Lymphedema management in head and neck cancer

Evaluating observer reliability and diagnostic accuracy of CT-LEFAT criteria for post-treatment head and neck lymphedema: A prospective blinded comparative analysis

BACKGROUND

Radiation-associated lymphedema and fibrosis (LEF) is a significant toxicity following radiation therapy (RT) for head and neck cancer (HNC) patients. Recently, the CT Lymphedema and Fibrosis Assessment Tool (CT-LEFAT) was developed to standardize LEF diagnosis through fat stranding visualized on CT. This study aims to evaluate the inter-observer reliability and diagnostic accuracy of the CT-LEFAT criteria.

MATERIALS AND METHODS

This study retrospectively evaluated 26 HNC patients treated with RT that received a minimum of two contrast-enhanced CT scans. Qualitative review was conducted by five physician raters to assess the fat stranding observed on CT according to the CT-LEFAT criteria. Fleiss' kappa analysis was used to assess the inter- and intra-rater reliability, and Receiver Operating Characteristic (ROC) Area Under the Curve (AUC) analysis was used to evaluate diagnostic accuracy.

RESULTS

The inter-rater reliability across the six CT-LEFAT regions generally indicated a slight to fair agreement across all raters (0.04 ≤ kappa ≤ 0.36). Intra-observer agreement was generally fair to moderate (overall kappa = 0.44). The ROC AUC analysis varied based on aggregation method used (0.60 ≤ average AUC ≤ 0.70).

CONCLUSION

This specific use-case evaluating CT-LEFAT criteria displays limited performance. This suggests that additional materials, such as further training, refinement of imaging methods, or other processes may be required before achieving clinically-ready diagnostic performance of LEF diagnosis.

Brain alterations and neurologic disorder progression induced by lymphatic dysfunction in the head and neck region

The potential negative impact of lymphatic dysfunction caused by head and neck cancer treatment remains underexplored. Emerging evidence suggests that waste clearance and fluidic balance in the brain are connected to the peripheral lymphatic system in the head and neck region, implying that lymphatic injury in this area could contribute to brain damage. This study aimed to investigate the pathological alterations in the brain induced by peripheral lymphatic dysfunction in the head and neck region using the lymphatic obstruction animal model. An animal model underwent cervical lymph node dissection combined with radiation therapy to simulate the condition with the peripheral lymphatic dysfunction in the head and neck region after cancer treatment. Lymphatic drainage impairment in the head and neck region was associated with significant swelling, disrupted lymphatic drainage, and immune cell infiltration in the white matter. The imaging techniques revealed ventricular enlargement and increased brain water content caused by fluid imbalance leading to significant structural alterations in the brain. Histopathological analysis demonstrated structural brain alterations similar to that of hydrocephalus and cerebral edema, while rotarod tests showed a substantial decline in motor performance. These findings highlight the impact of peripheral lymphatic dysfunction on brain integrity and function. This study provides evidence that brain damage in head and neck cancer patients may be influenced not only by chemotherapy or radiotherapy but also by lymphatic dysfunction caused by surgical interventions. Lymphatic injury in the head and neck region emerges as a potential risk factor for brain damage, underscoring the need for further research into preventive and therapeutic strategies.

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.

Validity and Responsiveness of Measuring Facial Swelling With 3D Stereophotogrammetry in Patients After Bilateral Sagittal Split Osteotomy-A Prospective Clinimetric Study

Introduction: This study is aimed at determining the validity and responsiveness of three-dimensional (3D) stereophotogrammetry as a measurement instrument for evaluating soft tissue changes in the head and neck area. Method: Twelve patients received a bilateral sagittal split osteotomy (BSSO). 3D stereophotogrammetry, tape measurements, and a global perceived effect scale were performed within the first, second, and third postoperative weeks and at 3 months postoperatively. Distance measurements, mean and root mean square of the distance map, and volume differences were obtained from 3D stereophotogrammetry. Validity and responsiveness were assessed by correlation coefficients. Results: Significant correlations between distances from 3D stereophotogrammetry and tape measurements varied from 0.583 to 0.988, meaning moderate to very high validity. The highest correlations were found for the total sum of distances (r ≥ 0.922). 3D stereophotogrammetry parameters presented weak to high responsiveness, depending on the evaluated head and neck region. None of the parameters for 3D stereophotogrammetry significantly correlated with the global perceived effect scale outcomes for all measurement moments. Conclusion: 3D stereophotogrammetry has high to very high construct validity for the total sum of distances and weak to high responsiveness. 3D stereophotogrammetry seems promising for measuring soft tissue changes after surgery but is not interchangeable with subjective measurements.

Feasibility and efficacy of home-based lymphedema exercises for head and neck cancer patients at a safety net hospital

PURPOSE

Lymphedema therapy is an effective tool in mitigating head and neck lymphedema morbidity and long-term fibrosis. Studies have shown the efficacy of facility-based therapy; however, access can be limited by sociodemographic factors, including socioeconomic status and transportation. This study evaluates the feasibility and effectiveness of home-based lymphedema therapy in a socially vulnerable patient population.

MATERIALS AND METHODS

A retrospective chart review analyzed patients who underwent home-based lymphedema exercise regimen after training with a lymphedema-trained speech language pathologist between 2019 and 2022 at a tertiary academic medical center. Patient and cancer demographics were collected. Primary outcomes measured were quality of life surveys and diet status.

RESULTS

Of the 27 patients included, 85.1 % were in the two highest quintiles of neighborhood deprivation based on national Area Deprivation Index (ADI). Treatment breakdown included 78 % who were treated with surgery, 96 % completed radiation and 59.3 % chemotherapy. Six months after initiating lymphedema therapy, most patients (59.3 %) were compliant with exercises. Quality of life scores showed trends toward improvement, but only a decrease in condition-related anxiety at 3 months (p = 0.004) reached statistical significance. Improvement in diet was significant at 6 and 9 months after initiation of treatment (p = 0.020).

CONCLUSIONS

Patient compliance rate demonstrates feasibility of home exercises for lymphedema treatment in a tertiary care setting with a socially vulnerable patient population. Home-based head and neck lymphedema treatment showed improvements in patient diet over time.

Facial Lymphedema Following Head and Neck Tumor Resection: Preliminary Experience of Supermicrosurgical Treatment With LVA-Report of Three Cases

Facial lymphedema (FL) is a potential complication following head-and-neck tumor (HNT) therapy. Conservative management is often difficult, and there is limited literature on surgical treatments for FL. This report presents three cases of FL treated with lymphaticovenular anastomosis (LVA). All three patients were male with ISL stage 2 FL following treatment for oral squamous cell carcinoma, aged 59, 45, and 55 years. In each case, double end-to-end LVAs were performed in the preauricular region (right side in cases 1 and 3, left side in case 2). Follow-up was 12 months for cases 1 and 2 and 9 months in case 3, with no post-operative complications. Case 1 showed a 4% reduction in two of three anthropometric parameters, case 2 demonstrated an 8% reduction in all the parameters along with quality-of-life improvement, and case 3 had a 6% reduction in all parameters with improvement in both pinch test and quality-of-life. LVA supermicrosurgery appears to be an effective treatment for FL, improving quality of life with minimal complications and no need for further surgical interventions.

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.

