Evaluating predictive factors for determining enteral nutrition in patients receiving radical radiotherapy for head and neck cancer: A retrospective review

The Effect of Nasogastric Feeding after Surgery in Patients with Head and Neck Cancers - Retrospective Single Center Experience

This study aimed to assess clinical factors that could predict the need for nasogastric feeding after surgery in patients with head and neck cancer (HNC) and evaluate the effect of tube feeding on selected laboratory parameters.This single-center retrospective study included 153 patients who underwent surgery for HNC. Data on patient and tumor characteristics were collected, along with laboratory measurements. Logistic regression was used to identify the predictors of the need for nasogastric feeding. Laboratory parameters were compared between patients who required nasogastric feeding vs those who did not.Nasogastric feeding was required in 90 patients (59%). Significant predictors of nasogastric feeding in HNC patients after surgery, which were revealed by univariate regression analysis, included low body mass index (odds ratio [OR] = 0.84), squamous cell carcinoma histology (OR = 8.05), T2 tumor stage (OR = 2.27), red blood cell count (M/µL) (OR = 0.44), hemoglobin levels (g/dL) (OR = 0.80), and mean corpuscular volume (fL) (OR = 1.10). Multivariate analysis showed that low BMI (OR = 0.87) and red blood cell count (M/µL) (OR = 0.32) were prognostic factors for nasogastric feeding. A significant percentage increase in white blood cell count from admission to discharge was noted in patients who required nasogastric feeding vs those who did not (p = 0.003).Determining factors that predict the need for nasogastric feeding in HNC patients after surgery may support more personalized treatment planning to optimize clinical outcomes.

Risk Factors for Feeding Tube Dependency in Patients Undergoing Function Preservation Surgery for Advanced-Stage Laryngohypopharyngeal Cancer

Dysphagia and feeding tube dependency commonly occur in patients with laryngeal or hypopharyngeal cancer (LHC) during and after treatment, often leading to poor functional outcomes. Therefore, we examined the factors related to feeding tube dependency among advanced-stage LHC patients undergoing curative surgery. This study included 69 consecutive patients who underwent conservative surgery for previously untreated, advanced-stage LHC (squamous cell carcinoma) between 2006 and 2016. Persistent feeding tube dependency was defined as 1 year or more after treatment completion. Binary logistic regression analysis was used to determine the factors associated with reactive prolonged and persistent feeding tube dependency. Cox proportional hazard regression analysis was used to determine the association between feeding tube dependency and survival. None of the study patients had a prophylactic feeding tube, but 15 (21.7%) patients had reactive feeding tube placement for 3 months or more. A total of 9 (13.0%) patients had persistent feeding tube dependency. Univariate analysis showed that age, tracheostomy, and common terminology criteria for adverse events (CTCAE) ≥ 3 were significantly associated with reactive prolonged and persistent feeding tube dependency (all P < 0.05). In the multivariate analysis, advanced age and CTCAE ≥ 3 remained the independent factors of reactive prolonged and persistent feeding tube dependency (all P < 0.05). Feeding tube dependency was not associated with overall survival or disease-free survival (P > 0.1). Feeding tube dependency might be related to clinical factors, such as age and severe adverse events, in the patients undergoing function-preserving surgery for advanced-stage LHC.

Predictors of Gastrostomy Tube Placement in Head and Neck Cancer Patients at a Rural Tertiary Care Hospital

Background Head and neck cancer is a leading cause of cancer. Treatment often requires surgical resection, free-flap reconstruction, radiation, and/or chemotherapy. Tumor burden and pain may limit swallowing and impair nutrition, increasing complications and mortality. Patients commonly require gastrostomy tubes (G-tube), but predicting which patients are in need remains elusive. This study identifies predictors of G-tube among head and neck cancer patients undergoing immediate free-flap reconstruction.

Methods Institutional Review Board approval was obtained. Retrospective database review was performed of patients at 18 years of age or older with head and neck cancer who underwent resection with immediate free-flap reconstruction from 2011 to 2019. Patients who underwent nonfree-flap or delayed reconstruction or with mortality within 7 days postoperatively were excluded. Patient demographics and comorbidities, tumor/treatment characteristics, and need for G-tube were analyzed to identify univariate and multivariate predictors.

Results In total, 107 patients were included and 72 required G-tube placement. On multivariate analysis, tracheostomy (odds ratio [OR]: 81.78; confidence interval [CI]: 7.43–1,399.92; p < 0.01), anterolateral thigh flap reconstruction (OR: 16.18; CI: 1.14–429.66; p = 0.04), and age 65 years or younger (OR: 9.35; CI: 1.47–89.11; p = 0.02) were predictors of G-tube placement.

Conclusion Head and neck cancer treatment commonly involves extensive resection, reconstruction, and/or chemoradiation. These patients are at high risk for malnutrition and need G-tube. Determining who requires a pre- or postoperative G-tube remains a challenge. In this study, the need for tracheostomy or ALT flap reconstruction and age 65 years or younger were predictive of postoperative G-tube placement. Future research will guide a multidisciplinary perioperative pathway to facilitate the optimization of nutrition management.

Concurrent Chemoradiotherapy Induces Body Composition Changes in Locally Advanced Head and Neck Squamous Cell Carcinoma: Comparison between Oral Cavity and Non-Oral Cavity Cancer

Few prospective cohort trials have evaluated the difference in treatment-interval total body composition (TBC) changes assessed by dual-energy X-ray absorptiometry (DXA) between two patient subgroups with locally advanced head and neck squamous cell carcinoma (LAHNSCC) receiving concurrent chemoradiotherapy (CCRT): oral cavity cancer with adjuvant CCRT (OCC) and non-oral cavity with primary CCRT (NOCC). This study prospectively recruited patients with LAHNSCC. Clinicopathological variables, blood nutritional/inflammatory markers, CCRT-related factors, and TBC data assessed by DXA before and after treatment were collected. Multivariate linear regression analysis identified the factors associated with treatment-interval changes in body composition parameters, including lean body mass (LBM), total fat mass (TFM), and bone mineral content (BMC). A total of 127 patients (OCC (n = 69) and NOCC (n = 58)) were eligible. Body composition parameters were progressively lost during CCRT in both subgroups. Extremities lost more muscle mass than the trunk for LBM, whereas the trunk lost more fat mass than the extremities for TFM. BMC loss preferentially occurred in the trunk region. Different factors were independently correlated with the interval changes of each body composition parameter for both OCC and NOCC subgroups, particularly mean daily calorie intake for LBM and TFM loss, and total lymphocyte count for BMC loss. In conclusion, treatment-interval TBC changes and related contributing factors differ between the OCC and NOCC subgroups.

