pp 1–10 | Cite as

Optimising Radiation Therapy Dose to the Swallowing Organs at Risk: An In Silico Study of feasibility for Patients with Oropharyngeal Tumours

  • Molly K. BarnhartEmail author
  • Bena Cartmill
  • Elizabeth C. Ward
  • Elizabeth Brown
  • Jonathon Sim
  • George Saade
  • Sandra Rayner
  • Rachelle A. Robinson
  • Virginia A. Simms
  • Robert I. Smee
Original Article


Recent evidence suggests that reducing radiotherapy dose delivered to specific anatomical swallowing structures [Swallowing Organs at Risk (SWOARs)] may improve swallowing outcomes post-treatment for patients with head and neck cancer. However, for those patients with tumours of the oropharynx, which typically directly overlap the SWOARs, reducing dose to these structures may be unachievable without compromising on the treatment of the disease. To assess the feasibility of dose reduction in this cohort, standard IMRT plans (ST-IMRT) and plans with reduced dose to the SWOARs (SW-IMRT) were generated for 25 oropharyngeal cancer patients (Brouwer et al. in Radiother Oncol 117(1):83–90,, 2015; Christianen et al. in Radiother Oncol 101(3):394–402,, 2011). ST-IMRT and SW-IMRT plans were compared for: mean dose to the SWOARs, volume of pharynx and larynx receiving 50 Gy and 60 Gy (V50 and V60 respectively) and overlap between the tumour volume and the SWOARs. Additionally, two different SWOARs delineation guidelines (Brouwer et al. in Radiother Oncol 117(1):83–90,, 2015; Christianen et al. in Radiother Oncol 101(3):394–402,, 2011) were used to highlight differences in calculated volumes between existing contouring guidelines. Agreement in SWOARs volumes between the two guidelines was calculated using a concordance index (CI). Despite a large overlap between the tumour and SWOARs, significant (p < 0.05) reductions in mean dose to 4 of the 5 SWOARs, and V50/V60 for the pharynx and larynx were achieved with SW-IMRT plans. Low CIs per structure (0.15–0.45) were found between the two guidelines highlighting issues comparing data between studies when different guidelines have been used (Hawkins et al. in Semin Radiat Oncol 28(1):46–52,, 2018; Brodin et al. in Int J Radiat Oncol Biol Phys 100(2):391–407,, 2018). This study found reducing dose to the SWOARs is a feasible practice for patients with oropharyngeal cancer. However, future prospective research is needed to determine if the extent of dose reduction achieved equates to clinical benefits.


Head and neck cancer Radiation therapy planning Swallowing organs at risk Dose optimisation Dysphagia 



The authors wish to thank the speech pathology department and radiation therapy department at the Prince of Wales Hospital and Princess Alexandra Hospital for their contributions and support to this project. This project was funded by the Head and Neck Cancer Research Fund at Prince of Wales Hospital, Sydney Australia.


This project was funded by the Head and Neck Cancer Research Fund at Prince of Wales Hospital, Sydney Australia.

Compliance with Ethical Standards

Conflict of interest

All authors declares that he/she has no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants performed by any of the authors.


