Systematic review of head and neck lymphedema assessment

Exploring Quantitative MRI Biomarkers of Head and Neck Post-Radiation Lymphedema and Fibrosis: Post Hoc Analysis of a Prospective Trial

BACKGROUND

Quantifying head and neck lymphedema and fibrosis (HN-LEF) is crucial in the investigation and management of treatment sequelae in head and neck cancer (HNC).

METHODS

The T1- and T2-weighted MRI signal intensity (SI) was examined in relation to HN-LEF categories per physical/tactile examination (No-LEF, A-B = edema, C = edema + fibrosis, D = fibrosis), and MRI structural volumes were examined in relation to a novel 10-point HN-LEF score in the intraoral and submental regions.

RESULTS

We identified differences in ranks among HN-LEF categories in relation to the MRI SI (A-B and C are higher than D and No-LEF for T2 SI, and A-B is the highest for T1). Furthermore, six pairs of FOM volumes on MRI demonstrated a strong negative correlation (p < 0.05) with the HN-LEF score at adjacent palpable sites.

CONCLUSION

Both MRI SI and structural volumes can potentially be imaging biomarkers of edematous soft tissue states in HNC patients.

Neck dose-limiting rings reduce head and neck lymphedema in early nasopharyngeal carcinoma patients undergoing IMRT: a dosimetric-clinical validation

This study aimed to determine the optimal limiting dose to reduce head and neck lymphedema in patients with early nasopharyngeal carcinoma (NPC) receiving intensity-modulated radiotherapy (IMRT) by setting dose limiting rings at the anterior and posterior regions of the neck. A total of 15 patients with early NPC were included, and 5 sets of IMRT plans were designed for each patient. Plan A was a conventional plan without dose limiting rings, while Plans B-E were set dose limiting rings with gradients of 20 Gy, 18 Gy, 16 Gy, and 14 Gy, respectively, whose remaining parameters were consistent with Plan A. Through Analysis of Variance (ANOVA) for randomized block design data and Bonferroni pairwise multiple comparisons, the impact of dose limiting rings on target coverage and doses to organs at risk was evaluated and the optimal limiting dose was determined. After that, 50 patients with early NPC (25 with rings according to the optimal limiting dose, 25 without rings) were treated with IMRT to determine if there was a difference in the incidence of head and neck lymphedema. Ultimately, 16 Gy was determined as the optimal limiting dose threshold for achieving the balance of target coverage and protection of organs at risk. Compared with the conventional plan, setting cervical anterior and posterior dose limiting rings of 16 Gy did not affect the target dose coverage (all P > 0.05), only slightly affected homogeneity index and increased monitor units (MUs) (both P < 0.05). The doses of the inner ears, mandible, and brainstem were not affected (all P > 0.05), meanwhile, the doses of the oral cavity, larynx, and thyroid were reduced significantly (all P < 0.05). The doses of the parotid glands and spinal cord slightly increased (both P < 0.05), but still within the tolerance range. Clinical cohort verification showed that setting the dose limiting rings of 16 Gy at the anterior and posterior regions of the neck significantly reduced the occurrence of head and neck lymphedema (P < 0.05). Through dosimetric and clinical cohort verification studies, the optimal limiting dose for the cervical anterior and posterior dose limiting rings has been determined, hoping to provide a new design method of IMRT plans to reduce head and neck lymphedema after radiotherapy for early NPC.

Initial Proof-of-Concept Study on Immediate Effects of External Advanced Pneumatic Compression on Pharyngeal and Laryngeal Internal Lymphedema Using a Fluoroscopic Measurement Tool

BACKGROUND

External and internal head and neck cancer related lymphedema (HNCRL) is a common consequence of radiation treatment (RT). Currently, internal HNCRL can be clinically assessed endoscopically using a visuoperceptual, ordinal rating scale. Use of fluoroscopy to identify and measure internal HNCRL has been explored but is not widely used in clinical practice. Advanced Pneumatic Compression (APC) has shown external HNCRL reduction after a single treatment, whereas internal HNCRL reduction has not yet been assessed.