Malnutrition screening in head and neck cancer patients with oropharyngeal dysphagia

BACKGROUND & AIMS

Malnutrition in head and neck cancer (HNC) patients is associated with increased morbidity and mortality. The purpose of this study is two-fold: to identify the risk of malnutrition in patients with oropharyngeal dysphagia (OD) secondary to HNC, and to determine the relationship between the risk of malnutrition versus tumor characteristics, treatment modality, time interval (between the end of oncological treatment and swallowing assessment date), level of oral intake, body mass index (BMI), aspiration, pharyngeal pooling, and OD-related quality of life (QoL).

METHODS

The Short Nutritional Assessment Questionnaire (SNAQ) was used to screen patients for the risk of malnutrition. Patients underwent a standardized swallowing examination protocol including an endoscopic evaluation of swallowing.

RESULTS

Seventy-five dysphagic HNC patients were included. Forty-eight percent of the patients presented a high risk of malnutrition using SNAQ. The majority of the patients (81.3%) was on a total oral diet. Moreover, BMI did not appear to be a reliable measure to screen for malnutrition as a normal BMI was often associated with an increased risk of malnutrition on the SNAQ. In contrast, patients who were underweight or overweight did not show an association with a high risk of malnutrition. With the exception of BMI, no other patient and tumor characteristics were found to be associated with the risk of malnutrition.

CONCLUSIONS

This study emphasizes the importance of early nutritional screening in dysphagic HNC patients, as almost half of these patients presented a high risk of malnutrition. Malnutrition screening using SNAQ can identify HNC patients with OD who are at risk of malnutrition and subsequently need to be referred to a dietician for additional nutritional assessment, diagnosis of malnutrition, and nutritional support, even when their BMI is within normal range.

Prognostic Nutritional Index Predicts Toxicity in Head and Neck Cancer Patients Treated with Definitive Radiotherapy in Association with Chemotherapy

Background: The Prognostic Nutritional Index (PNI) is a parameter of nutritional and inflammation status related to toxicity in cancer treatment. Since data for head and neck cancer are scanty, this study aims to investigate the association between PNI and acute and late toxicity for this malignancy. Methods: A retrospective cohort of 179 head and neck cancer patients treated with definitive radiotherapy with induction/concurrent chemotherapy was followed-up (median follow-up: 38 months) for toxicity and vital status between 2010 and 2017. PNI was calculated according to Onodera formula and low/high PNI levels were defined according to median value. Odds ratio (OR) for acute toxicity were calculated through logistic regression model; hazard ratios (HR) for late toxicity and survival were calculated through the Cox proportional hazards model. Results: median PNI was 50.0 (interquartile range: 45.5–53.5). Low PNI was associated with higher risk of weight loss > 10% during treatment (OR = 4.84, 95% CI: 1.73–13.53 for PNI < 50 versus PNI ≥ 50), which was in turn significantly associated with worse overall survival, and higher risk of late mucositis (HR = 1.84; 95% CI:1.09–3.12). PNI predicts acute weight loss >10% and late mucositis. Conclusions: PNI could help clinicians to identify patients undergoing radiotherapy who are at high risk of acute and late toxicity.

The reliable predictors of severe weight loss during the radiotherapy of Head and Neck Cancer

Side effects of severe weight loss during radiation therapy and its definitive risk factors are the significant complexities of cancer treatment. This study aimed to identify the reliable predictors of severe weight loss during three-dimensional conformal radiation therapy (3D-CRT) in head and neck cancer patients. Weight changes during radiotherapy were investigated on 87 patients. Tumor site, T-stage, BMI, age, smoking, treatment modality, and prior surgery were considered as effective factors. During the 3D-CRT, 78.7% of patients experienced weight loss (p<0.001). The risk of weight loss was higher in patients with cancer in the larynx and oral cavity. Severe weight loss (≥5% during the radiation course) was observed in 47.8% of patients. There was the highest risk of severe weight loss in patients undergoing chemoradiation therapy with previous surgical resection (83.3%). The incidence of severe weight loss in normal-weight patients compared to overweight patients was significant. Severe weight loss was more common at higher doses and in younger patients. BMI regardless of body composition is not a credible predictor. Advanced tumor stage and combined treatment modality in head and neck cancer patients which result in synergizing of treatment toxicities, can be used as the reliable risk factors of severe weight loss during radiotherapy.

Assessment of nutritional status and risk factors for malnutrition among the elderly in Loikaw, Myanmar

OBJECTIVES

Malnutrition among the elderly is an important health concern in Myanmar. The country is challenged by both an aging population and poor nutritional status. The aim of this study was to estimate the prevalence of malnutrition and elucidate its associated factors among the elderly in Loikaw, Myanmar.

METHODS

A cross-sectional study was conducted from July to August 2019. Using a multistage sampling method, 747 elderly individuals (313 men and 434 women) were recruited. The nutritional status of these participants was assessed using the Mini-Nutritional Assessment tool, with a face-to-face interview method. Body mass index, mid-upper arm and calf circumference, blood pressure, and random blood sugar levels were also assessed. Multinomial logistic regression analysis was performed.

RESULTS

The prevalence of malnutrition and at risk for malnutrition were 21.7% and 59.4%, respectively. In the multivariate model, dental problem (adjusted odds ratio [aOR], 2.18; 95% confidence interval [CI], 1.24-3.83), low level of education (aOR, 3.13; 95% CI, 1.44-6.81), aged ≥70 y (aOR, 3.55; 95% CI, 1.83-6.88), current betel chewing (aOR, 2.82; 95% CI, 1.64-4.87), and having heart disease (aOR, 8.04; 95% CI, 2.29-18.13) were positively associated with malnutrition.

CONCLUSION

One in five elderly study participants were malnourished and 50% were at risk for malnutrition. Malnutrition was associated with being ≥70 y of age, having a low educational level, chewing betel, having a history of heart disease, and having dental problems. These findings may alert policymakers to develop and implement effective interventions for improving nutritional status of the elderly population.

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery

Importance

Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck.

Objective

To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck.

Design, Setting, and Participants

In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018.

