Impact of dosimetric factors on long-term percutaneous enteral gastrostomy (PEG) tube dependence in head and neck cancer patients after (chemo)radiotherapy—results from a prospective randomized trial

Abstract

Purpose/objective To analyze dose–volume histogram (DVH)-derived data on the exposure of organs at risk with impact on long-term percutaneous enteral gastrostomy (PEG) tube dependence in head and neck cancer patients at 6 and 12 months after definitive or adjuvant (chemo)radiotherapy. Materials and methods Sixty-one patients were prospectively treated with (chemo)radiotherapy. Prophylactic or reactive gastrostomy tube placement was performed in 41 (67.2%) patients. Dose–volume histogram parameters were obtained for the swallowing apparatus. Results Median follow-up time was 25 (2–34) months. Overall survival was shorter in patients with inlying PEG tubes at 6 and 12 months (log rank p = 0.038 and p = 0.017) after therapy completion. The estimated median time of tube dependency was 6 (95% confidence interval: 2–14) months. After 6 months, 46.5% of patients were tube dependent. After 12 months, this estimated proportion fell to 31.5%. For both time points, the volume to the larynx (in %) receiving at least 50 Gy (larynx V50Gy) exceeding 53% was predictive for long-term tube feeding (6 months: p = 0.041 and 12 months: p = 0.042) being an independent predictor during multivariable analysis. There was no clinical feature influencing tube dependence after 12 months. Conclusion Long-term gastrostomy dependence was found to be strongly associated with an exposure of laryngeal structures (specifically, V50Gy ≥ 53%) during radiotherapy. Consequently, the avoidance of supraglottic as well as glottic structures is warranted.

Irradiation dose to the swallowing apparatus impacts nutritional status in head and neck cancer patients—results from the prospective randomized HEADNUT trial

“…For this analysis, complete patient data were available in 60 patients. Basic patient characteristics (together with a CONSORT chart) have already been published elsewhere [ 3 , 18 ].…”

“…Pretreatment dysphagia was known in 19 patients (31.7%), with 8 in the definitive and 11 patients in the adjuvant treatment setting [ 18 ]. During the entire follow-up period, 2 patients reported their individual most severe grade of dysphagia already before the start of RT.…”

“…Anatomical organ delineation was performed in accordance with Levendag et al. (scm: mid C2 to upper C3; mcm: upper C3 to upper C4/caudal part of the corpus of the hyoid bone; icm: upper C4 to mid C6; cphm: mid C6 to esophageal junction) [ 14 , 18 ].…”

“…Being crucial due to its elevation during swallowing, the larynx constitutes another risk structure during RT [ 15 ]. The mean dose (Dmean) to the larynx (and to the icm) predicts long-term swallowing complications and percutaneous endoscopic gastrostomy (PEG) tube dependence [ 16 – 18 ]. Regardless of modern RT techniques like intensity-modulated radiotherapy (IMRT) or volumetric arc technique (VMAT), strict attention to the dose constraints of these risk structures is inevitable.…”

“…We have published our results about the impact of RT dose on feeding tube dependence in the HEADNUT study population previously [ 18 ]. In contrast, this work focuses on the influence of dose exposure of the swallowing apparatus on malnutrition in the same population.…”