Percutaneous Endoscopic Gastrostomy Tube Dependence Research Articles

A Retrospective Comparative Cohort Study of Craniotomy and Prophylactic Enoxaparin Timing.

Introduction: Post-operative venous thromboembolism (VTE) prophylaxis is the standard of care after craniotomy, but there is debate over when to initiate VTE prophylaxis to decrease the morbidity and mortality experienced by these patients. This study aims to determine the effects of starting enoxaparin on day one vs. day three after craniotomy.Methods: We used a multi-institutional health research network (TriNetX) to gather data from the electronic medical records of patients who started enoxaparin one day after craniotomy (cohort 1) and patients who started it three days later (cohort 2). Our primary endpoint was mortality, with the secondary endpoints of deep venous thrombosis (DVT), additional craniotomy, pulmonary embolism (PE), myocardial infarction (MI), ischemic stroke (IS), intracerebral hemorrhage (ICH), ventilator and tracheostomy dependence, or percutaneous endoscopic gastrostomy (PEG) tube dependence. Patients were propensity score-matched for demographics, common comorbidities, and anticoagulant and antiplatelet use.Results: After propensity score matching, 1,554 patients were identified in each cohort. In cohort 1, 21.171% of patients were deceased after five years vs. 26.126% in cohort 2 (p= 0.0012; OR 0.759, 95% CI (0.643,0.897)). The 30-day survival was 94.521% vs. 93.049%, the 90-day survival was 90.200% vs. 87.335%, and the 365-day survival was 80.619 vs. 76.817%. Deep venous thrombosis occurred in 5.277% of cohort 1 and 7.851% of cohort 2 (p=0.0038, OR 0.654, 95% CI [0.49,0.873]). There was no increase in intracerebral hemorrhage in cohort 1. There were no statistically significant differences in subsequent craniotomy rates, PE, MI, IS, ventilator/tracheostomy, or PEG tube dependence.Conclusion: Starting enoxaparin on day one after craniotomy was associated with decreased mortality and DVTs, with no difference in rates of PE, MI, IS, tracheostomy/PEG dependence, or further craniotomy.

Patient-oriented toxicity endpoints after head and neck reirradiation with intensity modulated radiation therapy

ObjectivesTo characterize specific serious toxicities of reRT with intensity modulated radiation therapy (IMRT) for squamous cell carcinoma of the head and neck (SCCHN) and identify treatment-related predictors of toxicity for patient counseling and decision-making. Materials/Methods75 consecutive patients with recurrent or 2nd primary SCCHN received reRT from 8/2004-02/2013. All patients had prior definitive or postoperative RT. Objective endpoints of “serious toxicity” were defined as: hospitalization during reRT, tracheotomy after reRT, hemorrhage, soft tissue complication requiring operative intervention, or other CTCAE grade ≥4 toxicity. ResultsPatients received definitive (n=41,55%) or postoperative (n=34,45%) reRT (median dose 60Gy, range 59.4–70Gy). Most patients (88%) had concurrent chemotherapy. With a median follow-up of 1.4years, 39 (52%) patients had at least one serious toxicity: hospitalization during reRT (24%), surgically-managed soft tissue complication (19%), and/or urgent tracheotomy (18%). There were no grade 5 acute toxicities but there were 4 fatal hemorrhages (median 8.3months) including 2 attributed to local-regional recurrence (LRR). Most patients (69%) had a percutaneous endoscopic gastrostomy (PEG) tube at last follow-up; those with a LRR had higher PEG tube-dependence rates (86% vs. 53%, p=0.001). LRR, site of reRT, and laryngeal RT dose, were marginally associated with toxicity-risk. ConclusionsPatients considering reRT should be counseled on the high rate of PEG tube-dependence, and events of urgent tracheotomy, hospitalization, hemorrhage, and operative intervention, which typically occur months after reRT completion. Further study of baseline patient function and cumulative radiation dose to the larynx and other organs-at-risk may improve estimates of serious toxicity-risk after reRT.

