of the distributed velocity gradient, with higher gradients being associated with increased shear rate and bolus fragmentation. Lastly, we made a sensitivity analysis on tongue stiffness and contractility by varying the degree of extracellular matrix (ECM) stiffness through effects on the Mooney-Rivlin derived passive matrix and by varying maximum tetanized isometric stress, and observed that a graded increase of ECM stiffness was associated with reduced bolus spreading, posterior displacement, and surface velocity gradients, whereas a reduction of global contractility resulted in a graded reduction of obtainable accommodation volume, absent bolus spreading, and loss of posterior displacement. We portray a unidirectionally coupled solid-liquid FEM which associates myoarchitecture-based lingual deformation with intra-oral bolus flow, and deduce that local elevation of the velocity gradient correlates with bolus fragmentation, a precondition believed to be associated with aspiration vulnerability during oropharyngeal swallowing.

Diagnostic performance of core needle biopsy for nodal recurrences in patients with head and neck squamous cell carcinoma

This study investigated the diagnostic accuracy and affecting factors of ultrasound (US)-guided core-needle biopsy (CNB) in patients with treated head and neck squamous cell carcinoma (HNSCC). We retrospectively reviewed patients with treated HNSCC who received US-guided CNB from January 2011 to December 2018 with corresponding imaging. Pathological necrosis and fibrosis of targeted lymph nodes (LNs) were evaluated. We analyzed the correlation between CNB accuracy and clinical and pathological characteristics. In total, 260 patients were included. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CNB for nodal recurrence were 84.47%, 100%, 100%, 54.67%, and 86.92%, respectively. CNB of fibrotic LNs had significantly worse sensitivity, NPV, and accuracy than that of non-fibrotic LNs. Similarly, CNB of necrotic LNs had significantly worse sensitivity, NPV, and accuracy than non-necrotic LNs. Multivariate regression revealed that fibrotic LN was the only independent factor for a true positive rate, whereas both necrotic LN and fibrotic LN were independent factors for a false negative rate. The diagnostic accuracy of CNB in treated HNSCC patients is affected by LN necrosis and fibrosis. Therefore, CNB results, particularly for necrotic or fibrotic LNs, should be interpreted carefully.

Subjective and perceptive assessment of speech/voice and swallowing function before and after radiation therapy in patients of head-and-neck squamous cell cancer

Aim

To prospectively assess subjective and perceptive speech/voice and swallowing function before and after radiation therapy (RT) in patients of head-and-neck squamous cell cancer (HNSCC).

Materials and Methods

The study cohort comprised eligible consecutive HNSCC patients planned for curative RT from April 2018 to July 2018 who consented for the study. Prospective evaluation of speech/voice and swallowing function was done before and after RT. For subjective and perceptive evaluation of speech/voice, speech handicap index (SHI) and Grade, Roughness, Asthenia, Breathiness, and Strain (GRABS) Scale was used, respectively. For subjective and perceptive evaluation of swallowing, M D Anderson Dysphagia Inventory (MDADI) and Performance Status Scale for head and neck (PSSHN) were used, respectively. All patients were taught speech/voice and swallowing exercises before RT. Statistical analysis was performed using SYSTAT version-12 (Cranes software, Bengaluru).

Results

The study cohort comprised 30 patients of HNSCC with a median age of 57 years and male-to-female ratio of 4:1. The most common subsite was the oral cavity (43.33%) and a majority (76.66%) presented in the locally advanced stage. Post-RT there was significant improvement in speech/voice function (SHI P = 0.0006, GRABS score P = 0.003). Perceptive assessment of swallowing function by PSSHN showed significant improvement (P = 0.0032), but subjective assessment by MDADI showed no significant (P = 0.394) improvement until the first follow-up.

Conclusion

Speech/voice function improved significantly after radiotherapy when combined with rehabilitation exercises. Swallowing function did not improve till the first follow-up. Future studies with the large number of patients and long-term follow-up are needed to document the changes in organ function.

The health risks of dysphagia for patients with head and neck cancer: a multicentre prospective observational study

It is well known that malnutrition is a frequent co-morbidity in cancer patients, especially in those with head and neck neoplasms. This may be due both to the presence of dysphagia symptoms and to the appearance of adverse effects on chemotherapy and / or radiotherapy. The aim of this retrospective observational multicentric study is to evaluate the nutritional status between dysphagia cancer patients and non-dysphagia cancer patients. Data from 60 patients were analysed, 31 of which without dysphagia and 29 with dysphagia. Results highlight that patients with dysphagia had higher involuntary body weight loss than non-dysphagia ones (p < 0.001). By analysing the entire population, it stands out a weight loss rate of 12 ± 9% compared to the usual weight was observed and a prevalence of moderate / severe malnutrition diagnosis of 53%. Furthermore, 76% of the population who manifested the symptom of dysphagia presented severe malnutrition already at the first visit, compared to 32% of non-dysphagia subjects.

