基线改良钡餐吞咽检查对口咽癌围手术期吞咽困难的预后价值：ECOG-ACRIN E3311的二次分析

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中文摘要

背景： 经口手术（TOS）治疗HPV相关口咽癌（OPC）显示出优异的肿瘤学结局，但术后早期吞咽困难仍然常见且具有临床意义。术前识别风险增加的患者对于指导早期支持治疗至关重要。我们研究了通过改良钡餐吞咽检查（MBS）评估的基线吞咽障碍是否可预测TOS术后早期吞咽困难。
方法： 在这项对II期ECOG-ACRIN E3311试验选定子集的回顾性、探索性二次分析中，89例具有配对基线和TOS术后（辅助治疗前）MBS的患者接受了使用吞咽毒性动态成像分级（DIGEST）的盲法中心审查。主要结局是中度至重度TOS术后吞咽困难（DIGEST ≥ 2）；次要结局是任何吞咽困难（DIGEST ≥ 1）和DIGEST恶化。使用Firth惩罚逻辑回归评估基线DIGEST ≥ 1的预后价值，并针对年龄、性别、种族、T/N分期和原发部位进行调整。
结果： 基线时，80%无吞咽困难，17%有轻度吞咽困难（DIGEST = 1）；中度至重度障碍罕见（3%）。术后，45例患者（51%）DIGEST等级恶化≥1级，16%出现中度至重度吞咽困难。基线DIGEST ≥ 1与TOS术后DIGEST ≥ 2独立相关（调整OR 4.69；95% CI 1.32-16.64），绝对风险差异为23.8%（95% CI 2.6-48.8%），乐观校正区分度中等（AUC 0.75；95% CI 0.59-0.88）。
结论： MBS识别的基线轻度吞咽障碍与HPV相关OPC患者TOS术后急性重度吞咽困难相关。术前基于影像的吞咽评估可能有助于对患者进行风险分层，以进行针对性的预康复、营养支持，并在五分之一的患者中进行早期术后吞咽影像检查，以减轻术后吞咽相关疾病负担。

英文摘要

BACKGROUND: Transoral surgery (TOS) for HPV-related oropharyngeal cancer (OPC) demonstrated excellent oncologic outcomes, but early postoperative dysphagia remains common and clinically consequential. Identifying patients at increased risk before surgery is critical to guide early supportive care. We examined whether baseline swallowing impairment assessed by modified barium swallow (MBS) predicts early post-TOS dysphagia.
METHODS: In this retrospective, exploratory secondary analysis of a selected subset of Phase II ECOG-ACRIN E3311 trial, 89 patients with paired baseline and post-TOS MBS (before adjuvant therapy) underwent blinded central review using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST). The primary outcome was moderate-to-severe post-TOS dysphagia (DIGEST ≥ 2); secondary outcomes were any dysphagia (DIGEST ≥ 1) and worsening DIGEST. The prognostic value of baseline DIGEST ≥ 1 was assessed with Firth penalized logistic regression adjusted for age, sex, race, T/N stage, and primary site.
RESULTS: At baseline, 80% had no dysphagia and 17% had mild dysphagia (DIGEST = 1); moderate-to-severe impairment was rare (3%). Postoperatively, 45 patients (51%) worsened by ≥ 1 DIGEST grade, and 16% developed moderate-to-severe dysphagia. Baseline DIGEST ≥ 1 was independently associated with post-TOS DIGEST ≥ 2 (adjusted OR 4.69; 95% CI 1.32-16.64), with an absolute risk difference of 23.8% (95% CI 2.6-48.8%) and moderate optimism-corrected discrimination (AUC 0.75; 95% CI 0.59-0.88).
CONCLUSIONS: Baseline mild swallowing impairment identified on MBS was associated with high-grade acute postoperative dysphagia following TOS for HPV-related OPC. Preoperative imaging-based swallowing assessment before surgery may help risk-stratify patients for targeted pre-habilitation, nutritional support, and early postoperative swallowing imaging in 1 in 5 patients to mitigate postoperative swallowing morbidity.