Main Outcomes and Measures

Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked.

Results

Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications.

Conclusions and Relevance

Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit.

Level of Evidence

NA.

Prophylactic percutaneous endoscopic gastrostomy in patients with head and neck cancer: Influence on nutritional status, utilisation rate and complications

BACKGROUND

Patients with head and neck cancer (HNC) are at high risk for malnutrition because of tumour localisation and therapy. Prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement is common practice to prevent malnutrition.

OBJECTIVE

To investigate the benefits of prophylactic PEG tube placement for HNC patients in terms of the influence on patients' nutritional status, utilisation rate, complications and to identify the predictors of PEG tube utilisation.

METHODS

All consecutive HNC patients who underwent prophylactic PEG tube insertion between 1 January 2011 and 31 December 2012 prior to therapy were enrolled. The PEG tube utilisation rate, complications, the patients' nutritional status and tumour therapy were evaluated with the help of electronic patient charts and telephone interviews.

RESULTS

A total of 181 patients (48 female, median 67.5 years) were included. The PEG utilisation rate in the entire cohort was 91.7%. One hundred and forty-nine patients (82.3%) used the PEG tube for total enteral nutrition, 17 patients (9.4%) for supplemental nutrition and 15 patients (8.3%) made no use of the PEG tube. Peristomal wound infections were the most common complications (40.3%) in this study. A high Nutritional Risk Screening (NRS) score prior to tube insertion was found to be independently associated with PEG utilisation. No significant weight changes were observed across the three patient subgroups.

CONCLUSIONS

The overall PEG tube utilisation rate was high in this study. However, given the high rate of infections, diligent patient selection is crucial in order to determine which patients benefit most from prophylactic PEG tube insertion.

Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy

INTRODUCTION

Head and neck cancer (HNC) patients often experience malnutrition before and during treatment. Prophylactic gastrostomy has emerged as an efficient tool for ensuring adequate nutrition. However, there is no suitable algorithm able to identify patients at high risk of malnutrition. The aim of this study was to describe the nutritional management, to assess the impact of prophylactic gastrostomy, and to identify predictors of malnutrition.

METHODS

This retrospective study included 152 patients treated with surgery, radiotherapy, or chemotherapy for HNC. The patients were classified according to their gastrostomy status (prophylactic or non-prophylactic). Nutritional, tumoral and treatment characteristics were reported. Clinical and nutritional outcomes were measured 6 weeks after the beginning of treatment. In order to describe the nutritional management and the impact of prophylactic gastrostomy on patients, univariate analysis was generated using chi-square test and Mann-Whitney test or Student's t-test. Logistic regression was performed to identify factors associated with malnutrition.

RESULTS

Forty-one patients received prophylactic gastrostomy whereas 111 patients had no nutritional support. Prophylactic gastrostomy placement was associated with a lower initial body mass index, with severe malnutrition, and with initial oral intake disorder. Patients who did not experienced prophylactic gastrostomy had much worse outcomes such as hospital readmissions (P=0.042), relative weight loss at 6 weeks (P<0.0001), dysphagia, severe malnutrition, and poor state of health (P=0.001). Our complication rates (4.9%) were lower than the usual range (5.9-9.3%) and no life-threatening complication was reported. Positive N status, oral intake disorder, concomitant radiochemotherapy, nasopharyngeal, and hypopharyngeal tumor site were significant predictive factors for malnutrition.

CONCLUSIONS

Prophylactic percutaneous endoscopic gastrostomy showed advantages in terms of hospital readmissions, relative weight loss at 6 weeks, dysphagia, severe malnutrition, and poor state of health. Tumoral, nutritional and treatment characteristics seem to be predictors for malnutrition. Hence, physicians should integrate these factors in their nutrition algorithm approach.

Pretreatment risk stratification of feeding tube use in patients treated with intensity-modulated radiotherapy for head and neck cancer

BACKGROUND

The purpose of this study was to establish a risk stratification model for feeding tube use in patients who undergo intensity-modulated radiotherapy (IMRT) for head and neck cancers.

METHODS

One hundred thirty-nine patients treated with definitive IMRT (+/- concurrent chemotherapy) for head and neck mucosal cancers were included in this study. Patients were recommended a prophylactic feeding tube and followed up by a dietician for at least 8 weeks postradiotherapy (post-RT). Potential prognostic factors were analyzed for risk and duration of feeding tube use for at least 25% of dietary requirements.

RESULTS

Many variables had significant effects on risk and/or duration of feeding tube use in univariate analyses. Subsequent multivariable analysis showed that T classification ≥3 and level 2 lymphadenopathy were the best independent significant predictors of higher risk and duration of feeding tube use, respectively, in oral cavity, pharyngeal, and supraglottic primaries.

CONCLUSION

In patients treated with definitive IMRT, T classification ≥3 and level 2 lymphadenopathy can potentially stratify patients into 4 risk groups for developing severe dysphagia requiring feeding tube use.

Long-term outcomes in oral cavity squamous cell carcinoma with adjuvant and salvage radiotherapy after surgery

OBJECTIVE

Early-stage oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients, and locoregional recurrence rates are as high as 25% with surgery alone. Radiotherapy (RT) is typically reserved as part of salvage multimodality therapy after salvage surgery because it is generally thought that there is no significant detriment to salvage therapy. Our aim was to examine outcomes for recurrent OCSCC treated with salvage surgery and radiation and compare them to outcomes for patients treated with adjuvant postoperative RT upfront.

METHODS

We identified 425 patients with OCSCC treated with postoperative RT at our institution. The 5-year rates of local failure, locoregional failure (LRF), survival, and distant metastasis (DM) were the main outcome measures. We performed a landmark analysis and examined the same outcomes in the adjuvant versus salvage cohorts using Cox proportional hazards and Fine-Gray competing risk method.

RESULTS

The adjuvant cohort had higher tumor (T) (P < 0.0001) and nodal (N) (P < 0.0001) stage than the salvage cohort's stage at initial presentation. On multivariate analysis, a strategy of salvage RT experienced poorer overall survival (OS) compared to upfront adjuvant RT (hazard ratio [HR] 1.84; 95% confidence interval [CI], 1.26-2.70; P = 0.002). Moreover, salvage surgery followed by RT patients experienced increasing risk of LRF (HR 1.56; 95% CI, 1.18-2.06; P = 0.002) and (DM) (HR 1.53; 95% CI, 1.08-2.17; P = 0.02) on multivariate analysis. Additional analysis was performed excluding salvage cohort with advanced disease at initial presentation (T3-T4 and N2). Salvage RT treatment selection for early-stage OCSCC continued to experience significantly poorer OS as compared to adjuvant RT (HR 1.48; 95% CI, 1.002-2.19; P = 0.049).

