Dysphagia after chemoradiotherapyDysphagia and trismus after concomitant chemo-Intensity-Modulated Radiation Therapy (chemo-IMRT) in advanced head and neck cancer; dose–effect relationships for swallowing and mastication structures
Section snippets
Patient characteristics
Patients with advanced stage squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, larynx, or nasopharynx treated at our Institute with chemo-IMRT were enrolled in this study. Informed written consent was obtained from all patients prior to participation in the study. Patients were included when they had advanced stage (III and IV), functional or anatomical inoperable disease, and when able to comprehend and conduct the exercises in the swallowing programs mentioned in the
Results
Of the 55 patients included, 29 patients (53%) had a primary cancer in the oral cavity/oropharynx, 19 patients (35%) in the laryngo/hypopharynx, and 7 patients (13%) in the nasopharynx (Table 1). A total of 48 patients had completed the chemo-IMRT treatment successfully and could be evaluated at 10 weeks after the end of treatment (range 9–12 weeks; one outlier at 16 weeks). Six patients discontinued the treatment because of death (N = 2), progressive disease (N = 2), patient refusal (N = 1), and change
Discussion
The presented data show that the first question of this paper can be answered positively. There are dose–effect relationships between the radiation doses to the critical swallowing and mastication structures and dysphagia and trismus endpoints. In summary, objective dysphagia (PAS), correlated significantly to the inferior constrictor (IC). Subjective patient-reported problems with swallowing solids at 10 weeks post-treatment correlated with the radiation dose to the IC and masseter muscle, and
Limitations of the present study
In the present study, the effects on the pharyngeal constrictor muscles, and mastication structures were analyzed. It is clearly of interest to also evaluate the influence of the mean radiation doses on other key structures involved in swallowing (e.g. the base of tongue, supraglottic larynx, glottis, upper esophageal sphincter, and the esophagus). This was indeed recommended recently by a panel of experts [23] and should definitely be considered in future studies of this kind.
Conclusions
The present study shows that dose relationships between dysphagia and trismus measures and the radiation doses to the critical swallowing-, and mastication structures exist. However, since dose relationships seem to vary at different measurement points, a strict multidimensional assessment protocol, including objective and subjective assessment, is mandatory. No thresholds were found, but delineation of organs at risk, especially the masseter muscle, for treatment planning is essential to
Conflict of interest
Part of the study is supported by an unrestricted research grant from Atos Medical AB, Hörby, Sweden.
Acknowledgement
The authors would like to express gratitude to Jasper Nijkamp for his assistance with the software that was used to outline the organs at risk.
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Present address: Academic Medical Center, Department of Radiation Oncology, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands.