Results of fiberoptic endoscopic evaluation of swallowing vs. radiation dose in the swallowing muscles after radiotherapy of cancer in the oropharynx

Dysphagia-optimised intensity-modulated radiotherapy versus standard intensity-modulated radiotherapy in patients with head and neck cancer (DARS): a phase 3, multicentre, randomised, controlled trial

BACKGROUND

Most newly diagnosed oropharyngeal and hypopharyngeal cancers are treated with chemoradiotherapy with curative intent but at the consequence of adverse effects on quality of life. We aimed to investigate if dysphagia-optimised intensity-modulated radiotherapy (DO-IMRT) reduced radiation dose to the dysphagia and aspiration related structures and improved swallowing function compared with standard IMRT.

METHODS

DARS was a parallel-group, phase 3, multicentre, randomised, controlled trial done in 22 radiotherapy centres in Ireland and the UK. Participants were aged 18 years and older, had T1-4, N0-3, M0 oropharyngeal or hypopharyngeal cancer, a WHO performance status of 0 or 1, and no pre-existing swallowing dysfunction. Participants were centrally randomly assigned (1:1) using a minimisation algorithm (balancing factors: centre, chemotherapy use, tumour type, American Joint Committee on Cancer tumour stage) to receive DO-IMRT or standard IMRT. Participants and speech language therapists were masked to treatment allocation. Radiotherapy was given in 30 fractions over 6 weeks. Dose was 65 Gy to primary and nodal tumour and 54 Gy to remaining pharyngeal subsite and nodal areas at risk of microscopic disease. For DO-IMRT, the volume of the superior and middle pharyngeal constrictor muscle or inferior pharyngeal constrictor muscle lying outside the high-dose target volume had a mandatory 50 Gy mean dose constraint. The primary endpoint was MD Anderson Dysphagia Inventory (MDADI) composite score 12 months after radiotherapy, analysed in the modified intention-to-treat population that included only patients who completed a 12-month assessment; safety was assessed in all randomly assigned patients who received at least one fraction of radiotherapy. The study is registered with the ISRCTN registry, ISRCTN25458988, and is complete.

FINDINGS

From June 24, 2016, to April 27, 2018, 118 patients were registered, 112 of whom were randomly assigned (56 to each treatment group). 22 (20%) participants were female and 90 (80%) were male; median age was 57 years (IQR 52-62). Median follow-up was 39·5 months (IQR 37·8-50·0). Patients in the DO-IMRT group had significantly higher MDADI composite scores at 12 months than patients in the standard IMRT group (mean score 77·7 [SD 16·1] vs 70·6 [17·3]; mean difference 7·2 [95% CI 0·4-13·9]; p=0·037). 25 serious adverse events (16 serious adverse events assessed as unrelated to study treatment [nine in the DO-IMRT group and seven in the standard IMRT group] and nine serious adverse reactions [two vs seven]) were reported in 23 patients. The most common grade 3-4 late adverse events were hearing impairment (nine [16%] of 55 in the DO-IMRT group vs seven [13%] of 55 in the standard IMRT group), dry mouth (three [5%] vs eight [15%]), and dysphagia (three [5%] vs eight [15%]). There were no treatment-related deaths.

INTERPRETATION

Our findings suggest that DO-IMRT improves patient-reported swallowing function compared with standard IMRT. DO-IMRT should be considered a new standard of care for patients receiving radiotherapy for pharyngeal cancers.

FUNDING

Cancer Research UK.

The Impact of Postoperative Radiotherapy on Dietary Function of Head and Neck Cancer Patients after Pharyngoesophageal Reconstruction with Free Jejunal Flap

This study investigated the impact of postoperative radiotherapy (PORT) on dietary function in patients who underwent pharyngoesophageal defect reconstruction using a free jejunal flap. A retrospective chart review of 36 patients who underwent circumferential pharyngoesophageal defect reconstruction using a free jejunal flap was performed. The European Organization for the Research and Treatment of Cancer head and neck cancer module questionnaire was used. Five items related to dietary function were selected and analyzed for changes in scores before and after PORT. Both the PORT and non-PORT groups showed improved dietary function before surgery, and no significant changes were noted at 3 and 12 months postoperatively. Repeated measures ANOVA showed that PORT had no significant impact on dietary function. In univariate analysis, no variable was a significant predictor of the score at 12 months, postoperatively. Previous radiotherapy and neck dissection had a close statistically significant relation. The multivariate analysis showed that neoadjuvant chemotherapy, previous radiotherapy, and neck dissection were significant predictors of the score at 12 months, postoperatively. PORT did not show a significant effect on the 12 months postoperative score. Free jejunal flap is an effective pharyngoesophageal defect reconstruction method that does not cause any dietary function disruption after PORT.