Weaving attention U-net: A novel hybrid CNN and attention-based method for organs-at-risk segmentation in head and neck CT images

PURPOSE

In radiotherapy planning, manual contouring is labor-intensive and time-consuming. Accurate and robust automated segmentation models improve the efficiency and treatment outcome. We aim to develop a novel hybrid deep learning approach, combining convolutional neural networks (CNNs) and the self-attention mechanism, for rapid and accurate multi-organ segmentation on head and neck computed tomography (CT) images.

METHODS

Head and neck CT images with manual contours of 115 patients were retrospectively collected and used. We set the training/validation/testing ratio to 81/9/25 and used the 10-fold cross-validation strategy to select the best model parameters. The proposed hybrid model segmented 10 organs-at-risk (OARs) altogether for each case. The performance of the model was evaluated by three metrics, that is, the Dice Similarity Coefficient (DSC), Hausdorff distance 95% (HD95), and mean surface distance (MSD). We also tested the performance of the model on the head and neck 2015 challenge dataset and compared it against several state-of-the-art automated segmentation algorithms.

RESULTS

The proposed method generated contours that closely resemble the ground truth for 10 OARs. On the head and neck 2015 challenge dataset, the DSC scores of these OARs were 0.91 ± 0.02, 0.73 ± 0.10, 0.95 ± 0.03, 0.76 ± 0.08, 0.79 ± 0.05, 0.87 ± 0.05, 0.86 ± 0.08, 0.87 ± 0.03, and 0.87 ± 0.07 for brain stem, chiasm, mandible, left/right optic nerve, left/right submandibular, and left/right parotid, respectively. Our results of the new weaving attention U-net (WAU-net) demonstrate superior or similar performance on the segmentation of head and neck CT images.

CONCLUSIONS

We developed a deep learning approach that integrates the merits of CNNs and the self-attention mechanism. The proposed WAU-net can efficiently capture local and global dependencies and achieves state-of-the-art performance on the head and neck multi-organ segmentation task.

Quercetin and piperine enriched nanostructured lipid carriers (NLCs) to improve apoptosis in oral squamous cellular carcinoma (FaDu cells) with improved biodistribution profile

Oral squamous cellular carcinoma (OSCC) is considered a life-threatening disease with detection in late stages, which forces us to opt for dangerous treatment with a combination of chemotherapy and radiotherapy. Herbal components such as piperine and quercetin are derived from edible sources, proving their anticancer potential against oral cancer cells in vitro. Encapsulation into lipid matrix-mediated nanostructured lipid carriers (NLCs) can make both drugs bio-accessible. NLCs were synthesised using the high shear homogenisation method and characterised for their physicochemical properties, followed by in vitro cellular evaluation in FaDu oral cancer cells. NLCs showed negatively charged particles smaller than 180 nm with a polydispersity index (PDI) of <0.3. Both drugs were found to encapsulate sufficiently, with >85% entrapment efficiency and an improved drug release profile compared to their pristine counterparts. Differential scanning calorimetry (DSC) thermograms showed conversion into an amorphous matrix in lyophilized NLCs, which was supported by X-ray diffraction (XRD) analysis. The cytotoxicity assay showed the IC₅₀ concentration for dual drug-loaded NLCs, which was more effective than the pure drug solution. NLCs were found to be internalised in cells in a short time with an almost 95% co-localization rate. Dual drug-loaded NLCs showed maximum depolarisation of the mitochondrial membrane along with more apoptotic changes. Improved apoptosis was confirmed in NLCs using flow cytometry. The in vivo biodistribution of Coumarin-6 labelled NLCs in rats confirmed their efficient distribution in various parts of the oral cavity through oral administration. Optimised dual drug-loaded NLCs provide a better option for delivering both drugs through a single lipid matrix against oral cancer.

Can the Risk of Dysphagia in Head and Neck Radiation Therapy Be Predicted by an Automated Transit Fluence Monitoring Process During Treatment? A First Comparative Study of Patient Reported Quality of Life and the Fluence-Based Decision Support Metric

PURPOSE/OBJECTIVE(S)

The additional personnel and imaging procedures required for Adaptive Radiation Therapy (ART) pose a challenge for a broad implementation. We hypothesize that a change in transit fluence during the treatment course is correlated with the change of quality of life and thus can be used as a replanning trigger.

