Manual Therapy for Patients With Radiation-Associated Trismus After Head and Neck Cancer

Importance

Trismus is highly prevalent in head and neck cancer (HNC) survivorship. Current standards for trismus treatment include various stretch-based exercise protocols as a primary and single treatment modality with limited evidence regarding the role of manual therapy (MT) for this indication.

Objective

To assess the effect size and associations of response to MT to increase oral opening in the setting of radiation-associated trismus.

Design, Setting, and Participants

This retrospective case series was conducted at the University of Texas MD Anderson Cancer Center between 2016 and March 2020 (before COVID-19 interruption) and included 49 disease-free survivors of HNC who were referred for treatment of radiation-associated trismus.

Intervention

Intraoral MT (including or excluding external head and neck) targeting the muscles of mastication.

Main Outcomes and Measures

Maximum interincisal opening (MIO) before and after the initial MT session compared with serial MT sessions. Covariates were examined to determine the association with response to MT for trismus.

Results

A total of 49 survivors of HNC (13 women [27%]; 24 [49%] 64 years or younger; 25 [51%] 65 years or older; mean [range] of 6.6 [0-33] years postradiotherapy were included, 9 [18.4%] of whom underwent a single MT session; 40 [81.6%] who underwent multiple sessions [mean, 6; median (range), 3 (2-48)]). The MIO improved after a single session by a mean (SD) of 4.1 (1.9) mm (0.45 effect size) and after serial MT sessions by a mean (SD) of 6.4 (4.8) mm with an effect size of 0.7. No covariates were found to be clinically meaningfully associated with MIO improvement following MT.

Conclusions and Relevance

The findings of this case series study suggest that MT improved MIO with a medium to large effect size in survivors of HNC with radiation-associated trismus. The results suggest that the largest increase in oral opening was achieved after the initial treatment and although gains were more modest, oral opening continued to improve with serial treatment. Covariates were not associated with MT response, suggesting that patients with clinical features often considered treatment refractory (eg, advanced disease, multiple lines of oncology treatment, ≥5 years posttreatment) may benefit from treatment with MT. Manual therapy may be a beneficial frontline or adjuvant treatment when combined with traditional stretching therapy. A clinically meaningful increase in oral opening has the potential to improve swallow function, speech, pain, and quality of life.

Manual Therapy for Fibrosis-Related Late Effect Dysphagia in head and neck cancer survivors: the pilot MANTLE trial

INTRODUCTION

Late dysphagia that develops or persists years after head and neck cancer (HNC) is a disabling survivorship issue. Fibrosis is thought to stiffen connective tissues and compress peripheral nerve tracts, thereby contributing to diminished strength, flexibility, and in some cases denervation of swallowing muscles. Manual therapy (MT) is used in cancer survivors for pain and other indications, but it is unknown if increasing blood flow, flexibility and cervical range of motion (CROM) in the head and neck may improve late dysphagia.

METHODS AND ANALYSIS

Manual Therapy for Fibrosis-Related Late Effect Dysphagia (MANTLE) is a National Cancer Institute-funded prospective single-arm pilot trial evaluating the feasibility, safety and therapeutic potential of MT in patients with late dysphagia after radiotherapy (RT) for HNC. Disease-free survivors ≥2 years after curative-intent RT for HNC with at least moderate dysphagia and grade ≥2 Common Terminology Criteria for Adverse Events version 4.0 fibrosis are eligible. The target sample size is 24 participants who begin the MANTLE programme. MANTLE is delivered in 10 MT sessions over 6 weeks with an accompanying home exercise programme (HEP). Patients then transition to a 6-week post-washout period during which they complete the HEP and then return for a final post-washout evaluation. Feasibility (primary endpoint) and safety will be examined. Serial assessments include CROM, modified barium swallow studies, quantitative MRI, electromyography (optional) and patient-reported outcomes as secondary, tertiary and exploratory endpoints.

ETHICS AND DISSEMINATION

The research protocol and informed consent document was approved by the Institutional Review Board at the University of Texas MD Anderson Cancer Center. Findings will be disseminated through peer-reviewed publication that will be made publicly available on PubMed Central on acceptance for publication, in compliance with NIH public access policy.

TRIAL REGISTRATION NUMBER

NCT03612531.

