Abstract
The goals of this study were to facilitate sparing of the major salivary glands while adequately treating tumor targets in patients requiring comprehensive bilateral neck irradiation (RT), and to assess the potential for improved xerostomia. Since 1994 techniques of target irradiation and locoregional tumor control with conformal and intensity modulated radiation therapy (IMRT) have been developed. In patients treated with these modalities, the salivary flow rates before and periodically after RT have been measured selectively from each major salivary gland and the residual flows correlated with glands’ dose volume histograms (DVHs). In addition, subjective xerostomia questionnaires have been developed and validated. The pattern of locoregional recurrence has been examined from computed tomography (CT) scans at the time of recurrence, transferring the recurrence volumes to the planning CT scans, and regenerating the dose distributions at the recurrence sites. Treatment plans for target coverage and dose homogeneity using static, multisegmental IMRT were found to be significantly better than standard RT plans. In addition, significant parotid gland sparing was achieved in the conformal plans. The relationships among dose, irradiated volume, and the residual saliva flow rates from the parotid glands were characterized by dose and volume thresholds. A mean radiation dose of 26 Gy was found to be the threshold for preserved stimulated saliva flow. Xerostomia questionnaire scores suggested that xerostomia was significantly reduced in patients irradiated with bilateral neck, parotid-sparing RT, compared to patients with similar tumors treated with standard RT. Examination of locoregional tumor recurrence patterns revealed that the large majority of recurrences occurred inside targets, in areas that had been judged to be at high risk and that had received RT doses according to the perceived risk. Tangible gains in salivary gland sparing and target coverage are being achieved, and an improvement in some measures of quality of life is suggested by our findings. Additional reduction of xerostomia may be achieved by further sparing of the salivary glands and the non-involved oral cavity. A mean parotid gland dose of ≤ 26 Gy should be a planning objective if significant parotid function preservation is desired. The pattern of recurrence suggests that careful escalation of the dose to areas judged to be at highest risk may improve tumor control.
Similar content being viewed by others
References
JS Cooper K Fu J Marks et al. (1995) ArticleTitleLate effects of radiation therapy in the head and neck region Int. J. Radiat. Oncol. Biol. Phys. 31 1141–1164 Occurrence Handle10.1016/0360-3016(94)00421-G Occurrence Handle1:STN:280:ByqB38bks10%3D Occurrence Handle7713779
LB Harrison MJ Zelefski DG Pfitzer et al. (1997) ArticleTitleDetailed quality of life assessment in patients treated with primary radiotherapy for cancer of the base of tongue Head Neck 19 169–175 Occurrence Handle10.1002/(SICI)1097-0347(199705)19:3<169::AID-HED1>3.3.CO;2-5 Occurrence Handle1:STN:280:ByiB1cjkt1Y%3D Occurrence Handle9142514
K Bjordal S Kaasa A Mastekaasa (1994) ArticleTitleQuality of life in patients treated for head and neck cancer: a follow up study 7 to 11 years after radiotherapy Int. J. Radiat. Oncol. Biol. Phys. 28 847–856 Occurrence Handle1:STN:280:ByuC1cnjvVE%3D Occurrence Handle8138437
AB Jensen O Hanse K Jorgensen et al. (1994) ArticleTitleInfluence of late side-effects upon daily life after radiotherapy for laryngeal and pharyngeal cancer Acta Oncol. 33 487–491 Occurrence Handle1:STN:280:ByqD3c%2FntlA%3D Occurrence Handle7917360