MATERIALS/METHODS

Twenty-one head and neck cancer (HNC) patients filled out an MD Anderson Dysphagia Inventory (MDADI) questionnaire, before-and-after the radiotherapy treatment course. The transit fluence was measured by the Watchdog (WD) in-vivo portal dosimetry system. The patients were monitored with daily WD and weekly CBCTs. The region of interest (ROI) of each patient was defined as the outer contour of the patient between approximate spine levels C1 to C4, essentially the neck and mandible inside the beam's eye view. The nth day integrated transit fluence change, Δϕ_n, and the volume change, ΔV_ROI, of the ROI of each patient was calculated from the corresponding WD and CBCT measurements. The correlation between MDADI scores and age, gender, planning mean dose to salivary glands <D_sg>, weight change ΔW, ΔV_ROI, and Δϕ_n, were analyzed using the ranked-Pearson correlation.

RESULTS

No statistically significant correlation was found for age, gender and ΔW. <D_sg> was found to have clinically important correlation with functional MDADI (ρ = -0.39, P = 0.081). ΔV_ROI was found to have statistically significant correlation of 0.44, 0.47 and 0.44 with global, physical and functional MDADI (P-value < 0.05). Δϕ_n was found to have statistically significant ranked-correlation (-0.46, -0.46 and -0.45) with physical, functional and total MDADI (P-value < 0.05).

CONCLUSION

A transit fluence based decision support metric (DSM) is statistically correlated with the dysphagia risk. It can not only be used as an early signal in assisting clinicians in the ART patient selection for replanning, but also lowers the resource barrier of ART implementation.

Surveillance Imaging Following Head and Neck Cancer Treatment and Microvascular Reconstruction

OBJECTIVES/HYPOTHESIS

To assess the accuracy and utility of positron emission tomography/computed tomography (PET/CT) compared with magnetic resonance imaging (MRI) for detecting head and neck cancer (HNC) recurrence after microvascular reconstructive surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Analysis of HNC patients who underwent microvascular reconstruction at a single, tertiary academic center following ablative surgery from 1998 to 2015. Forty-six patients aged 61.4 ± 15.8 years with both PET/CT and MRI examinations were identified. Two radiologists were blinded and interpreted each imaging study. Recurrence certainty scores were determined via continuous (0-100) and Likert ("Likely" to "Unlikely") scales, with larger values indicating a higher likelihood of recurrence. Pathologic confirmation of recurrence was confirmed in 23 patients (50%).

RESULTS

Among those with primary site recurrences, mean recurrence certainty was significantly higher with PET/CT versus MRI on the continuous scale (63.9 vs. 44.4, P = .006). A receiver operating characteristic analysis for predicting primary site recurrence demonstrated a significantly larger area under the curve of 0.79 for PET/CT compared to 0.64 for MRI (P = .044). Categorization of "Likely" primary site recurrence on PET/CT, versus MRI, had higher sensitivity (0.63 vs. 0.40), but lower specificity (0.90 vs. 1.0). MRI demonstrated higher sensitivity (1.0 vs. 0.78) at detecting regional site recurrences.

CONCLUSION

PET/CT demonstrates greater sensitivity than MRI as a surveillance tool for primary site recurrence following microvascular reconstruction where clinical evaluation is hindered by anatomical distortion. Therefore, PET/CT should be pursued as first-line imaging, with MRI utilized for confirmation of positive imaging findings at the primary site.

LEVEL OF EVIDENCE

2 Laryngoscope, 2021.

Salivary molecules of bone remodeling and tissue repair after head and neck radiotherapy

Head and neck radiotherapy causes quantitative and qualitative changes in saliva. The objective of this case-control study was to evaluate the salivary biomarkers associated with bone remodeling and tissue repair in patients submitted to radiotherapy for head and neck cancer treatment, compared with non-irradiated individuals. Total unstimulated saliva was collected for ELISA assay analysis of receptor activator for nuclear factor κ B (RANK) and its ligand (RANK-L), osteoprotegerin, matrix metalloproteinase-9/ tissue inhibitor of metalloproteinase-2, vascular endothelial growth factor, and epidermal growth factor. Statistics were performed, and revealed that salivary RANK (p = 0.0304), RANK-L (p = 0.0005), matrix metalloproteinase-9/ tissue inhibitor of metalloproteinase-2 (p = 0.0067), vascular endothelial growth factor (p = 0.0060), and epidermal growth factor (p < 0.0001) were reduced in patients, compared with the control group. Osteoprotegerin did not differ between the groups (p = 0.3765). Salivary biomarkers did not differ according to radiotherapy completion time (p > 0.05). In conclusion, the lower output of the salivary molecules - essential for bone remodeling and tissue repair - may disrupt tissue homeostasis and play a role in the pathogenesis of the radiotherapy-induced deleterious effects in the oral cavity.

The Long-Term Recovery of Parotid Glands in Nasopharyngeal Carcinoma Treated by Intensity-Modulated Radiotherapy

Background

Xerostomia is one of the most common adverse events of radiotherapy in head and neck cancer patients. There have been many reports on functional changes of the parotid gland after radiation therapy, but there have been few reports on the volume of the parotid gland and its relationship with oral quality of life (QOL) and even fewer reports on longitudinal change of the parotid gland volume. The purpose of this study was to evaluate the long-term change of the parotid gland volume after intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma and the relationship between parotid irradiation dose and xerostomia symptoms.

