Dosimetric Factors Associated With Long-Term Dysphagia After Definitive Radiotherapy for Squamous Cell Carcinoma of the Head and Neck
Intensification of radiotherapy and chemotherapy for head-and-neck cancer may lead to increased rates of dysphagia. Dosimetric predictors of objective findings of long-term dysphagia were sought.
From an institutional database, 83 patients were identified who underwent definitive intensity-modulated radiotherapy for squamous cell carcinoma of the head and neck, after exclusion of those who were treated for a second or recurrent head-and-neck primary lesion, had locoregional recurrence at any time, had less than 12 months of follow-up, or had postoperative radiotherapy. Dosimetric parameters were analyzed relative to three objective endpoints as a surrogate for severe long-term dysphagia: percutaneous endoscopic gastrostomy (PEG) tube dependence at 12 months, aspiration on modified barium swallow, or pharyngoesophageal stricture requiring dilation.
Mean dose greater than 41 Gy and volume receiving 60 Gy (V(60)) greater than 24% to the larynx were significantly associated with PEG tube dependence and aspiration. V(60) greater than 12% to the inferior pharyngeal constrictor was also significantly associated with increased PEG tube dependence and aspiration. V(65) greater than 33% to the superior pharyngeal constrictor or greater than 75% to the middle pharyngeal constrictor was associated with pharyngoesophageal stricture requiring dilation.
Doses to the larynx and pharyngeal constrictors predicted long-term swallowing complications, even when controlled for other clinical factors. The addition of these structures to intensity-modulated radiotherapy optimization may reduce the incidence of dysphagia, although cautious clinical validation is necessary.
Available from: Judith E Raber-Durlacher
- "As a consequence, RT techniques sparing the above-mentioned structures have been employed and they seem to improve patients' health-related quality of life (HRQoL) (Pow et al., 2006; Nutting et al., 2011; Bhide et al., 2009), even when RT is combined with CT (Hancock et al., 2003; Roe et al., 2010; Van der Laan et al., 2012). Yet, few studies report the exact dose-volume correlation for each individual DARS, AMRS and XRS (Nutting et al., 2011; Caudell et al., 2010; Eisbruch et al., 2011; Jensen et al., 2007; Levendag et al., 2007; Li et al., 2009; Bhide et al., 2012), and the majority of these are retrospective. However, recently published reviews (Van der Laan et al., 2012; Nutting, 2012; Wang et al., 2011; Goldstein et al., 1999) concluded that a number of the structures' dosimetric constraints might reduce the negative impact of RT on swallowing. "
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ABSTRACT: Radiotherapy alone or in combination with chemotherapy and/or surgery is the typical treatment for head and neck cancer patients. Acute side effects (such as oral mucositis, dermatitis, salivary changes, taste alterations, etc.), and late toxicities in particular (such as osteo-radionecrosis, hypo-salivation and xerostomia, trismus, radiation caries etc.), are often debilitating. These effects tend to be underestimated and insufficiently addressed in the medical community. A multidisciplinary group of head and neck cancer specialists met in Milan with the aim of reaching a consensus on clinical definitions and management of these toxicities. The Delphi Appropriateness method was used for developing the consensus, and external experts evaluated the conclusions. This paper contains 10 clusters of statements about the clinical definitions and management of head and neck cancer treatment sequels (dental pathologies and osteo-radionecroses) that reached consensus, and offers a review of the literature about these topics. The review was split into two parts: the first part dealt with dental pathologies and osteo-radionecroses (10 clusters of statements), whereas this second part deals with trismus and xerostomia.
Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Available from: Arjen van der Schaaf
- "The treatment of these patients with radiotherapy (RT), chemoradiation (CRT) or radiotherapy plus cetuximab (CetRT) may further affect swallowing function, eventually leading to tube feeding dependence. Incidences of tube feeding dependence at 2 years after treatment of up to 51% have been reported     . Ronis et al. showed that at 1 year after treatment, the presence of a feeding tube was the most powerful predictor of quality of life in HNC patients , thus indicating the clinical importance of preventing tube feeding dependence. "
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ABSTRACT: Background and purpose:
Curative radiotherapy/chemo-radiotherapy for head and neck cancer (HNC) may result in severe acute and late side effects, including tube feeding dependence. The purpose of this prospective cohort study was to develop a multivariable normal tissue complication probability (NTCP) model for tube feeding dependence 6 months (TUBEM6) after definitive radiotherapy, radiotherapy plus cetuximab or concurrent chemoradiation based on pre-treatment and treatment characteristics.
Materials and methods:
The study included 355 patients with HNC. TUBEM6 was scored prospectively in a standard follow-up program. To design the prediction model, the penalized learning method LASSO was used, with TUBEM6 as the endpoint.
The prevalence of TUBEM6 was 10.7%. The multivariable model with the best performance consisted of the variables: advanced T-stage, moderate to severe weight loss at baseline, accelerated radiotherapy, chemoradiation, radiotherapy plus cetuximab, the mean dose to the superior and inferior pharyngeal constrictor muscle, to the contralateral parotid gland and to the cricopharyngeal muscle.
We developed a multivariable NTCP model for TUBEM6 to identify patients at risk for tube feeding dependence. The dosimetric variables can be used to optimize radiotherapy treatment planning aiming at prevention of tube feeding dependence and to estimate the benefit of new radiation technologies.
Available from: Charlotte L Brouwer
- "We decided to use this publication as a reference as it was the only one dedicated to the description of SWOARs delineation guidelines and because these guidelines were actually used in a subsequent publication that reported on the development of multivariate NTCP-models for different endpoints related to dysphagia . This publication also included an overview of eight other guidelines for delineation of SWOARs that were published between 2000 and 2010        . "
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To test the hypothesis that delineation of swallowing organs at risk (SWOARs) based on different guidelines results in differences in dose–volume parameters and subsequent normal tissue complication probability (NTCP) values for dysphagia-related endpoints.
Materials and methods
Nine different SWOARs were delineated according to five different delineation guidelines in 29 patients. Reference delineation was performed according to the guidelines and NTCP-models of Christianen et al. Concordance Index (CI), dosimetric consequences, as well as differences in the subsequent NTCPs were calculated.
The median CI of the different delineation guidelines with the reference guidelines was 0.54 for the pharyngeal constrictor muscles, 0.56 for the laryngeal structures and 0.07 for the cricopharyngeal muscle and esophageal inlet muscle. The average difference in mean dose to the SWOARs between the guidelines with the largest difference (maxΔD) was 3.5 ± 3.2 Gy. A mean ΔNTCP of 2.3 ± 2.7% was found. For two patients, ΔNTCP exceeded 10%.
The majority of the patients showed little differences in NTCPs between the different delineation guidelines. However, large NTCP differences >10% were found in 7% of the patients. For correct use of NTCP models in individual patients, uniform delineation guidelines are of great importance.
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