CONCLUSION

Early-stage OCSCC patients who are observed and experienced recurrence requiring salvage therapy (surgery and RT) have worse oncologic outcomes than locally advanced patients receiving upfront adjuvant RT. Prospective randomized studies are needed to identify high-risk subset of early-stage OCSCC comparing adjuvant RT versus observation, followed by salvage surgery and RT at recurrence.

LEVEL OF EVIDENCE

4. Laryngoscope, 2539-2545, 2018.

Preservation of swallowing function with de-intensified chemoradiation therapy for HPV-associated oropharyngeal squamous cell carcinoma

Purpose

This study aimed to compare the swallowing function in patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma treated with de-intensified chemoradiation therapy (6 weeks, 60 Gy) versus those receiving standard-of-care chemoradiation therapy (7 weeks, 70 Gy).

Methods and materials

A retrospective review was conducted of 78 patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma with modified barium swallow studies pretreatment and 6 to 8 weeks posttreatment. The swallowing function was objectively scored for penetration, aspiration, and pharyngeal residue. Forty patients received de-intensified chemoradiation therapy (60 Gy image guided radiation therapy with weekly cisplatin 30 mg/m²) and 38 patients received standard-of-care chemoradiation therapy (70 Gy image guided radiation therapy with chemotherapy of the medical oncologist's choosing). Univariate and multivariate analyses were performed to detect differences between the cohorts with regard to laryngeal penetration, aspiration, and pharyngeal residue. A multivariate logistic regression was used to determine the overall effect of treatment on the swallowing function. Patient-reported swallowing outcomes in de-intensified cohort were assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Module for Head and Neck Cancer and the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events questionnaires.

Results

Patients treated with de-intensified chemoradiation therapy were associated with a suggestion of lower risk of developing overall swallowing dysfunction (odds ratio [OR], 0.62; P = .07), laryngeal penetration (OR, 0.63; P = .12), and pharyngeal residue (OR, 0.61; P = .08). The mean pre- and 2-year post-European Organisation for Research and Treatment of Cancer Quality of Life scores pertaining to swallowing (1-4 scale, higher worse) in the de-intensified cohort were 1.4 and 1.2 for liquids; 1.2 and 1.1 for purees; 1.5 and 1.7 for solids, 1.0 and 1.3 for choked when swallowing; and 9.0 and 10.8 for composite score, respectively. The mean pre- and 2-year post-Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events swallowing difficulty scores (1-5 scale, with higher scores being worse) were 1.5 and 1.8, respectively.

Conclusions

Compared with 7 weeks of 70 Gy, 6 weeks of 60 Gy de-intensified chemoradiation therapy appears to better preserve the baseline swallowing function (per objective modified barium swallow assessment). Patients treated with de-intensified chemoradiation therapy reported minimal changes in swallowing function.

Recent advances of medical foods in China: The opportunities and challenges under standardization

Malnutrition with high incidence in hospitalized patients in China has brought a significant burden of disease. Although many clinical studies have demonstrated the importance of nutritional for patients with malnutrition, the application of medical foods in China is still restricted. For the classification, limits, production and registration of medical foods, the Chinese government newly enacted a series of regulations. In this review, comparing the policy, researches, and product variety of medical foods in China with other countries, although the current status of the development of medical foods in China is still far behind that of developed countries, some of regulations are stricter than those of many other countries or organizations. The medical foods in China are divided into four categories, the nutrients and environmental contaminants are limited to ensure the safety. As a prospect, the development of medical foods in China is expected to get out of the predicament of lack of emphasis, shortage of supply, backward of local processing technology and the imperfect management system. After all, in view of the huge population and the increasing demand of nutrition in China, there must be a very good prospect for the future development of the medical foods industry in China.

Perspectives in Head and Neck Medical Oncology

The modern treatment of locoregionally advanced disease often requires a multimodality combination approach. A number of chemotherapeutic agents can be combined with radiation, but the platinum agent cisplatin, a potent radiation sensitizer, is best studied in head and neck cancer. Newer agents such as cetuximab can be used in combination with radiation therapy for those patients who cannot tolerate cisplatin. For chemotherapy-naïve patients with metastatic head and neck cancer who demonstrate a good performance status, platinum doublet regimens are commonly used. Doublet regimens generally improve response rates compared to single-agent chemotherapies, although they have not demonstrated a survival benefit over single agents and they have added toxicity. Immunotherapies, alternative cytotoxic chemotherapies, and targeted therapies are second-line options for patients with disease that has progressed on platinum-based therapy. Immunotherapy, in particular, has gained focus by enhancing the ability of the immune system to recognize and destroy malignant cells. When multimodal approaches are used, as in combined chemotherapy and radiation therapy, toxicities are increased. It is imperative that patients are followed closely in order to maximize treatment benefit while minimizing complications.

Clinical predictors for reactive tube feeding in patients with advanced oropharynx cancer receiving radiotherapy ± chemotherapy

Enteral feeding is often required for nutrition support in head and neck cancer patients when oral intake is inadequate. When to initiate the insertion of a feeding tube continues to be a debated issue in our institution. We investigated the use of reactive feeding tubes (RFTs) in patients with advanced stage oropharynx cancer (OPC). Data were retrospectively collected on 131 patients who had radiotherapy (RT) ± chemotherapy from 2005 to 2015. Predictors for RFT insertion were investigated. Weight loss during RT was compared between those with RFT versus prophylactic tubes (PFTs) versus no tube, and survival outcomes evaluated. RFTs were more likely to be needed in patients who had bilateral neck node irradiation (p = 0.001) and concurrent chemoradiotherapy (CRT) (p = 0.038). Patients with RFTs had significantly higher mean percentage weight loss during RT (9.5 ± 3.4%) (p < 0.001) when compared to those with a PFT (5.2 ± 4.7%) and those with no tube (5.4 ± 3.1%). No difference was seen in 5-year survival rates in patients who did not have a feeding tube to those who required a RFT. RFT use is frequent in OPC, although difficult to predict. CRT and bilateral neck node irradiation were found to be associated with the need for the insertion of a feeding tube during RT. These patients also experience significantly higher weight loss, therefore, prophylactic tubes may need to be considered more often in this population.