Methods

We retrospectively analyzed 26 patients with nasopharyngeal cancer treated by IMRT. Longitudinal changes of parotid gland volumes after IMRT were evaluated on CT images. The parotid gland volumes in each period were converted to the ratio to parotid gland volumes before radiotherapy (relative parotid volume). Dunnett’s test was used to evaluate the longitudinal changes in relative parotid volumes at 0-6, 7-18, 19-30, 31-42, 43-54 and 55-66 months after IMRT. We assessed xerostomia 3 years or more after IMRT by measuring the degree of oral moisture using a moisture-checking device (Mucus, Life Co., Ltd.) and oral QOL evaluation by GOHAI (General Oral Health Assessment Index).

Results

The relative parotid volumes during radiotherapy and at 0-6, 7-18, 19-30, 31-42, 43-54 and 55-66 months after IMRT were 75.2 ± 14.3%, 67.2 ± 11.4%, 68.5 ± 15.9%, 72.4 ± 14.8%, 73.0 ± 13.8%, 76.2 ± 17.5%, and 77.1% ± 17.3%, respectively. The parotid volume had recovered significantly at 43-54 and 55-66 months after IMRT, especially in parotids receiving less than 40 Gy as the mean dose. The mean irradiated dose for bilateral parotids showed negative correlations with oral QOL score and oral moisture after a long period.

Conclusions

The parotid volume recovered gradually but had not reached a plateau even 3 years after radiotherapy, especially in parotids receiving less than 40 Gy as the mean dose.

Early Quantification of Salivary Gland Function after Radioiodine Therapy

Purpose of the Study:

Radioiodine (I-131) is used as an effective noninvasive treatment for thyroid malignancies. Salivary gland is one of the most affected nontarget organs. The present study aims to perform early quantification of salivary gland function after I-131 therapy (RIT) for thyroid cancer considering I-131 down-scatter in the Tc-99m window.

Materials and Methods:

A total of 20 patients (6 males and 14 females) with differentiated thyroid carcinoma were enrolled in the study. Baseline dynamic salivary scintigraphy was performed in all patients using 185–370 MBq (5–10 mCi) Tc-99m pertechnetate. Posttherapy, salivary scintigraphy was performed 10–25 days after RIT in the range of 1.85–7.4 GBq (50–200 mCi). Time–activity curves obtained from the pre- and posttherapy dynamic salivary scintigraphy were used for semi-quantitative analysis. Uptake ratio (UR), ejection fraction (EF%), and maximum accumulation (MA%) were calculated by drawing regions of interest of individual parotid and submandibular glands over a composite image, after correcting for down-scatter from I-131 in the Tc-99m window. A paired t-test was used for comparison of the parameters obtained.

Results:

Significant changes were observed in UR and EF% of both parotid and submandibular glands (P < 0.05). No significant changes were found in the value of MA% of left parotid gland and both submandibular glands in the posttherapy scans in comparison to pretherapy scans (P > 0.05). However, significant difference was observed in the MA% of the right parotid gland (P = 0.025).

Conclusion:

Salivary gland function was found to deteriorate after RIT, with the parotid glands affected more than the submandibular glands.

Clinical features of post-radiation nasopharyngeal necrosis and their outcomes following surgical intervention in nasopharyngeal cancer patients

PURPOSE

To investigate the incidence and clinical features of post-radiation nasopharyngeal necrosis (PRNN), and effectiveness of surgical intervention for its treatment.

MATERIALS AND METHODS

Retrospectively, we reviewed 380 NPC patients who underwent high dose radiotherapy (RT) (single RT in 355 and re-RT in 25) from January 2008 till December 2017 at the authors' institute, among who 22 developed Grade ≥ 3 PRNN. The management of PRNN was discussed through weekly multidisciplinary head and neck oncology conference, and surgical debridement was performed when feasible.

RESULTS

The incidence of PRNN was significantly higher following re-RT than in single RT (11/355, 3.1% vs. 11/25, 44.0%, p < 0.001). The PRNN patients in single RT group tended to be older and had more advanced initial tumor extents. The intervals from the latest RT start till PRNN assignment were similar between groups (7.3 vs. 6.6 months, p = 0.140). Nineteen patients underwent surgical debridement: two open; and 17 endoscopic approach, respectively. Endoscopic mucosal reconstruction was performed in eight patients. Resolution of PRNN was achieved in 11 patients (64.7%). The rates of 3-year overall survivals (OS) from the initial RT, latest RT (adjusting re-RT), and PRNN assignment were 84.4%, 70.9%, and 54.7%, respectively. Eight patients (36.4%) succumbed to death: NPC progression in three (13.6%); evidently PRNN-related events in two (9.1%), probably PRNN-related events in two (9.1%); and inter-current death in one (4.5%), respectively.

