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Charters E, Bogaardt H, Clark J, Milross C, Freeman-Sanderson A, Ballard K, Britton R, McCabe N, Davis H, Sullivan T, Wu R. Functional swallowing outcomes related to radiation exposure to dysphagia and aspiration-related structures in patients with head and neck cancer undergoing definitive and postoperative intensity-modulated radiotherapy. Head Neck 2021; 44:399-411. [PMID: 34808023 DOI: 10.1002/hed.26936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The relationship between swallowing outcomes and radiotherapy dose to dysphagia and aspiration-related structures (DARS) may be different following definitive versus postoperative radiotherapy (PORT) for mucosal head and neck cancer (HNC) and has not been well-studied. METHOD Patient- and clinician-reported swallowing measures were prospectively collected at six time points from baseline to 24 months postradiotherapy HNC. Radiotherapy plans were retrospectively analyzed to assess dose delivered to DARS. The association between swallowing outcomes and participant demographics, tumor characteristics, and radiotherapy dose in definitive and postoperative treatment cohorts was assessed. RESULTS Ninety-three participants who received radiotherapy for HNC were included in the analysis (n = 49 definitive radiotherapy for laryngeal/pharyngeal primary tumors and n = 44 postoperative PORT for predominantly oral cavity/salivary gland tumors). Participants undergoing PORT had lower doses to DARS than those undergoing definitive RT. High dose to the pharyngeal constrictors and base of tongue for definitive RT and the esophageal inlet, supraglottic larynx and cervical esophagus for the PORT group were associated with worse swallowing function. CONCLUSION Radiation dose to DARS is associated with post-treatment swallowing outcomes. These dose/outcome relationships may vary between the definitive and postoperative settings.
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Affiliation(s)
- Emma Charters
- Department of Allied Health, Speech Pathology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Hans Bogaardt
- University of Adelaide, Faculty of Health and Medical Sciences, School of Allied Health Science and Practice, Adelaide, South Australia, Australia
| | - Jonathan Clark
- Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia.,Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Chris Milross
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | | | - Kirrie Ballard
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rafe Britton
- Lubrication Explained, Biostatistics Department, Sydney, Australia
| | - Natalie McCabe
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Hannah Davis
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Tom Sullivan
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Raymond Wu
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
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Hedström J, Tuomi L, Finizia C, Olsson C. Identifying organs at risk for radiation-induced late dysphagia in head and neck cancer patients. Clin Transl Radiat Oncol 2019; 19:87-95. [PMID: 31646203 PMCID: PMC6804434 DOI: 10.1016/j.ctro.2019.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 11/02/2022] Open
Abstract
Background and purpose Dysphagia is a common, severe and dose-limiting toxicity after oncological treatment of head and neck cancer (HNC). This study aims to investigate relationships between radiation doses to structures involved in normal swallowing and patient-reported as well as clinically measured swallowing function in HNC patients after curative (chemo-) radiation therapy (RT) with focus on late effects. Materials and methods Patients (n = 90) with HNC curatively treated with RT ± chemotherapy in 2007-2015 were assessed for dysphagia post-treatment by telephone interview and videofluoroscopy (VFS). A study-specific symptom score was used to determine patient-reported dysphagia. The Penetration-Aspiration Scale (PAS) was applied to determine swallowing function by VFS (PAS ≥ 4/ ≥ 6 = moderate/severe dysphagia). Thirteen anatomical structures involved in normal swallowing were individually delineated on the patients' original planning CT scans and associated dose-volume histograms (DVHs) retrieved. Relationships between structure doses and late toxicity were investigated through univariable and multivariable logistic regression analysis (UVA/MVA) accounting for effects by relevant clinical factors. Results Median assessment time was 7 months post-RT (range: 5-34 months). Mean dose to the contralateral parotid gland and supraglottic larynx as well as maximum dose to the contralateral anterior digastric muscle predicted patient-reported dysphagia (AUC = 0.64-0.67). Mean dose to the pharyngeal constrictor muscle, the larynx, the supraglottic larynx and the epiglottis, as well as maximum dose to the contralateral submandibular gland predicted moderate and severe dysphagia by VFS (AUC = 0.71-0.80). Conclusion The patients in this cohort were consecutively identified pre-treatment, and were structurally approached and assessed for dysphagia after treatment at a specific time point. In addition to established dysphagia organs-at-risk (OARs), our data suggest that epiglottic and submandibular gland doses are important for swallowing function post-RT. Keeping DVH thresholds below V60 = 60% and V60 = 17%, respectively, may increase chances to reduce occurrence of severe late dysphagia. The results need to be externally validated in future studies.