Intensity-modulated radiation therapy in head-and-neck carcinomas: Potential beyond sparing the parotid glands

Head-and-neck cancer (HNC) is in close proximity to several critical structures. Intensity-modulated radiation therapy (IMRT) has the potential of generating highly conformal and concave dose distributions around complex target and is ideally suited for HNC treatment. Conventionally, the focus of IMRT for HNC patients has been on prevention of radiation-induced parotid dysfunction. In the present article, we review the potential of IMRT to reduce the risk of posttreatment aspiration and dysphagia and spare submandibular gland. We also discuss the impact of IMRT on overall survival and quality of life (QoL) for HNC patients. Small retrospective and prospective studies show that reducing dose to adjoining organs at risks is feasible and decreases the risk of posttreatment dysphagia and aspiration without compromising local control. IMRT is associated with improved QoL in several important domains including swallowing, dry mouth, sticky saliva, social eating, and opening of the mouth; however, improvement in global QoL is inconsistent. Delivery of IMRT for HNC is associated with improved survival at nasopharyngeal subsite. Small studies demonstrate improved treatment outcomes with swallowing-sparing IMRT. These results now need validation within the prospective multicenter randomized controlled trial setting.

Predicting Swallowing Outcomes from Objective Videofluoroscopic Timing and Displacement Measures in Head and Neck Cancer Patients

Radiation therapy with or without chemotherapy compromises swallowing efficiency and safety in patients with head and neck cancer (HNC). The resulting dysphagia leads to overall morbidity, with altered diets, reduced nutritional intake, reduced quality of life, and potential interruption of curative cancer treatment. Despite well-documented radiation-related changes in swallowing physiology, scarce research exists on the potential clinical value for measurements of swallowing timing and displacement in this population. This study investigated the discriminatory value of quantitative timing and displacement parameters for the Functional Oral Intake Scale and Penetration Aspiration Scale scores using pre- and post-radiation videofluoroscopy data. Swallowtail Software Version 1 (Belldev Medical, Arlington Heights, IL) was used to obtain objective timing and displacement measurements from the pre- and post-radiation videofluoroscopy data for 31 patients who underwent radiation therapy, with or without chemotherapy, for head and neck cancer. The total pharyngeal transit time (BP2) (p < 0.000, r = 0.43) in pudding bolus trials and the maximal upper esophageal sphincter opening (PESMax/cm) (p = 0.001, r = 0.31) in thin bolus trials were discriminatory for Functional Oral Intake Scale (FOIS). Findings suggest that measurement of post-radiation changes using objective and quantitative parameters may offer some discriminatory value regarding future dysphagia risk and prognosis based on total pharyngeal transit time and degree of UES opening. In addition, the results suggest that different bolus types may offer different discriminatory values in HNC population, and that some timing and displacement variables may have discriminatory value for patients' diet levels independent from any aspiration risk.

Radiotherapy dose-volume parameters predict videofluoroscopy-detected dysphagia per DIGEST after IMRT for oropharyngeal cancer: Results of a prospective registry

PURPOSE

Our primary aim was to prospectively validate retrospective dose-response models of chronic radiation-associated dysphagia (RAD) after intensity modulated radiotherapy (IMRT) for oropharyngeal cancer (OPC). The secondary aim was to validate a grade ≥2 cut-point of the published videofluoroscopic dysphagia severity (Dynamic Imaging Grade for Swallowing Toxicity, DIGEST) as radiation dose-dependent.

MATERIAL AND METHODS

Ninety-seven patients enrolled on an IRB-approved prospective registry protocol with stage I-IV OPC underwent pre- and 3-6 month post-RT videofluoroscopy. Dose-volume histograms (DVH) for swallowing regions of interest (ROI) were calculated. Dysphagia severity was graded per DIGEST criteria (dichotomized with grade ≥2 as moderate/severe RAD). Recursive partitioning analysis (RPA) and Bayesian Information Criteria (BIC) were used to identify dose-volume effects associated with moderate/severe RAD.

RESULTS

31% developed moderate/severe RAD (i.e. DIGEST grade ≥2) at 3-6 months after RT. RPA found DVH-derived dosimetric parameters of geniohyoid/mylohyoid (GHM), superior pharyngeal constrictor (SPC), and supraglottic region were associated with DIGEST grade ≥2 RAD. V61 ≥ 18.57% of GHM demonstrated optimal model performance for prediction of DIGEST grade ≥2.

CONCLUSION

The findings from this prospective longitudinal registry validate prior observations that dose to submental musculature predicts for increased burden of dysphagia after oropharyngeal IMRT. Findings also support dichotomization of DIGEST grade ≥2 as a dose-dependent split for use as an endpoint in trials or predictive dose-response analysis of videofluoroscopy results.