Facial Swelling and Neuritis After Internal Carotid Endarterectomy in an 81-Year-Old Woman With Type 2 Diabetes Mellitus: A Case Report

OBJECTIVE

Patients with type 2 diabetes mellitus (DM2) may develop carotid artery stenosis, requiring surgical intervention. Nerve injury following carotid endarterectomy (CEA) is a rare and often unrecognized postoperative side effect. This case report describes the diagnostic process and rehabilitation course of a patient with greater auricular and trigeminal neuritis symptoms following internal CEA.

METHODS

The patient is an 81-year-old woman with DM2 who underwent a left internal CEA. She subsequently developed swelling in her left neck and face, and pain along the greater auricular and trigeminal nerve pathways. Pertinent examination findings included incision placement across the path of the greater auricular nerve and cervical lymphatic vessels that drain the face, with overlying scar adhesion. A course of physical therapy was initiated 12 days after surgery, and included mobilization and manual lymphatic drainage, modalities, and application of kinesiotape.

RESULTS

The Patient-Specific Functional Scale improved from 10/30 at evaluation to 27/30 at discharge. Swelling and pain were significantly reduced, with patient reporting no difficulty with sleeping, chewing, or talking at discharge. The reported pain level consistently correlated with fluctuations in face swelling throughout treatment.

CONCLUSION

Patients with DM2 may present with symptoms of cardiovascular disease, requiring invasive surgical procedures. DM2 can cause damage to neural and vascular structures, predisposing patients to nerve injuries or hypersensitivity following procedures. This case report demonstrates a likely connection between postoperative facial swelling and nerve irritation in the head and neck. Mobilization and manual lymphatic drainage, modalities, and kinesiotape were effective to reduce pain and swelling.

IMPACT

Physical therapists are uniquely qualified to identify, evaluate, and treat postoperative swelling and nerve pain associated with CEA.

LAY SUMMARY

Patients with type 2 diabetes mellitus may develop carotid artery stenosis, requiring surgical intervention. Nerve injury following carotid endarterectomy (CEA) is a rare and often unrecognized postoperative side effect. Physical therapists diagnose and provide treatment to patients with greater auricular and trigeminal neuritis symptoms following internal CEA.

Dropped head syndrome secondary to head and neck cancer: Impact on functıonal and body image scale

Objective

The primary aim of our prospective study was to assess the impact of Dropped Head Syndrome (DHS), a rare condition in Head and Neck Cancer (HNC) clinics, on patients' functional status and body image. Our secondary aim is to investigate the relationship between head and neck lymphoedema (HNL) and DHS, which will be examined for the first time in the literature.

Methods

We conducted a study involving 47 patients, aged between 18 and 75, who had been diagnosed with HNC, and exhibited clinical symptoms of DHS for at least 12 months. The staging of HNL was assessed using the MD Anderson Cancer Center HNL (MDACC HNL) staging system. We also administered The Total Functional Scale (TFS) which was a subscale of EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30) and the Body Image Scale (BIS).

Results

In the study, it was observed that the BIS was significantly lower in patient groups aged 50 and over (p = 0.0495), those with a laryngectomy (p = 0.0002), those who had undergone bilateral neck dissection (p = 0.0291), and particularly in patients with stage 2-3 lymphedema (p < 0.0001). Similarly, it was noted that passive cervical extension limitation had a statistically significant impact on both the BIS (p < 0.0001) and the TFS (p < 0.0001). It was also found that BIS (p < 0.0001) and TFS (p < 0.0001) improved in the late postoperative period (12 months ≤) and this improvement was statistically significant.

Conclusions

In this study, we found statistical relationships between age, laryngectomy, surgery procedures, lymphedema stages, passive cervical extension limitations, total functional score, and BIS. Early diagnosis of DHS allows for supportive care and physiotherapy methods, which can lead to improvement. HNL and DHS should be prevented to improve quality of life and body image and increase survival. Therefore, further research with a much larger patient population is needed.

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.

MD Anderson Head and Neck Cancer Symptom Working Group, West NA, Attia SK, Kaffey Z, Dede C, Mulder SL, El-Habashy DM, Neuberger R, Naser MA, Frank SJ, Mao S, McMillan H, Smith B, Rosenthal D, Lai SY, Hutcheson KA, Moreno AC, Fuller CD. Evaluating Observer Reliability and Diagnostic Accuracy of CT-LEFAT Criteria for Post-Treatment Head and Neck Lymphedema: A Prospective Blinded Comparative Analysis of Oncologist Human Inter-Rater Performance

Background

Radiation-associated lymphedema and fibrosis (LEF) is a significant toxicity following radiation therapy (RT) for head and neck cancer (HNC) patients. Recently, the CT Lymphedema and Fibrosis Assessment Tool (CT-LEFAT) was developed to standardize LEF diagnosis through fat stranding visualized on CT. This study aims to evaluate the inter-observer reliability and diagnostic accuracy of the CT-LEFAT criteria.

Materials and Methods

This study retrospectively evaluated 26 HNC patients treated with RT that received a minimum of two contrast-enhanced CT scans. Qualitative review was conducted by five physician raters to assess the fat stranding observed on CT according to the CT-LEFAT criteria. Fleiss' kappa analysis was used to assess the inter- and intra-rater reliability, and Receiver Operating Characteristic (ROC) Area Under the Curve (AUC) analysis was used to evaluate diagnostic accuracy.

Results

The inter-rater reliability across the six CT-LEFAT regions generally indicated a slight to fair agreement across all raters (0.04 ≤ kappa ≤ 0.36). Intra-observer agreement was generally fair to moderate (overall kappa=0.44). The ROC AUC analysis varied based on aggregation method used (0.60 ≤ average AUC ≤ 0.70).

Conclusion

This specific use-case evaluating CT-LEFAT criteria displays limited performance. This suggests that additional materials, such as further training, refinement of imaging methods, or other processes may be required before achieving clinically-ready diagnostic performance of LEF diagnosis.

Clinical, Pathologic, and Dosimetric Predictors of Head and Neck Lymphedema Following Definitive or Adjuvant Radiation Therapy for Head and Neck Cancer

Purpose

Head and neck lymphedema (HNL) following radiation therapy for head and neck cancer (HNC) causes patient morbidity. Predicting individual patients' risk of HNL after treatment is challenging. We aimed to identify the demographic, disease-related, and treatment-related factors associated with external and internal HNL following treatment of HNC with definitive or adjuvant radiation therapy.

Methods and Materials

Relevant clinical, pathologic, and dosimetric data for 76 consecutive patients who received definitive or adjuvant radiation ± chemotherapy were retrospectively collected from a single institution. Multivariable models predictive of external and internal lymphedema using clinicopathologic variables alone and in combination with dosimetric variables were constructed and optimized using competing risk regression.

Results

After median follow-up of 550 days, the incidence of external and internal HNL at 360 days was 70% and 34%, respectively. When evaluating clinical and treatment-related factors alone, number of lymph nodes removed and advanced adenopathy status were predictive of external lymphedema. With incorporation of dosimetric variables, the optimized model included the percentage volume of the contralateral lymph node level VII receiving 30Gy V30 ≥50%, number of lymph nodes removed, and advanced adenopathy status. For internal lymphedema, our clinicopathologic model identified both adjuvant radiation, as opposed to definitive radiation, and advanced adenopathy status. With inclusion of a dosimetric variable, the optimized model included larynx V45 ≥50% and advanced adenopathy.