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Key Words
- 3D-CRT, Three Dimensional Conformal Radiation Therapy
- AAA, Anisotropic Analytical Algorithm
- ACE-27, Adult Comorbidity Evaluation 27
- AUC, area under the Receiver Operating Characteristic (ROC) curve
- BMI, body mass index
- CI, confidence interval
- CT, computed tomography
- Cc, cubic centimeter
- DARS, dysphagia-aspiration-related structures
- DESdC, Drinking, Eating, Swallowing difficulties and Coughing when eating/drinking
- DVH, dose-volume histogram
- Deglutition disorders
- Dysphagia-aspiration-related structures
- EBRT, external beam radiation therapy
- EQD2, equivalent dose in 2Gy fractions
- Gy, Gray
- HNC, head and neck cancer
- Head and neck neoplasms
- ICRU, International Commission on Radiation Units and Measurements
- IMRT, intensity-modulated radiation therapy
- MVA, multivariable logistic regression
- N.A, non applicable
- OAR, organ-at-risk
- OR, odds ratio
- PAS, penetration-aspiration scale
- PCM, pharyngeal constrictor muscle
- PRO, patient-reported outcome
- QoL, quality of life
- ROC, Receiver Operating Characteristic curve
- RT, radiation therapy
- Radiation dose
- Radiation therapy
- SD, standard deviation
- SEM, standard error of the mean
- SLP, speech-language pathologist
- TNM, Tumor location, Nodular engagement, Metastasis
- UES, upper esophageal sphincter
- UVA, univariable logistic regression
- VFS, videofluoroscopy
- VMAT, volumetric-modulated radiation therapy
- Vx, the volume (%) of a structure receiving ≥xGy.
- ρ, Spearman’s Correlation Coefficient
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Affiliation(s)
- Johanna Hedström
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 413 45 Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Anesthesia and Intensive Care, Area 2, 416 85 Gothenburg, Sweden
| | - Lisa Tuomi
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 413 45 Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Otorhinolaryngology, 413 45 Gothenburg, Sweden
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 413 45 Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Otorhinolaryngology, 413 45 Gothenburg, Sweden
| | - Caroline Olsson
- Department of Radiation Physics, Institute of Clinical Sciences, the Sahlgrenska Academy Gothenburg University, 413 45 Gothenburg, Sweden.,Regional Cancer Center West, the Western Sweden Healthcare Region, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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Geiger JL, Ku JA. Postoperative Treatment of Oropharyngeal Cancer in the Era of Human Papillomavirus. Curr Treat Options Oncol 2019; 20:20. [DOI: 10.1007/s11864-019-0620-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Managing the late effects of chemoradiation on swallowing: bolstering the beginning, minding the middle, and cocreating the end. Curr Opin Otolaryngol Head Neck Surg 2018; 26:180-187. [DOI: 10.1097/moo.0000000000000455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Petkar I, Bhide S, Newbold K, Harrington K, Nutting C. Dysphagia-optimised Intensity-modulated Radiotherapy Techniques in Pharyngeal Cancers: Is Anyone Going to Swallow it? Clin Oncol (R Coll Radiol) 2017; 29:e110-e118. [PMID: 28242166 DOI: 10.1016/j.clon.2017.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/24/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Abstract