An Investigation of the Post-laryngectomy Swallow Using Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

This study investigates the post-laryngectomy swallow. Presence and degree of residue on the post-laryngectomy swallow as observed on videofluoroscopy and FEES is described. In addition, videofluoroscopy and FEES are assessed for reliability and inter-instrument agreement. 30 laryngectomy subjects underwent dysphagia evaluation using simultaneous videofluoroscopy and FEES. These were reviewed post-examination by three expert raters using a rating scale designed for this purpose. Raters were blinded to subject details, type of laryngectomy surgery, pairing of FEES and videofluoroscopy examinations and the scores of other raters. There was a finding of residue in 78% of videofluoroscopy ratings, and 83% of FEES ratings. Comparison of the tools indicated poor inter-rater reliability and poor inter-instrument agreement. Dysphagia is an issue post laryngectomy as measured by patient self-report and by instrumental evaluation. However, alternative dysphagia rating tools and dysphagia evaluation tools are required to enable accurate identification and intervention for underlying swallow physiology post laryngectomy.

[Head and neck intensity-modulated radiation therapy: Normal tissues dose constraints. Pharyngeal constrictor muscles and larynx]

Radio-induced pharyngolaryngeal chronic disorders may challenge the quality of life of head and neck cancer long survivors. Many anatomic structures have been identified as potentially impaired by irradiation and responsible for laryngeal edema, dysphonia and dysphagia. Some dose constraints might be plausible such as keeping the mean dose to the pharyngeal constrictor muscles under 50 to 55Gy, the mean dose to the supra-glottic larynx under 40 to 45Gy and, if feasible, the mean dose to the glottic larynx under 20Gy. A reduction of the dose delivered to the muscles of the floor of the mouth and the cervical esophagus would be beneficial as well. Nevertheless, the publications available do not provide an extensive enough level of proof. One should consider limiting as low as possible the dose delivered to these structures without compromising the quality of irradiation of the target tumor volumes.

IMRT for head and neck cancer: reducing xerostomia and dysphagia

Dysphagia and xerostomia are the main sequellae of chemoradiotherapy for head and neck cancer, and the main factors in reducing long-term patient quality of life. IMRT uses advanced technology to focus the high radiation doses on the targets and avoid irradiation of non-involved tissues. The decisions about sparing organs and tissues whose damage causes xerostomia and dysphagia depends on the evidence for dose-response relationships for the organs causing these sequellae. This paper discusses the evidence for the contribution of radiotherapy to xerostomia via damage of the major salivary glands (parotid and submandibular) and minor salivary glands within the oral cavity, and the contribution of radiotherapy-related effect on important swallowing structures causing dysphagia. Recommendations for dose limits to these organs, based on measurements of xerostomia and dysphagia following radiotherapy, are provided here.

Structured review of papers reporting specific functions in patients with cancer of the head and neck: 2006 - 2013

Health-related quality of life (HRQoL) focuses on 4 core domains: physical and psychological function, social interaction, disease, and treatment-related symptoms, and is a key outcome in patients with cancer of the head and neck. We reviewed papers published between 2006 and 2013 that used validated questionnaires to report functional outcome in this group. A total of 572 papers were identified and 118 of them concerned function. Specific outcomes included anxiety, chewing, maxillectomy, mucositis, pain, shoulder function, and trismus. The specific functions most often identified were xerostomia, speech or voice, and swallowing or dysphagia. A considerable body of evidence has now accumulated on HRQoL and functional outomes although the precise role of HRQoL during the planning of treatment remains controversial. Over time, the emphasis of the studies included has tended to move away from the reporting of outcomes in general to more hypothesis-driven and group-specific work.

Swallowing performance and tube feeding status in patients treated with parotid-sparing intensity-modulated radiotherapy for head and neck cancer

BACKGROUND

The purpose of this prospective study was to evaluate the swallowing performance of patients with head and neck cancer treated with parotid-sparing intensity-modulated radiotherapy (IMRT).

METHODS

Sixty-two patients were recruited. Data were collected before and up to 12 months after treatment. Measures included the Performance Status Scale for head and neck cancer (PSS-HN Normalcy of Diet and Eating in Public subscales), tube feeding status, and 100 mL water swallow test (WST) volume and capacity scores.

RESULTS

There was a significant reduction in PSS-HN and WST scores from baseline to 3 months (p < .001). Significant improvements were observed up to 12 months on the PSS-HN. Swallowing volume and capacity scores recovered but did not reach statistical significance. Tube feeding was not required in 47% of the patients.

CONCLUSION

IMRT significantly impacts on swallowing performance, although there is a trend for improvement up to 12 months after treatment. Our data support a case-by-case approach to tube feeding. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1436-E1444, 2016.

Is aspiration as detected on pretreatment video fluorography, a harbinger of poor quality of life and early mortality in cancers of the upper aerodigestive tract treated with radiotherapy?

Background:

Patients with cancers of the upper aerodigestive tract (head and neck cancer (HNC)) tend to aspirate, either due to disease or treatment. The association of aspiration (documented on video fluorography (VFG)) with quality of life (QOL) and unexpected mortality was studied prospectively in patients treated with simultaneous integrated boost technique of intensity-modulated radiotherapy (SIB-IMRT).

