Caudell Jimmy J, Schaner Philip E, Meredith Ruby F, Locher Julie L, Nabell Lisle M, Carroll William R, Magnuson J Scott, Spencer Sharon A, Bonner James A
Department of Radiation Oncology, University of Alabama-Birmingham, Birmingham, AL, USA.
Int J Radiat Oncol Biol Phys. 2009 Feb 1;73(2):410-5. doi: 10.1016/j.ijrobp.2008.04.048. Epub 2008 Jul 16.
The use of altered fractionation radiotherapy (RT) regimens, as well as concomitant chemotherapy and RT, to intensify therapy for locally advanced head-and-neck cancer can lead to increased rates of long-term dysphagia.
We identified 122 patients who had undergone definitive RT for locally advanced head-and-neck cancer, after excluding those who had been treated for a second or recurrent head-and-neck primary, had Stage I-II disease, developed locoregional recurrence, had <12 months of follow-up, or had undergone postoperative RT. The patient, tumor, and treatment factors were correlated with a composite of 3 objective endpoints as a surrogate for severe long-term dysphagia: percutaneous endoscopic gastrostomy tube dependence at the last follow-up visit; aspiration on a modified barium swallow study or a clinical diagnosis of aspiration pneumonia; or the presence of a pharyngoesophageal stricture.
A composite dysphagia outcome occurred in 38.5% of patients. On univariate analysis, the primary site (p = 0.01), use of concurrent chemotherapy (p = 0.01), RT schedule (p = 0.02), and increasing age (p = 0.04) were significantly associated with development of composite long-term dysphagia. The use of concurrent chemotherapy (p = 0.01), primary site (p = 0.02), and increasing age (p = 0.02) remained significant on multivariate analysis.
The addition of concurrent chemotherapy to RT for locally advanced head-and-neck cancer resulted in increased long-term dysphagia. Early intervention using swallowing exercises, avoidance of nothing-by-mouth periods, and the use of intensity-modulated RT to reduce the dose to the uninvolved swallowing structures should be explored further in populations at greater risk of long-term dysphagia.
采用改变分割放疗（RT）方案以及同步化疗与放疗，强化局部晚期头颈癌的治疗，可能会导致长期吞咽困难发生率增加。
我们确定了122例接受局部晚期头颈癌根治性放疗的患者，排除了那些接受过第二次或复发性头颈原发性肿瘤治疗、患有I-II期疾病、出现局部区域复发、随访时间不足12个月或接受过术后放疗的患者。将患者、肿瘤和治疗因素与3个客观终点的综合指标相关联，以此作为严重长期吞咽困难的替代指标：最后一次随访时经皮内镜胃造瘘管依赖情况；改良钡餐吞咽检查时的误吸或误吸性肺炎的临床诊断；或存在咽食管狭窄。
38.5%的患者出现了综合吞咽困难结局。单因素分析显示，原发部位（p = 0.01）、同步化疗的使用（p = 0.01）、放疗方案（p = 0.02）以及年龄增加（p = 0.04）与综合长期吞咽困难的发生显著相关。多因素分析显示，同步化疗的使用（p = 0.01）、原发部位（p = 0.02）以及年龄增加（p = 0.02）仍然具有显著性。
局部晚期头颈癌放疗中加用同步化疗会导致长期吞咽困难增加。对于长期吞咽困难风险较高的人群，应进一步探索采用吞咽练习进行早期干预、避免禁食期以及使用调强放疗以降低未受累吞咽结构的剂量。
