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Pattern of dysphagia after swallowing-sparing intensity-modulated radiotherapy (IMRT) of head and neck cancers: results of a mono-institutional prospective study

Muster von Dysphagie nach intensitätsmodulierter Strahlentherapie unter Schonung schluckrelevanter Strukturen bei Kopf-Hals-Tumoren: Ergebnisse einer monoinstitutionellen prospektiven Studie

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Abstract

Background and purpose

A prospective instrumental assessment of late dysphagia using swallowing organs at risk (SWOARs)-sparing IMRT for nasopharyngeal and oropharyngeal cancers.

Materials and methods

Objective instrumental assessment included fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy (VFS) at baseline, and at 6 and 12 months after treatment. FEES assessed the pharyngeal residue according to the Farneti pooling score (P-score) as follows: 4–5 no dysphagia; 6–7 mild dysphagia; 8–9 moderate dysphagia; 10–11 severe dysphagia. Three different consistencies were tested for the P‑score: liquid (L), semisolid (SS), and solid (S). VFS assessed penetration-aspiration according to the Penetration-Aspiration Scale (PAS) and two different consistencies of the bolus were tested: thin liquid barium (L) and paste barium (S).

Results

38 patients were evaluable. There was a significant worsening of the P‑score at 6 months both for SS (p = 0.015) and S (p < 0.001), which persisted only for S at 12 months (p < 0.0001). Similarly, there was a significant worsening of the PAS score at 6 and 12 months (p = 0.065 and 0.039, respectively) for the S bolus. Overall, 3–7 and 10–14% aspiration after L and S was observed, respectively.

Conclusions

Promising results using a SWOARs-sparing IMRT technique are reported. Therefore, treatment plans should be optimized for reducing doses to these structures.

Zusammenfassung

Hintergrund und Zielsetzung

Eine prospektive instrumentelle Einschätzung der späten Dysphagie bei intensitätsmodulierter Strahlentherapie (IMRT) unter Schonung schluckrelevanter Strukturen (SWOAR, „swallowing organs at risk“) bei Nasopharynx- und Oropharynxkarzinomen.

Material und Methoden

Die objektive instrumentelle Einschätzung beinhaltete die glasfaseroptisch-endoskopische-Einschätzung des Schluckakts (FEES, „fiberoptic endoscopic evaluation of swallowing“) sowie eine Videofluoroskopie (VFS) zu Beginn sowie nach 6 und 12 Monaten nach der Behandlung. FEES bewertete den pharyngealen Restrückstand nach dem Farneti-Pooling-Score (P-Score) wie folgt: 4–5 keine Dysphagie; 6–7 leichte Dysphagie; 8–9 moderate Dysphagie; 10–11 schwere Dysphagie. Drei verschiedene Konsistenzen wurden für den P‑Score getestet: flüssig (L), halbflüssig (SS) und fest (S). Die VFS bewertete Penetration und Aspiration anhand der Penetration-Aspiration-Skala (PAS). Es wurden 2 verschiedene Boluskonsistenzen geprüft: dünnflüssiger Bariumbrei (L) und dickflüssiger Bariumbrei (S).

Ergebnisse

Es konnten 38 Patienten evaluiert werden. Eine signifikante Verschlechterung des P‑Scores zeigte sich nach 6 Monaten sowohl für SS (p = 0,015) als auch für S (p < 0,001), der allerdings nur bei S auch nach 12 Monaten weiter bestand (p < 0,0001). Gleichermaßen ergab sich für den S‑Bolus eine signifikante Verschlechterung des PAS-Werts nach 6 und 12 Monaten (jeweils p = 0,065 bzw. p = 0,039). Insgesamt wurde nach L und S eine Aspiration von jeweils 3–7 % und 10–14 % beobachtet.

Schlussfolgerung

Die Ergebnisse bei Verwendung einer SWOAR-schonenden IMRT-Technik sind vielversprechend. Daher sollten die Behandlungspläne optimiert werden, um die Dosis für diese Strukturen zu verringern.

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Authors and Affiliations

  1. Department of Radiation Oncology, University Hospital S. Chiara, Via Roma 55, Pisa, Italy

    Stefano Ursino MD, Paola Cocuzza, Durim Delishaj, Agostino Cristaudo, Francesco Pasqualetti & Fabiola Paiar

  2. First Otorhinolaryngology Unit, University Hospital Cisanello, Via Paradisa 2, Pisa, Italy

    Veronica Seccia

  3. Department of Radiology, University Hospital Cisanello, Via Paradisa 2, Pisa, Italy

    Patrizia Giusti

  4. Otorhinolaryngology-Audiology-Phoniatric Unit, University Hospital Cisanello, Via Paradisa 2, Pisa, Italy

    Stefania Santopadre & Bruno Fattori

  5. Department of Clinical and Experimental Medicine, Section of Statistics, Via Roma 55, Pisa, Italy

    Riccardo Morganti

  6. Department of Radiation Oncology, University Hospital Ferrara, Via Aldo Moro 8, Cona, Ferrara, Italy

    Francesco Fiorica

  7. Department of Radiation Oncology, University Hospital Santa Chiara, Via Roma 67, 56126, Pisa, Italy

    Stefano Ursino MD

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Correspondence to Stefano Ursino MD.

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Conflict of interest

Travel, congress, and course grants (Merck Serono, Nestlè, Kyowakirin) have to be declared for authors S. Ursino, S. Santopadre, V. Seccia, and B. Fattori. Travel, congress, and course grants (Merck Serono, Nestlè, Kyowakirin, Varian) have to be declared for author F. Paiar. P. Cocuzza, Durim Delishaj, A. Cristaudo, F. Pasqualetti, P. Giusti, R. Morganti, and F. Fiorica declare that they have no competing interests.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Target volume delineation criteria and dose fractionation schedule; Dosimetric Treatment Plan Evaluation Criteria; Constraints of primary and secondary organs at risk including optimization criteria for Swallowing Organs at risk

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Ursino, S., Cocuzza, P., Seccia, V. et al. Pattern of dysphagia after swallowing-sparing intensity-modulated radiotherapy (IMRT) of head and neck cancers: results of a mono-institutional prospective study. Strahlenther Onkol 194, 1114–1123 (2018). https://doi.org/10.1007/s00066-018-1328-9

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