CONCLUSION

PRNN needs close collaboration among head and neck oncologists and could be successfully recovered, without compromising survival, following timely surgical intervention.

Translation and cross-cultural adaption of the Chinese version of the Vanderbilt Head and Neck Symptom Survey version 2.0: a tool for oral symptom assessment in head and neck cancer patients

Background

Patients with head and neck cancer (HNC) who are receiving radiotherapy commonly face detrimental complications, including oral issues. However, oral symptoms are not well understood given the lack of available specific assessment instruments. The Vanderbilt Head and Neck Symptom Survey version (VHNSS) 2.0 is an instrument specifically developed to identify oral symptoms in HNC patients receiving radiotherapy in the United States.

Objective

To perform the translation and cross-cultural adaptation of the original English version of VHNSS 2.0 into a Chinese version (Mainland China).

Methods

The translation and cultural adaptation process involved translation by independent translators, construction of a consensus version, back translation into the original English version, analysis by the expert committee and a pretest. The pretest was administered to 90 patients with HNC to assess the feasibility and practicality of the tool.

Results

The final Chinese version approved by the expert committee was well understood by all participants in the study. The instrument had satisfactory content validity, with indexes of 0.83 for semantic and idiomatic equivalence, 0.90 for cultural equivalence, and 0.91 for conceptual equivalence. Furthermore, this version had good internal consistency, with Cronbach's alpha coefficients ranging from 0.74 to 0.95.

Conclusion

The Chinese version of VHNSS 2.0 was translated and cross-culturally adapted for use in China. This translation is a feasible instrument to assess oral health-related quality of life in HNC patients undergoing radiotherapy and will be useful for symptom management by clinicians and researchers in China.

Influence of implant-specific radiation doses on peri-implant hard and soft tissue: An observational pilot study

OBJECTIVES

The aim of this study was to investigate the influence of real implant-bed-specific radiation doses on peri-implant tissue health in head and neck cancer (HNC) patients after radiotherapy.

MATERIAL AND METHODS

Specific radiation doses in the area of 81 implants, in 15 irradiated HNC patients, were analyzed by matching data from the radiotherapy planning system with those of three-dimensional follow-up scans after implantation. Peri-implant bone resorption was measured radiographically after 1 and 3 years, and peri-implant tissue health was evaluated clinically. Individual parameters, such as age, gender, and localization, regarding the implant-specific radiation dose distribution were analyzed statistically.

RESULTS

The mean implant-bed-specific radiation dose was high, with 45.95 Gy to the mandible and 29.02 Gy to the maxilla, but significantly lower than the mean total dose to the tumor bed. Peri-implant bone resorption correlated with local inflammation and plaque. After 1 year, women temporarily showed significantly more bone loss than men and implant-specific radiation dose had a significant impact on peri-implant bone loss after 3 years.

CONCLUSIONS

The presented method is a feasible option to define precise implant-bed-specific radiation doses for research or treatment planning purposes. Implant-based dental restoration after radiotherapy is a relatively safe procedure, but a negative radiation dose-dependent long-term effect on peri-implant bone resorption calls for interdisciplinary cooperation between surgeons and radio-oncologists to define high-risk areas.

Radiation-Induced Salivary Gland Dysfunction: Mechanisms, Therapeutics and Future Directions

Salivary glands sustain collateral damage following radiotherapy (RT) to treat cancers of the head and neck, leading to complications, including mucositis, xerostomia and hyposalivation. Despite salivary gland-sparing techniques and modified dosing strategies, long-term hypofunction remains a significant problem. Current therapeutic interventions provide temporary symptom relief, but do not address irreversible glandular damage. In this review, we summarize the current understanding of mechanisms involved in RT-induced hyposalivation and provide a framework for future mechanistic studies. One glaring gap in published studies investigating RT-induced mechanisms of salivary gland dysfunction concerns the effect of irradiation on adjacent non-irradiated tissue via paracrine, autocrine and direct cell-cell interactions, coined the bystander effect in other models of RT-induced damage. We hypothesize that purinergic receptor signaling involving P2 nucleotide receptors may play a key role in mediating the bystander effect. We also discuss promising new therapeutic approaches to prevent salivary gland damage due to RT.