METHODS

Fluoroscopic lateral scouts and TIMS Review software (TIMS Medical) were used to assess immediate internal HNCRL measures of 30 HNC patients with RT history following a single APC treatment. Pre and post external measures were also obtained. Paired t-test was used to assess changes in pre and post measures. A post-treatment survey was completed.

RESULTS

All 30 patients had both immediate external and internal HNCRL reductions, and all reductions were statistically significant. All reported positive benefit.

CONCLUSIONS

A single, external APC treatment immediately impacted the extent of pharyngeal and laryngeal edema in post-radiated HNC survivors. Fluoroscopy can be a clinically useful and complementary modality to detect, surveil, and measure internal HNCRL.

Evaluating the effects of lymphoedema management strategies on functional status and health-related quality of life following treatment for head and neck cancer: a systematic review

PURPOSE

Patients living with head and neck lymphoedema (HNL) after completion of head and neck cancer (HNC) often can experience long-term functional challenges and overall poorer health-related quality of life (HRQOL). This systematic review aims to explore components of effective HNL interventions through identification and synthesising literature on existing HNL management interventions.

METHODS

Five electronic databases (MEDLINE via Ovid and PubMed, CINAHL, CENTRAL, and Scopus) were systematically searched using Medical Subject Headings and free text, as well as citation tracking and Google Scholar for grey literature.

RESULTS

A total of 1910 studies were screened, with 12 studies meeting the inclusion criteria. Findings indicated vast heterogeneity within HNL interventions. Patients' adherence to intervention strategies was reported as low and partially adhered to, particularly at home. This impacted on function domains and overall HRQOL during the post-treatment HNC phase, as well as further increasing the demands placed on healthcare professionals.

CONCLUSIONS

Synthesis of the research findings highlighted a need to provide and educate patients with individualised HNL self-management intervention strategies. Promoting adherence was reported as being essential, with self-efficacy and behaviour change techniques being emphasised as a critical element to enhance motivation and therefore effective intervention delivery. Further work is important to address barriers to adherence and promote both motivation and behaviour change, to develop individualised self-management interventions for this cancer population.

IMPLICATIONS FOR CANCER SURVIVORS

The findings from this systematic review will provide guidance in the development and delivery of individualised self-management HNL interventions for patients who have completed HNC treatment.

Current and Future Implications of Lymphedema Surgery in Head and Neck Reconstruction

In this study, the authors shed light on the underappreciated realm of head and neck lymphedema (HNL) amid the backdrop of significant advancements in extremity lymphedema management. Despite its prevalence and impact, HNL has long been overlooked, attributed to its subtle symptom presentation and lack of awareness among primary care providers. The study delves into the unique challenges associated with diagnosing and treating HNL, emphasizing the predominance of internal swelling over external manifestations. The authors advocate for the refinement and standardization of outcome measures and the integration of innovative techniques such as indocyanine green lymphography and patient-reported outcomes.

Lymphedema of the Head and Neck-Where Do We Stand and Where We Are Headed

Great advancements have been made in the management of lymphedema of the extremities with lymphatic surgery. However, lymphedema of other regions, including head and neck, has remained neglected. Recent discovery of lymphatic system in the brain and the communication between intracranial and paracranial lymphatic systems has drawn attention to the head and neck lymphatics. Lymphedema of the head and neck region can result from inherent abnormality of the lymphatic system (primary) or be caused by accidental or iatrogenic injury to lymphatics (secondary). The head and neck contain a large network of lymphatic tissue. They may be affected by direct tumor infiltration, surgical resection of tumors and surrounding cancer tissue, and/or radiotherapy. Proper screening and counseling of patients before facial aesthetic procedures may avoid managing the distress of lymphedema postprocedure. Progression of head and neck lymphedema (HNL) can lead to chronic inflammatory, fibrosclerotic, and fibrofatty deposition, resulting in permanent deformity and disability. Patients may experience functional impairment, including skin changes, pain, range of motion limitations, contracture, dysphagia, dysarthria, dyspnea, and trismus, all leading to reduced quality of life. Despite these known disabilities, HNL is underdiagnosed due to a lack of awareness about this entity and of tools available for measuring internal or external swelling. The authors' article comprehensively reviews the current diagnostic methods and management strategies and what lies ahead.