L Beeken F Calman (1994) ArticleTitleA return to normal eating after curative treatment for oral cancer: long term prospects Oral Oncol. Eur. J. Cancer 6 387–392 Occurrence Handle10.1016/0964-1955(94)90017-5
JT Johnson GA Ferretti WJ Nethery (1993) ArticleTitleOral pilocarpine for post-irradiation xerostomia in patients with head and neck cancer N. Engl. J. Med. 329 390–395 Occurrence Handle10.1056/NEJM199308053290603 Occurrence Handle1:STN:280:ByyA3MnpvFw%3D Occurrence Handle8326972
S McDonald C Meyerowitz T Smudzin et al. (1994) ArticleTitlePreliminary results of a pilot study using WR-2721 before fractionated irradiation of the head and neck to reduce salivary gland dysfunction Int. J. Radiat. Biol. 29 747–754 Occurrence Handle1:STN:280:ByuA3MvlvFY%3D
D Brizel R Sauer M Wannemacher et al. (1998) ArticleTitleRandomized phase III trial of radiation + Amifostine in patients with head and neck cancer Int. J. Radiat. Oncol. Biol. Phys. 42 224
R Marsh J Balter VL Evans et al. (1997) ArticleTitleDesign and analysis of an immobilization and repositioning system for treatment of neck malignancies Med. Dosimetry 22 293–297 Occurrence Handle10.1016/S0958-3947(97)00102-7 Occurrence Handle1:STN:280:DyaK1c7msVWjsQ%3D%3D
RK Haken ParticleTen AF Thornton HM Sandler et al. (1992) ArticleTitleA quantitative assessment of the addition of MRI to CT-based, 3-D treatment planning of brain tumors Radiother. Oncol. 25 121–133 Occurrence Handle1332134
AA Mancusso (1994) Imaging in patients with head and neck cancer RR Million NJ Cassisi (Eds) Management of Head and Neck Cancer JB Lippincott Philadelphia 43–59
A Eisbruch JA Ship MK Martel et al. (1996) ArticleTitleParotid gland sparing in patients undergoing bilateral head and neck irradiation: techniques and early results Int. J. Radiat. Oncol. Biol. Phys. 36 469–480 Occurrence Handle10.1016/S0360-3016(96)00264-7 Occurrence Handle1:STN:280:ByiD2cjlsFc%3D Occurrence Handle8892473
Million, RR, NJ, Cassisi, Mancuso, AA et al. (1994) “Management of the neck for squamous cell carcinoma” In: Million, RR, Cassisi, NJ (eds.), Management of Head and Neck Cancer, 2nd edition, JB Lippincott, Philadelphia, pp 101
BA Fraas LM Marsh BA Watson et al. (1999) ArticleTitleOptimization and clinical use of multisegment intensity modulation for high dose conformal therapy Semin. Radiat. Oncol. 9 60–77 Occurrence Handle10196399
A Eisbruch LH Marsh MK Martel et al. (1998) ArticleTitleComprehensive irradiation of head and neck cancer using conformal multisegmental fields: assessment of target coverage and noninvolved tissue sparing Int. J. Radiat. Oncol. Biol. Phys. 41 559–568 Occurrence Handle10.1016/S0360-3016(98)00082-0 Occurrence Handle1:STN:280:DyaK1c3pslKhtw%3D%3D Occurrence Handle9635702
MK Martel A Eisbruch TS Lawrence et al. (1998) ArticleTitleCord dose from standard head and neck treatments: implications for conformal treatment plans Radiother. Oncol. 47 185–189 Occurrence Handle10.1016/S0167-8140(97)00212-0 Occurrence Handle1:STN:280:DyaK1czks12htg%3D%3D Occurrence Handle9683367
ML Kessler JJH Kim DL McShan (1998) ArticleTitleA general framework for interactive and automated treatment plan optimization: part I. Evaluators, modifiers, and costlets Med. Phys. 25 118
DL McShan BA Fraas ML Kessler (1998) ArticleTitleIntensity modulation using beamlets Med. Phys. 25 149
JA Ship PC Fox BJ Baum (1991) ArticleTitleHow much saliva is enough? Normal function defined J. Am. Dent. Assoc. 122 63–69 Occurrence Handle1:STN:280:By6B3M%2Fkslc%3D
RE Jones T Takeuchi A Eisbruch et al. (1996) ArticleTitleIpsilateral parotid sparing study in head and neck cancer patients receiving radiation therapy Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 81 642–648