Predictors for Weight Loss in Head and Neck Cancer Patients Undergoing Radiotherapy: A Systematic Review

BACKGROUND

Head and neck cancer patients are at high risk of weight loss because of their disease process and the treatment of their disease. Recognition of predictors for weight loss may be able to give proactive or reactive nutritional treatment to patients at risk.

OBJECTIVE

The aim of this study is to identify the independent risk factors for head and neck cancer patients developing weight loss undergoing radiotherapy.

METHODS

A comprehensive literature search was performed on January 2014. Articles reporting studies of the predictors for weight loss in head and neck cancer patients undergoing radiotherapy were included. These studies were published between 1982 and 2014. Study quality was assessed using a modified quality assessment tool that was designed previously for an observational study. The effects of studies were combined with the study quality score using a best-evidence synthesis model.

RESULTS

Twenty-two observational studies involving 6159 patients were included. There was strong evidence for 3 predictors, including advanced tumor stage, a higher body mass index before treatment, and the use of concurrent chemoradiotherapy. We also identified 8 moderate evidence predictors and 30 limited evidence predictors.

CONCLUSION

The scientific literature to date indicates that patients with advanced tumor stage, or a higher body mass index before treatment, or the use of concurrent chemotherapy are at high risk to have weight loss during radiotherapy.

IMPLICATIONS FOR PRACTICE

These data provide evidence to guide healthcare professionals in admitting patients who will have weight loss and choosing an optimal prophylactic strategy.

Pretreatment factors associated with functional oral intake and feeding tube use at 1 and 6 months post-radiotherapy (+/- chemotherapy) for head and neck cancer

A proportion of patients with head and neck cancer (HNC) experience significant swallowing difficulty during and post-radiotherapy/chemoradiotherapy (RT/CRT). Identifying patients during the pretreatment period who are anticipated to have compromised oral intake would allow for early and accurate patient education, and prioritisation of their management. Ascertaining a clear set of pretreatment predictors from the literature is challenging due to heterogeneity in study designs and patient cohorts, with minimal prospective data available (especially at 1-month post-treatment). The objectives of this study were to investigate which pretreatment factors predicted compromised oral intake and feeding tube use at 1 and 6 months post-RT/CRT. Prospective data were collected on 80 consecutive HNC patients receiving RT/CRT from 2011 to 2014. The primary outcome was to identify predictors of a modified diet at 1 and 6 months post-RT/CRT. Secondary outcomes were to identify predictors of feeding tube use at these time intervals, and <6 vs. >6 week duration of feeding tube use. Multivariate analysis revealed bilateral neck radiotherapy treatment was a strong predictor of modified diets at 1 month (p < 0.001), and T-stages T3/T4 a predictor of modified diets at 6 months (p = 0.03). Patients treated with concurrent CRT (p = 0.02) and bilateral neck treatment (p = 0.02) predicted feeding tube use at 1 month, and concurrent CRT predicted feeding tube use for >6 weeks (p = 0.04). Therefore, patients receiving bilateral neck treatment and/or CRT are at greatest risk of requiring modified diets and feeding tube use early post-treatment, and should be prioritised for intervention and ongoing support.

Influence of dosimetric and clinical criteria on the requirement of artificial nutrition during radiotherapy of head and neck cancer patients

PURPOSE/OBJECTIVE(S)

Intensification of radiotherapy and chemotherapy for head-and-neck cancer (HNC) may lead to increased rates of long term dysphagia as a severe side effect. Mucositis and consequent swallowing problems require artificial nutrition in many HNC patients undergoing radiotherapy or chemoradiation. It is unknown, which predict factors for prophylactic PEG tube insertion appear useful.

MATERIALS/METHODS

From an institutional database, 101 patients (72 male, 29 female, mean age 59.5years) were identified who underwent radiotherapy or chemoradiation for HNC. Primary end point of the investigation was the need for artificial nutrition for more than 4days during radiotherapy. Dose volume parameters of defined normal tissue structures potentially of relevance for swallowing ability as well as clinical factors were used to develop a predictive model using a binary multiple logistic regression model.

RESULTS

Whereas several dosimetric and clinical factors were significant predictors for the need of artificial nutrition on univariate analysis, on multivariate analysis only three factors remained independently significant: mean dose to the oropharynx+1cm circumferential margin, ECOG performance state (0-1 vs. 2-4), and the use of chemotherapy (yes vs. no).

CONCLUSIONS

Using a 3 parameter model we could distinguish HNC-patients with different risks for the need of artificial nutrition during radiotherapy. After independent validation, the model could be helpful to decision on prophylactic PEG tube insertion.

Factors associated with malnutrition in hospitalized cancer patients: a croos-sectional study

Introduction

The incidence of cancer is increasing worldwide and with it the prevalence of malnutrition, which is responsible for the death of almost 20 % of cancer patients. The objective of this study was to identify the factors associated with malnutrition in hospitalized cancer patients.

Methods

Cross-sectional study conducted with 277 hospitalized patients in the Institute of Integrative Medicine Prof. Fernando Figueira from March to November 2013. The nutritional status was classified as well-nourished and moderate/severe malnutrition, according to the Patient-Generated Subjective Global Assessment. The association between moderate/severe malnutrition and demographic, behavioral, socioeconomic, clinical, therapeutic and nutritional variables was investigated through univariate regression and hierarchical Poisson models, with a 5 % significance level.

Results

The prevalence of malnutrition was 71.1 %, being classified as moderate in 35.4 % and severe in 35.7 %. After multivariate analysis, smokers/ex-smokers low socioeconomic status, performance status ≥2 and age ≥60 years were associated with increased risk of malnutrition.

Conclusion

There was observed a high prevalence of moderate/severe malnutrition in cancer patients, with the increased risk of malnutrition associated with the presence of factors that can be assessed during hospital admission suggesting a higher alert of the medical and health care staff about the need for nutritional assessment and intervention.

The association between gastrostomy tube placement, poor post-operative outcomes, and hospital re-admissions in head and neck cancer patients

OBJECTIVES

Investigate the relationship of G-tube placement timing on post-operative outcomes.