Patient-reported outcome measures and physical function following head and neck lymphedema - a systematic review

PURPOSE

Head and neck cancer (HNC) treatments often lead to significant morbidity, including lymphedema. This systematic review aims to comprehensively explore the prevalence and impact of head and neck lymphedema (HNL) following treatment.

METHODS

A systematic literature search was conducted up to September 2023. Studies evaluating HNL prevalence, associated factors, impact, patient-reported outcomes (PROMs), and physical assessments were included. Methodological quality assessment was performed, and data were synthesised narratively.

RESULTS

Twelve studies met the inclusion criteria, with methodological quality ranging from moderate to high. Internal lymphedema prevalence was consistently higher than external lymphedema, with varying rates attributed to treatment modalities and assessment methods. PROMs such as the Lymphedema Symptom Intensity and Distress-Head and Neck and physical assessments including Patterson's Rating Scale were commonly utilised. HNL significantly impacted quality of life and physical function, with reported symptoms including discomfort, tightness, swallowing difficulties, and psychological distress.

CONCLUSION

HNL is a common sequela of HNC treatment with significant implications for individuals' QoL. Standardised assessment protocols and tailored interventions are needed to address the needs of individuals with HNL and improve overall outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

This systematic review highlights a significant prevalence of lymphedema, particularly internal lymphedema in the larynx and pharynx, following treatment. Swallowing difficulties, nutritional issues, anxiety, depression, and body image concerns were associated with both internal and external lymphedema. The impact on quality of life is substantial, with survivors experiencing physical symptoms and psychosocial challenges, emphasising the importance of integrated care approaches tailored to both aspects of well-being.

Current diagnostic and quantitative techniques in the field of lymphedema management: a critical review

Lymphedema evaluation entails multifaceted considerations for which options continue to evolve and emerge. This paper provides a critical review of the current status of diagnostic and quantitative measures for lymphedema, from traditional and novel bedside assessment tools for volumetric and fluid assessment, to advanced imaging modalities. Modalities are contrasted with regard to empirical support and feasibility of clinical implementation. The manuscript proposes a grid framework for comparing the ability of each modality to quantify specific lymphedema characteristics, including distribution, dysmorphism, tissue composition and fluid content, lymphatic anatomy and function, metaplasia, clinical symptoms, and quality of life and function. This review additionally applies a similar framework approach to consider how well assessment tools support important clinical needs, including: (1) screening, (2) diagnosis and differential diagnosis, (3) individualization of treatment, and (4) monitoring treatment response. The framework highlights which clinical needs are served by an abundance of assessment tools and identifies others that have problematically few. The framework clarifies which tools have greater or lesser empirical support. The framework is designed to assist stakeholders in selecting appropriate diagnostic and surveillance modalities, gauging levels of confidence when applying tools to specific clinical needs, elucidating overarching patterns of diagnostic and quantitative strengths and weaknesses, and informing future investigation.

Effect of Complex Decongestive Therapy on Quality of Life and Physical Parameters in Head and Neck Lymphedema

OBJECTIVE

To assess the effect of complex decongestive therapy treatment (CDT) on quality of life, neck disability, cervical range of motion, and facial and neck lymphedema size using specific anatomical landmark points.

METHODS

This prospective study was conducted in a tertiary cancer center in Turkey. Thirty patients included in the study were treated with CDT for 21 days. The patients were evaluated before and after CDT with MD Anderson Cancer Center Head and Neck Lymphedema (MDACC HNC) staging system, The Neck Disability Index, European Organization for Research and Treatment of Cancer Quality of Life 30 (EORTC-QLOC30), Facial Composite score and Neck Circumferences, cervical range of motion.

