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Radiation-induced acute dysphagia

Prospective observational study on 42 head and neck cancer patients

Strahleninduzierte akute Dysphagie

Prospektive Beobachtungsstudie an 42 Kopf-Hals-Malignompatienten

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Abstract

Purpose

Acute toxicity in head and neck (H&N) cancer patients treated with definitive radiotherapy (RT) has a crucial role in compliance to treatments. The aim of this study was to correlate doses to swallowing-associated structures and acute dysphagia.

Methods

We prospectively analyzed 42 H&N cancer patients treated with RT. Dysphagia (grade ≥ 3) and indication for percutaneous endoscopic gastrostomy (PEG) insertion were classified as acute toxicity. Ten swallowing-related structures were considered for the dosimetric analysis. The correlation between clinical information and the dose absorbed by the contoured structures was analyzed. Multivariate logistic regression method using resampling methods (bootstrapping) was applied to select model order and parameters for normal tissue complication probability (NTCP) modelling.

Results

A strong multiple correlation between dosimetric parameters was found. A two-variable model was suggested as the optimal order by bootstrap method. The optimal model (Rs = 0.452, p < 0.001) includes V45 of the cervical esophagus (odds ratio [OR] = 1.016) and Dmean of the cricopharyngeal muscle (OR = 1.057). The model area under the curve was 0.82 (95% confidence interval 0.69–0.95).

Conclusion

Our results suggested that the absorbed dose to the cricopharyngeal muscle and cervical esophagus might play a relevant role in the development of acute RT-related dysphagia.

Zusammenfassung

Hintergrund und Ziel

Bei Kopf-Hals-Tumorpatienten, die mit einer kurativen Strahlentherapie („radiation therapy“, RT) behandelt werden, spielt die Akuttoxizität eine entscheidende Rolle für die Patientencompliance bei der Behandlung. Ziel dieser Studie war es, die Dosen im Bereich des Schluckapparates mit der akuten Dysphagie zu korrelieren.

Material und Methodik

Prospektiv analysiert wurden 42 mit einer RT behandelten Patienten. Eine Dysphagie III und/oder die Indikation für eine PEG(perkutane endoskopische Gastrostomie)-Anlage wurden als Akuttoxizität klassifiziert. Für die dosimetrische Analyse wurden 10 am Schluckvorgang beteiligte Strukturen berücksichtigt. Analysiert wurde die Korrelation zwischen klinischer Information und der von den konturierten Strukturen absorbierten Dosis. Um die Modellreihenfolge und die Parameter für die NTCP(Normal Tissue Complication Probability)-Modellierung auszuwählen, wurde die multivariate logistische Regressionsmethode mit Resampling-Methoden (Bootstrapping) angewendet.

Ergebnisse

Es fand sich eine starke Mehrfachkorrelation zwischen dosimetrischen Parametern. Ein zweidimensionales Modell wurde als optimale Reihenfolge durch die Bootstrap-Methode vorgeschlagen. Das optimale Modell („Spearman’s rank correlation coefficient“, Rs = 0,452; p < 0,001) umfasst V45 des zervikalen Ösophagus (OR, Odds Ratio, = 1,016) und Dmean des M. cricopharyngeus (OR = 1,057). Das Modell-AUC („area under the curve”) betrug 0,82 (95 %-Konfidenzintervall 0,69–0,95).

Schlussfolgerung

Unsere Ergebnisse deuten darauf hin, dass die absorbierte Dosis im M. cricopharyngeus und im zervikalen Ösophagus eine wichtige Rolle bei der radiogenen akuten Dysphagie spielt.

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Acknowledgements

The authors wish to thank Giuseppe Fanetti who assisted in the translation of the abstract.

Author information

Authors and Affiliations

  1. Department of Radiotherapy, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy

    D. Alterio, M. A. Gerardi, R. Spoto, C. Fodor, D. Ciardo, A. Ferrari, S. Colangione, S. Dicuonzo & B. A. Jereczek-Fossa

  2. Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy

    L. Cella, V. D’Avino, M. Conson, R. Pacelli & G. Palma

  3. Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy

    R. Spoto, S. Dicuonzo & B. A. Jereczek-Fossa

  4. Division of Head and Neck Surgery, European Institute of Oncology, Milan, Italy

    V. Zurlo & R. Bruschini

  5. Dietetic and Clinical Nutrition Unit, European Institute of Oncology, Milan, Italy

    A. Sabbatini & F. Valoriani

  6. Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy

    R. Pacelli

  7. Department of Epidemiology and Statistics, European Institute of Oncology, Milan, Italy

    P. Maisonneuve

  8. Department of Radiology, European Institute of Oncology, Milan, Italy

    L. Preda

  9. Division of Urogenital and Head and Neck Tumors, Department of Medical Oncology, European Institute of Oncology, Milan, Italy

    M. Cossu Rocca

  10. Unit of Medical Physics, European Institute of Oncology, Milan, Italy

    E. Rondi

  11. Scientific Directorate, European Institute of Oncology, Milan, Italy

    R. Orecchia

  12. Istituto Tumori Regina Elena, Rome, Italy

    G. Sanguineti

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  1. D. Alterio
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  2. M. A. Gerardi
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  23. G. Sanguineti
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  24. B. A. Jereczek-Fossa
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Corresponding author

Correspondence to D. Alterio.

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Conflict of interest

D. Alterio, M.A. Gerardi, L. Cella, R. Spoto, V. Zurlo, A. Sabbatini, C. Fodor, V. D’Avino, M. Conson, F. Valoriani, D. Ciardo, R. Pacelli, A. Ferrari, P. Maissoneuve, L. Preda, R. Bruschini, M. Cossu Rocca, E. Rondi, S. Colangione, G. Palma, S. Dicuonzo, R. Orecchia, G. Sanguineti and B.A. Jereczek-Fossa declare that they have no competing interests.

Ethical standards

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.

Additional information

The Authors D. Alterio and M.A. Gerardi contributed equally to the manuscript.

Caption Electronic Supplementary Material

Supplementary Table S1. Anatomic borders of swallowing-related structures

66_2017_1206_MOESM2_ESM.docx

Supplementary Figure S1. Graphical representation of all the swallowing related structures contoured on the simulation CT for the dosimetric analysis

66_2017_1206_MOESM3_ESM.docx

Supplementary Table S2. Summary of significant dosimetric statistics for cervical esophagus, cricopharyngeal and inferior constrictor muscles and correlation coefficient (Rs) with severe acute dysphagia incidence

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Alterio, D., Gerardi, M.A., Cella, L. et al. Radiation-induced acute dysphagia. Strahlenther Onkol 193, 971–981 (2017). https://doi.org/10.1007/s00066-017-1206-x

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