Conclusions

HNL following HNC treatment is common. For both external and internal lymphedema, nodal disease burden at diagnosis predicts increased risk. For external lymphedema, increasing extent of lymph node dissection prior to adjuvant therapy increases risk. The contralateral level VII lymph node region is also predictive of external lymphedema when radiation dose to V30 is ≥50%, meriting investigation. For internal lymphedema, we confirm that increasing radiation dose to the larynx is the most significant dosimetric predictor of mucosal edema when larynx V45 is ≥50%.

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.

Determining risk and predictors of head and neck cancer treatment-related lymphedema: A clinicopathologic and dosimetric data mining approach using interpretable machine learning and ensemble feature selection

Background and purpose

The ability to determine the risk and predictors of lymphedema is vital in improving the quality of life for head and neck (HN) cancer patients. However, selecting robust features is challenging due to the multicollinearity and high dimensionality of radiotherapy (RT) data. This study aims to overcome these challenges using an ensemble feature selection technique with machine learning (ML).

Materials and methods

Thirty organs-at-risk, including bilateral cervical lymph node levels, were contoured, and dose-volume data were extracted from 76 HN treatment plans. Clinicopathologic data was collected. Ensemble feature selection was used to reduce the number of features. Using the reduced features as input to ML and competing risk models, internal and external lymphedema prediction capability was evaluated with the ML models, and time to lymphedema event and risk stratification were estimated using the risk models.

Results

Two ML models, XGBoost and random forest, exhibited robust prediction performance. They achieved average F1-scores and AUCs of 84 ± 3.3 % and 79 ± 11.9 % (external lymphedema), and 64 ± 12 % and 78 ± 7.9 % (internal lymphedema). Predictive ML and risk models identified common predictors, including bulky node involvement, high dose to various lymph node levels, and lymph nodes removed during surgery. At 180 days, removing 0-25, 26-50, and > 50 lymph nodes increased external lymphedema risk to 72.1 %, 95.6 %, and 57.7 % respectively (p = 0.01).

Conclusion

Our approach, involving the reduction of HN RT data dimensionality, resulted in effective ML models for HN lymphedema prediction. Predictive dosimetric features emerged from both predictive and competing risk models. Consistency with clinicopathologic features from other studies supports our methodology.

Lymphedema and Trismus after Head and Neck Cancer, and the Impact on Body Image and Quality of Life

BACKGROUND

To assess the prevalence of chronic lymphedema and trismus in patients > 6 months after head and neck cancer (HNC) treatment, and to explore how the severity of these conditions correlates with body image and quality of life.

METHODS

The cross-sectional sample included 59 patients, treated for HNC between six months to three years ago. Physical measurements were performed to assess the presence of external lymphedema and trismus (<36 mm). Furthermore, participants completed two questionnaires regarding body image (BIS) and quality of life (UW-QoL V4).

RESULTS

Lymphedema prevalence was 94.1% (95% CI 0.86-0.98), with a median severity score of 9 (range 0-24). Trismus prevalence in this sample was 1.2%. The median BIS score was 2, indicating a positive body image. The UW-QoL score showed a good QOL with a median of 100. Only the domain of saliva and overall related health had a lower median of 70 and 60, respectively. There was no correlation between lymphedema and body image (r = 0.08, p = 0.544). Patients with higher lymphedema scores reported poorer speech with a moderate correlation (r = -0.39, p = 0.003).

CONCLUSION

Lymphedema is a highly prevalent, but moderately severe late side-effect of HNC with a limited impact on quality of life domains except for speech, in our cohort.

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).

Rehabilitation Interventions for Head and Neck Cancer-Associated Lymphedema: A Systematic Review

Importance

Head and neck cancer-associated lymphedema (HNCaL) affects up to 90% of survivors of head and neck cancer and is a substantial contributor to disability following head and neck cancer treatment. Despite the prevalence and morbidity associated with HNCaL, rehabilitation interventions are not well studied.

Objective

To identify and appraise the current evidence for rehabilitation interventions in HNCaL.

Evidence Review

Five electronic databases were searched systematically from inception to January 3, 2023, for studies on HNCaL rehabilitation interventions. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers.

Findings

Of 1642 citations identified, 23 studies (1.4%; n = 2147 patients) were eligible for inclusion. Six studies (26.1%) were randomized clinical trials (RCTs) and 17 (73.9%) were observational studies. Five of the 6 RCTs were published during 2020 to 2022. Most studies had fewer than 50 participants (5 of 6 RCTs; 13 of 17 observational studies). Studies were categorized by intervention type, including standard lymphedema therapy (11 studies [47.8%]) and adjunct therapy (12 studies [52.2%]). Lymphedema therapy interventions included standard complete decongestive therapy (CDT) (2 RCTs, 5 observational studies), modified CDT (3 observational studies), therapy setting (1 RCT, 2 observational studies), adherence (2 observational studies), early manual lymphatic drainage (1 RCT), and inclusion of focused exercise (1 RCT). Adjunct therapy interventions included advanced pneumatic compression devices (APCDs) (1 RCT, 5 observational studies), kinesio taping (1 RCT), photobiomodulation (1 observational study), acupuncture/moxibustion (1 observational study), and sodium selenite (1 RCT, 2 observational studies). Serious adverse events were either not found (9 [39.1%]) or not reported (14 [60.9%]). Low-quality evidence suggested the benefit of standard lymphedema therapy, particularly in the outpatient setting and with at least partial adherence. High-quality evidence was found for adjunct therapy with kinesio taping. Low-quality evidence also suggested that APCDs may be beneficial.

Conclusions and Relevance

The results of this systematic review suggest that rehabilitation interventions for HNCaL, including standard lymphedema therapy with kinesio taping and APCDs, appear to be safe and beneficial. However, more prospective, controlled, and adequately powered studies are needed to clarify the ideal type, timing, duration, and intensity of lymphedema therapy components before treatment guidelines can be established.

Test-Retest Reliability of Local Tissue Water and Circumference Measurements in the Head and Neck Area of Healthy Women and Men

Background: Measurements of local tissue water and circumferences are methods to evaluate lymphedema. Knowledge about reference values and reproducibility needs, however, to be determined for the head and neck (HN) area of healthy persons before it can be used in persons with HN lymphedema. The objective of this study was to evaluate the test-retest reliability including measurement errors of local tissue water and neck circumference measurements (CM) in the HN area in a healthy cohort. Methods and Results: Thirty-one women and 29 men were measured on 2 occasions, 14 days apart. The percentage of tissue water content (PWC) were calculated in four facial points and neck CM at three levels. Intraclass correlation coefficient (ICC), changes in mean, standard error of measurement (SEM%), and smallest real difference (SRD%) were calculated. Reliability for PWC was fair to excellent for both women (ICC 0.67-0.89) and men (ICC 0.71-0.87). Measurement errors were acceptable in all points in both women (SEM% 3.6%-6.4%, SRD% 9.9%-17.7%) and men (SEM% 5.1%-10.9%, SRD% 14.2%-30.3%). For the CM, ICCs were excellent both for women (ICC 0.85-0.90) and men (ICC 0.92-0.94), and measurement errors were low (SEM% for women 1.9%-2.1%, SRD% 5.1%-5.9%; SEM% for men 1.6%-2.0%, SRD% 4.6%-5.6%). Most of the lowest values were found close to bone and vessels. Conclusion: Measurements for PWC and CM in the HN area are reliable in healthy women and men, with acceptable to low measurement errors. PWC points close to bony structures and vessels should, however, be used with caution.