  1. 1.
    Pulte D, Brenner H. Changes in survival in head and neck cancers in the late 20th and early 21st century: a period analysis. Oncologist. 2010;15(9):994–1001. Scholar
  2. 2.
    Dirix P, Nuyts S. Evidence-based organ-sparing radiotherapy in head and neck cancer. Lancet Oncol. 2010;11(1):85–91. Scholar
  3. 3.
    Forastiere AA. Chemotherapy in the treatment of locally advanced head and neck cancer. J Surg Oncol. 2008;97(8):701–7. Scholar
  4. 4.
    Patterson JM, McColl E, Carding PN, Hildreth AJ, Kelly C, Wilson JA. Swallowing in the first year after chemoradiotherapy for head and neck cancer: clinician-and patient-reported outcomes. Head Neck. 2014;36(3):352–8.CrossRefGoogle Scholar
  5. 5.
    Moroney LB, Helios J, Ward EC, Crombie J, Wockner LF, Burns CL, Spurgin AL, Blake C, Kenny L, Hughes BG. Patterns of dysphagia and acute toxicities in patients with head and neck cancer undergoing helical IMRT ± concurrent chemotherapy. Oral Oncol. 2017;64:1–8. Scholar
  6. 6.
    Bressan V, Stevanin S, Bianchi M, Aleo G, Bagnasco A, Sasso L. The effects of swallowing disorders, dysgeusia, oral mucositis and xerostomia on nutritional status, oral intake and weight loss in head and neck cancer patients: a systematic review. Cancer Treat Rev. 2016;45:105–19. Scholar
  7. 7.
    Barnhart MK, Robinson RA, Simms VA, Ward EC, Cartmill B, Chandler SJ, Smee RI. Treatment toxicities and their impact on oral intake following non-surgical management for head and neck cancer: a 3-year longitudinal study. Support Care Cancer. 2018;26(7):2341–51. Scholar
  8. 8.
    Schindler A, Denaro N, Russi EG, Pizzorni N, Bossi P, Merlotti A, Spadola Bissetti M, Numico G, Gava A, Orlandi E, Caspiani O, Buglione M, Alterio D, Bacigalupo A, De Sanctis V, Pavanato G, Ripamonti C, Merlano MC, Licitra L, Sanguineti G, Langendijk JA, Murphy B. Dysphagia in head and neck cancer patients treated with radiotherapy and systemic therapies: literature review and consensus. Crit Rev Oncol Hematol. 2015;96(2):372–84. Scholar
  9. 9.
    Cohen EE, LaMonte SJ, Erb NL, Beckman KL, Sadeghi N, Hutcheson KA, Stubblefield MD, Abbott DM, Fisher PS, Stein KD, Lyman GH, Pratt-Chapman ML. American Cancer Society Head and neck cancer survivorship care guideline. CA Cancer J Clin. 2016;66(3):203–39. Scholar
  10. 10.
    Burnet NG, Thomas SJ, Burton KE, Jefferies SJ. Defining the tumour and target volumes for radiotherapy. Cancer Imaging. 2004;4(2):153–61. Scholar
  11. 11.
    Mendez LC, Moraes FY, Poon I, Marta GN. The management of head and neck tumors with high technology radiation therapy. Expert Rev Anticancer Ther. 2016;16(1):99–110. Scholar
  12. 12.
    Roe JW, Drinnan MJ, Carding PN, Harrington KJ, Nutting CM. Patient-reported outcomes following parotid-sparing intensity-modulated radiotherapy for head and neck cancer. How important is dysphagia? Oral Oncol. 2014;50(12):1182–7. Scholar
  13. 13.
    Gupta T, Agarwal J, Jain S, Phurailatpam R, Kannan S, Ghosh-Laskar S, Murthy V, Budrukkar A, Dinshaw K, Prabhash K, Chaturvedi P, D’Cruz A. Three-dimensional conformal radiotherapy (3D-CRT) versus intensity modulated radiation therapy (IMRT) in squamous cell carcinoma of the head and neck: a randomized controlled trial. Radiother Oncol. 2012;104(3):343–8. Scholar
  14. 14.
    Marta GN, Silva V, de Andrade Carvalho H, de Arruda FF, Hanna SA, Gadia R, da Silva JL, Correa SF, Vita Abreu CE, Riera R. Intensity-modulated radiation therapy for head and neck cancer: systematic review and meta-analysis. Radiother Oncol. 2014;110(1):9–15. Scholar
  15. 15.
    Nutting CM, Morden JP, Harrington KJ, Urbano TG, Bhide SA, Clark C, Miles EA, Miah AB, Newbold K, Tanay M, Adab F, Jefferies SJ, Scrase C, Yap BK, A’Hern RP, Sydenham MA, Emson M, Hall E. Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial. Lancet Oncol. 2011;12(2):127–36. Scholar
