Dysphagia after chemoradiotherapy
Dysphagia 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

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Abstract

Background and purpose

Prospective assessment of dysphagia and trismus in chemo-IMRT head and neck cancer patients in relation to dose-parameters of structures involved in swallowing and mastication.

Material and methods

Assessment of 55 patients before, 10-weeks (N = 49) and 1-year post-treatment (N = 37). Calculation of dose–volume parameters for swallowing (inferior (IC), middle (MC), and superior constrictors (SC)), and mastication structures (e.g. masseter). Investigation of relationships between dose-parameters and endpoints for swallowing problems (videofluoroscopy-based laryngeal Penetration-Aspiration Scale (PAS), and study-specific structured questionnaire) and limited mouth-opening (measurements and questionnaire), taking into account baseline scores.

Results

At 10-weeks, volume of IC receiving ⩾60 Gy (V60) and mean dose IC were significant predictors for PAS. One-year post-treatment, reported problems with swallowing solids were significantly related to masseter dose-parameters (mean, V20, V40 and V60) and an inverse relationship (lower dose related to a higher probability) was observed for V60 of the IC. Dose-parameters of masseter and pterygoid muscles were significant predictors of trismus at 10-weeks (mean, V20, and V40). At 1-year, dose-parameters of all mastication structures were strong predictors for subjective mouth-opening problems (mean, max, V20, V40, and V60).

Conclusions

Dose–effect relationships exist for dysphagia and trismus. Therefore treatment plans should be optimized to avoid these side effects.

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.

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