Proximal Esophageal Stenosis in Head and Neck Cancer Patients after Total Laryngectomy and Radiation

Abstract

Background: There has been an increasing focus on late functional effects of head and neck cancer (HNC) treatment. This study was undertaken to evaluate the incidence of late proximal esophageal stricture in patients undergoing total laryngectomy (TL) and radiation therapy (RT). Material and Methods: An institutional retrospective review of HNC patients treated between 1995 and 2003 with TL and RT was undertaken. Thirty-three patients with stage II–IV disease were included; 25 patients had TL and postoperative RT (group 1), while 8 patients had definitive RT with salvage laryngectomy (group 2). Results: The median follow-up was 28 months. At the last follow-up, 25 patients (76%) were alive and disease free. Four had died and 3 developed distant metastasis. Dysphagia or stenosis developed in 40% in group 1 and 75% in group 2 patients. The median time to dysphagia was 5.5 months for all patients. Conclusions: The incidence of esophageal stenosis was 33% for all patients. Contributing factors for esophageal stenosis after TL and RT include continued alcohol and tobacco use, the dose-volume relationship of the RT and normal tissue damage from the tumor and the treatment.

Errata

“…Even though the numerically observed decrease in incidence after modification of EBRT was not statistically significant, the present data give some indication that the risk of developing this serious iatrogenic injury can be reduced with irradiation of smaller volumes, thus sparing normal tissues. This indication of a reduced risk of irradiation injury to the upper esophagus is consistent with that in other studies on patients with head and neck cancer 6, 10, 11. Recent advances in better planning techniques may thus spare the normal tissue and reduce the risk of side effects such as esophageal stricture.…”

“…Patients were identified at 1 head and neck cancer center, and received EBRT as a single‐modality treatment or in combination with surgery. Other studies have shown an increase in stricture formation with the use of chemotherapy and radiotherapy given concurrently,2, 10 but none of the patients in the present study received any chemotherapy.…”

Outcomes of serial dilation for high‐grade radiation‐related esophageal strictures in head and neck cancer patients

“…Specifically, patients treated with endoscopic mucosal resection of neoplastic Barrett's esophagus had nonsignificantly increased odds of developing esophageal stricture if patients had greater than or equal to 25 pack‐years of smoking (adjusted odds ratio: 3.33, 95% confidence interval: 0.929‐12.1) . Another study of head and neck cancer patients treated with both total laryngectomy and radiation therapy found an incidence of esophageal stricture of 33%, and alcohol and tobacco use were contributing factors to formation . Another study failed to demonstrate an increased risk of stricture formation based on smoking status …”

Effects of chemoradiotherapy on voice and swallowing

“…Swallow motility disorders significantly related to oral intake varied by evaluation point, with reduced tongue base retraction and reduced laryngeal elevation most related to oral intake at 1 month, delayed pharyngeal swallow, incomplete laryngeal vestibule closure, reduced laryngeal elevation and a rating of nonfunctional swallow at 3 months, and reduced cricopharyngeal opening at 6 and 12 months after chemoradiotherapy. This last disorder is not surprising, as cricopharyngeal stricture is frequently seen as a late swallowing impairment after primary chemoradiotherapy [33] as well as postoperative radiotherapy after total laryngectomy [42]. A recent study by Logemann et al .…”