  16. 16.
    Eisbruch A, Schwartz M, Rasch C, Vineberg K, Damen E, Van As CJ, Marsh R, Pameijer FA, Balm AJM. Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: which anatomic structures are affected and can they be spared by IMRT? Int J Radiat Oncol Biol Phys. 2004;60(5):1425–39. Scholar
  17. 17.
    Christianen MEMC, Langendijk JA, Westerlaan HE, van de Water TA, Bijl HP. Delineation of organs at risk involved in swallowing for radiotherapy treatment planning. Radiother Oncol. 2011;101(3):394–402. Scholar
  18. 18.
    Brouwer CL, Steenbakkers RJHM, Bourhis J, Budach W, Grau C, Grégoire V, van Herk M, Lee A, Maingon P, Nutting C, O’Sullivan B, Porceddu SV, Rosenthal DI, Sijtsema NM, Langendijk JA. CT-based delineation of organs at risk in the head and neck region: DAHANCA, EORTC, GORTEC, HKNPCSG, NCIC CTG, NCRI, NRG Oncology and TROG consensus guidelines. Radiother Oncol. 2015;117(1):83–90. Scholar
  19. 19.
    Petkar I, Bhide S, Newbold K, Harrington K, Nutting C. Dysphagia-optimised intensity-modulated radiotherapy techniques in pharyngeal cancers: is anyone going to swallow it? Clin Oncol (R Coll Radiol). 2017;29(7):e110–8. Scholar
  20. 20.
    Duprez F, Madani I, De Potter B, Boterberg T, De Neve W. Systematic review of dose-volume correlates for structures related to late swallowing disturbances after radiotherapy for head and neck cancer. Dysphagia. 2013;28(3):337–49. Scholar
  21. 21.
    Vainshtein JM, Samuels S, Tao Y, Lyden T, Haxer M, Spector M, Schipper M, Eisbruch A. Impact of xerostomia on dysphagia after chemotherapy–intensity-modulated radiotherapy for oropharyngeal cancer: prospective longitudinal study. Head Neck. 2016;38(S1):E1605–12. Scholar
  22. 22.
    Feng FY, Kim HM, Lyden TH, Haxer MJ, Worden FP, Feng M, Moyer JS, Prince ME, Carey TE, Wolf GT, Bradford CR, Chepeha DB, Eisbruch A. Intensity-modulated chemoradiotherapy aiming to reduce Dysphagia in patients with oropharyngeal cancer: clinical and functional results. J Clin Oncol. 2010;28(16):2732–8. Scholar
  23. 23.
    Brodin NP, Kabarriti R, Garg MK, Guha C, Tome WA. Systematic review of normal tissue complication models relevant to standard fractionation radiation therapy of the head and neck region published after the QUANTEC reports. Int J Radiat Oncol Biol Phys. 2018;100(2):391–407. Scholar
  24. 24.
    van der Laan HP, Christianen MEMC, Bijl HP, Schilstra C, Langendijk JA. The potential benefit of swallowing sparing intensity modulated radiotherapy to reduce swallowing dysfunction: an in silico planning comparative study. Radiother Oncol. 2012;103(1):76–81. Scholar
  25. 25.
    van der Laan HP, Gawryszuk A, Christianen MEMC, Steenbakkers RJHM, Korevaar EW, Chouvalova O, Wopken K, Bijl HP, Langendijk JA. Swallowing-sparing intensity-modulated radiotherapy for head and neck cancer patients: treatment planning optimization and clinical introduction. Radiother Oncol. 2013;107(3):282–7.CrossRefGoogle Scholar
  26. 26.
    Christianen ME, van der Schaaf A, van der Laan HP, Verdonck-de Leeuw IM, Doornaert P, Chouvalova O, Steenbakkers RJ, Leemans CR, Oosting SF, van der Laan BF, Roodenburg JL, Slotman BJ, Bijl HP, Langendijk JA. Swallowing sparing intensity modulated radiotherapy (SW-IMRT) in head and neck cancer: clinical validation according to the model-based approach. Radiother Oncol. 2016;118(2):298–303. Scholar
  27. 27.
    Rancati T, Schwarz M, Allen AM, Feng F, Popovtzer A, Mittal B, Eisbruch A. Radiation dose volume effects in the larynx and pharynx. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S64–9. Scholar
  28. 28.