Swallowing Function After Treatment of Laryngeal Cancer

Dysphagia is a common functional outcome following treatment of laryngeal cancer. Despite curative advances in both nonsurgical and surgical approaches, preserving and optimizing swallowing function is critical. Understanding the nature and severity of dysphagia depending on initial tumor staging and treatment modality and intensity is crucial. This chapter explores current evidence on the acute and chronic impacts of treatments for laryngeal cancer on swallow function, as well as the medical and nonmedical management of dysphagia in this population.

Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients

Introduction  Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective  To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods  Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results  A total of 38 patients were included (subsites: larynx = 27; thyroid = 4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection ( p  = 0.02). Conclusion  Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Under recognition and treatment of lymphedema in head and neck cancer survivors - a database study

PURPOSE

Head and neck cancer (HNC) will be diagnosed in approximately 54,000 Americans in 2022 with more than 11,000 dying as a result. The treatment of HNC often involves aggressive multimodal therapy including surgery, radiotherapy, and systemic therapy. HNC and its treatments are associated with multiple painful and function-limiting neuromusculoskeletal and visceral long-term and late effects. Among these is head and neck lymphedema (HNL), the abnormal accumulation of protein rich fluid, in as many as 90% of survivors. Though HNL is common and potentially contributory to other function-limiting issues in this population, it is notoriously understudied, underrecognized, underdiagnosed, and undertreated. This study seeks to determine the incidence of HNC-related lymphedema diagnosis and treatment in a large US healthcare claims repository database.

METHODS

A retrospective observational cohort design and data from an integrated US healthcare claims repository-the IBM MarketScan Commercial Claims and Encounters (CCAE) and Medicare Supplemental and Coordination of Benefits (MDCR) Databases spanning the period April 1, 2012 through March 31, 2020.

RESULTS

Of the 16,654 HNC patients eligible for evaluation, 1,082 (6.5%) with a diagnosis of lymphedema were identified based on eligibility criteria. Of the 521 HNC patients evaluated for lymphedema treatment, 417 (80.0%) patients received 1.5 courses of MLD, 71 (13.6%) patients were prescribed compression garments, and 45 (8.6%) patients received an advanced pneumatic compression device.

CONCLUSION

HNL in this population of HNC survivors was underdiagnosed and treated compared with contemporary assessments HNL incidence.

Assessment of Measures of Head and Neck Lymphedema Following Head and Neck Cancer Treatment: A Systematic Review

Purpose: Head and neck lymphedema is a common condition following head and neck cancer (HNC) treatment, with substantial functional morbidity. This systematic review aimed to (1) identify tools used to assess head and neck lymphedema in HNC patients and (2) determine their validity and reliability. Methods: Electronic and hand searches of Prospero, MEDLINE, Cochrane Library, and Embase were searched from their inception until April 2021, and hand searches were independently screened by two reviewers. Studies were included if they were available in English and measured lymphedema in adult HNC patients (aged ≥18 years). Data including psychometric characteristics were extracted and synthesized narratively, with the Quality Assessment of Diagnostic Accuracy Studies-2 and the COnsensus-based Standards for the selection of health Measurement INstruments checklists used to assess risk of bias. Results: Thirty-three studies, reporting 38 assessment tools, were included. Assessments included clinician rating scales, symptom inventories, size measures, measures of internal edema, radiographic and ultrasonographic measures, and quality-of-life measures. Of the 38 measures cited, only 11 had any degree of validation and reliability testing. Risk of bias varied among the different assessment tools. Conclusion: While many tools are used in the assessment of head and neck lymphedema, the majority of these tools lack validation and reliability data. Only one tool, the Head and Neck Lymphedema and Fibrosis Symptom Inventory, met criteria for strong quality assessment. Further efforts to establish a core set of metrics for this complex condition are warranted.

Case series report: radiation-induced oropharyngeal carcinoma

The incidence of radiation-induced secondary primary tumors (SPTs) is estimated to be between 1 and 20%. The oropharynx is not a common site for postradiotherapy head and neck SPTs. We describe the cases of eight patients, each with an SPT of the oropharynx. These developed after a long median latency of 17.7 years with each receiving two-dimensional radiation therapy and delivery of at least 5000 cGy per pharynx, except for one who was treated with IMRT. Tumor histological commonalities revealed squamous cell carcinoma p16 negative staining, local invasion, and limited lymphatic spread, with posterior wall of the oropharynx and the base of the tongue being the most common locations. Limited and challenging treatment options have been reported such as surgery, reirradiation, or clinical trials. Radiation-induced SP oropharyngeal carcinoma has unique clinical and pathological features. Patients with this disease have limited treatment options, which should be discussed in a multidisciplinary tumor board meeting. For this population, lifelong follow-up may help in early diagnosis and improve outcomes.

Validity Testing of the Head and Neck Lymphedema and Fibrosis Symptom Inventory

Background: Lack of reliable and valid tools significantly impacts early identification and timely treatment of lymphedema and fibrosis (LEF) in the head and neck cancer population. To address this need, we developed and reported a patient-reported outcome measure (Head and Neck Lymphedema and Fibrosis Symptom Inventory [HN-LEF SI]). This article reports the construct validity (convergent and divergent validity) testing of the tool. Materials and Methods: A prospective, longitudinal, instrument validation study was conducted in patients with a newly diagnosed oral cavity or oropharyngeal cancer. Participants completed the HN-LEF SI and six carefully selected self-report measures at pretreatment, end-of-treatment, and every 3 months up to 12 months after treatment. Spearman correlations were used. Results: A total of 117 patients completed the study. Patterns of correlations of the HN-LEF SI scores with the established self-report measure scores were consistent with expected convergent and divergent validity. Conclusion: Evidence from this work supports the construct validity of the HN-LEF SI.

Reliability of 3D Stereophotogrammetry for Measuring Postoperative Facial Swelling

This study aimed to determine the reliability of three-dimensional (3D) stereophotogrammetry as a measurement instrument for evaluating soft tissue changes in the head and neck area. Twelve patients received a bilateral sagittal split osteotomy (BSSO). Test and retest 3D photographs were captured within the first three postoperative weeks, and a reference 3D photograph was capture at three months postoperatively. Distance measurements, mean and root mean square of the distance map, and volume differences were obtained. Reliability of these parameters was assessed by intraclass correlation coefficients (ICCs), standard error of measurement (SEM), and smallest detectable change (SDC). All distance measurements had an ICC > 0.91, and the distance map parameters and volume differences showed ICCs > 0.89. The neck region presented the largest SEMs (5.09 mL) and SDC (14.1 mL) for the volume difference. In conclusion, 3D stereophotogrammetry is reliable for distance and volume measurements of soft tissues in patients after a BSSO advancement.

