Internal lymphedema underlies swallow dysfunction in head and neck cancer

CHICAGO, IL— Treatment-related dysphagia symptoms are likely caused by internal lymphedema among patients with head and neck cancer, according to research presented at the 2014 American Society of Clinical Oncology (ASCO) Annual Meeting.

“Internal lymphedema (correlated with subjective and objective measures of swallow dysfunction,” said lead author Leanne Kolnick Jackson, MD, at the Vanderbilt University Medical Center, Nashville, Tennessee.  “Most of the time patients have silent aspiration, which is most dangerous. So if a patient ever says they have dysphagia, it warrants an exam” including imaging as well as endoscopy, Jackson said.

External lymphedema is visible and recognizable, but internal lymphedema—which occurs in up to 90% of cases of external lymphedema—can go undetected, the coauthors noted.

“External lymphedema is just the tip of the iceberg,” said senior author Barbara A. Murphy, MD, of Vanderbilt University Medical Center. “Only 10% of patients with lymphedema have only external lymphedema.”

Secondary lymphedema and fibrosis are “ubiquitous and underreported” late effects among patients with head and neck cancers, Jackson reported.

Using the Vanderbilt Head and Neck Symptom Survey (VHNSS) version 1.0, the researchers collected patient-reported swallow dysfunction among study participants undergoing treatment for head and neck cancer. They subsequently studied patients’ swallow function and internal lymphedema, using endoscopic assessments, modified-barium videofluoroscopy, the Dysphagia Outcome and Severity Scale (DOSS), and National Outcomes Measurement System (NOMS).

Endoscopy does not detect internal lymphedema well “for every site,” Jackson noted. “Some sites are not well evaluated by endoscopy.”

At 18 months posttreatment, VHNSS swallow/nutrition scores correlated with “maximum grade of swelling for any single structure” but VHNSS and NOMS score correlations were strongest for inflammation of the aryepiglottic and pharyngoepiglottic folds, epiglottis, and pyriform sinus, (Ps < .004). Internal lymphedema was more strongly correlated with the NOMS than the DOSS, Jackson noted.

Longitudinal analysis of the trajectory and impact of lymphedema on dysphagia is ongoing, with 100 patients enrolled to date, she said,

Abstract #6051

Clinical trial information: NCT01187173