Oral Mucosa Dose Parameters Predicting Grade ≥3 Acute Toxicity in Locally Advanced Nasopharyngeal Carcinoma Patients Treated With Concurrent Intensity-Modulated Radiation Therapy and Chemotherapy: An Independent Validation Study Comparing Oral Cavity versus Mucosal Surface Contouring Techniques

Kaixin Li, Ling Yang, Qiang-Ying Hu, Xiao-Zhong Chen, Ming Chen, Yuanyuan Chen, Kaixin Li, Ling Yang, Qiang-Ying Hu, Xiao-Zhong Chen, Ming Chen, Yuanyuan Chen

Abstract

Purpose: To determine whether volumes based on the contours of the mucosal surface instead of the oral cavity can be used to predict grade ≥3 acute oral mucosa toxicity in patients with locally advanced nasopharyngeal carcinoma (LANPC) treated with concurrent intensity-modulated radiation therapy (IMRT) and chemotherapy.

Methods and materials: A standardized method for the oral cavity (oral cavity contours, OCC) and a novel method for the mucosal surface (mucosal surface contours, MSC) were developed for the oral mucosa and prospectively applied to the radiation treatment plans of 92 patients treated with concurrent IMRT and chemotherapy for LANPC. Dose-volume histogram (DVH) data were extracted and then toxicity was analyzed. Receiver operating characteristic analysis and logistic regression were carried out for both contouring methods.

Results: Grade ≥3 acute oral mucosa toxicity occurred to 20.7% (19/92) of patients in the study. A highly significant dose-volume relationship between oral mucosa irradiation and acute oral mucosa toxicity was supported by using both oral cavity and mucosal surface contouring techniques. In logistic regression, body weight loss was an independent factor related to grade ≥3 acute toxicity for OCC and MSC (P=.017 and 0.005, respectively), and the independent factor of dosimetric parameters for OCC and MSC were V30Gy (P=.003) and V50Gy (P=.003) respectively. In the receiver operating characteristics curve, the areas under V30Gy of the OCC curves was 0.753 (P=.001), while the areas under V50Gy of MSC curves was 0.714 (P=.004); the cut-off value was 73.155% (sensitivity, 0.842; specificity, 0.671) and 14.32% (sensitivity, 0.842; specificity, 0.575), respectively.

Conclusion: DVH analysis of mucosal surface volumes accurately predicts grade ≥3 acute oral mucosa toxicity in patients with LANPC receiving concurrent IMRT and chemotherapy, but in clinical practice the MSC method appears no better than the OCC one.

Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
Computed tomography (CT) scan of a nasopharyngeal carcinoma patient with oral cavity contours (OCC) (up) and mucosal surface contours (MSC) (down) shown with a blue line. The OCC outlines more solid tissue, tongues for instance, whereas what the MSC depicts is the mucosal surface with more accuracy.
Figure 2
Figure 2
Mean oral mucosa minus target PTVs volumes versus dose for patients experiencing grade ≥3 acute toxicity compared with patients experiencing grade 0–2 acute toxicity. Grade ≥3 acute toxicity was associated with a greater volume irradiated for each 5-Gy dose increment from 10 to 55 Gy. CI = confidence interval; MSC = mucosal surface contours; OCC = oral cavity contours; ROM = radiation-induced oral mucositis.
Figure 3
Figure 3
ROC curve of V30 with OCC method and V50 with MSC method for grade ≥3 acute toxicity of oral mucosa. MSC = mucosal surface contours; OCC = oral cavity contours; ROC = receiver operating characteristics.

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