A Prospective, Longitudinal and Exploratory Study of Head and Neck Lymphoedema and Dysphagia Following Chemoradiotherapy for Head and Neck Cancer

The aim of the study was to examine the following: (a) the trajectory of external and internal head and neck lymphoedema (HNL) in patients with head and neck cancer (HNC) up to 12 months post-chemoradiotherapy (CRT) and (b) the relationship between HNL and swallowing function. Using a prospective longitudinal cohort study, external/internal HNL and swallowing were examined in 33 participants at 3, 6 and 12 months post-CRT. External HNL was assessed using the Assessment of Lymphoedema of the Head and Neck and the MD Anderson Cancer Centre Lymphoedema Rating Scale. Internal HNL was rated using Patterson’s Radiotherapy Oedema Rating Scale. Swallowing was assessed via clinical, instrumental and patient-reported measures. Associations between HNL and swallowing were examined using multivariable regression models. External HNL was prevalent at 3 months (71%), improved by 6 months (58%) and largely resolved by 12 months (10%). In contrast, moderate/severe internal HNL was prevalent at 3 months (96%), 6 months (84%) and at 12 months (65%). More severe penetration/aspiration and increased diet modification were associated with higher severities of external HNL (p=0.006 and p=0.031, respectively) and internal HNL (p<0.001 and p=0.007, respectively), and more diffuse internal HNL (p=0.043 and p=0.001, respectively). Worse patient-reported swallowing outcomes were associated with a higher severity of external HNL (p=0.001) and more diffuse internal HNL (p=0.002). External HNL largely resolves by 12 months post-CRT, but internal HNL persists. Patients with a higher severity of external and/or internal HNL and those with more diffuse internal HNL can be expected to have more severe dysphagia.

Effect of early interventions with manual lymphatic drainage and rehabilitation exercise on morbidity and lymphedema in patients with oral cavity cancer

BACKGROUND

There are clinical and statistical inconsistencies regarding early intervention with manual lymphatic drainage (MLD). The purpose of this study was to compare the short-term effect of early interventions with rehabilitation exercise versus MLD and rehabilitation exercise in terms of pain, range of motion (ROM) and lymphedema in patients with oral cancer after surgery.

METHODS

A total of 39 patients who underwent surgery from December 2014 to December 2018 participated in this randomized single-blind study. There were 20 patients in the rehabilitation (R) group and 19 in the MLD (M) plus rehabilitation group. The R group received 30 minutes of rehabilitation intervention; and the M group received 30 minutes of MLD, in addition to 30 minutes of rehabilitation intervention in a work day. Clinical measures, including the visual analog pain scale (VAS), ROM of the neck and shoulder, ultrasonography and face distance for lymphedema, and the Földi and Miller lymphedema scales, were assessed before surgery, before intervention and when discharged from the hospital.

RESULTS

The VAS pain score, ROM of the neck, and internal and external rotation of the right shoulder were significantly improved after the interventions. Right-face distance (P = .005), and skin-to-bone distance (SBD) of the bilateral horizontal mandible and left ascending mandibular ramus were significantly improved after the interventions. Left lateral flexion of the neck (P = .038) and SBD of the right ascending mandibular ramus (P < .001) in the MLD group showed more improvement than that of the rehabilitation group.

CONCLUSION

Early intervention with MLD and the rehabilitation program were effective in improving ROM of the neck and controlling lymphedema in acute-phase rehabilitation. The preliminary findings suggest a potential therapeutic role for early intervention with MLD, in addition to rehabilitation exercise, in that they yielded more benefits in lymphedema control and improvement of ROM of the neck in acute care.

A prospective observational cohort study examining the development of head and neck lymphedema from the time of diagnosis

INTRODUCTION

Head and neck lymphedema can occur in the internal or external structures of the head and neck region. Little is known about the development of this condition over the course of treatment for head and neck cancer. This study aimed to observe the development of internal and external lymphedema from diagnosis to 12 weeks postacute treatment.

METHODS

A single center, prospective observational cohort study assessed participants for external lymphedema, internal lymphedema, quality of life, and symptom burden. Assessments were conducted prior to starting radiotherapy (RT), at the end of RT, 6 and 12 weeks after RT.

RESULTS

Forty-six participants were recruited. External lymphedema as measured by percentage water content, increased from 41.9 at baseline (95% CI: 39.3-44.4) to 50.4 (95% CI: 46.0-54.8) at 12 weeks following RT (p-value < .001). After adjusting for changes in weight and participant age at baseline, a general increase in tape measurements was observed over time with significant increases from baseline to 12 weeks post-RT for all measurement points. By 12 weeks post-RT, all participants had lymphedema present in eight of 13 internal sites assessed.

CONCLUSIONS

Internal and external head and neck lymphedema was observed to increase from baseline to 12 weeks after completion of RT without abatement. People with head and neck cancer should be educated about the potentially extended duration of this treatment side effect. Further research is required to determine the point at which swelling symptoms recede.

Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022

Disclaimer

This article is based on recommendations from the 12th WALT Congress, Nice, October 3-6, 2018, and a follow-up review of the existing data and the clinical observations of an international multidisciplinary panel of clinicians and researchers with expertise in the area of supportive care in cancer and/or PBM clinical application and dosimetry. This article is informational in nature. As with all clinical materials, this paper should be used with a clear understanding that continued research and practice could result in new insights and recommendations. The review reflects the collective opinion and, as such, does not necessarily represent the opinion of any individual author. In no event shall the authors be liable for any decision made or action taken in reliance on the proposed protocols.

Objective

This position paper reviews the potential prophylactic and therapeutic effects of photobiomodulation (PBM) on side effects of cancer therapy, including chemotherapy (CT), radiation therapy (RT), and hematopoietic stem cell transplantation (HSCT).

Background

There is a considerable body of evidence supporting the efficacy of PBM for preventing oral mucositis (OM) in patients undergoing RT for head and neck cancer (HNC), CT, or HSCT. This could enhance patients’ quality of life, adherence to the prescribed cancer therapy, and treatment outcomes while reducing the cost of cancer care.

Methods

A literature review on PBM effectiveness and dosimetry considerations for managing certain complications of cancer therapy were conducted. A systematic review was conducted when numerous randomized controlled trials were available. Results were presented and discussed at an international consensus meeting at the World Association of photobiomoduLation Therapy (WALT) meeting in 2018 that included world expert oncologists, radiation oncologists, oral oncologists, and oral medicine professionals, physicists, engineers, and oncology researchers. The potential mechanism of action of PBM and evidence of PBM efficacy through reported outcomes for individual indications were assessed.

Results

There is a large body of evidence demonstrating the efficacy of PBM for preventing OM in certain cancer patient populations, as recently outlined by the Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Building on these, the WALT group outlines evidence and prescribed PBM treatment parameters for prophylactic and therapeutic use in supportive care for radiodermatitis, dysphagia, xerostomia, dysgeusia, trismus, mucosal and bone necrosis, lymphedema, hand-foot syndrome, alopecia, oral and dermatologic chronic graft-versus-host disease, voice/speech alterations, peripheral neuropathy, and late fibrosis amongst cancer survivors.

Conclusions

There is robust evidence for using PBM to prevent and treat a broad range of complications in cancer care. Specific clinical practice guidelines or evidence-based expert consensus recommendations are provided. These recommendations are aimed at improving the clinical utilization of PBM therapy in supportive cancer care and promoting research in this field. It is anticipated these guidelines will be revised periodically.