Predictive dose accumulation for HN adaptive radiotherapy

During radiation therapy (RT) of head and neck (HN) cancer, the shape and volume of the parotid glands (PG) may change significantly, resulting in clinically relevant deviations of delivered dose from the planning dose. Early and accurate longitudinal prediction of PG anatomical changes during the RT can be valuable to inform decisions on plan adaptation. We developed a deep neural network for longitudinal predictions using the displacement fields (DFs) between the planning computed tomography (pCT) and weekly cone beam computed tomography (CBCT). Sixty-three HN patients treated with volumetric modulated arc were retrospectively studied. We calculated DFs between pCT and week 1-3 CBCT by B-spline and Demon deformable image registration (DIR). The resultant DFs were subsequently used as input to our novel network to predict the week 4 to 6 DFs for generating predicted weekly PG contours and weekly dose distributions. For evaluation, we measured dice similarity (DICE), and the uncertainty of accumulated dose. Moreover, we compared the detection accuracies of candidates for adaptive radiotherapy (ART) when the trigger criteria were mean dose difference more than 10%, 7.5%, and 5%, respectively. The DICE of ipsilateral/contralateral PG at week 4 to 6 using the prediction model trained with B-spline were 0.81 [Formula: see text] 0.07/0.81 [Formula: see text] 0.04 (week 4), 0.79 [Formula: see text] 0.06/0.81 [Formula: see text] 0.05 (week 5) and 0.78 [Formula: see text] 0.06/0.82 [Formula: see text] (week 6). The DICE with the Demons model were 0.78 [Formula: see text] 0.08/0.82 [Formula: see text] 0.03 (week 4), 0.77 [Formula: see text] 0.07/0.82 [Formula: see text] 0.04 (week 5) and 0.75 [Formula: see text] 0.07/0.82 [Formula: see text] 0.02 (week 6). The dose volume histogram (DVH) analysis with the predicted accumulated dose showed the feasibility of predicting dose uncertainty due to the PG anatomical changes. The AUC of ART candidate detection with our predictive model was over 0.90. In conclusion, the proposed network was able to predict future anatomical changes and dose uncertainty of PGs with clinically acceptable accuracy, and hence can be readily integrated into the ART workflow.

Head and neck multi-organ auto-segmentation on CT images aided by synthetic MRI

PURPOSE

Because the manual contouring process is labor-intensive and time-consuming, segmentation of organs-at-risk (OARs) is a weak link in radiotherapy treatment planning process. Our goal was to develop a synthetic MR (sMR)-aided dual pyramid network (DPN) for rapid and accurate head and neck multi-organ segmentation in order to expedite the treatment planning process.

METHODS

Forty-five patients' CT, MR, and manual contours pairs were included as our training dataset. Nineteen OARs were target organs to be segmented. The proposed sMR-aided DPN method featured a deep attention strategy to effectively segment multiple organs. The performance of sMR-aided DPN method was evaluated using five metrics, including Dice similarity coefficient (DSC), Hausdorff distance 95% (HD95), mean surface distance (MSD), residual mean square distance (RMSD), and volume difference. Our method was further validated using the 2015 head and neck challenge data.

RESULTS

The contours generated by the proposed method closely resemble the ground truth manual contours, as evidenced by encouraging quantitative results in terms of DSC using the 2015 head and neck challenge data. Mean DSC values of 0.91 ± 0.02, 0.73 ± 0.11, 0.96 ± 0.01, 0.78 ± 0.09/0.78 ± 0.11, 0.88 ± 0.04/0.88 ± 0.06 and 0.86 ± 0.08/0.85 ± 0.1 were achieved for brain stem, chiasm, mandible, left/right optic nerve, left/right parotid, and left/right submandibular, respectively.

CONCLUSIONS

We demonstrated the feasibility of sMR-aided DPN for head and neck multi-organ delineation on CT images. Our method has shown superiority over the other methods on the 2015 head and neck challenge data results. The proposed method could significantly expedite the treatment planning process by rapidly segmenting multiple OARs.

Preradiation tooth extraction and jaw osteoradionecrosis: Nationwide population-based retrospective study in Taiwan

OBJECTIVE

Radiotherapy (RT) for head and neck cancer (HNC) within 7 days of tooth extraction is contraindicated because it may increase the risk of osteoradionecrosis of the jaw (ORNJ). However, delayed RT could compromise survival in patients with HNC. By using a national healthcare database, we reviewed the contraindications and analysed other risk factors for ORNJ.

DESIGN

A retrospective cohort study.

SETTING

By using Taiwan's National Health Insurance Research Database, 5,062 HNC patients with at least one tooth extraction 1-21 days before the first RT day (index day) and without any extractions during or after RT from 2000 to 2013 were included. The patients were divided into two groups according to the time of tooth extraction before the index day: 1-7 days and 8-21 days.

PARTICIPANTS

Taiwanese patients with head and neck cancer.

MAIN OUTCOMES MEASURE

Univariate and multivariate Cox proportional hazard regression models were used to evaluate the risk factors of ORNJ.