Respiratory and Swallowing Outcomes Based on Aneurysm Location in 360 Patients with Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) may result in abnormal respiratory and swallowing function. We analyzed factors that may influence long-term respiratory and swallowing function in aSAH patients and compared patients with anterior and posterior aneurysm locations. We retrospectively reviewed 360 consecutive aSAH patients. We recorded location of the aneurysm and respiratory indices on admission, in-hospital adverse respiratory events, and the need for tracheostomy (for respiratory failure) or percutaneous endoscopic gastrostomy (PEG) tube (for prolonged dysphagia). Respiratory and swallowing function was also reviewed at 1 year and at most recent clinical follow-up. Aneurysms consisted of 293 described as anterior circulation (81.4%) and 67 described as posterior circulation (18.6%), including 31 patients with basilar artery aneurysms and 16 with posterior inferior cerebellar artery (PICA) aneurysms. There were no differences in oxygen saturation or PaO2:FiO2 ratio on admission, though patients with PICA aneurysms presented significantly more commonly with endotracheal intubation. PICA aneurysm patients had higher rates of tracheostomy and PEG tube dependence at 1 year in univariate analysis. Higher Hunt-Hess grade was a predictor of pneumonia and prolonged intubation, whereas older age and prolonged hospitalization were predictors of PEG placement in multivariate analysis. Ruptured anterior and posterior circulation aneurysms have similar rates of in-hospital respiratory and swallowing dysfunction. There was a higher rate of swallowing dysfunction in the posterior circulation aneurysm group compared with the anterior group at most recent follow-up (12% vs. 2%, P= 0.035). Patients with PICA aneurysms demonstrated higher rates of tracheostomy and PEG, though the latter did not achieve statistical significance.

Development of Late Toxicities in Patients with Oral Tongue Cancer Treated with Surgical Resection and Adjuvant Radiation Therapy.

The late effects of RT are not well reported in patients with oral tongue cancer (OTC). This study reports the incidence of late effects and factors associated with the development of late effects in OTC patients. Patients with OTC treated in our institution from 2003 to 2013 were evaluated. The association between RT doses, including mandible maximum and minimum doses and total 3D maximum dose, and late toxicity, defined as development of osteoradionecrosis (ORN), percutaneous endoscopic gastrostomy (PEG) tube dependence for >6 months after treatment, and narcotic dependency >6 months posttreatment were assessed using both univariate and multivariable (MV) analysis. Seventy-six patients with OTC (45% males and 55% females) were treated with definitive surgical resection followed by adjuvant RT. The median follow-up was 4.3 years. Combined late toxicities were reported in 38% of patients. Thirty-four percent of the patients had narcotic dependency and, 3.9% of the patients had ORN of the mandible. Thirteen percent of patients developed PEG tube dependency that was significantly associated with a higher 3D maximum radiation dose on univariate analysis (p < 0.01). On MV analysis, 3D maximum dose remained significantly associated with long-term PEG tube dependency (p = 0.05). Patients with OTC treated with adjuvant RT are at significant risk for development of late toxicities. Increasing maximum dose is associated with long-term PEG tube dependence, and care should be taken to reduce the "hot spot" within radiation treatment plans as much as possible.

Initial Experience Using Transoral Robotic Surgery for Advanced-Stage (T3) Tumors of the Head and Neck