PARTICIPANTS

908 patients underwent resection of head and neck upper aerodigestive tract tumors between 2007 and 2013. Patient charts were retrospectively screened for patient demographics, pre-operative nutrition variables, co-morbid conditions, Tumor-Node-Metastasis staging, surgical treatment type, and timing of G-tube placement. Exclusionary criteria included death within the first three months of the resection and resections performed solely for nodal disease.

MAIN OUTCOMES

Post-surgical outcomes, including wound and medical complications, hospital re-admissions, length of inpatient hospital stay (LOS), intensive care unit (ICU) time.

RESULTS

793 surgeries were included: 8% of patients had G-tubes pre-operatively and 25% had G-tubes placed post-operatively. Patients with G-tubes (pre-operative or post-operative) were more likely to have complications and prolonged hospital care as compared to those without G-tubes (p < 0.001). Patients with pre-operative G-tubes had shortened length of stay (p = 0.007), less weight loss (p = 0.03), and fewer wound care needs (p < 0.0001), when compared to those that received G-tubes post-operatively. Those with G-tubes placed post-operatively had worse outcomes in all categories, except pre-operative BMI.

CONCLUSIONS

Though having enteral access in the form of a G-tube at any point suggests a more high risk patient, having a G-tube placed in the pre-operative period may protect against poor post-operative outcomes. Post-operative outcomes can be predicted based on patient characteristics available to the physician in the pre-operative period.

[Nutritional management of patients with head and neck cancer treated with radiation]

Radiotherapy and chemotherapy are standard treatment of head and neck cancer alone or associated to surgical treatment. Early (during treatment or the following weeks) and late side effects contribute to malnutrition in this population at risk. In this context, nutritional support adapted by dietary monitoring and enteral nutrition (nasogastric tube or gastrostomy) are often necessary. The early identification of the patients with high malnutrition risk and requiring enteral nutrition is necessary to improve the tolerance and efficacy of treatment.

Smoking during radiotherapy for head and neck cancer and acute mucosal reaction

AIM

We compared the incidence of RTOG/EORTC grade III and higher acute mucositis in patients with head and neck cancer who continued to smoke during radiotherapy with those who quit smoking.

BACKGROUND

There are conflicting data on the relationship between smoking during radiotherapy and the severity of acute mucosal reaction. More studies dealing with this issue are needed.

MATERIALS AND METHODS

Among 136 patients receiving curative radio(chemo)therapy, 37 (27%) declared that they had not quit smoking during radiotherapy. The intensity of mucositis was scored daily by a nurse and weekly by a physician using the RTOG/EORTC scale. The main end-point of the study was the highest observed RTOG/EORTC grade of mucositis.

RESULTS

Patients who smoked during radiotherapy (smokers) were younger than their counterparts who quit smoking (non-smokers), p = 0.06. There were no other differences in the baseline characteristics between smokers and non-smokers. Grade III/IV acute mucositis was observed in 43.5% of all patients. The percentage of patients with grade III/IV acute mucositis was similar in smokers and non-smokers (46% vs. 42%, p = 0.71). Nine patients (smokers [13.5%]; non-smokers [4%], p = 0.05) required prolonged hospitalization to heal mucositis.

CONCLUSIONS

In the whole group, smoking during radiotherapy was not related to acute mucosal toxicity evaluated as the rate of the highest observed grade of mucositis.

Age most significant predictor of requiring enteral feeding in head-and-neck cancer patients

Background

A significant number of patients treated for head and neck squamous cell cancer (HNSCC) undergo enteral tube feeding. Data suggest that avoiding enteral feeding can prevent long-term tube dependence and disuse of the swallowing mechanism which has been linked to complications such as prolonged dysphagia and esophageal constriction. We examined detailed dosimetric and clinical parameters to better identify those at risk of requiring enteral feeding.

Methods

One hundred patients with advanced stage HNSCC were retrospectively analyzed after intensity-modulated radiation therapy (IMRT) to a median dose of 70 Gy (range: 60-75 Gy) with concurrent chemotherapy in nearly all cases (97%). Patients with significant weight loss (>10%) in the setting of severely reduced oral intake were referred for placement of a percutaneous endoscopic gastrostomy (PEG) tube. Detailed DVH parameters were collected for several structures. Univariate and multivariate analyses using logistic regression were used to determine clinical and dosimetric factors associated with needing enteral feeding. Dichotomous outcomes were tested using Fisher’s exact test and continuous variables between groups using the Wilcoxon rank-sum test.

Results

Thirty-three percent of patients required placement of an enteral feeding tube. The median time to tube placement was 25 days from start of treatment, after a median dose of 38 Gy. On univariate analysis, age (p = 0.0008), the DFH (Docetaxel/5-FU/Hydroxyurea) chemotherapy regimen (p = .042) and b.i.d treatment (P = 0.040) (used in limited cases on protocol) predicted need for enteral feeding. On multivariate analysis, age remained the single statistically significant factor (p = 0.003) regardless of other clinical features (e.g. BMI) and all radiation planning parameters. For patients 60 or older compared to younger adults, the odds ratio for needing enteral feeding was 4.188 (p = 0.0019).

Conclusions

Older age was found to be the most significant risk factor for needing enteral feeding in patients with locally advanced HNSCC treated with multimodal treatment. Pending further validation, this would support maximizing early nutritional guidance, targeted supplementation, and symptomatic support for older adults (>60) undergoing chemoradiation. Such interventions and others (e.g. swallowing therapy) could possibly delay or minimize the use of enteral feeding, thereby helping avoid tube dependence and tube-associated long-term physiologic consequences.

Oral cancer malnutrition impacts weight and quality of life

Diet is important for both quality of life (QoL) and survival of patients with oral cancer. Their intake of food is impeded by functional restrictions in chewing and swallowing. In the DÖSAK REHAB STUDY 1652 patients from 38 hospitals within the German-language area of Germany; Austria and Switzerland were examined with regard to functional and psychological variables having an impact on diet. Chewing and swallowing are correlated with mobility of the tongue and the mandible as well as opening of the mouth. Thirty five percent of the patients lost weight; 41% maintained their weight and 24% gained weight. The QoL of patients who were able to maintain their weight and of those who gained weight was significantly better than that of patients who lost weight. A normal diet was important for maintaining weight. Mashed food; liquid food and loss of appetite were closely associated with loss of weight; although it was possible for nutritional counseling and dietary support to be implemented particularly favorably in this respect. Due to problems with eating patients' strength deteriorated; thus restricting activity. Radiotherapy had a negative impact on diet and weight. It influenced sense of taste; dryness of the mouth; swelling and discomfort when ingesting food. Pain and scars in the region of the operation also cause patients to dislike hard; spicy and sour food. Support from a nutritional counselor in implementing a calorie-rich diet remedied this and such support needs to be integrated into patient management. The fact that a poor nutritional status is of such great importance is well-known; but what is often lacking is the systematic implementation of continued professional nutritional counseling over a long period of time; weight control and psycho-social support of the operated patients; particularly those who also have had radiotherapy.

