Katherine A. Hutcheson

Late dysphagia after radiotherapy-based treatment of head and neck cancer.

Changing trends in head and neck cancer (HNC) merit an understanding of the late effects of therapy, but few studies examine dysphagia beyond 2 years of treatment.

Candidate dosimetric predictors of long-term swallowing dysfunction after oropharyngeal intensity-modulated radiotherapy.

PURPOSE To investigate long-term swallowing function in oropharyngeal cancer patients treated with intensity-modulated radiotherapy (IMRT), and to identify novel dose-limiting criteria predictive for dysphagia. METHODS AND MATERIALS Thirty-one patients with Stage IV oropharyngeal squamous carcinoma enrolled on a Phase II trial were prospectively evaluated by modified barium swallow studies at baseline, and 6, 12, and 24 months post-IMRT treatment. Candidate dysphagia-associated organs at risk were retrospectively contoured into original treatment plans. Twenty-one (68%) cases were base of tongue and 10 (32%) were tonsil. Stage distribution was T1 (12 patients), T2 (10), T3 (4), T4 (2), and TX (3), and N2 (24), N3 (5), and NX (2). Median age was 52.8 years (range, 42-78 years). Thirteen patients (42%) received concurrent chemotherapy during IMRT. Thirteen (42%) were former smokers. Mean dose to glottic larynx for the cohort was limited to 18 Gy (range, 6-39 Gy) by matching IMRT to conventional low-neck fields. RESULTS Dose-volume constraints (V30 < 65% and V35 < 35% for anterior oral cavity and V55 < 80% and V65 < 30% for high superior pharyngeal constrictors) predictive for objective swallowing dysfunction were identified by univariate and multivariate analyses. Aspiration and feeding tube dependence were observed in only 1 patient at 24 months. CONCLUSIONS In the context of glottic laryngeal shielding, we describe candidate oral cavity and superior pharyngeal constrictor organs at risk and dose-volume constraints associated with preserved long-term swallowing function; these constraints are currently undergoing prospective validation. Strict protection of the glottic larynx via beam-split IMRT techniques promises to make chronic aspiration an uncommon outcome.

Eat and Exercise During Radiotherapy or Chemoradiotherapy for Pharyngeal Cancers: Use It or Lose It

IMPORTANCE Data support proactive swallowing therapy during radiotherapy (RT) or chemoradiotherapy (CRT) for pharyngeal cancers. The benefits of adherence to a regimen of swallowing exercises and maintaining oral intake throughout treatment are reported, but independent effects are unclear. OBJECTIVE To evaluate the independent effects of maintaining oral intake throughout radiotherapy and adherence to preventive swallowing exercise. DESIGN Retrospective observational study. SETTING The University of Texas MD Anderson Cancer Center, Houston. PATIENTS The study included 497 patients treated with definitive RT or CRT for pharyngeal cancer (458 oropharynx, 39 hypopharynx) between 2002 and 2008. MAIN OUTCOMES AND MEASURES Swallowing-related end points were final diet after RT or CRT and duration of gastrostomy dependence. Primary independent variables included oral intake status at the end of RT or CRT (no oral intake, partial oral intake, or full oral intake) and adherence to a swallowing exercise regimen. Multiple linear regression and ordered logistic regression models were analyzed. RESULTS At the conclusion of RT or CRT, 131 patients (26%) had no oral intake and 74% maintained oral intake (167 partial [34%], 199 full [40%]). Fifty-eight percent (286 of 497) reported adherence to swallowing exercises. Maintenance of oral intake during RT or CRT and swallowing exercise adherence were independently associated with better long-term diet after RT or CRT (P = .045 and P < .001, respectively) and shorter duration of gastrostomy dependence (P < .001 and P = .007, respectively) in models adjusted for tumor and treatment burden. CONCLUSIONS AND RELEVANCE The data indicate independent, positive associations of maintenance of oral intake throughout RT or CRT and swallowing exercise adherence with long-term swallowing outcomes. Patients who either eat or exercise fare better than those who do neither. Patients who both eat and exercise have the highest rate of return to a regular diet and shortest duration of gastrostomy dependence.