Materials and Methods:

Moderately advanced (stage III/IV) HNC were treated by SIB-IMRT delivering 66 Gy/30 fr, 60 Gy/30 fr, and 54 Gy/30 fr to high, intermediate, and low risk volumes, respectively. They underwent serial VFG and QOL assessments (Quality of Life Questionnaire-Core 30 (QLQ-C30) and head and neck-35 (HN35) European Organisation for Research and Treatment of Cancer (EORTC) tools) at 0, 3, and 6 months. Pharyngeal musculature (PM) was additionally delineated on planning computed tomography (CT) scans as potential organs at risk (OARs).

Results:

Between November 2009 and May 2011, 20 HNC were treated as per protocol. All patients were fit (Karnofsky performance status (KPS) ≥ 80). Based on VFG findings, seven patients (4/9 oropharynx and 3/11 laryngopharynx) were grouped as aspirators (A) and remaining 13 as non-aspirators (NA). The QOL study showed that pretreatment coughing and swallowing difficulties were greater in group A versus NA and remained persistently higher. In group A, deaths attributable to aspiration were seen in 3/7 patients, while none occurred in the NA group (Fisher's exact P = 0.03). The mean PM dose was 60 Gy in both the groups and mean V60 was similar at 69 and 67% in A and NA groups, respectively.

Conclusions:

VFG helps identify patients who aspirate and are at risk of premature death due to its complications, alerting caregivers to direct attention appropriately.

Late radiation-associated dysphagia (late-RAD) with lower cranial neuropathy after oropharyngeal radiotherapy: a preliminary dosimetric comparison

BACKGROUND AND OBJECTIVES

Late radiation-associated dysphagia (late-RAD) is a rare delayed toxicity, in oropharyngeal cancer (OPC) survivors. Prevention of late-RAD is paramount because the functional impairment can be profound and refractory to standard therapies. The objective of this analysis is to identify candidate dosimetric predictors of late-RAD and associated lower cranial neuropathies after radiotherapy (RT) or chemo-RT (CRT) for OPC.

MATERIALS AND METHODS

An unmatched retrospective case-control analysis was conducted. Late-RAD cases were identified among OPC patients treated with definitive RT or CRT. Controls were selected with minimum of 6 years without symptoms of late-RAD. Dysphagia-aspiration related structures (DARS) and regions of interest containing cranial nerve paths (RCCNPs) were retrospectively contoured. Dose volume histograms were calculated. Non-parametric bivariate associations were analyzed with Bonferroni correction and multiple logistic regression models were fit.

RESULTS

Thirty-eight patients were included (12 late-RAD cases, 26 controls). Median latency to late-RAD was 5.8 years (range: 4.5-11.3 years). Lower cranial neuropathies were present in 10 of 12 late-RAD cases. Mean superior pharyngeal constrictor (SPC) dose was higher in cases relative to controls (median: 70.5 vs. 61.6 Gy). Mean SPC dose significantly predicted late-RAD (p = 0.036) and related cranial neuropathies (p = 0.019). RCCNPs did not significantly predict late-RAD or cranial neuropathies.

CONCLUSIONS

SPC dose may predict for late-RAD and related lower cranial neuropathies. These data, and those of previous studies that have associated SPC dose with classical dysphagia endpoints, suggest impetus to constrain dose to the SPCs when possible.

Weight and body mass index in relation to irradiated volume and to overall survival in patients with oropharyngeal cancer: a retrospective cohort study

Background

Weight loss is a common problem in patients with Squamous Cell Carcinoma of the Head and Neck (SCCHN) treated with radiotherapy (RT). The aims of the present study were to determine if treated volume (TV), as a measure of the radiation dose burden, can predict weight loss in patients with oropharyngeal cancer and to analyze weight loss and body mass index (BMI) in the same patient group in relation to 5-year overall survival.

Methods

The ARTSCAN trial is a prospective, randomized, multicenter trial in patients with SCCHN. Nutritional data from the ARTSCAN trial were analyzed retrospectively using univariate and multivariate statistical methods based on information on percentage weight loss from the start of RT up to five months after the termination of RT (study cohort 1, n = 232) and information on patients’ BMI at the start of RT (study cohort 2, n = 203). TV was defined as the volume of the patient receiving at least 95% of the prescribed dose. TV_{64.6 Gy} encompasses macroscopic tumor and TV_{43.7 Gy} elective lymph nodes of the neck.

Results

TV_{64.6 Gy} and TV_{43.7 Gy} were both significantly correlated with higher weight loss up to five months after the termination of RT in study cohort 1 (p < 0.001 for both). BMI at the start of RT was shown to be a prognostic factor for 5-year overall survival in study cohort 2 but weight loss was not. The hazard ratios and 95% confidence intervals were 3.78 (1.46–9.75) and 2.57 (1.43–4.62) in patients with underweight and normal weight, respectively.

Conclusions

TV can predict weight loss during RT in patients with oropharyngeal cancer regardless of clinical stage. A high BMI (>25 kg/m²) at the start of RT is positively associated with survival in patients with oropharyngeal cancer.

