Decreased Rates of Radiation-induced Trismus and Lowered Mastication Structure Doses in Patients Treated for Head and Neck Cancer During the Last Two Decades

Aims: To investigate how absorbed doses to mastication structures in modern radiotherapy (RT) technique for head and neck cancer (HNC) compared with earlier RT techniques and with published trismus tolerance doses. To compare the incidence of radiation-induced trismus by earlier and newer RT techniques. Materials and methods: This study investigated two HNC patient cohorts treated with RT in 2007-2012 (three-dimensional conformal radiotherapy [3DCRT] and/or intensity-modulated radiotherapy [IMRT]; n =121 [Cohort 1]) and 2017-2020 (volumetric-modulated arc therapy [VMAT]; n =124 [Cohort 2]). All patients underwent RT without mastication structure-sparing intent, had normal mouth-opening ability before RT, and were prospectively assessed. Trismus was defined as the maximal interincisal opening <= 35 mm at any follow-up (3-, 6-, and 12-months post-RT). The temporomandibular joints (TMJs), masseter, and medial/lateral pterygoid muscles were delineated on the planning CT:s. Mean doses were compared between cohorts, and evaluated with respect to published trismus tolerance doses. P values <= 0.05 indicated statistical significance. Results: Within 12 months post RT, 74/121 (61%) of patients in Cohort 1 had experienced trismus compared to 11/124 (9%) in Cohort 2. Averaged mean doses (+/- S.D.) for the masseter muscles were 35.2 +/- 8.3 Gy in Cohort 1 and 20.2 +/- 8.7 Gy in Cohort 2 (P <0.001). Corresponding numbers were 19.1 +/- 16.2 and 4.3 +/- 4.3 Gy for the TMJs, 53.7 +/- 10.1 and 40.2 +/- 16.8 Gy for the medial pterygoid muscles, and 29.2 +/- 18.7 and 9.2 +/- 8.4 Gy for the lateral pterygoid muscles (all P <0.001). Masseter muscle doses were below tolerance doses in 23% of patients in Cohort 1 compared with 90% in Cohort 2. The corresponding numbers were 52% and 96% for the TMJs, 8% and 36% for the medial pterygoid muscles and 72% and 100% for the lateral pterygoid muscles. Conclusion: Mastication structure mean doses by more recent RT techniques were generally below proposed tolerance doses, with dose reductions of 10-20 Gy compared with earlier techniques. Modern RT without mastication-structure-sparing intent resulted in below 10% of HNC patients experiencing trismus compared with 60% treated with earlier techniques. (c) 2024 The Authors. Published by Elsevier Ltd on behalf of The Royal College of Radiologists. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).