Systematic review of head and neck lymphedema assessment

Head and neck lymphedema (HNL) is an increasingly recognized complication of head and neck cancer and its treatment. However, no consensus exists on the "gold-standard" assessment tool for the purposes of diagnosis, classification, or monitoring of HNL. We conducted a systematic review of the literature regarding HNL assessment to determine the optimal method/s of assessment for patients with HNL. A review of publications between January 2000 and September 2021 was undertaken on four electronic databases. Studies were excluded if no clear assessment method of HNL was documented. Sixty-seven articles were included in the study. A wide range of assessment methods for HNL have been reported in the literature. For the purposes of diagnosis and classification of physical findings, computed tomography (CT) appears the most promising tool available for both external and internal HNL. In terms of monitoring, ultrasound appears optimal for external HNL, while a clinician-reported rating scale on laryngoscopy is the gold standard for internal HNL. Patient-reported assessment must be considered alongside objective methods to classify symptom burden and monitor improvement with treatment.

The efficacy of Kinesio taping on lymphedema following head and neck cancer therapy: a randomized, double blind, sham-controlled trial

OBJECTIVE

The aim was to investigate the effectiveness of Kinesio taping for lymphedema following head and neck cancer therapy and its effect on patient compliance and quality of life.

METHODS

A total of 66 patients with lymphedema following head and neck cancer therapy were randomly allocated to the therapeutic Kinesio taping group (n = 33) and the sham Kinesio taping group (n = 33). All participants received manual lymphatic drainage, Kinesio taping, and home exercises for the first four weeks, and only home exercises for the second four weeks. The tape measurements, a scale of external lymphedema, a scale of the internal lymphedema, and quality of life were evaluated in both groups. The perceived discomfort consisting of limitation of daily living activities, pain, tightness, stiffness, and heaviness were also recorded.

RESULTS

When the group x time effect was evaluated, it was observed that external lymphedema was significantly reduced in both groups according to neck and face composite measurements (p < .001). However, in these measurements, a significant difference was found between the groups in favor of the KT group (p = .001, p = .032, respectively). At the end of the study, there was no significant difference in terms of internal lymphedema in both groups (p = .860). The quality of life parameters such as global health status and swallowing were significantly better in the Kinesio taping group (p < .001). There was no significant difference in the parameters of perceived discomfort between the two groups (p = .282, p = .225, p = .090, p = .155, p = .183, respectively).

CONCLUSION

Kinesio taping is effective in tape measurements and positively affects the quality of life in lymphedema following head and neck cancer therapy.

Hypertonic packs to reverse blindness caused by facial lymphoedema in the setting of head and neck cancer - A case report

BACKGROUND

Severe, cancer-related facial oedema can impair vision. It can result from lymphatic and/or venous obstruction due to disease and/or treatment related fibrosis. There is very limited data on the use of directly applied hypertonic packs for the relief of periorbital oedema.

CASE

A 63 year old man with recurrent laryngeal squamous cell carcinoma developed functional blindness secondary to periorbital oedema in the setting of severe facial swelling. This was refractory to maximal facial lymphatic massage available in the community setting.

POSSIBLE COURSES OF ACTION

Management dilemmas included what non-medical interventions may relieve his periorbital oedema and thereby restore his vision outside of daily lymphatic massage from a qualified physiotherapist.

FORMULATION OF MANAGEMENT PLAN

The patient agreed to an initial dry hypertonic pack with a great functional improvement of his vision. He was taught how to do this so that he could repeat ad libitum.

OUTCOME

The patient had previously expressed that his most distressing thought was the prospect of becoming functionally blind prior to dying. The provision of an easy additional therapy to relieve his visual obstruction provided him with much comfort. He passed away peacefully a few weeks later.

LESSONS

The case demonstrates that application of a dry hypertonic pack can relieve periorbital oedema in the setting of facial oedema in cases which are refractory to the combination of self-massage, cold-compress application, and daily lymphatic massage by a certified physiotherapist.

RESEARCH AVENUES

A case series to define incidence of adverse effects and duration of treatment effectiveness.

Head and neck cancer survivorship consensus statement from the American Head and Neck Society

OBJECTIVES

To provide a consensus statement describing best practices and evidence regarding head and neck cancer survivorship.

METHODS

Key topics regarding head and neck cancer survivorship were identified by the multidisciplinary membership of the American Head and Neck Society Survivorship, Supportive Care & Rehabilitation Service. Guidelines were generated by combining expert opinion and a review of the literature and categorized by level of evidence.

RESULTS

Several areas regarding survivorship including dysphonia, dysphagia, fatigue, chronic pain, intimacy, the ability to return to work, financial toxicity, lymphedema, psycho-oncology, physical activity, and substance abuse were identified and discussed. Additionally, the group identified and described the role of key clinicians in survivorship including surgical, medical and radiation oncologists; dentists; primary care physicians; psychotherapists; as well as physical, occupational, speech, and respiratory therapists.

CONCLUSION

Head and neck cancer survivorship is complex and requires a multidisciplinary approach centered around patients and their caregivers. As survival related to head and neck cancer treatment improves, addressing post-treatment concerns appropriately is critically important to our patient's quality of life. There continues to be a need to define effective and efficient programs that can coordinate this multidisciplinary effort toward survivorship.

Head and neck lymphoedema-research challenges during the COVID-19 pandemic

Management of secondary head and neck lymphoedema has undergone little research investigation. Its treatment is time and labour intensive and involves multiple therapeutic modalities without a clear understanding of which is most effective. This study aimed to determine the feasibility of a randomised controlled trial comparing two therapeutic modalities to manage head and neck lymphoedema. The secondary objective was to evaluate the clinical effects of these treatments. Participants were randomised to receive treatment with manual lymphatic drainage or compression over 6 weeks, with the primary outcome-percentage tissue water-measured 12 weeks after treatment. Six participants were recruited until the study was ceased due to restrictions imposed by the COVID-19 pandemic. Some 86% of required attendances were completed. Percentage tissue water increased in all participants at 12 weeks. No consistent trends were identified between internal and external lymphoedema. The small number of people recruited to this study informs its feasibility outcomes but limits any conclusions about clinical implications.

Radiotherapy dose-volume parameters predict facial lymphedema after concurrent chemoradiation for nasopharyngeal carcinoma

Background

To investigate risk factors for developing radiation-associated facial lymphedema (FL) in nasopharyngeal carcinoma (NPC) patients after concurrent chemoradiation (CCRT).

Methods

Clinical data from 87 patients who underwent definitive CCRT for NPC in 2010–2018 was retrospectively evaluated. FL severity was graded using MD Anderson Cancer Center head and neck lymphedema rating scale. Logistic regression analysis was used to examine the factors associated with the presence of moderate/severe FL (grade ≥ 2).

Results

At a median follow-up of 34 months (range, 18–96), 26/87 (29.9%) patients experienced grade ≥ 2 FL. A majority (84.6%) was experienced grade ≥ 2 FL 3–6 months after CCRT. Mean dose to the level IV, level I-VII neck node and N stage were significantly correlated with grade ≥ 2 FL at univariate analysis. At multivariate analysis, mean dose of level IV neck node (hazard ratio [HR], 1.238; 95% confidence interval [CI] = 1.084–1.414; p = 0.002) and level I-VII neck node (HR, 1.384; 95% CI = 1.121–1.708; p = 0.003) were independent predictors. Receiver Operating Characteristics (ROC) curve analysis showed that cut-off value of mean level IV neck node dose was 58.7 Gy (area under the curve [AUC] = 0.726; 95% CI = 0.614–0.839, p = 0.001) and mean level I-VII neck node dose was 58.6 Gy (AUC = 0.720; 95% CI = 0.614–0.826, p = 0.001) for grade ≥ 2 FL.