Pediatric transoral robotic surgery for oropharyngeal malignancy: a case report

The treatment of oropharyngeal malignancy is associated with numerous functional morbidities. Transoral robotic surgery has been used with increased frequency in adult oropharyngeal malignancy. The benefits include decreased surgical morbidity and improved functional outcomes. Use of transoral robotic has been limited in children. This case represents our experience with a 17-month old child who was diagnosed with a high-grade undifferentiated sarcoma of the soft palate. She was able to be successfully treated with transoral robotic surgery as a part of her multimodal therapy, representing the first case of transoral robotic surgery for an oropharyngeal malignancy in a young child.

Predictors of PEG dependence after IMRT±chemotherapy for oropharyngeal cancer

PURPOSE

To prospectively assess predictors of PEG dependence after IMRT with/without concomitant chemotherapy (CHT).

METHODS AND MATERIALS

One-hundred-seventy-one patients were considered (exclusive RT: 58, RT+CHT: 113; 159/171 treated at a median dose of 70 Gy, 2 Gy/fr). Patients treated with RT+CHT underwent prophylactic PEG insertion; PEG was as needed for the others. A number of clinical factors and dose-volume information concerning oral mucosa (OM), constrictors, masticatory muscles, larynx, esophagus and parotids were available. The 25th/10th percentiles of the duration of PEG dependence were our end-points (respectively 3.3 and 7 months, PEG3/PEG7). Logistic uni and multi-variate (MVA) analyses were performed.

RESULTS

Concerning PEG3, the independent predictors at MVA were: CHT/PEG policy (OR: 6.8, p=0.001), V9.5G_OMGy/week (OR: 1.017, p=0.01), larynx V50 (OR: 1.018, p=0.01) and superior constrictor (SC) D_mean (OR: 1.002, p=0.005); the predictive value of the model (AUC) was 0.818 (95% CI: 0.751-0.873). The independent predictors of PEG7 were: larynx V50 (OR: 1.042, p=0.0005) and SC D_mean (OR: 1.003, p=0.02), symptoms at diagnosis (yes vs no, OR: 3.6, p=0.08) and sex (male vs female, OR: 0.25, p=0.07); AUC was 0.897 (95% CI: 0.841-0.939).

CONCLUSIONS

OM V9.5 Gy/week and CHT/PEG_policy modulate the risk of early PEG dependence. For longer PEG dependence, larynx V50 (or D_mean) and SC D_mean are highly predictive, suggesting that the fibrosis of constrictors and larynx is the main cause.

Practical considerations in reducing swallowing dysfunction following concurrent chemoradiotherapy with intensity-modulated radiotherapy for head and neck cancer

Data have emerged that the addition of concurrent chemotherapy to radiation can lead to swallowing dysfunction that may have an impact on patient quality of life and lead to significant morbidities such as poor nutritional status, enteral feeding tube dependence, and aspiration pneumonia. Although intensity-modulated radiation therapy (IMRT) for head and neck cancer was initially developed to spare the parotid gland to reduce xerostomia, attention has recently focused on its utility to selectively decrease radiation dose to specified anatomic structures responsible for a functional swallow. Recent reports have proposed a variety of dose thresholds or constraints to these swallowing-related structures, which may guide IMRT planning with the aim of reducing dysphagia. This critical review of the current literature assesses the feasibility of IMRT to maintain swallowing function and appraises the various dosimetric parameters that have been proposed to help minimize long-term dysphagia.

Risk model and nomogram for dysphagia and xerostomia prediction in head and neck cancer patients treated by radiotherapy and/or chemotherapy

In our randomized trial on hyperbaric oxygen (HBO), it was shown that HBO could reduce dysphagia and xerostomia, which are frequently encountered after (chemo-) radiotherapy (RT) and/or surgery for head and neck cancer (HNC). A risk model and nomogram are developed to select those patients who most likely will respond to HBO treatment. A total of 434 HNC patients treated from 2000 to 2008 were analyzed and filled out the EORTC QLQC-30 and H&N35 questionnaires. Age, gender, chemotherapy, T and N stages, site, radiotherapy technique, RT boost, surgery of the primary tumor and neck, bilateral RT, and dose were analyzed in a statistical model. The discriminative value of the model was evaluated based on receiver operating characteristics (ROC), the area under the curve (AUC), sensitivity, specificity, and proportion of correctly classified measures. Significant factors in predicting swallowing problems are age, follow-up duration, tumor site, chemotherapy, surgery of the primary tumor and neck, and dose. For dry mouth, the significant factors are age, gender, tumor site, N stage, chemotherapy, and bilateral irradiation. For dysphagia and xerostomia, the area under the ROC curve is 0.7034 and 0.7224, respectively, with a specificity of 89/77%, sensitivity of 27/58%, and a positive predictive value of 83/67% for dysphagia and xerostomia, respectively. The developed predictive risk model could be used to select patients for costly hyperbaric oxygen treatment to prevent or reduce severe late side effects of HNC treatment. Our model serves as a guideline for the Department of Radiation Oncology to reduce costs by excluding patients not amenable to hyperbaric oxygen protocols. The nomogram presented is a useful tool for clinicians in assessing patient risks when deciding on follow-up strategies (e.g., hyperbaric oxygen treatment) after RT or surgery for HNC.