RESULTS

Median follow-up was 7.2 months. After treatment of 30 patients significant cognitive function, emotional function, and social function (p < 0.001). After CDT treatment, the quality of life sub-parameters of EORTC QLQ-C30 showed significant improvement (p < 0.001). The facial composite score and neck circumferences indices showed significant improvement (p < 0.001). A decrease of 2% or more in the facial composite score and neck circumferences was observed in all patients participating in the study.

CONCLUSION

There have been few studies on the effectiveness of CDT on the EORTC QLQ-C30, facial composite score, and neck circumferences in head and neck lymphedema. In patients with head and neck lymphedema following head and neck cancer, our study demonstrated the positive effects of complex decongestive therapy (CDT) on neck disability, range of motion, quality of life, and facial and neck lymphedema tissue size.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3152-3157, 2024.

Quercetin induces ferroptosis by inactivating mTOR/S6KP70 pathway in oral squamous cell carcinoma

Although recent studies increasingly suggest the potential anti-cancer effect of quercetin, the exact underlying mechanism remains poorly demonstrated in oral squamous cell carcinoma (oSCC). Therefore, our research explored the impacts of quercetin on the ferroptosis and mTOR/S6KP70 axis in oSCC cell lines. After treating oSCC cells with quercetin or indicated compounds and transfection with SLC7A11- or S6KP70-overexpressing plasmid, cell viability was detected by CCK-8 assay. The level of ferroptosis in oSCC cells was assessed by measuring ROS and GSH levels. The activation of mTOR/S6KP70 axis was assessed by Western blotting. Quercetin promoted ferroptosis in an mTOR/S6KP70-dependent manner to inhibit tumor growth in oSCC cells. Mechanistically, we revealed that quercetin induced lipid peroxidation and reduced GSH levels by repressing SLC7A11 expression in oSCC cells. Specifically, the effects of quercetin on ferroptosis and mTOR and S6KP70 phosphorylation were partially blocked by both mTOR agonist and S6KP70 overexpression. Moreover, mTOR inhibitor promoted ferroptosis in quercetin-treated oSCC cells. Our findings showed that ferroptosis may be a new anti-tumor mechanism of quercetin. Additionally, we identified that quercetin can target mTOR/S6KP70 cascade to inhibit the growth of oSCC cells.

Managing lymphoedema following treatment for head and neck cancer: is complete decongestive therapy an effective intervention to improve dysphagia outcomes?

PURPOSE OF REVIEW

The purpose of this review is to summarize current evidence regarding management of head and neck lymphoedema (HNL) to improve dysphagia outcomes following head and neck cancer (HNC) treatment. This review aims to support complete decongestive therapy (CDT) comprising compression, manual lymphatic drainage (MLD), exercises and skincare as an adjunct of dysphagia rehabilitation.

RECENT FINDINGS

Research in the limbs supports the use of CDT to improve lymphoedema outcomes. Emerging evidence supports the use of CDT for the head and neck, though, there is no consensus on optimal treatment required to improve dysphagia outcomes. Current evidence is limited due to a paucity of randomized controlled trials, case series or cohort studies with small participant numbers, and a lack of functional and instrumental dysphagia outcome measures. This provides a foundation to design and test an individually tailored programme of HNL intervention to evaluate swallowing outcomes post CDT.

SUMMARY

As the incidence of HNC is increasing with HPV, with patients living for longer with late effects of HNC treatment, it is vital to understand how the presence of HNL impacts on the swallow, and if functional dysphagia outcomes improve following treatment of HNL. Prospective, longitudinal research with objective and functional outcome measures are required to help determine optimal management of HNL and its impact on the swallow.