Purpose/Objective(s): Currently transoral robotic surgery (TORS) using the DaVinci system is FDA approved for use in benign and malignant early-stage T1 and T2 tumors. At institutions with a robust TORS program, there is an increased comfort level with both the technology and transoral anatomy as such larger tumors are being excised. We sought to identify how many stage T3 oropharyngeal squamous cell carcinomas (OPSCC) have been attempted using robotic surgery at a high-volume institution (>50 cases per year). In particular, we evaluated the following outcomes: initial clinical T stage, margin status, hospital stay, tracheostomy, and percutaneous endoscopic gastrostomy (PEG) tube dependence and use of adjuvant therapy. Materials/Methods: We conducted an institutional review boardeapproved retrospective chart review of 280 consecutive cases between 2011 and 2015. All pathology reports were reviewed, and those with final pathology demonstrating stage T3 and T4 (pT3-4) OPSCC were included. One patient with incomplete records was excluded. Results: Fourteen patients were identified as pT3, and 1 patient was excluded for incomplete preoperative staging. Mean age was 65 years (range 50-85 years) and 64% (nZ9 of 14) were human papillomavirus positive. All but 1 of the patients was male, and 57% (nZ8 of 14) had a history of tobacco use. Preoperative clinical staging for the cohort was cT1 (nZ2), cT2 (nZ9), cT3 (nZ2), and cT4 (nZ1). Tumors were pathologically staged as either pT3 (nZ13) or pT4a (nZ1). Overall length of stay was 5 days (range 2-8 days). Negative margins were achieved in 86% of patients (nZ12 of 14). One patient required a tracheostomy, and 1 patient remained PEG tube dependent. All patients had postoperative XRT, and the 2 patients with positive margins had chemotherapy (either docetaxel and cetuximab or cisplatin). Conclusion: TORS may be used to resect advanced T-stage malignancies; however, there are risks of positive margins, tracheostomy, and PEG tube dependence, as well as hospital stays that exceed the typical 1 to 2 days. The potential benefit of avoiding 3-modality treatment (surgery, radiation, and chemotherapy) should only be considered in tumors in which negative margins can be achieved. Author Disclosure: J. Kass: None. C. Pool: None. M. Teng: None. B. Miles: None. E. Genden: None.

A Prospective Study of Proton Beam Reirradiation for Esophageal Cancer

Reirradiation to the esophagus carries a significant risk of complications. Proton therapy may offer an advantage in the reirradiation setting due to the lack of exit dose and potential sparing of previously radiated normal tissues. Between June 2010 and February 2014, 14 patients with a history of thoracic radiation and newly diagnosed or locally recurrent esophageal cancer began proton beam reirradiation on a prospective trial. Primary endpoints were feasibility and acute toxicity. Toxicity was graded according Common Toxicity Criteria version 4.0. The median follow-up was 10 months (2-25 months) from the start of reirradiation. Eleven patients received concurrent chemotherapy. The median interval between radiation courses was 32 months (10-307 months). The median reirradiation prescription dose was 54.0 Gy (relative biological effectiveness [RBE]) (50.4-61.2 Gy[RBE]), and the median cumulative prescription dose was 109.8 Gy (76-129.4 Gy). Of the 10 patients who presented with symptomatic disease, 4 patients had complete resolution of symptoms, and 4 had diminished or stable symptoms. Two patients had progressive symptoms. The median time to symptom recurrence was 10 months. Maximum acute nonhematologic toxicity attributable to radiation was grade 2 (64%, N=9), 3 (29%, N=4), 4 (0%), and 5 (7%, N=1). The acute grade 5 toxicity was an esophagopleural fistula more likely related to tumor progression than radiation. Grade 3 nonhematologic acute toxicities included dysphagia, dehydration, and pneumonia. There was 1 late grade 5 esophageal ulcer more likely related to tumor progression than radiation. There were 4 late grade 3 toxicities: heart failure, esophageal stenosis requiring dilation, esophageal ulceration from tumor, and percutaneous endoscopic gastrostomy tube dependence. The median time to local failure was 10 months, and the median overall survival was 14 months. Our data demonstrate that proton reirradiation is feasible, with an encouraging symptom control rate, modest radiation-related toxicity, and favorable survival in this high-risk population.