A model for predicting gastrostomy tube placement in patients undergoing surgery for upper aerodigestive tract lesions

IMPORTANCE

Identifying high-risk patients in the preoperative period can allow physicians to optimize nutritional status early for better outcomes after head and neck cancer resections.

OBJECTIVE

To develop a model to predict preoperatively the need for gastrostomy tube (G-tube) placement in patients undergoing surgery of the upper aerodigestive tract.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective medical record review included all adult patients diagnosed with head and neck cancers who underwent tumor resection from 2007 through 2012 at Wake Forest Baptist Health, a level 1 tertiary care center. Records were screened for patient demographics, tumor characteristics, surgical treatment type, and postoperative placement of G-tube. A total of 743 patients underwent resection of head and neck tumors. Of these, 203 were excluded for prior G-tube placement, prior head and neck resection, G-tube placement for chemoradiotherapy, and resection for solely nodal disease, leaving 540 patients for analysis.

MAIN OUTCOMES AND MEASURES

Placement of postoperative G-tube.

RESULTS

Of the 540 included patients, 23% required G-tube placement. The following variables were significant and independent predictors of G-tube placement: preoperative irradiation (odds ratio [OR], 4.1; 95% CI, 2.4-6.9; P < .001), supracricoid laryngectomy (OR, 26.0; 95% CI, 4.9-142.9; P < .001), tracheostomy tube placement (OR, 2.6; 95% CI, 1.5-4.4; P < .001), clinical node stage N0 vs N2 (OR, 2.4; 95% CI, 1.4-4.2; P = .01), clinical node stage N1 vs N2 (OR, 1.6; 95% CI, 0.8-3.3; P = .01), preoperative weight loss (OR, 2.0; 95% CI, 1.2-3.2; P = .004), dysphagia (OR, 2.0; 95% CI, 1.2-3.2; P = .005), reconstruction type (OR, 1.9; 95% CI, 1.1-2.9; P = .02), and tumor stage (OR, 1.8; 95% CI, 1.1-2.9; P = .03). A predictive model was developed based on these variables. In the validation analysis, we found that the average predicted score for patients who received G-tubes was statistically different than the score for the patients who did not receive G-tubes (P = .01).

CONCLUSIONS AND RELEVANCE

We present a validated and comprehensive model for preoperatively predicting the need for G-tube placement in patients undergoing surgery of the upper aerodigestive tract. Early enteral access in high-risk patients may prevent complications in postoperative healing and improve overall outcomes, including quality of life.

Clinical nutrition guidelines of the French Speaking Society of Clinical Nutrition and Metabolism (SFNEP): Summary of recommendations for adults undergoing non-surgical anticancer treatment

Up to 50% of patients with cancer suffer from weight loss and undernutrition (as called cachexia) even though it is rarely screened or properly handled. Patients' prognosis and quality of life could be greatly improved by simple and inexpensive means encompassing nutritional status assessment and effective nutritional care. These guidelines aim to give health professionals and patients practical and up-to-date advice to manage nutrition in the principal situations encountered during the cancer course according to the type of tumour and treatment (i.e. radio and/or chemotherapy). Specific suggestions are made for palliative and elderly patients because of specific risks of undernutrition and related comorbidities in this subset. Levels of evidence and grades of recommendations are detailed as stated by current literature and consensus opinion of clinical experts in each field.

A prospective analysis of factors that influence weight loss in patients undergoing radiotherapy

Malnutrition occurs frequently in patients with cancer. Indeed, a variety of nutritional and tumor-related factors must be taken into account in these patients. Recognizing this relationship, we aimed to prospectively evaluate the risk factors that influence weight loss in patients undergoing radiotherapy with oral nutritional supplementation and dietetic counseling. Weight loss of 74 patients during radiotherapy and 1 month after treatment was analyzed. Parameters such as age, gender, tumor location, tumor stage, Eastern Cooperative Oncology Group performance status (ECOG PS) score, and the use of chemotherapy were analyzed to evaluate their influence on weight loss. All patients underwent oral nutritional supplementation and dietetic counseling. Forty-six (65.7%) patients lost weight, with a mean weight loss of (4.73 ± 3.91) kg, during radiotherapy. At 1 month after treatment, 45 (66.2%) patients lost weight, presenting a mean weight loss of (4.96 ± 4.04) kg, corresponding to a (6.84 ± 5.24)% net reduction from their baseline weight. Head and neck cancer patients had a mean weight loss of (3.25 ± 5.30) kg, whereas the remaining patients had a mean weight loss of (0.64 ± 2.39) kg (P = 0.028) during radiotherapy. In the multivariate analysis, the head and neck tumor location (P = 0.005), use of chemotherapy (P = 0.011), and ECOG PS score of 2-3 (P = 0.026) were considered independent risk factors. Nutritional status and parameters, such as tumor location (especially the head and neck), the use of chemotherapy, and the ECOG PS score, should be evaluated before radiotherapy because these factors can influence weight loss during radiotherapy and 1 month after treatment.

Factors associated with acute and late dysphagia in the DAHANCA 6 & 7 randomized trial with accelerated radiotherapy for head and neck cancer

BACKGROUND

Dysphagia is a common and debilitating side effect in head and neck radiotherapy (RT). Prognostic factors are numerous and their interrelationship not well understood. The aim of this study was to establish a multivariate prognostic model for acute and late dysphagia after RT, based on information from a prospective trial.

MATERIAL AND METHODS

The DAHANCA 6&7 randomized study included 1476 patients with head and neck cancer eligible for primary RT alone. Patients were randomized between 5 and 6 weekly fractions of conventional RT, and received 62-70 Gy in 31-35 fractions. Patients were scored for dysphagia weekly during treatment and at regular intervals until five years after treatment. Dysphagia scores were available from 1461 patients.

