Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer
Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer
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DOI：
10.1016/s0360-3016(02)02712-8
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发表时间：
2002-05-01
影响因子：
7
通讯作者：
Wolf, GT
中科院分区：
文献类型：
--
作者：
Eisbruch, A;Lyden, T;Wolf, GT
目的：为了客观地评估吞咽功能后，局部晚期头颈癌的强化放化疗方案，并评估吞咽dysfunction.Patients和方法的临床意义：29例不可切除的第四阶段头颈癌患者参加了I期研究的放射，70戈伊/7周，同时每周吉西他滨。由于粘膜毒性发生率高，随后的患者组减少了药物剂量：300、150、50和10 mg/m2/周。其中26例患者接受了吞咽功能的前瞻性评价，包括视频透视和食管造影。研究进行了治疗前，治疗后早期（1-3个月），治疗后晚期（6-12个月）。结果：完整的测试进行治疗前22例，治疗后早期20例，治疗后晚期1 - 3例。25例患者至少接受了一项治疗后研究。治疗后功能障碍的特征是会厌内翻减少、吞咽开始延迟和推注时间不协调、颈咽肌开放和喉闭合，所有这些都促进了吞咽期间和之后的抽吸。此外，舌根回缩减少，与咽后壁的接触减少，颈咽松弛不完全，导致残留物在梨状窦和谷中淤积，吞咽后经常被吸出。治疗后的吸入通常是“无声的”，没有引起咳嗽反射，或咳嗽延迟，不能有效地排出残留物。在治疗前研究中观察到3例患者（14%）吸入，在治疗后早期研究中观察到13例患者（65%）吸入，在治疗后晚期研究中观察到8例患者（62%）吸入（治疗后与治疗前的吸入率：p = 0.0002）。6例患者在治疗后1-14个月（中位数：2.5个月）发生需要住院治疗的肺炎，2例患者可能因肺炎死亡。在治疗后研究中，17例证实有误吸的患者中发生了5例肺炎，而8例未证实有误吸的患者中没有发生肺炎（p = 0.1）。在未接受任何治疗后研究的4例患者中，我发生了肺炎。粘膜炎评分，长期管喂养，气管切开管的存在，吉西他滨剂量没有被发现与吸入或肺炎risk.Conclusions：强化放化疗后，显着的客观吞咽功能障碍是普遍的。它促进误吸，这可能不会引起咳嗽反射，并可能与肺炎有关。吸入性肺炎可能是头颈部癌症放化疗的一种未充分报道的并发症。未来的研究应该检查常规治疗后视频透视和培训抽吸患者安全吞咽策略是否可以降低这种风险。(C)2002年爱思唯尔科技有限公司
Purpose: To objectively assess swallowing function after an intensive chemoradiation regimen for locally advanced head-and-neck cancer and to assess the clinical implications of swallowing dysfunction.Patients and Methods: Twenty-nine patients with nonresectable Stage IV head-and-neck cancer participated in a Phase I study of radiation, 70 Gy/7 weeks, concurrent with weekly gemcitabine. Because of a high rate of mucosal toxicity, reduced drug doses were delivered to subsequent patient groups: 300, 150, 50, and 10 mg/m(2)/week. Twenty-six of these patients underwent prospective evaluation of swallowing function with videofluoroscopy and esophagogram. Studies were performed pretherapy, early post-therapy (1-3 months), and late post-therapy (6-12 months).Results: Complete tests were performed pretherapy in 22 patients, early post-therapy in 20, and late post-therapy in 13. Twenty-five patients had at least one post-therapy study. Post-therapy dysfunction was characterized by reduced inversion of the epiglottis, delayed swallow initiation and uncoordinated timing of the propulsion of the bolus, opening of the cricopharyngeal muscle, and closure of the larynx, all of which promoted aspiration during and after the swallow. In addition, reduced base-of-tongue retraction with reduced contact to the posterior pharyngeal wall and incomplete cricopharyngeal relaxation resulted in pooling in the pyriform sinuses and vallecula of residue, which was frequently aspirated after the swallow. Post-therapy aspirations were typically "silent," eliciting no cough reflex, or the cough was delayed and noneffective in expelling the residue. Aspiration was observed in 3 patients (14%) in the pretherapy studies, in 13 (65%) in the early post-therapy studies, and in 8 (62%) in the late post-therapy studies (aspiration rates post-therapy vs. pretherapy: p = 0.0002). Six patients had pneumonia requiring hospitalization 1-14 months after therapy (median: 2.5 months), being the likely cause of death in 2 patients. Five cases of pneumonia occurred among 17 patients who had demonstrated aspiration in the post-therapy studies, compared with no cases of pneumonia among 8 patients who had not demonstrated aspiration (p = 0.1). Of the 4 patients who had not undergone any post-therapy study, I developed pneumonia. Mucositis scores, prolonged tube feeding, presence of tracheostomy tube, and gemcitabine doses were not found to be related to aspiration or pneumonia risk.Conclusions: After intensive chemoradiotherapy, significant objective swallowing dysfunction is prevalent. It promotes aspiration, which may not elicit a cough reflex and may be associated with pneumonia. Aspiration pneumonia may be an underdocumented complication of chemoradiotherapy for head-and-neck cancer. Future studies should examine whether routine post-therapy videofluoroscopy and training aspirating patients in safe swallowing strategies can reduce this risk. (C) 2002 Elsevier Science Inc.