Dysphagia after primary chemoradiotherapy or radiation alone in pharyngeal cancers can have a devastating impact on a patient's physical, social and emotional state. Establishing and validating efficient dysphagia-optimised radiotherapy techniques is, therefore, of paramount importance in an era where health-related quality of life measures are increasingly influential determinants of curative management strategies, particularly as the incidence of good prognosis, human papillomavirus-driven pharyngeal cancer in younger patients continues to rise. The preferential sparing achievable with intensity-modulated radiotherapy (IMRT) of key swallowing structures implicated in post-radiation dysfunction, such as the pharyngeal constrictor muscles (PCM), has generated significant research into toxicity-mitigating strategies. The lack of randomised evidence, however, means that there remains uncertainty about the true clinical benefits of the dosimetric gains offered by technological advances in radiotherapy. As a result, we feel that IMRT techniques that spare PCM cannot be incorporated into routine practice. In this review, we discuss the swallowing structures responsible for functional impairment, analyse the studies that have explored the dose-response relationship between these critical structures and late dysphagia, and consider the merits of reported dysphagia-optimised IMRT (Do-IMRT) approaches, thus far. Finally, we discuss the dysphagia/aspiration-related structures (DARS) study (ISRCTN 25458988), which is the first phase III randomised controlled trial designed to investigate the impact of swallow-sparing strategies on improving long-term function. To maximise patient benefits, improvements in radiation delivery will need to integrate with novel treatment paradigms and comprehensive rehabilitation strategies to eventually provide a patient-centric, personalised treatment plan.
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Affiliation(s)
- I Petkar
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - S Bhide
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - K Newbold
- The Royal Marsden NHS Foundation Trust, London, UK
| | - K Harrington
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C Nutting
- The Royal Marsden NHS Foundation Trust, London, UK
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Kelly JR, Husain ZA, Burtness B. Treatment de-intensification strategies for head and neck cancer. Eur J Cancer 2016; 68:125-133. [PMID: 27755996 PMCID: PMC5734050 DOI: 10.1016/j.ejca.2016.09.006] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 01/16/2023]
Abstract
Increasingly, squamous cell carcinoma of the oropharynx (OPSCC) is attributable to transformation resulting from high-risk human papillomavirus (HPV) infection. Such cancers are significantly more responsive to treatment than traditional tobacco- and alcohol-associated squamous cell cancers of the head and neck. Conventional management with definitive chemoradiation, surgery and adjuvant radiation, or radiation given with altered fractionation schemes, while effective, incurs long-term morbidity that escalates with treatment intensity and significantly impairs quality of life. Recent trials have suggested that less intensive treatment regimens may achieve similar efficacy with decreased toxicity. In this article, we review the primary strategies used for de-escalation of treatment, which include the reduction of radiation dose, substitution and/or elimination of concurrent radiosensitising chemotherapy, and the use of minimally invasive surgery. We discuss the rationale behind these approaches and the preliminary data demonstrating the success of de-escalation, as well as potential considerations raised by treatment de-intensification in HPV-associated OPSCC.
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Affiliation(s)
- Jacqueline R Kelly
- Yale University School of Medicine, Department of Therapeutic Radiology, 35 Park St, LL509, New Haven, CT 06519, USA
| | - Zain A Husain
- Yale University School of Medicine, Department of Therapeutic Radiology, 35 Park St, LL509, New Haven, CT 06519, USA
| | - Barbara Burtness
- Yale University School of Medicine, Department of Medicine (Medical Oncology), 333 Cedar St., PO Box 208028, New Haven, CT 06520-8028, USA.
