Correlation of Planned Dose to Area Postrema and Dorsal Vagal Complex with Clinical Symptoms of Nausea and Vomiting in Oropharyngeal Cancer (OPC) patients treated with radiation alone using IMRT

Abstract

Objective: To correlate the planned dose to the nausea center (NC) - area postrema (AP) and dorsal vagal complex (DVC) - with nausea and vomiting symptoms in OPC patients treated with IMRT without chemotherapy. We also investigated whether it was possible to reduce doses to the NC without significant degradation of the clinically accepted treatment plan.

Methods: From 11/04 to 4/09, 37 OPC patients were treated with definitive or adjuvant IMRT without chemotherapy. Of these, only 23 patients had restorable plans and were included in this analysis. We contoured the NC with the assistance of an expert board-certified neuroradiologist. We searched for correlation between the delivered dose to the NC and patient-reported nausea and vomiting during IMRT. We used one-paired t-test: two-sample assuming equal variances to compare differences in dose to NC between symptomatic and asymptomatic patients. We then replanned each case to determine if reduced dose to the NC could be achieved without compromising coverage to target volumes, increasing unwarranted hotspots or increasing dose to surrounding critical normal tissues.

Results: Acute symptoms of nausea were as follows: Grade 0 (n=6), Grade 1 (n=13), Grade 2 (n=3), and Grade 3 (n=1). Patients with no complaints of nausea had a median dose to the DVC of 34.2 Gy (range 4.6-46.6 Gy) and AP of 32.6 Gy (range 7.0-41.4Gy); whereas those with any complaints of nausea had a median DVC dose of 40.4 Gy (range 19.3-49.4 Gy) and AP dose of 38.7 Gy (range 16.7-46.8 Gy) (p=0.04). Acute vomiting was as follows: Grade 0 (n=17), Grade 1 (n=4), Grade 2 (n=1), and Grade 3 (n=1). There was no significant difference in DVC or AP dose among those with and without vomiting symptoms (p=0.28).Upon replanning of each case to minimize dose to the NC, we were, on average, able to reduce the radiation dose to AP by 18% and DVC by 17%; while the average dose variations to the PTV coverage, brainstem, cord, temporal lobes, and cochlea were never greater than 3%. Hotspots increased by 2% for 3 patients while hotspots for remaining patients were less than 2% variation.

Conclusion: For OPC cancer patients treated with IMRT without chemotherapy, dose to AP and DVC may be associated with development of nausea. We were able to show that reducing doses substantially to the NC is achievable without significant alteration of the clinically accepted plan and may reduce the incidence and grade of nausea. As symptoms of nausea can be devastating to patients, one can consider routine contouring and constraining of the NC to minimize chances of having this complication.

Keywords: Radiation-induced nausea and vomiting; area postrema; dorsal vagal complex; head and neck; intensity modulated radiation therapy.

Fig. 1

(A) T2 MRI axial contour of the area postrema (green) and dorsal vagal complex (yellow) (B) T2 MRI sagittal contour of the dorsal vagal complex (yellow).