Gastrostomy tube placement in patients with hypopharyngeal cancer treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence.

Placement of gastrostomy tubes (g‐tubes) in patients with hypopharyngeal cancers undergoing radiation and chemotherapy is generally empirically determined. We examined our experience to identify predictive factors for g‐tube placement and length of dependence.

Swallowing Outcomes After Radiotherapy for Laryngeal Carcinoma

OBJECTIVE To describe swallowing physiology and functional outcomes at select intervals after definitive radiotherapy for laryngeal carcinoma. We also examined associations among patient, tumor, and treatment characteristics and swallowing outcomes. DESIGN Retrospective review. SETTING The University of Texas M. D. Anderson Cancer Center, Houston. PATIENTS This study cohort included 40 patients who underwent definitive radiotherapy for laryngeal carcinoma (from February 2001 to June 2004). MAIN OUTCOME MEASURES Modified barium swallow (MBS) studies were performed for 32 patients at 3 test intervals following irradiation: less than 6 months, 6 to 11 months, and 12 or more months. We recorded the presence or absence of aspiration (sensate or silent), 5 pharyngeal phase disorders, and 2 structural abnormalities. We also recorded pretreatment dysphagia complaints, feeding tube dependency, T classification, disease site, mucositis grade, and radiotherapy schedule with or without chemotherapy. RESULTS Eighty-four percent of patients (27 of 32) referred for MBS studies after undergoing radiotherapy aspirated; 44% (12 of 27) did so silently. Silent aspiration was more prevalent during MBS studies conducted 1 or more years after radiotherapy. Pharyngeal phase disorders were observed more frequently than structural abnormalities (P < .01). Most patients required a feeding tube (78% [31 of 40]); however, 52% of the tubes (16) were eventually removed. We found no significant association between the occurrence of aspiration and disease site, T classification, treatment regimen, or pretreatment variables (P > .05). Pretreatment and posttreatment levels of feeding tube dependency were significantly associated (P = .03). Patient-reported dysphagia before treatment did not predict posttreatment swallowing outcomes (P > .05). CONCLUSIONS Dysphagia is a common outcome after laryngeal preservation with radiotherapy. Contrary to expectations, few parameters that we measured were significantly associated with swallowing outcomes in our study.

Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients

To reduce the risk of long‐term swallowing complications after radiation, swallowing exercises may be helpful. Both the rate of adherence to swallowing exercises and its impact on future swallowing function are unknown.

Functional outcomes after chemoradiotherapy of laryngeal and pharyngeal cancers

Organ preservation regimens that combine chemotherapy and radiotherapy (chemoradiotherapy) are increasingly used as the primary treatment of laryngeal and pharyngeal cancers. Meta-analytic data show a survival benefit with combined modality therapy, but the functional sequelae can be significant. Dysphagia is recognized as a common and often devastating late effect of chemoradiotherapy. This review examines functional outcomes after chemoradiotherapy for laryngeal and pharyngeal cancers, with a particular emphasis on dysphagia. Topics examined include the burden of dysphagia after chemoradiation, pathophysiology of dysphagia, baseline functioning, recommendations to improve long-term function, and voice outcomes.

FUNCTIONAL ANALYSIS OF SWALLOWING OUTCOMES AFTER SUPRACRICOID PARTIAL LARYNGECTOMY

In this study, we analyzed swallowing recovery after supracricoid partial laryngectomy (SCPL).

A multi-institution pooled analysis of gastrostomy tube dependence in patients with oropharyngeal cancer treated with definitive intensity-modulated radiotherapy

Severe swallowing dysfunction necessitating enteral support is a well known late sequela of nonsurgical therapy for oropharyngeal cancer, but its incidence after intensity‐modulated radiotherapy has not been quantified comprehensively outside of small single‐institution series.

Enlarged tracheoesophageal puncture after total laryngectomy: a systematic review and meta-analysis.

Enlargement of the tracheoesophageal puncture (TEP) is a challenging complication after laryngectomy with TEP. We sought to estimate the rate of enlarged puncture, associated pneumonia rates, potential risk factors, and conservative treatments excluding complete surgical TEP closure.