Long-Term Quality of Life After Swallowing and Salivary-Sparing Chemo–Intensity Modulated Radiation Therapy in Survivors of Human Papillomavirus–Related Oropharyngeal Cancer

To evaluate long-term health-related quality of life (HRQOL) in 2 prospective studies of chemo-intensity modulated radiation therapy (chemo-IMRT) for oropharyngeal cancer (OPC). Of 93 patients with stage III/IV OPC treated on prospective studies of swallowing and salivary organ-sparing chemo-IMRT, 69 were eligible for long-term HRQOL assessment. Three validated patient-reported instruments, the Head and Neck QOL (HNQOL) questionnaire, the University of Washington quality of life (UWQOL) questionnaire, and the Xerostomia Questionnaire (XQ), previously administered from baseline through 2years in the parent studies, were readministered at long-term follow-up, along with the Short-Form 36. Long-term changes in HRQOL from before treatment and 2years were evaluated. Forty patients (58%) with a median follow-up of 6.5years participated, 39 of whom (97.5%) had confirmed human papillomavirus-positive OPC. Long term, no clinically significant worsening was detected in mean HRQOL scores compared with 2years, with stable or improved HRQOL from before treatment in nearly all domains. "Moderate" or greater severity problems were uncommon, reported by 5% of patients for eating, 5% for swallowing, and 2.5% and 5% by HNQOL and UWQOL summary scores, respectively. Freedom from percutaneous endoscopic gastrostomy tube dependence and stricture dilation beyond 2years was 97.5% and 95%, respectively. Eleven percent and 14% of patients reported "moderate" or "severe" long-term worsening in HNQOL Pain and Overall Bother domains, respectively, which were associated with mean dose to the cervical esophagus, larynx, and pharyngeal constrictors. At more than 6 years' median follow-up, OPC patients treated with swallowing and salivary organ-sparing chemo-IMRT reported stable or improved HRQOL in nearly all domains compared with both before treatment and 2-year follow-up. New late toxicity after 2years was uncommon. Further emphasis on sparing the swallowing organs may yield additional HRQOL gains for long-term OPC survivors.

Percutaneous endoscopic gastrostomy tube dependence following chemoradiation in head and neck cancer patients.

Compare long-term percutaneous endoscopic gastrostomy (PEG) tube dependence, stricture rate, and weight loss in patients receiving a prophylactic gastrostomy tube with those who initially rely on oral intake during chemoradiation for head and neck cancer. Also, to determine what other patient and treatment characteristics influence development of long-term severe dysphagia. Retrospective review. Seventy-nine patients received a PEG tube and 25 did not. The prophylactic and initial oral intake groups were then analyzed to assess the primary outcomes of PEG dependence at last follow-up >1 year. On univariate and multivariate analysis, Zubrod score >1, prophylactic PEG placement, and higher T classification were predicted for PEG tube dependence at last follow-up at least 1 year after treatment. Prophylactic PEG tube, high Zubrod score, and high T stage were independent predictors for PEG tube dependence at least 1 year after treatment in patients with head and neck cancer receiving definitive chemoradiation. 4.

A Comparison of Outcomes Using Intensity-Modulated Radiation Therapy and 3-Dimensional Conformal Radiation Therapy in Treatment of Oropharyngeal Cancer

Approximately 50% of head and neck cancer survivors experience dysphagia and related morbidity. Intensity-modulated radiation therapy (IMRT) is increasingly used to treat oropharyngeal cancers with excellent oncologic outcomes, but few studies have compared it with conventional 3-dimensional conformal radiation therapy (3D-CRT) to determine whether it can decrease treatment-related toxic and adverse effects. To determine whether IMRT improves percutaneous endoscopic gastrostomy (PEG) tube and treatment-related toxicity outcomes compared with 3D-CRT in patients with oropharyngeal squamous cell carcinoma. Retrospective review of 159 patients with oropharyngeal primary tumors with no history of chemotherapy, radiation therapy, or surgery of the head and neck who underwent definitive treatment with radiotherapy for oropharyngeal squamous cell carcinoma at the Hollings Cancer Center outpatient clinic, Medical University of South Carolina, from 2000 to 2009. Doses of 70 Gy in 35 daily fractions of radiotherapy delivered via IMRT or 3D-CRT. Primary end points included PEG tube dependence 1 year after radiotherapy start, weight loss during treatment, and change in Eastern Cooperative Oncology Group performance status. Secondary end points included overall and disease-free survival, disease recurrence, and toxic effect profiles. The IMRT group (n = 103) had a significantly lower rate of PEG tube dependence 1 year after treatment initiation than the 3D-CRT group (n = 56) for all patients (P = .02) and for those with advanced T stage (P = .01) and a shorter time to PEG tube removal (P < .001). Acute grade 3 or greater toxic effects to skin and mucous membranes occurred less frequently in the IMRT group (P = .02 and P < .001, respectively). The 2 groups did not differ significantly in weight loss, treatment failure (hazard ratio, 0.82 [95% CI, 0.47-1.41]), overall survival (P = .45), or disease-free survival (P = .26). The use of IMRT significantly improves PEG tube and toxicity-related outcomes compared with 3D-CRT in the treatment of oropharyngeal primary cancers. Given the association between mucosal toxic effects, PEG tube dependence, and dysphagia, these findings may be an indication of improved swallowing outcomes with IMRT.