Conclusions

Keeping mean dose to the level IV and level I-VII below 58.7 Gy and 58.6 Gy may reduce the likelihood of moderate/severe FL after CCRT for NPC.

Radiation-induced swallowing dysfunction in patients with head and neck cancer: A literature review

Swallowing dysfunction is a prevailing state following radiotherapy in patients with head and neck cancer. Following the advancement of cancer treatment in recent years, the survival rate of head and neck cancer has gradually increased. Simultaneously, patients with head and neck cancer suffer due to the long-duration and more prominent swallowing dysfunction states. Based on an extensive literature review, we aimed to explore the mechanisms, risk factors, and clinical evaluations of swallowing dysfunction and their related symptoms following radiotherapy. These include functional changes of the muscles, trismus, xerostomia, neuropathy, and lymphedema. When swallowing dysfunction occurs, patients usually seek medical help and are referred for rehabilitation therapy, such as muscle strengthening and tongue resistance exercise. Furthermore, clinicians should discuss with patients how and when to place the feeding tube. Only through detailed evaluation and management can swallowing dysfunction resolve and improve the quality of life of patients with head and neck cancer following radiotherapy.

Lymphoedema after head and neck cancer treatment: an overview for clinical practice

Lymphoedema is a disorder of the lymphatic system that presents as an atypical swelling and accumulation of protein-rich fluid within the interstitial spaces. Head and neck lymphoedema (HNL) is highly prevalent in patients who have been treated for head and neck cancer (HNC) and may manifest externally on the face and neck; internally within the oral cavity, pharynx or larynx; or as a combination of both. HNL is known to contribute to a wide range of physical, functional and psychological issues, and presents several unique challenges in terms of its management. This review article provides an overview of HNL for clinicians and aims to improve awareness of this condition and the impact it has on patients.

Radiotherapy-Specific Chronic Pain Syndromes in the Cancer Population: An Evidence-Based Narrative Review

While radiation therapy is increasingly utilized in the treatment paradigm of many solid cancers, the chronic effects of radiation therapies are poorly characterized. Notably, understanding radiation-specific chronic pain syndromes is paramount given that the diagnosis and management of these conditions can serve to prevent long-standing functional impairments, optimize quality of life, and even allow for continued radiotherapy candidacy. These radiation-specific chronic pain phenomena include dermatitis, mucositis, enteritis, connective tissue fibrosis, lymphedema, and neuropathic pain syndromes. It is necessary to maintain a low threshold of suspicion for appropriately diagnosing these conditions as there exists a variance in when these symptoms arise after radiation. However, we present key epidemiological data delineating vulnerable cancer populations for each pain syndrome along with the available evidence for the management for each specific condition.

Clinical Characteristics of and Services Provided for Patients with Lymphedema Referred to a Physiotherapy Program During the Years 2009 Through 2019

Background: Lymphedema is a chronic and progressive disease whose diagnosis involves determination of clinical and demographic characteristics. The aim of this retrospective study was to analyze the clinical characteristics of patients with lymphedema and their various diagnoses. We studied patients who were referred for physiotherapy services at any point during the years 2009 through 2019. Methods: Retrospective data were collected from the files of 430 lymphedema patients. The type, cause, localization, stage, and severity of lymphedema and physiotherapy needs were analyzed and reported. Results: Primary and secondary lymphedema were observed in 18 (4.2%) and 412 (95.8%) patients, respectively. The patients' mean body mass index score was 30.66 kg/m². The data indicated that the most common cause of secondary lymphedema was breast cancer and its treatments (n = 196, 47.6%). Other causes were chronic venous insufficiency (CVI) (n = 140, 34%), lipolymphedema (n = 11, 2.7%), and other types of cancers (n = 65, 15.7%). According to the affected body regions, 416 patients had unilateral/bilateral upper and lower extremity lymphedema and 14 had head and neck lymphedema. The patients were followed with a home-based physiotherapy program (n = 353, 82.1%) or they underwent treatments through an outpatient program (n = 77, 17.9%). Conclusions: Most patients admitted to the clinic had a diagnosis of breast cancer and CVI. The severity and stages of lymphedema were variable. The data indicated that most patients were followed through a home-based physiotherapy program. These results may set a frame for understanding the treatment and care needs of patients with lymphedema.

The Effects of Clinical and Home-based Physiotherapy Programs in Secondary Head and Neck Lymphedema

OBJECTIVES/HYPOTHESIS

To determine the effects of complex decongestive physiotherapy (CDP) and home programs on external lymphedema, staging of lymphedema, fibrosis, and three-dimensional (3D) surface scanning and volume evaluation in head and neck lymphedema.

STUDY DESIGN

A prospective randomized controlled study.

METHODS

Twenty-one patients were randomly divided into three groups: CDP (n:7), home program (n:7), and control (n:7). Assessment methods were applied at baseline and 4 weeks later for all groups. MD. Anderson Cancer Center Head and Neck Lymphedema Protocol was implemented to evaluate head and neck external lymphedema, staging of lymphedema, and fibrosis. A 3D scanner and a software were used to determine and calculate the volume of the head and neck region via 3D surface scanning. Head and neck external lymphedema and fibrosis assessment criteria were performed to evaluate visible soft tissue edema and the degree of stiffness.

RESULTS

The severity and volume of lymphedema decreased in the CDP program group (P < .05). Besides, external lymphedema and fibrosis at submental region were decreased in both CDP program and home program groups (P < .05).

CONCLUSIONS

While the benefits of home program are limited, a CDP program may be more effective in the management of lymphedema and fibrosis in patients diagnosed with head and neck cancer. The clinical trial registration number: NCT04286698, date: 02/25/2020, retrospectively registered.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1550-E1557, 2021.

Refinement and Validation of the Head and Neck Lymphedema and Fibrosis Symptom Inventory

PURPOSE

Lymphedema and fibrosis (LEF) are common yet overlooked late effects of head and neck cancer and its therapy. Lack of reliable and valid measures of head and neck LEF is a critical barrier to the timely identification and management of head and neck LEF. To fill this gap, we developed and pilot tested a 64-item patient-reported outcome measure ( Lymphedema Symptom Intensity and Distress Survey-Head and Neck, LSIDS-H&N). This article aims to report the process of further validation and refinement of the tool.

METHODS AND MATERIALS

A prospective, longitudinal study was conducted, and 120 patients with oral cavity and oropharyngeal cancer were recruited. Participants completed the LSIDS-H&N at pretreatment, end of treatment, and every 3 months up to 12 months after treatment. SAS PROC VARCLUS was used to generate preliminary clusters of item responses. Internal consistency of the item responses within each cluster was assessed using Cronbach's alpha.

RESULTS

A total of 117 patients completed the study. The participants reported that the LSIDS-H&N was easy to understand and captured their symptoms and medical conditions. However, >50% of participants indicated that the survey was burdensome due to length. Thus, we proceeded with item reduction, and the shortened tool (33-item) was named Head and Neck Lymphedema and Fibrosis Symptom Inventory (HN-LEF Symptom Inventory). The subsequent exploration of symptom clusters identified 7 symptom domain clusters (eg, soft tissue and neurologic toxicity), all of which demonstrated good internal consistency.