Hypopharyngeal dose is associated with severe late toxicity in locally advanced head-and-neck cancer: an RTOG analysis

PURPOSE

Concurrent chemoradiation therapy (CCRT) for squamous cell carcinoma of the head and neck (SCCHN) increases local tumor control but at the expense of increased toxicity. We recently showed that several clinical/pretreatment factors were associated with the occurrence of severe late toxicity. This study evaluated the potential relationship between radiation dose delivered to the pharyngeal wall and toxicity.

METHODS AND MATERIALS

This was an analysis of long-term survivors from 3 previously reported Radiation Therapy Oncology Group (RTOG) trials of CCRT for locally advanced SCCHN (RTOG trials 91-11, 97-03, and 99-14). Severe late toxicity was defined in this secondary analysis as chronic grade 3-4 pharyngeal/laryngeal toxicity and/or requirement for a feeding tube≥2 years after registration and/or potential treatment-related death (eg, pneumonia) within 3 years. Radiation dosimetry (2-dimensional) analysis was performed centrally at RTOG headquarters to estimate doses to 4 regions of interest along the pharyngeal wall (superior oropharynx, inferior oropharynx, superior hypopharynx, and inferior hypopharynx). Case-control analysis was performed with a multivariate logistic regression model that included pretreatment and treatment potential factors.

RESULTS

A total of 154 patients were evaluable for this analysis, 71 cases (patients with severe late toxicities) and 83 controls; thus, 46% of evaluable patients had a severe late toxicity. On multivariate analysis, significant variables correlated with the development of severe late toxicity, including older age (odds ratio, 1.062 per year; P=.0021) and radiation dose received by the inferior hypopharynx (odds ratio, 1.023 per Gy; P=.016). The subgroup of patients receiving ≤60 Gy to the inferior hypopharynx had a 40% rate of severe late toxicity compared with 56% for patients receiving >60 Gy. Oropharyngeal dose was not associated with this outcome.

CONCLUSIONS

Severe late toxicity following CCRT is common in long-term survivors. Age is the most significant factor, but hypopharyngeal dose also was associated.

Performance of the EORTC questionnaire for the assessment of quality of life in head and neck cancer patients EORTC QLQ-H&N35: a methodological review

PURPOSE

The EORTC QLQ-H&N35 (H&N35) is widely used to measure quality of life in head and neck cancer patients. The aims of this study were to obtain insight into a) the languages in which the H&N35 has been used and the psychometric properties in those languages, b) the study designs, and c) its acceptance by patients and investigators.

METHODS

A systematic literature review was performed searching for all original papers that had used at least one item of the H&N35. Identified papers were read and the information about methodological issues abstracted statistically analysed.

RESULTS

A total of 136 papers were identified. The H&N35 was administered in 19 different languages in 27 countries. The study design was cross-sectional in the majority of studies (53 %), prospective cohort studies (31 %), phase-II-trials (7 %), phase-III-trials (6 %) and case-control studies (1 %). The scales with the highest percentages of missing values were Sexuality (11.5 %) and Speech (7 %). The median Cronbach's alpha of the multi-item scales ranged from 0.61 (Senses) to 0.93 (Sexuality). Construct validity was rarely investigated. On average, 12 scales (range 0-18) of the instrument were used by the investigators. The scale most often used was swallowing (in 85 % of studies) and least often used was Weight Gain (39 %).

CONCLUSION

The H&N35 is widely used throughout the world, mainly in observational studies, and has demonstrated robust psychometric features in different languages. However, some methodological problems reported imply that the instrument can be improved in some areas.

Emerging understanding of dosimetric factors impacting on dysphagia and nutrition following radiotherapy for oropharyngeal cancer

BACKGROUND

Research has reported relationships between 3-dimensional (3D) radiation dose to head and neck structures and consequential swallowing/nutritional outcomes. However, this evidence is preliminary. The current study aimed to identify which reported dose constraints identified functional impairment at 6 months posttreatment.

METHODS

Dose constraints with reported relationships to swallowing and nutrition were identified through a systematic literature review. Dose-volume histograms for 12 patients with T1-T3 oropharyngeal cancer treated with 3D conformal radiotherapy determined dosages delivered to specific structures. Doses were examined in relation to published dose constraints and the swallowing and nutritional outcomes at 6 months posttreatment.

RESULTS

In all, 66% of the reported mean, maximum, and partial doses to 8 structures correctly identified swallowing and nutrition outcomes at 6 months.

CONCLUSION

The relationships observed between known dosimetric constraints and functional outcomes highlight the potential for dosimetric data to assist in prognosis and treatment. Systematic research is required to refine dosimetric parameters and the impact on functional outcomes.