Evaluating the effects of lymphoedema management strategies on functional status and health-related quality of life following treatment for head and neck cancer: Protocol for a systematic review

INTRODUCTION/BACKGROUND

Patients living with and after head and neck cancer often experience treatment-related consequences. Head and neck lymphoedema can be described as a common chronic side effect of head and neck cancer and recognised as a contributing factor to impairment of functional status, symptom burden and health-related quality of life. The effects of head and neck lymphoedema can limit patients' involvement in daily activities and alter their appearance, increasing symptom burden and negatively affecting health-related quality of life.

OBJECTIVE

The protocol outlines the rationale and aims for the systematic review. The main aim of the systematic review is to identify and systematically synthesise the literature on the effectiveness of head and neck lymphoedema management strategies, on both function status and health-related quality of life for head and neck cancer patients.

METHODS AND ANALYSIS

This protocol will be conducted according to the PRISMA-P guidelines. Electronic databases will be systematically searched using MEDLINE via Ovid and PubMed, CINAHL, Cochrane Central Register of Controlled Trials and Scopus. Inclusion criteria will involve intervention studies for head and neck lymphoedema management, English language, and adult human participants following head and neck cancer. The software Covidence will be used to export, manage, and screen results. Risk of bias and quality will be assessed in included studies using the Cochrane Handbook of Systematic Reviews of Intervention risk of bias and GRADE tools. A meta-analysis will be performed if there are sufficient homogenous studies. Alternatively, a narrative synthesis will be completed on study findings.

ETHICS AND DISSEMINATION

No ethical approval is required as the study does not involve patient and public involvement. The findings of the review will be disseminated in conferences and submitted for approval to be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022378417. (S1 Appendix).

Advances in and applications of imaging and radiomics in head and neck cancer survivorship

PURPOSE OF REVIEW

Radiological imaging is an essential component of head/neck cancer (HNC) care. Advances in imaging modalities (including CT, PET, MRI and ultrasound) and analysis have enhanced our understanding of tumour characteristics and prognosis. However, the application of these methods to evaluate treatment-related toxicities and functional burden is still emerging. This review showcases recent literature applying advanced imaging and radiomics to the assessment and management of sequelae following chemoradiotherapy for HNC.

RECENT FINDINGS

Whilst primarily early-stage/exploratory studies, recent investigations have showcased the feasibility of using radiological imaging, particularly advanced/functional MRI (including diffusion-weighted and dynamic contrast-enhanced MRI), to quantify treatment-induced tissue change in the head/neck musculature, and the clinical manifestation of lymphoedema/fibrosis and dysphagia. Advanced feature analysis and radiomic studies have also begun to give specific focus to the prediction of functional endpoints, including dysphagia, trismus and fibrosis.

SUMMARY

There is demonstrated potential in the use of novel imaging techniques, to help better understand pathophysiology, and improve assessment and treatment of functional deficits following HNC treatment. As larger studies emerge, technologies continue to progress, and pathways to clinical translation are honed, the application of these methods offers an exciting opportunity to transform clinical practices and improve outcomes for HNC survivors.

Head and neck lymphedema and quality of life: the patient perspective

PURPOSE

Head and neck lymphedema (HNL) is common after head and neck cancer (HNC). This study aimed to explore quality of life (QoL) in patients with HNL to guide the development of a patient-reported QoL measure.

METHODS

We conducted semi-structured interviews with 22 HNC survivors with HNL. Interviews explored participants' experiences of living with HNL. Analysis of interview transcripts drew on qualitative content analysis to ensure themes were grounded in patient experience.

RESULTS

Two main themes were established: "I want to live my life" and "It was like things were short-circuited." These themes encompassed the substantial disruption patients attributed to the HNL and their desire to normalize life.

CONCLUSIONS

Understanding the impact of HNL on individual patients may be critical to optimizing treatment strategies to improve the physical burden of HNL and QoL. This study provides the framework for developing a patient-reported HNL QoL measure.

IMPLICATIONS FOR CANCER SURVIVORS

The development of an HNL-specific QoL measure, grounded in the patient perspective, may provide cancer care teams with a tool to better understand HNL's impact on each patient to tailor patient-centered care and optimize QoL outcomes.