    Moroney LB, Helios J, Ward EC, Crombie J, Pelecanos A, Burns CL, Spurgin A, Blake C, Kenny L, Chua B, Hughes BG (In Press) Helical IMRT with concurrent chemotherapy for oropharyngeal SCC: a prospective investigation of acute swallowing and toxicity patterns. Head Neck Oncol.Google Scholar
  29. 29.
    Cilla S, Deodato F, Macchia G, Digesù C, Ianiro A, Piermattei A, Valentini V, Morganti AG. Volumetric modulated arc therapy (VMAT) and simultaneous integrated boost in head-and-neck cancer: is there a place for critical swallowing structures dose sparing? Br J Radiol. 2016;89(1059):20150764. Scholar
  30. 30.
    Brouwer CL, Steenbakkers RJHM, Gort E, Kamphuis ME, van der Laan HP, van’t Veld AA, Sijtsema NM, Langendijk JA. Differences in delineation guidelines for head and neck cancer result in inconsistent reported dose and corresponding NTCP. Radiother Oncol. 2014;111(1):148–52. Scholar
  31. 31.
    Garden AS, Beadle BM, Gunn GB. Radiotherapy for head and neck cancers indications and tehniques. 5th ed. Philadelphia: Wolters Kluwer; 2018.Google Scholar
  32. 32.
    Robbins K, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by the american head and neck society and the american academy of otolaryngology–head and neck surgery. Arch Otolaryngol Head Neck Surg. 2002;128(7):751–8. Scholar
  33. 33.
    Deasy JO, Moiseenko V, Marks L, Chao KS, Nam J, Eisbruch A. Radiotherapy dose-volume effects on salivary gland function. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S58–63. Scholar
  34. 34.
    Hanna GG, Hounsell AR, O’Sullivan JM. Geometrical analysis of radiotherapy target volume delineation: a systematic review of reported comparison methods. Clin Oncol. 2010;22(7):515–25. Scholar
  35. 35.
    Hawkins PG, Kadam AS, Jackson WC, Eisbruch A. Organ-sparing in radiotherapy for head-and-neck cancer: improving quality of life. Semin Radiat Oncol. 2018;28(1):46–52. Scholar
  36. 36.
    Schwartz DL, Hutcheson K, Barringer D, Tucker SL, Kies M, Holsinger FC, Ang KK, Morrison WH, Rosenthal DI, Garden AS, Dong L, Lewin JS. Candidate dosimetric predictors of long-term swallowing dysfunction after oropharyngeal intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2010;78(5):1356–65. Scholar
  37. 37.
    Petkar I, Rooney K, Roe JWG, Patterson JM, Bernstein D, Tyler JM, Emson MA, Morden JP, Mertens K, Miles E, Beasley M, Roques T, Bhide SA, Newbold KL, Harrington KJ, Hall E, Nutting CM. DARS: a phase III randomised multicentre study of dysphagia- optimised intensity- modulated radiotherapy (Do-IMRT) versus standard intensity- modulated radiotherapy (S-IMRT) in head and neck cancer. BMC Cancer. 2016;16(1):770. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Molly K. Barnhart
    • 1
    • 2
    Email author
  • Bena Cartmill
    • 3
    • 4
  • Elizabeth C. Ward
    • 2
    • 3
  • Elizabeth Brown
    • 5
  • Jonathon Sim
    • 6
  • George Saade
    • 6
  • Sandra Rayner
    • 6
  • Rachelle A. Robinson
    • 1
  • Virginia A. Simms
    • 1
  • Robert I. Smee
    • 6
    • 7
  1. 1.Speech Pathology DepartmentPrince of Wales Hospital (POWH)SydneyAustralia
  2. 2.School of Health and Rehabilitation SciencesThe University of QueenslandSt LuciaAustralia
  3. 3.Centre for Functioning and Health Research, Metro South Hospital and Health ServiceQueensland HealthBurandaAustralia
  4. 4.Speech Pathology, Princess Alexandra Hospital, Metro South Hospital and Health ServiceQueensland HealthWoolloongabbaAustralia
  5. 5.Radiation Oncology, Princess Alexandra Hospital, Metro South Hospital and Health ServiceQueensland HealthWoolloongabbaAustralia
  6. 6.Radiation Oncology, Nelune Comprehensive Cancer CentrePOWHSydneyAustralia
  7. 7.The Clinical Teaching SchoolUniversity New South WalesKensingtonAustralia

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