RESULTS

The overall incidence of ORNJ in the included patients was 1.03% (mean follow-up duration, 4.07 ± 3.01 years; range, 1.00-13.99 years). Tooth extraction within 7 days before RT was not associated with increased ORNJ risk (hazard ratio [HR] =0.734; P = .312). Significant risk factors for ORNJ included oral cancer (adjusted HR = 3.961), tumour excision surgery within 3 months before RT (adjusted HR = 3.488) and mandibulectomy within 3 months before RT (adjusted HR = 5.985; all P < .001).

CONCLUSION

In a mean follow-up of 4 years, tooth extraction within 7 days before RT for HNC treatment did not increase the ORNJ risk compared with tooth extraction 7-21 days before RT.

Does prehospital spinal immobilization influence in hospital decision to obtain imaging after trauma?

IMPORTANCE

This study highlights the unnecessarily high suspicion for cervical spine injury among study providers and shows that cervical CT scans were more likely in patients who arrived to the emergency department wearing a cervical collar, even when clinically cleared for suspicion of cervical spine injury by the emergency department provider.

OBJECTIVE

To determine if patients with a cervical collar were more likely to undergo cervical spine imaging than those who arrived to the emergency department without a collar.

DESIGN

Adult trauma patients at a level 1 trauma center over 4 months (n = 1,438) were stratified by acuity (1,2, or 3), mechanism, and known injury cephalad to clavicles, defined as pain, wounds, or hematomas. Cervical spine imaging findings were recorded.

RESULTS

975 patients (67.8%) had cervical CT scans. Twenty-six (1.81%) sustained a fracture or ligamentous injury, all with known injury cephalad to clavicles. 161 (11.2%) patients without injury cephalad to clavicles all had a negative cervical CT. Category 1 patients with gunshot wounds with injury cephalad to clavicles were more likely to have CT if they arrived with a collar versus without (66.7% vs 14.3%, p = 0.027). Category 2 and 3 patients with injury cephalad to clavicles after motor vehicle collision (MVC) (88.2% vs 69.6%, p = 0.011), low energy falls (88.3% vs 59.4%, p < 0.0001), and assault (86.0% vs 37.1%, p < 0.0001) underwent cervical CT more frequently if they arrived wearing a collar. Category 2 and 3 trauma patients without injury cephalad to clavicles were also more likely to undergo CT when wearing a collar after MVC (66.3% vs 21.4%, p = 0.001), low energy fall (81.8% vs 35.3%, p = 0.016), and pedestrian vs MVC (55.6% vs 12.5%, p = 0.04).

CONCLUSION

Certain trauma patients were more likely to undergo cervical CT if they arrived wearing a cervical collar. No conscious patients without complaints proximal to the clavicles had cervical injury.

Investigation of a Novel Decision Support Metric for Head and Neck Adaptive Radiation Therapy Using a Real-Time In Vivo Portal Dosimetry System

In adaptive radiation therapy of head and neck cancer, any significant anatomical changes observed are used to adapt the treatment plan to maintain target coverage without elevating the risk of xerostomia. However, the additional resources required for adaptive radiation therapy pose a challenge for broad-based implementation. It is hypothesized that a change in transit fluence is associated with volumetric change in the vicinity of the target and therefore can be used as a decision support metric for adaptive radiation therapy. This was evaluated by comparing the fluence with volumetric changes in 12 patients. Transit fluence was measured by an in vivo portal dosimetry system. Weekly cone beam computed tomography was used to determine volume change in the rectangular region of interest from condyloid process to C6. The integrated transit fluence through the region of interest on the day of the cone beam computed tomography scan was calculated with the first treatment as the baseline. The correlation between fluence change and volume change was determined. A logistic regression model was also used to associate the 5% region of interest volume reduction replanning trigger point and the fluence change. The model was assessed by a chi-square test. The area under the receiver-operating characteristic curve was also determined. A total of 46 pairs of measurements were obtained. The correlation between fluence and volumetric changes was found to be -0.776 (P value <.001). The negative correlation is attributed to the increase in the photon fluence transport resulting from the volume reduction. The chi-square of the logistic regression was found to be 17.4 (P value <.001). The area under the receiver-operating characteristic curve was found to be 0.88. Results indicate the change in transit fluence, which can be measured without consuming clinical resources or requiring additional time in the treatment room, can be used as a decision support metric for adaptive therapy.

Interactive website for head and neck cancer patients: Adherence and coping program to prevent dysphagia after radiation

INTRODUCTION

Pharyngeal and laryngeal cancers are highly curable; however survivors are at high risk for long-term dysphagia after radiation. To address lack of access to preventive care in community settings, we developed a responsive web-based application to help patients adhere to preventive swallowing exercises and cope with radiation side effects. We conducted an interim study analysis to determine website usage characteristics and to examine the effect size for future trials.