CONCLUSIONS

The HN-LEF Symptom Inventory has been carefully developed and refined to allow clinicians and researchers to capture LEF-associated symptom burden and function impairments. Additional rigorous psychometric testing of the tool is ongoing to further validate the strength and internal validity of this tool.

Association between external and internal lymphedema and chronic dysphagia following head and neck cancer treatment

BACKGROUND

To examine the relationship between chronic external and internal head and neck lymphedema (HNL) and swallowing function in patients following head and neck cancer (HNC) treatment.

METHODS

Seventy-nine participants, 1-3 years post treatment were assessed for external HNL using the MD Anderson Cancer Centre Lymphedema Rating Scale, and internal HNL using Patterson's Radiotherapy Edema Rating Scale. Swallowing was assessed via instrumental, clinical and patient-reported outcome measures.

RESULTS

HNL presented as internal only (68%), combined external/internal (29%), and external only (1%). Laryngeal penetration/aspiration was confirmed in 20%. Stepwise multivariable regression models, that accounted for primary site, revealed that a higher severity of external HNL and internal HNL was associated with more severe penetration/aspiration (P < .004 and P = .006, respectively), diet modification (P < .001 both), and poorer patient-reported outcomes (P = .037 and P = .014, respectively).

CONCLUSION

Increased swallowing issues can be expected in patients presenting with more severe external HNL and/or internal HNL following HNC treatment.

A randomized pilot study on self-management in head and neck lymphedema

BACKGROUND

The purpose of this pilot trial was to determine the feasibility of a self-managed lymphedema randomized control trial to test the effectiveness of a head and neck-specific exercise protocol.

METHODS

Nine participants were randomized to receive usual treatment provided by an Australian metropolitan teaching hospital (n = 4) or usual treatment with an added head and neck exercise regime (n = 5). Feasibility was assessed through ease of recruitment, adherence, and safety. Lymphedema reduction and quality of life (QOL) data were assessed at baseline (0 week) and follow-up (6 weeks).

RESULTS

The study was feasible in terms of safety and participant retention. However, a slow recruitment rate and low adherence may impact future trials. There were no significant differences in lymphedema reduction or QOL between groups.

CONCLUSION

This pilot feasibility study demonstrated that a self-management trial can be implemented, however, modifications will be required due to the slow recruitment and poor adherence rates.

LEVEL OF EVIDENCE

1b: Individualized randomized control trial.

Selective Neck Dissection in Oral Cavity Cancer Is Not Without Morbidity

The objective of this study is to analyze the morbidity of selective neck dissection (SND) in oral cavity squamous cell carcinoma (OCSCC). This is a cross-sectional study of 106 consecutive patients with T1 and T2 (AJCC seventh edition) stage cancers. Morbidity in terms of scar characteristics, cervical lymphedema, sensation, shoulder dysfunction, and smile asymmetry were analyzed. Scar outcomes were inferior in terms of poor complexion in 15 patients (14.2%), poor texture in 25 patients (23.6%), limited skin movement in 9 patients (8.5%), soft tissue deficit in 13 patients (12.3%), and lymphedema in 14 patients (13.2%). Smile asymmetry was seen in 29.2%. Shoulder dysfunction was seen in 7.5%. Patients who received adjuvant treatment had significant scar issues (p = 0.001), lymphedema (p < 0.001), and sensory issues (p = 0.003). SND in OCSCC is not without morbidity. Smile asymmetry was the commonest problem. Patients who got adjuvant treatment had significantly more morbidity.

Comparing the prevalence, location, and severity of head and neck lymphedema after postoperative radiotherapy for oral cavity cancers and definitive chemoradiotherapy for oropharyngeal, laryngeal, and hypopharyngeal cancers

BACKGROUND

This study aimed to examine the prevalence, location, and severity of chronic internal, external, and combined head and neck lymphedema (HNL) in patients with head and neck (HNC) who were treated with definitive chemoradiotherapy (CRT) or postoperative radiotherapy (PORT).

METHODS

Sixty-two participants between 1 and 3 years post-treatment were recruited. Internal HNL was rated with Patterson's Scale. External HNL was graded with the MD Anderson Cancer Center Lymphedema Rating Scale.

RESULTS

Ninety-eight percent of participants presented with some form of chronic HNL. Sixty-one percent had internal HNL only, 35% had combined HNL, and 2% had external HNL only. Participants treated with PORT were more likely to experience combined HNL (69% vs 24%, P = .001), whereas those treated with CRT were more likely to have internal HNL only (74% vs 25%, P = .001).

CONCLUSIONS

Chronic HNL is highly prevalent following multimodal treatment, and differences in HNL presentations exist between treatment modalities.

Pilot Study: Pneumatic Compression Garment Therapy for Postradiotherapy Laryngopharyngeal Edema

OBJECTIVES

Pneumatic compression garment therapy (PCGT) has been established as treatment for postradiotherapy lymphedema, and its use in head and neck patients is becoming more common. Although effects on interstitial edema of the cervical soft tissues have been studied, effects on internal laryngopharyngeal edema, as well as associated symptoms of dysphagia and dysphonia, have yet to be published.

METHODS

We surveyed 7 patients treated with radiation for head and neck cancer (HNC) who had also been prescribed PCGT for cervical lymphedema. Patients were asked about subjective experience with the device, and also administered the Eating Assessment Tool-10 (EAT-10) and Voice Handicap Index-10 (VHI-10) surveys regarding their symptoms after using PCGT. Laryngoscopy videos from these same periods were also reviewed and scored using a validated tool for assessing laryngopharyngeal edema.

RESULTS

85% of patients reported at least some improvement in dysphagia and dysphonia following PCGT. Average EAT-10 score after PCGT was 11.4 and average VHI-10 score after PCGT was 8.7. These compare more favorably to historical scores for the same questionnaires in similar patient populations. Laryngeal edema scores on endoscopic examination were not significantly different after at least 3 months of therapy (pre: 20.15, post: 20.21, P = .975); however, the utility of this result is limited by a low inter-rater reliability (Krippendorff α = .513).

CONCLUSIONS

While we are unable to show any difference in objective assessment of laryngopharyngeal edema on endoscopic examination in this small pilot study, patients report substantial subjective improvement in postradiotherapy dysphagia and dysphonia following cervical PCGT that warrants more formal investigation.

Late Soft Tissue Complications of Head and Neck Cancer Therapy: Lymphedema and Fibrosis

Head and neck cancer and its treatment result in soft tissue damage secondary to lymphedema and fibrosis. Lymphedema is the result of pathological accumulation of interstitial fluid in tissues. It is caused by the inability of the lymphatic system to transport lymph fluid from the tissues to the central circulatory system and is manifested clinically by tissue swelling. Fibrosis is defined as an overaccumulation of fibrotic tissues within the skin and soft tissues after a single or repetitive injury and is characterized by hardening of the soft tissues with associated loss of elasticity. Lymphedema and fibrosis are common yet overlooked late effects of head and neck cancer and its therapy. They may result in profound long-term symptom burden, loss of critical functions, and altered quality of life. The following review will discuss the current pathobiology, clinical manifestations, and future directions for research related to lymphedema and fibrosis.