PC Fox KA Busch BJ Baum (1987) ArticleTitleSubjective reports of xerostomia and objective measure of salivary gland performance J. Am. Dent. Assoc. 115 581–584 Occurrence Handle1:STN:280:BieD3cfmvVA%3D Occurrence Handle3477595
RP Zimmerman RJ Mark LM Tran et al. (1997) ArticleTitleConcomitant pilocarpin during head and neck irradiation is associated with decreased posttreatment xerostomia. Int. J. Radiat. Onco; Biol. Phys. 37 571–575 Occurrence Handle10.1016/S0360-3016(96)00557-3 Occurrence Handle1:CAS:528:DyaK2sXjtFKmsLo%3D
JE Terrell KA Nanavati RM Esclamado et al. (1997) ArticleTitleHead and neck cancer specific quality of life: Instrument validation Arch. Otolaryngol. Head Neck Surg. 123 1125–1132 Occurrence Handle1:STN:280:ByiH2sbptFQ%3D Occurrence Handle9339991
Eisbruch A, Kim HM, Ten Haken R, et al. Dose, volume and function relationships in parotid glands following conformal and intensity modulated irradiation of head and neck cancer. Int. J. Radiat. Oncol. Biol. Phys. (in press)
A Eisbruch J Terrell M Kim et al. (1998) ArticleTitleAssessment of xerostomia -related quality of life in head and neck cancer patients receiving comprehensive radiation using parotid sparing techniques Head Neck 20 452
MD Leslie S Dische (1994) ArticleTitleThe early changes in salivary gland function during and after radiotherapy given for head and neck cancer Radiother. Oncol. 30 26–32 Occurrence Handle1:STN:280:ByuB3cvislM%3D Occurrence Handle8153377
JE Marks CC Davis VL Gottsman et al. (1981) ArticleTitleThe effects of radiation on parotid salivary function Int. J. Radiat. Oncol. Biol. Phys. 7 1013–1019 Occurrence Handle1:STN:280:Bi2D2M3lslQ%3D Occurrence Handle7298398
L Franzen U Funegard T Ericson et al. (1992) ArticleTitleParotid gland function during and following radiotherapy of malignancies in the head and neck: a consecutive study of salivary flow and patient discomfort Eur. J. Cancer 28 457–462 Occurrence Handle1:STN:280:By2B2szjtFY%3D Occurrence Handle1591063
C Rasch R Keus FA Pameijer et al. (1997) ArticleTitleThe potential impact of CT-MRI matching on tumor volume delineation in advanced head and neck cancer Int. J. Radiat. Oncol. Biol. Phys. 39 841–848 Occurrence Handle10.1016/S0360-3016(97)00465-3 Occurrence Handle1:STN:280:DyaK1c%2FjsVSltw%3D%3D Occurrence Handle9369132
P Nowak E Dieren Particlevan H Est Particlevan der et al. (1997) ArticleTitleTreatment portals for elective radiotherapy of the neck: an inventory in the Netherlands Radiother. Oncol. 43 81–86 Occurrence Handle10.1016/S0167-8140(96)01894-4 Occurrence Handle1:STN:280:ByiA3cjnvF0%3D Occurrence Handle9165141
Nowak P (1997) Elective irradiation of the neck: a three dimensional CT definition of the target for conformal radiotherapy. Doctoral Thesis. Dr. Daniel van Hoed Cancer Center, Erasmus University, Rotterdam, the Netherlands.
LA Hayman KH Taber PJ Diaz-Marchan et al. (1998) ArticleTitleSpatial compartments of the neck Int. J. Neuroradiol. 4 233–239
K Pigott S Dische MI Saunders (1995) ArticleTitleWhere exactly does failure occur after radiation in head and neck cancer? Radiother. Oncol. 37 17–19 Occurrence Handle10.1016/0167-8140(95)01584-4 Occurrence Handle1:STN:280:BymC38visVI%3D Occurrence Handle8539452
Acknowledgments.
This work was supported in part by National Institutes of Health grant CA78165.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Eisbruch, A., Ship, J., Dawson, L. et al. Salivary Gland Sparing and Improved Target Irradiation by Conformal and Intensity Modulated Irradiation of Head and Neck Cancer. World J. Surg. 27, 832–837 (2003). https://doi.org/10.1007/s00268-003-7105-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-003-7105-6