METHODS

Pharyngeal and laryngeal cancer patients were recruited for enrollment by speech language pathologists before primary radiation and introduced to the interactive website. The program (English and Spanish) features tracking logs for preventive exercises, instructional videos, patient stories and search features. Patients' self-reported swallowing function was assessed with the MD Anderson Dysphagia Inventory (MDADI) at baseline and at 6 months. Adherence to preventive exercises was assessed during the 10 week intervention. Number of unique website visits, total duration of website exposure, and rankings of the most popular webpages were calculated. Preliminary regression models were run using adherence and MDADI as outcomes.

RESULTS

Of the 160 enrolled, 96 had 10-week adherence data and 61 had 6-month MDADI data. The average age was 63 (SD = 12.26), 49.4% were from rural counties, 44% had a high school education or lower, and 42% reported annual income of $30,000 or less. The average number of visits was 5.49 (SD = 9.96) and the average total time spent with the website was 41.09 min (SD =88.48). Preliminary analyses indicated that number of unique visits to the website was independently associated with increased adherence to preventive exercises (p = .001-.008).

CONCLUSION

Our website showed significant effects in promoting adherence to swallowing exercises. However, our return visit rate showed that the platform needs improvement in navigability and usability for this older population undergoing challenging treatment in community settings with low resources.

Outcomes of tracheoesophageal puncture in twice-radiated patients

OBJECTIVE

Previous research has demonstrated the safety of tracheoesophageal puncture voice prosthesis (TEP) placement in radiated patients; however, there is a growing population of twice-radiated patients with limited research on the outcomes of TEP-placement in this cohort.

METHODS

After Institutional Review Board approval, a retrospective review of 80 patients that underwent TEP from 2006 to 2017 at a single institution was conducted, of which 16 patients underwent two courses of radiation. Outcome measures include TEP removal, complication and duration of usage.

RESULTS

Half of twice-radiated patients had ultimate removal of their voice prosthesis with removal occurring at a median of 24.9 months after placement. Reasons for prosthesis removal included widening tracheoesophageal fistula, local recurrence, and dysphagia/esophageal stenosis. Nearly one-third of these patients required surgical intervention for closure of a widening fistula. In contrast, only 17% of once-radiated patients had their prosthesis removed with removal occurring at a median of 28.1 months. This was statistically fewer than the twice-radiated group (p = 0.02). Reasons for removal included patient preference, persistent leakage, recurrence of disease, enlarging tracheoesophageal fistula, poor voice, and dysphagia. Eleven percent of once-radiated patients required surgical intervention for TEP-related complications (p = 0.057).

CONCLUSION

In the twice-radiated patient cohort, there is a higher rate of TEP removal and need for surgical intervention for a voice prosthesis-related complication as compared to a once-radiated cohort.

A Model-Based Method for Assessment of Salivary Gland and Planning Target Volume Dosimetry in Volumetric-Modulated Arc Therapy Planning on Head-and-Neck Cancer

This study examined the relationship of achievable mean dose and percent volumetric overlap of salivary gland with the planning target volume (PTV) in volumetric-modulated arc therapy (VMAT) plan in radiotherapy for a patient with head-and-neck cancer. The aim was to develop a model to predict the viability of planning objectives for both PTV coverage and organs-at-risk (OAR) sparing based on overlap volumes between PTVs and OARs, before the planning process. Forty patients with head-and-neck cancer were selected for this retrospective plan analysis. The patients were treated using 6 MV photons with 2-arc VMAT plan in prescriptions with simultaneous integrated boost in dose of 70 Gy, 63 Gy, and 58.1 Gy to primary tumor sites, high-risk nodal regions, and low-risk nodal regions, respectively, over 35 fractions. A VMAT plan was generated using Varian Eclipse (V13.6), in optimization with biological-based generalized equivalent uniform dose (gEUD) objective for OARs and targets. Target dose coverage (D₉₅, D_max, conformity index) and salivary gland dose (D_mean and D_max) were evaluated in those plans. With a range of volume overlaps between salivary glands and PTVs and dose constraints applied, results showed that dose D₉₅ for each PTV was adequate to satisfy D₉₅ >95% of the prescription. Mean dose to parotid <26 Gy could be achieved with <20% volumetric overlap with PTV₅₈ (parotid-PTV₅₈). On an average, the D_mean was seen at 15.6 Gy, 21.1 Gy, and 24.2 Gy for the parotid-PTV₅₈ volume at <5%, <10%, and <20%, respectively. For submandibular glands (SMGs), an average D_mean of 27.6 Gy was achieved in patients having <10% overlap with PTV₅₈, and 36.1 Gy when <20% overlap. Mean doses on parotid and SMG were linearly correlated with overlap volume (regression R² = 0.95 and 0.98, respectively), which were statistically significant (P < 0.0001). This linear relationship suggests that the assessment of the structural overlap might provide prospective for achievable planning objectives in the head-and-neck plan.