Toxicities and costs of placing prophylactic and reactive percutaneous gastrostomy tubes in patients with locally advanced head and neck cancers treated with chemoradiotherapy

We compared dependence rates, complications, toxicities, and costs associated with prophylactic versus reactive percutaneous endoscopic gastrostomy (PEG) tube placement. One hundred ninety-three patients with locally advanced head and neck squamous cell carcinoma treated with concurrent chemoradiotherapy were retrospectively reviewed. The 1-year and 2-year actuarial PEG tube dependence rate of the entire cohort was 24% and 13%, respectively. There was no difference in the PEG tube dependence rates between those placed prophylactically versus reactively. Patients who received a PEG tube reactively had a significantly higher stricture rate (p = .03) and aspiration rate (p < .001) compared to the prophylactic group. There were significantly fewer hospitalizations in the prophylactic group compared to the reactive group (p = .003). When accounting for both PEG placement and hospitalizations, the prophylactic approach was found to be more cost effective. PEG tubes placed prophylactically were associated with lower rates of strictures, aspirations, hospitalizations, and costs compared to those placed reactively.

Sparing the larynx and esophageal inlet expedites feeding tube removal in patients with stage III‐IV oropharyngeal squamous cell carcinoma treated with intensity‐modulated radiotherapy

To evaluate the effect of larynx and esophageal inlet sparing on dysphagia recovery after intensity-modulated radiotherapy (IMRT) for stage III-IV oropharyngeal squamous cell carcinoma. Retrospective study. Of 88 patients treated with IMRT, 38 were planned with a larynx + esophageal inlet mean dose <50 Gy constraint, 27 with a larynx alone mean dose constraint of <50 Gy, and 23 without a larynx/esophagus constraint. All had a percutaneous endoscopic gastrostomy (PEG) tube placed before IMRT, which was removed when the patient could swallow and maintain weight. All IMRT plans were retrieved, and the larynx; esophageal inlet; and superior, middle, and inferior constrictors were contoured. Dosimetric data were correlated with PEG tube dependence duration. The PEG tube was removed within 3, 6, 9, and 12 months after IMRT in 24%, 61%, 71%, and 83% of patients, respectively. Median times to PEG tube removal were 3.7 and 8.6 months (P = .0029) in patients planned with or without a larynx/larynx + esophageal inlet dose constraint. A mean dose to the larynx + esophageal inlet of ≤60 Gy reduced the median PEG tube duration from 10.8 to 6.1 months (P = .02), compared to >60 Gy. Mean pharyngeal constrictor doses in patients receiving a mean dose to the larynx + esophageal inlet of ≤50 Gy versus >50 Gy were: 60 Gy and 69 Gy, 55 Gy and 67 Gy, and 47 Gy and 57 Gy, for the superior, middle, and inferior constrictors, respectively (P < .0001). A dose constraint on the larynx and esophageal inlet during IMRT planning reduces dose to pharyngeal constrictors and expedites PEG tube removal.