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Frowen J, Drosdowsky A, Perry A, Corry J. Long-term swallowing after chemoradiotherapy: Prospective study of functional and patient-reported changes over time. Head Neck 2015; 38 Suppl 1:E307-15. [DOI: 10.1002/hed.23991] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2014] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jacqui Frowen
- Speech Pathology Department; Peter MacCallum Cancer Centre; East Melbourne Victoria Australia
| | - Allison Drosdowsky
- Department of Cancer Experiences Research; Peter MacCallum Cancer Centre; East Melbourne Victoria Australia
| | - Alison Perry
- Faculty of Education and Health Sciences; University of Limerick; Limerick Ireland
| | - June Corry
- Division of Radiation Oncology; Peter MacCallum Cancer Centre; East Melbourne Victoria Australia
- University of Melbourne; Grattan St Parkville Victoria Australia
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Wen L, Quan H, Li L, Huang C, Chen X, Yang Y, Wang L, He X, Zhang X. The clinical research of the endoscopic sequential treatment for patients with intermediate-advanced esophageal cancer: a randomized clinical trial. Med Oncol 2014; 31:284. [PMID: 25380842 DOI: 10.1007/s12032-014-0284-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 10/04/2014] [Indexed: 10/24/2022]
Abstract
We tried to find an ideal therapeutic regimen for patients with advanced esophageal cancer. Totally 240 patients with advanced esophageal cancer were randomly divided into experimental group (endoscopic sequential treatment, 126 cases) and control group (traditional treatment, 114 cases) with a 2-year follow-up period. The experimental group was randomly divided into three subgroups: group A: local chemotherapeutic drug injection with ordinary metal stent implantation; group B: local chemotherapeutic drug injection with iodine-125 particle implantation; and group C: radiofrequency (RF) therapy with ordinary metal stent group. The control group was also randomly divided into three subgroups: group D: local chemotherapeutic drug injection group; group E: RF therapy group; and group F: common metal stent implantation group. The survival rate, survival quality, adverse reactions, and complications were compared among these groups. A significant improvement of curative effect was found in the experimental group. Group A and B had higher survival rate and survival quality, and lower esophagotracheal fistula incidence and metastasis rate, compared with group C. There was no significant difference in survival rate between group A and group B, while the quality of life was higher in group B than in group A. While patients in group B had lower esophagotracheal fistula incidence and metastasis rate comparing with group A. Local chemotherapeutic drug injection combined with iodine-125 particle stent might be an effective sequential treatment to improve the life quality of advanced esophageal cancer patients.
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Affiliation(s)
- Liming Wen
- The Second Affiliated Hospital of North Sichuan Medical College, Mianyang, 621000, Sichuan, China,
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Urban D, Corry J, Rischin D. What is the best treatment for patients with human papillomavirus-positive and -negative oropharyngeal cancer? Cancer 2014; 120:1462-70. [PMID: 24578320 DOI: 10.1002/cncr.28595] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/17/2013] [Accepted: 12/20/2013] [Indexed: 12/21/2022]
Abstract
The discovery that the human papilloma virus (HPV) is associated with a high and increasing percentage of oropharyngeal squamous cell carcinomas (SCCs) is among the most significant advances in the field of head and neck oncology. HPV-positive oropharyngeal cancer (HPVOPC) has clinical, etiologic, pathologic, and molecular features that distinguish it from HPV-negative disease. Increasingly, HPVOPC is being diagnosed in clinical practice because of the easy availability of p16 immunohistochemistry, a surrogate marker of HPV. The superior prognosis of HPVOPC has led to a reexamination of treatment approaches, and clinical trials are currently investigating strategies to deintensify treatment to reduce acute and late toxicity while preserving efficacy. This is of particular interest in low-risk patients. Unfortunately, patients with HPV-negative tumors still have high rates of locoregional failure and more efficacious treatments are required. This review of oropharyngeal SCC focuses on current and investigational treatment strategies in patients with both HPV-positive and HPV-negative oropharyngeal SCC.
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Affiliation(s)
- Damien Urban
- Department of Medical Oncology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia; Head and Neck Service, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
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