Dose–volume correlates of the prevalence of patient-reported trismus in long-term survivorship after oropharyngeal IMRT: A cross-sectional dosimetric analysis

Abstract

PurposeTo ascertain the dose–toxicity relationship for the prevalence of self-reported trismus in long-term survivors after intensity-modulated radiotherapy (IMRT) for oropharyngeal carcinoma (OPC). Materials and methodsSelf-reported mouth opening was ascertained prospectively via a cross-sectional survey of OPC survivors using the intraoral finger-test. RT dose–volume histograms (DVHs) were generated for the following masticatory regions of interest: medial pterygoid, lateral pterygoid, and masseter muscles which were designated as ipsilateral or contralateral to the primary tumor. Trismus was defined as self-reported mouth opening of <3 finger-widths. Recursive partitioning analysis (RPA) was performed to identify the dose–volume thresholds associated with late trismus. ResultsAt a median follow-up time of 72 months (95% CI 68–74), 168 of the 587 (29%) survey respondents reported late trismus. Multivariate analysis demonstrated a significant association between late trismus and the following clinical variables: tonsillar primary site, advanced T stage, or higher total RT dose. RPA showed DVH-derived ipsilateral lateral pterygoid (ILP) mean dose of 61 Gy and volume receiving 27 Gy of at least 98.6% were independently associated with late trismus. The association between the ILP dosimetric parameters and the prevalence of late trismus was maintained after adjustment for clinical variables. ConclusionThe integral dose of IMRT results in unavoidable low/intermediate dose to non-target masticatory muscles that is associated with increased prevalence of late trismus in OPC survivors. Whenever clinically and technically applicable, applying the proposed dosimetric constraints to the ILP (V27 <98.6 and Dmean <61 Gy) may reduce the prevalence of late trismus after IMRT for OPC patients.