Assessment of vessel wall thickness in carotid atherosclerosis using spiral CT angiography

OBJECTIVES

the purpose of this study was to evaluate the amount of vessel wall thickening in the internal and common carotid arteries in patients undergoing spiral CT angiography for the investigation of significant atherosclerotic disease.

MATERIALS AND METHODS

forty-five carotid systems in patients with a 70% or greater stenosis (according to carotid duplex) were imaged with CT spiral angiography using a standardised protocol. The vessel wall thickness of the distal common and mid internal carotid artery was measured using axial CT sections.

RESULTS

vessel wall thickness was greater and more variable within the common carotid artery than within the internal carotid artery. The mean proportion of total vessel diameter constituted by vessel wall thickness was significantly greater in the common carotid artery as compared to the internal carotid artery: 28+/-12% (SD) vs 15+/-6%, respectively (p < 0.001).

CONCLUSIONS

significant and extended wall thickening is commonly present in the internal and common carotid arteries of patients with atherosclerotic disease, but the internal carotid artery is significantly less affected than the common carotid artery. These observations question the validity of using the common carotid artery as a reference vessel for angiographic stenosis measurements.

Evaluation of cross-sectional luminal morphology in carotid atherosclerotic disease by use of spiral CT angiography

BACKGROUND AND PURPOSE

This study sought to determine the frequency of noncircular lumens in patients with significant carotid atherosclerotic disease and to evaluate the effect of noncircular lumens on stenosis measurement derived from angiographic projections.

METHODS

One hundred consecutive patients presenting with an internal carotid artery stenosis of at least 50% were imaged with spiral CT angiography. The transverse morphology of the diseased lumen was assessed on axial images, and the frequency of noncircular lumens was determined. In these cases, maximum intensity projection angiograms were reconstructed in standardized angiographic planes and in a plane selected according to the luminal obliquity, which was chosen to optimize the angiographic representation of the maximal stenosis. North American Symptomatic Carotid Endarterectomy Trial (NASCET) measurements were calculated from the maximum intensity projection images, and differences between values obtained from standard and optimized projections were recorded.

RESULTS

Noncircular lumens were observed in 18 of 100 patients and consisted of elliptical and linear transverse profiles. The transverse orientation of the lumen in these cases ranged from +90 degrees to -87 degrees relative to the anteroposterior plane. An increase in the calculated NASCET stenosis was demonstrated when measurements were obtained from angiographic reconstructions obtained in the exact plane of the luminal obliquity compared with standard angiographic projections. As a result, the stenosis severity was upgraded from moderate to severe in 2 patients.

CONCLUSIONS

Noncircular transverse luminal profiles are not uncommon and may introduce error into NASCET calculations obtained from standard angiographic projections.

Telomerase activity in malignant and benign renal tumors

OBJECTIVES

An important characteristic of malignant cells is their unlimited replicative potential, their immortality. In conferring this immortality, the enzyme telomerase is believed to play a crucial role. The detection of telomerase activity provides new knowledge regarding the biologic growth behavior of tumors and offers new diagnostic and therapeutic tools.

METHODS

In the present study the sensitive TRAP assay (telomeric repeat amplification protocol) was used to examine 44 malignant renal tumors and 8 benign tumors of the kidney and 52 specimens of normal renal tissue for telomerase activity.

RESULTS

Telomerase activity was detected in 63% of tissue samples obtained from histologically confirmed renal cell carcinomas. In cases of renal cell carcinoma restricted to the kidney, telomerase activity was detected in 58%. In cases in which tumor growth has progressed beyond the limits of the organ, telomerase activity was found in 69%. This stage dependence, however, did not reach statistical significance. No correlation to tumor grading was observed. Telomerase activity was found less frequent in chromophobe renal cell carcinomas. Neither the 8 benign renal tumors (4 oncocytomas and 4 angiomyolipomas) nor the specimens of normal kidney showed any evidence of telomerase activity.

CONCLUSIONS

The proportion of remarkable slow-growing renal cell carcinomas showing telomerase activity is less than in other malignancies and may correlate with biologic growth behavior. Possible explanations include the presence of an alternative pathway, called ALT (alternative lengthening of telomeres) and an association with the loss or presence of the telomerase suppressor on the short arm of chromosome 3. Prolonged follow-up will be of special interest to determine whether lack of telomerase activity predicts favorable outcome.