RESULTS

Acute dysphagia according to DAHANCA grades 1, 2, 3 and 4 occurred in 83%, 71%, 43% and 23%, respectively. Severe dysphagia occurred in 47% and 38% of patients receiving accelerated or conventional radiotherapy, respectively (p = 0.001). At one, two, three, four and five years the prevalence of chronic dysphagia above grade 0, was 46%, 32%, 29%, 24%, 23%, respectively with no difference between 5 and 6 fractions. In multivariate analysis, the following parameters were independent factors for severe acute dysphagia: T3-T4 tumors, N-positive disease, non-glottic cancer, age> median, baseline dysphagia > 1 and accelerated radiotherapy. The following factors were prognostic factors for late dysphagia: non-glottic cancer, T3-T4, N-positive disease and baseline dysphagia > 1. The data confirmed previously published predictive models, as it was possible to separate patients in groups with low, medium and high risk of dysphagia, respectively, based on pre-treatment risk scores.

CONCLUSION

Prognostic models were established to characterize patients at risk of developing acute or late dysphagia in the DAHANCA 6&7 trial. The results may be useful to identify patients at risk of dysphagia and thus candidates for prophylactic measures against swallowing dysfunction.

Dysphagia in Head and Neck Cancer Patients: Pretreatment Evaluation, Predictive Factors, and Assessment during Radio-Chemotherapy, Recommendations

Progress in head and neck cancer (HNC) therapies has improved tumor response, loco-regional control, and survival. However, treatment intensification also increases early and late toxicities. Dysphagia is an underestimated symptom in HNC patients. Impairment of swallowing process could cause malnutrition, dehydration, aspiration, and pneumonia. A comprehensive literature review finalized in May 2012 included searches of electronic databases (Medline, Embase, and CAB abstracts) and scientific societies meetings materials (American Society of Clinical Oncology, Associazione Italiana Radioterapia Oncologica, Associazione Italiana di Oncologia Cervico-Cefalica, American Head and Neck Society, and European Society for Medical Oncology). Hand-searches of HNC journals and reference lists were carried out. Approximately one-third of dysphagia patients developed pneumonia requiring treatment. Aspiration pneumonia associated mortality ranged from 20% to 65%. Unidentified dysphagia caused significant morbidity, increased mortality, and decreased the quality of life. In this review we underline definition, causes, predictive factors of dysphagia and report on pretreatment and on-treatment evaluation, suggesting some key points to avoid underestimation. A multi-parameter assessment of swallowing problems may allow an earlier diagnosis. An appropriate evaluation might lead to a better treatment of both symptoms and cancer.

Weight loss in patients with head and neck cancer during and after conventional and accelerated radiotherapy

Background

Weight loss is common among patients with squamous cell carcinoma of the head and neck (SCCHN) and is mainly due to tumor and treatment related factors. The aim of the present study was to evaluate weight loss in patients with SCCHN undergoing two different radiotherapy (RT) schedules.

Material and methods

Nutritional data were analyzed from the ARTSCAN study, a controlled randomized prospective Swedish multicenter study conducted with the aim of comparing conventional fractionation (2.0 Gy per day, total 68 Gy during 7 weeks) and accelerated fractionation (1.1 + 2.0 Gy per day, total 68 Gy during 4.5 weeks). Seven hundred and fifty patients were randomized and 712 patients were followed from the start of RT in the present nutritional study.

Results

The patients had a weight loss of 11.3% (± 8.6%) during the acute phase (start of RT up to five months after the termination of RT). No difference in weight loss was seen between the two RT fractionation schedules (p = 0.839). Three factors were significantly predictive for weight loss during the acute phase, i.e. tumor site, overweight/obesity or lack of tube feeding at the start of RT. Moreover, the nadir point of weight loss occurred at five months after the termination of RT.

Conclusion

The results of the present study showed no difference in weight loss between the two RT fractionation schedules and also highlight that weight loss in SCCHN is a multifactorial problem. Moreover, the nadir of weight loss occurred at five months after the termination of treatment which calls for more intense nutritional interventions during the period after treatment.

A predictive model for dysphagia following IMRT for head and neck cancer: introduction of the EMLasso technique

BACKGROUND AND PURPOSE

Design a model for prediction of acute dysphagia following intensity-modulated radiotherapy (IMRT) for head and neck cancer. Illustrate the use of the EMLasso technique for model selection.

MATERIAL AND METHODS

Radiation-induced dysphagia was scored using CTCAE v.3.0 in 189 head and neck cancer patients. Clinical data (gender, age, nicotine and alcohol use, diabetes, tumor location), treatment parameters (chemotherapy, surgery involving the primary tumor, lymph node dissection, overall treatment time), dosimetric parameters (doses delivered to pharyngeal constrictor (PC) muscles and esophagus) and 19 genetic polymorphisms were used in model building. The predicting model was achieved by EMLasso, i.e. an EM algorithm to account for missing values, applied to penalized logistic regression, which allows for variable selection by tuning the penalization parameter through crossvalidation on AUC, thus avoiding overfitting.

RESULTS

Fifty-three patients (28%) developed acute ≥ grade 3 dysphagia. The final model has an AUC of 0.71 and contains concurrent chemotherapy, D2 to the superior PC and the rs3213245 (XRCC1) polymorphism. The model's false negative rate and false positive rate in the optimal operation point on the ROC curve are 21% and 49%, respectively.

CONCLUSIONS

This study demonstrated the utility of the EMLasso technique for model selection in predictive radiogenetics.

Percutaneous endoscopic gastrostomy site metastasis from head and neck squamous cell carcinoma: case series and literature review

Objectives

To present our experience with head and neck squamous cell carcinoma (HNSCC) seeding of percutaneous endoscopic gastrostomy (PEG) sites and to review all reported cases to identify risk factors and develop strategies for complication avoidance.

Materials and methods

The records of 4 patients with PEG site metastasis from HNSCC were identified from the authors’ institution. Thirty-eight further cases were reviewed following a PubMed search and evaluation of references in pertinent articles.

Results

Review of 42 cases revealed the average time from PEG to diagnosis of metastatic disease to be 8 months. Average time to death from detection of PEG disease was 5.9 months. One-year survival following PEG metastasis was 35.5% with an overall mortality of 87.1%.

Conclusion

PEG site metastatic disease portends a poor prognosis. Early detection and aggressive therapy may provide a chance of cure. Changes in PEG technique or in timing of adjunctive therapies are possible avenues in further research to prevent this complication.