Increased likelihood of long‐term gastrostomy tube dependence in head and neck cancer survivors without partners

We evaluated factors associated with long-term dependence on percutaneous endoscopic gastrostomy (PEG) tubes. One hundred fifty-four patients receiving treatment at the University of Alabama at Birmingham between 2002 and 2004 who underwent PEG tube placement were identified through retrospective review of medical records. Using binary logistic regression, we evaluated the association of various factors on long-term dependence on PEG tubes. A total of 25.3% of survivors remained PEG tube-dependent at 12 months. The odds of long-term PEG tube-dependence were greater for those who did not have partners compared with those who had partners (odds ratio [OR], 3.33; p = .004), for patients who received radiation therapy (OR, 6.21; p = .018), and for those who had a tracheotomy in place for longer than 30 days (OR, 4.328; p = .035). Data suggest that interventions targeted at reducing long-term dependence on PEG tubes take into account not only treatment-related factors, but also the important role that social support plays.

Dosimetric Factors Associated With Long-Term Dysphagia After Definitive Radiotherapy for Squamous Cell Carcinoma of the Head and Neck

Intensification of radiotherapy and chemotherapy for head-and-neck cancer may lead to increased rates of dysphagia. Dosimetric predictors of objective findings of long-term dysphagia were sought. From an institutional database, 83 patients were identified who underwent definitive intensity-modulated radiotherapy for squamous cell carcinoma of the head and neck, after exclusion of those who were treated for a second or recurrent head-and-neck primary lesion, had locoregional recurrence at any time, had less than 12 months of follow-up, or had postoperative radiotherapy. Dosimetric parameters were analyzed relative to three objective endpoints as a surrogate for severe long-term dysphagia: percutaneous endoscopic gastrostomy (PEG) tube dependence at 12 months, aspiration on modified barium swallow, or pharyngoesophageal stricture requiring dilation. Mean dose greater than 41 Gy and volume receiving 60 Gy (V(60)) greater than 24% to the larynx were significantly associated with PEG tube dependence and aspiration. V(60) greater than 12% to the inferior pharyngeal constrictor was also significantly associated with increased PEG tube dependence and aspiration. V(65) greater than 33% to the superior pharyngeal constrictor or greater than 75% to the middle pharyngeal constrictor was associated with pharyngoesophageal stricture requiring dilation. Doses to the larynx and pharyngeal constrictors predicted long-term swallowing complications, even when controlled for other clinical factors. The addition of these structures to intensity-modulated radiotherapy optimization may reduce the incidence of dysphagia, although cautious clinical validation is necessary.

Radiation technique influence on percutaneous endoscopic gastrostomy tube dependence: Comparison between two radiation schemes

Our aim was to determine whether percutaneous endoscopic gastrostomy (PEG) dependence was significantly different between 2 prospective trials with different radiation fractionation schemes. Stage III or IV locally advanced head and neck squamous cell carcinomas arising from the oral cavity, hypopharynx, oropharynx, nasopharynx, paranasal sinuses, or larynx were treated using hyperfractionation (A-3 protocol) or accelerated fractionation (A-4 protocol) with chemotherapy. Amifostine was administered 15 to 30 minutes preradiation, at a dose of 500 mg/day in both protocols. It was given as an infusion over 5 to 7 minutes (A-3 protocol) or subcutaneously (A-4 protocol). Data regarding PEG placement and removal were collected prospectively. Thirty-five evaluable A-3 protocol patients, 14 evaluable A-4 protocol patients, and 6 patients treated per A-4 protocol guidelines, but without amifostine as they refused the medication, were included in the analysis. Pretreatment characteristics, such as sex, age, race, T classification, N classification, American Joint Committee on Cancer (AJCC) stage, were compared between the 2 groups of patients. The only significant difference between the 2 groups was AJCC stage. Thirty-five A-3 patients and 20 A-4 patients had overall survivals of 88% versus 80%, 82% versus 75%, and 66% versus 67.5% at 1, 2, and 3 years, respectively (p = .958). With regard to PEG dependence, no significant differences were seen between the 2 groups at 6, 12, or 18 months. PEG dependence was not significantly different between the 2 study groups. Type of altered fractionation scheme may not influence PEG dependence in patients treated with similar protocols. Future randomized studies are needed to confirm these findings.