Swallowing dysfunction in head and neck cancer patients treated by radiotherapy: review and recommendations of the supportive task group of the Italian Association of Radiation Oncology

PURPOSE

Dysphagia is a debilitating complication in head and neck cancer patients (HNCPs) that may cause a high mortality rate for aspiration pneumonia. The aims of this paper were to summarize the normal swallowing mechanism focusing on its anatomo-physiology, to review the relevant literature in order to identify the main causes of dysphagia in HNCPs and to develop recommendations to be adopted for radiation oncology patients. The chemotherapy and surgery considerations on this topic were reported in recommendations only when they were supposed to increase the adverse effects of radiotherapy on dysphagia.

MATERIALS AND METHODS

The review of literature was focused on studies reporting dysphagia as a pre-treatment evaluation and as cancer and cancer therapy related side-effects, respectively. Relevant literature through the primary literature search and by articles identified in references was considered. The members of the group discussed the results and elaborated recommendations according to the Oxford CRBM levels of evidence and recommendations. The recommendations were revised by external Radiation Oncology, Ear Nose and Throat (ENT), Medical Oncology and Speech Language Pathology (SLP) experts.

RESULTS

Recommendations on pre-treatment assessment and on patients submitted to radiotherapy were given. The effects of concurrent therapies (i.e. surgery or chemotherapy) were taken into account.

CONCLUSIONS

In HNCPs treatment, disease control has to be considered in tandem with functional impact on swallowing function. SLPs should be included in a multidisciplinary approach to head and neck cancer.

Predictive modelling for swallowing dysfunction after primary (chemo)radiation: results of a prospective observational study

BACKGROUND AND PURPOSE

The purpose of this large multicentre prospective cohort study was to identify which dose volume histogram parameters and pre-treatment factors are most important to predict physician-rated and patient-rated radiation-induced swallowing dysfunction (RISD) in order to develop predictive models for RISD after curative (chemo) radiotherapy ((CH) RT).

MATERIAL AND METHODS

The study population consisted of 354 consecutive head and neck cancer patients treated with (CH) RT. The primary endpoint was grade 2 or more swallowing dysfunction according to the RTOG/EORTC late radiation morbidity scoring criteria at 6 months after (CH) RT. The secondary endpoints were patient-rated swallowing complaints as assessed with the EORTC QLQ-H&N35 questionnaire. To select the most predictive variables a multivariate logistic regression analysis with bootstrapping was used.

RESULTS

At 6 months after (CH) RT the bootstrapping procedure revealed that a model based on the mean dose to the superior pharyngeal constrictor muscle (PCM) and mean dose to the supraglottic larynx was most predictive. For the secondary endpoints different predictive models were found: for problems with swallowing liquids the most predictive factors were the mean dose to the supraglottic larynx and radiation technique (3D-CRT versus IMRT). For problems with swallowing soft food the mean dose to the middle PCM, age (18-65 versus >65 years), tumour site (naso/oropharynx versus other sites) and radiation technique (3D-CRT versus IMRT) were the most predictive factors. For problems with swallowing solid food the most predictive factors were the mean dose to the superior PCM, the mean dose to the supraglottic larynx and age (18-65 versus >65 years). And for choking when swallowing the V60 of the oesophageal inlet muscle and the mean dose to the supraglottic larynx were the most predictive factors.

CONCLUSIONS

Physician-rated and patient-rated RISD in head and neck cancer patients treated with (CH) RT cannot be predicted with univariate relationships between the dose distribution in a single organ at risk and an endpoint. Separate predictive models are needed for different endpoints and factors other than dose volume histogram parameters are important as well.

[Intensity-modulated radiation therapy for anal carcinoma]

Anal canal carcinoma are highly curable by irradiation, combined with chemotherapy in locally advanced disease, with preservation of sphincter function. The clinical target volume for the nodes is extended, often including the inguinal nodes, which is not usual for other pelvic tumours. Acute and late effects are correlated with the volume and dose delivered to organs at risk, i. e. small bowel, bladder and increased by concomitant chemotherapy. Intensity modulated irradiation (IMRT) makes it possible to optimize the dose distribution in this "complex U shaped" volume, while maintaining the dose distribution for the target volumes. The conversion from conformal irradiation to IMRT necessitates good knowledge of the definition and skills to delineate target volumes and organs at risk, including new volumes needed to optimize the dose distribution. Dosimetric and clinical benefits of IMRT are described, based on early descriptions and evidence-based publication. The growing development of IMRT in anal canal radiotherapy must be encouraged, and long-term benefits should be soon published. Radiation oncologists should precisely learn IMRT recommendations before starting the technique, and evaluate its early and late results for adverse effects, but also for long-term tumour control.

