Can Superficial Parotid Sparing Alone Reduce Xerostomia? A Retrospective Study Correlating Type of Tobacco Use, Chronic Xerostomia and Parotid Sparing

Abstract

<h3>Purpose/Objective(s)</h3> Head and neck cancer is one of the most common cancers in India. Tobacco chewing is the most widespread form of tobacco consumption. Majority of the patients present in locally advanced stage and achieving parotid sparing with IMRT in these patients can be challenging. We aimed to correlate the incidence of chronic xerostomia with the type of tobacco use and parotid volumes. <h3>Materials/Methods</h3> Patients with squamous carcinomas of head and neck region treated with conventionally fractionated curative-intent radiotherapy (bilateral neck) to a dose of 60-70 Gy between June 2017 and March 2020 were included in the study. The superficial and deep lobes of parotid were contoured retrospectively and the dosimetric data along with physician-assessed Radiation Therapy Oncology Group (RTOG) xerostomia toxicity grades at one year were retrieved. The individual, superficial and deep lobe parotids were considered spared if the mean dose was less than 26Gy. Patients were divided into five groups: Group 1 constituted bilateral parotid-spared, Group 2 of contralateral parotid-spared, Group 3 of contralateral superficial parotid-spared, Group 4 of bilateral superficial parotid-spared, and Group 5 where no sparing could be achieved. The groups were compared using chi-square test. <h3>Results</h3> 174 patients were included in the study. The median age was 59 years (IRQ 20 - 89). Chewing (40%), followed by smoking (35%) were the most frequent forms of tobacco consumption. The most common subsite was oropharynx (30.5%) followed by hypopharynx (26.4%), and about 83% had locally advanced disease. The mean bilateral parotid volume was 55.9 cc (18-130 cc). Tobacco chewers had significantly smaller mean parotid (53cc vs 60cc, p=0.02) and submandibular gland volumes (6cc vs 14cc, p<0.001) as compared to smokers. Bilateral or contralateral parotid sparing was achieved in 62.7%, bilateral or contralateral superficial lobe in 27.6%, and no sparing in 9.8% of patients. At one year, grade 0/I xerostomia was reported by 89.5%, and ≥grade II xerostomia in 11.5%. The grade of xerostomia was similar in smokers and chewers (p=0.95). The ipsilateral (26.5 Gy vs 37.8 Gy, p <0.001) and contralateral (23.3 Gy vs 34.1 Gy, p <0.001) superficial parotid mean dose in patients with grade 0/I and ≥grade II xerostomia was significantly different. Patients with bilateral or contralateral superficial lobe sparing had lower rates of grade II/III xerostomia compared to no sparing group (p<0.001). <h3>Conclusion</h3> Tobacco chewers have smaller parotid and submandibular glands compared to smokers. This did not impact the sparing of glands or the severity of xerostomia. Contralateral or bilateral superficial parotid sparing translated into superior salivary gland function at 1 year.