Dosimetric Predictors of Gastrostomy Tube Dependence at One Year in Patients with Squamous Cell Carcinoma of the Head and Neck

Percutaneous Endoscopic Gastrostomy (PEG) tube dependence can have a severe negative impact on the quality of life of patients treated for head and neck cancer with radiotherapy. We examined doses to swallowing associated structures and correlations with PEG tube dependence at 1 year.

Factors Associated With Long-Term Dysphagia After Definitive Radiotherapy for Locally Advanced Head-and-Neck Cancer

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.

Effect of Body Mass Index on Chemoradiation Outcomes in Head and Neck Cancer

To investigate the association between initial body mass index (BMI) and chemoradiation therapy (CRT) outcomes in head and neck cancer patients. Retrospective study of 72 patients with American Joint Committee on Cancer stage III or IV squamous cell carcinoma of the oropharynx, hypopharynx, or larynx treated with primary concurrent CRT with curative intent over a 5 year period. Logistic and Cox regression analyses were used to determine the association between initial BMI and percutaneous endoscopic gastrostomy tube dependence, tumor recurrence, disease-free survival, and overall survival while controlling for the independent variables of age, sex, race, site, stage, and smoking and alcohol use. Patients with normal or low BMI (BMI < or =25 kg/m) were significantly more likely to be percutaneous endoscopic gastrostomy dependent at last follow-up (odds ratio 4.13; 95% confidence interval [CI] 1.3-12.9; P = .014). This group also had significantly earlier recurrence (hazard ratio 4.4; 95% CI 1.2-15.9; P = .026) and shorter overall survival (hazard ratio 3.6; 95% CI 1.04-12.6, P = .043). The present study suggests that CRT patients with BMI greater than 25 have improved swallowing outcomes, longer time to disease recurrence, and improved survival when compared with similar patients with lower BMI. BMI at presentation may be an important clinical factor to consider when determining the optimal treatment modality for a head and neck cancer patient. Further investigation is required to determine whether primary surgery should be the preferred treatment in normal or low BMI patients.

Intensity-Modulated Radiotherapy for Head and Neck Cancer of Unknown Primary: Toxicity and Preliminary Efficacy

Unknown primary head and neck cancers often require comprehensive mucosal and bilateral neck irradiation. With conventional techniques, significant toxicity can develop. Intensity-modulated radiotherapy (IMRT) has the potential to minimize the toxicity. Between 2000 and 2005, 21 patients underwent IMRT for unknown primary head and neck cancer at our center. Of the 21 patients, 5 received IMRT with definitive intent and 16 as postoperative therapy; 14 received concurrent chemotherapy and 7 IMRT alone. The target volumes included the bilateral neck and mucosal surface. The median dose was 66 Gy. Acute and chronic toxicities, esophageal strictures, and percutaneous endoscopic gastrostomy tube dependence were evaluated. Progression-free survival, regional progression-free survival, distant metastasis-free survival, and overall survival were estimated with Kaplan-Meier curves. With a median follow-up of 24 months, the 2-year regional progression-free survival, distant metastasis-free survival, and overall survival rate was 90%, 90%, and 85%, respectively. Acute grade 1 and 2 xerostomia was seen in 57% and 43% of patients, respectively. Salivary function improved with time. Percutaneous endoscopic gastrostomy tube placement was required in 72% with combined modality treatment and 43% with IMRT alone. Only 1 patient required percutaneous endoscopic gastrostomy support at the last follow-up visit. Two patients treated with combined modality and one treated with IMRT alone developed esophageal strictures, but all had improvement or resolution with dilation. The preliminary analysis of IMRT for unknown primary head and neck cancer has shown acceptable toxicity and encouraging efficacy. The analysis of the dosimetric variables showed excellent tumor coverage and acceptable doses to critical normal structures. Esophageal strictures developed but were effectively treated with dilation. Techniques to limit the esophageal dose could help further minimize this complication.