Radiation-Induced Hypoglossal Nerve Palsy after Definitive Radiotherapy for Nasopharyngeal Carcinoma: Clinical Predictors and Dose-Toxicity Relationship

Abstract

Radiation-induced hypoglossal nerve palsy is a debilitating and irreversible late complication after definitive radiotherapy for nasopharyngeal carcinoma (NPC). This study sets to evaluate its incidence and clinical predictive factors, and to propose relevant dosimetric constraints for this structure to guide radiotherapy planning. We undertook a retrospective review of 797 NPC patients who underwent definitive intensity-modulated radiotherapy (IMRT) between 2003 and 2011. Cumulative incidence and clinical predictors for radiation-induced hypoglossal nerve palsy were evaluated. Clinical predictive factors were analyzed using the Cox proportional hazard model. Archived radiotherapy plans were retrieved and 330 independent hypoglossal nerves were retrospectively contoured following standardized atlas. Optimal threshold analyses of dosimetric parameters (Dmax, D0.5cc, D1cc, D2cc, Dmean) were conducted using receiver operating characteristic curves. Normal tissue complication probability was generated with logistic regression modeling. With a median follow-up of 8.1 years, sixty-nine (8.7%) patients developed radiation-induced hypoglossal nerve palsy. The 5-year and 8-year cumulative incidences were 2.1% and 12.4% respectively. The median latency time to development of palsy was 6.4 years. High radiotherapy dose, premorbid diabetes, advanced T-stage and radiological hypoglossal canal involvement were independent clinical risk factors. Maximum dose received by 1cc volume (D1cc) was the best predictor for the development of radiation-induced nerve palsy (AUC = 0.826). Hypoglossal nerves with D1cc of 74Gy EQD2 had an estimated palsy risk of 4.7%. Nerves with D1cc <74Gy EQD2 had significantly lower risk of palsy than those ≥74Gy EQD2 (2.4% vs 20.8%, p<0.001). Incidence of radiation-induced hypoglossal nerve palsy was high after definitive IMRT for NPC. D1cc <74Gy EQD2 can serve as a useful dose constraint to adopt during radiotherapy planning to limit palsy risk to <5%.