Organ-sparing radiation therapy for head and neck cancer

To improve locoregional tumor control and survival in patients with locally advanced head and neck cancer (HNC), therapy is intensified using altered fractionation radiation therapy or concomitant chemotherapy. However, intensification of therapy has been associated with increased acute and late toxic effects. The application of advanced radiation techniques, such as 3D conformal radiation therapy and intensity-modulated radiation therapy, is expected to improve the therapeutic index of radiation therapy for HNC by limiting the dose to critical organs and possibly increasing locoregional tumor control. To date, Review articles have covered the prevention and treatment of radiation-induced xerostomia and dysphagia, but few articles have discussed the prevention of hearing loss, brain necrosis, cranial nerve palsy and osteoradionecrosis of the mandible, which are all potential complications of radiation therapy for HNC. This Review describes the efforts to prevent therapy-related complications by presenting the state of the art evidence regarding advanced radiation therapy technology as an organ-sparing approach.

Dysphagia after Nonsurgical Head and Neck Cancer Treatment

Objective. Assess patients’ perspectives on the severity, time course, and relative importance of swallowing deficit before and after (chemo)radiotherapy for head and neck cancer.

Study Design. Before-and-after cohort study.

Setting. Head and neck cancer UK multidisciplinary clinic.

Subjects and Methods. A total of 167 patients with a primary cancer, mostly laryngopharyngeal, completed the MD Anderson Dysphagia Index (MDADI) and the University of Washington Quality of Life Questionnaire (UWQOL) before treatment and at 3, 6, and 12 months. Pretreatment swallowing, age, gender, and tumor site and stage were assessed. Statistical methods used were Mann-Whitney, analysis of variance, and logistic regression.

Results. There was a sharp deterioration in swallowing on average by 18%, from before treatment to 3 months post treatment (mean difference in MDADI score = 14.5; P < .001). Treatment schedule, pretreatment score, and age accounted for 37% of the variance in 3-month posttreatment MDADI scores. There was then little improvement from 3 to 12 months. Patients treated with only 50-Gy radiotherapy reported significantly less dysphagia at 1 year than patients receiving higher doses or combined chemoradiation ( P < .001). Swallowing was the most commonly prioritized of the 12 UWQOL domains both before and after therapy. The MDADI and UWQOL scores were strongly correlated: ρ > 0.69.

Conclusion. Swallowing is a top priority before and after treatment for the vast majority of patients with head and neck cancer. Swallowing deteriorates significantly posttreatment ( P < .001). Treatment intensity, younger age, and lower pretreatment scores predict long-term dysphagia. After chemoradiation, there is little improvement from 3 to 12 months.

Evidence-based organ-sparing radiotherapy in head and neck cancer

Intensification of radiotherapy treatment for locally advanced head and neck cancer by use of altered fractionation schedules or concomitant chemotherapy has resulted in substantially improved locoregional control and survival. However, these improvements have come at the cost of increased acute, and late, toxic effects. The application of technological advances, such as intensity-modulated radiotherapy, is expected to further improve the therapeutic index of radiotherapy for head and neck cancer, by limiting toxicity and possibly by increasing locoregional control. However, the organ-sparing potential of such highly conformal radiotherapy techniques relies heavily on the appropriate selection and accurate delineation of the crucial organs at risk, with the application of rigorous dose constraints during planning. Because xerostomia and dysphagia are the main causes of decreased quality of life after radiotherapy for head and neck cancer, the prevention of these two complications will form the focus of this review.

Clinical-dosimetric analysis of measures of dysphagia including gastrostomy-tube dependence among head and neck cancer patients treated definitively by intensity-modulated radiotherapy with concurrent chemotherapy

Purpose

To investigate the association between dose to various anatomical structures and dysphagia among patients with head and neck cancer treated by definitive intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy.

Methods and materials

Thirty-nine patients with squamous cancer of the head and neck were treated by definitive concurrent chemotherapy and IMRT to a median dose of 70 Gy (range, 68 to 72). In each patient, a gastrostomy tube (GT) was prophylacticly placed prior to starting treatment. Prolonged GT dependence was defined as exceeding the median GT duration of 192 days. Dysphagia was scored using standardized quality-of-life instruments. Dose-volume histogram (DVH) data incorporating the superior/middle pharyngeal constrictors (SMPC), inferior pharyngeal constrictor (IPC), cricoid pharyngeal inlet (CPI), and cervical esophagus (CE) were analyzed in relation to prolonged GT dependence, dysphagia, and weight loss.

Results

At 3 months and 6 months after treatment, 87% and 44% of patients, respectively, were GT dependent. Spearman's ρ analysis identified statistical correlations (p < 0.05) between prolonged GT dependence or high grade dysphagia with IPC V65, IPC V60, IPC Dmean, and CPI Dmax. Logistic regression model showed that IPC V65 > 30%, IPC V60 > 60%, IPC Dmean > 60 Gy, and CPI Dmax > 62 Gy predicted for greater than 50% probability of prolonged GT dependence.

Conclusion

Our analysis suggests that adhering to the following parameters may decrease the risk of prolonged GT dependence and dysphagia: IPC V65 < 15%, IPC V60 < 40%, IPC Dmean < 55 Gy, and CPI Dmax < 60 Gy.