Posttreatment Followup

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The highest risk for locoregional recurrence after definitive treatment for head and neck cancer patients is generally within the first 2 to 3 years after therapy. It is therefore imperative that they be followed closely, routinely and diligently.

Immediately after radiation therapy, we may follow those patients with particularly severe mucositis and weight loss on a weekly basis until sufficient

Figure 21-17. Radiation-induced acute brisk mucositis of the oropharynx.

recovery has occurred—which may take 3 to 4 weeks. Otherwise, they are seen monthly, usually for 2 months, at which point most patients have had sufficient recovery from the significant acute radiation reaction. We then follow them every 1 to 2 months, often alternating with the other physicians on the case unless we are monitoring the response of a mass. If indicated, a baseline CT or MRI study of the head and neck can be obtained 2 to 3 months after radiation therapy and then routinely in perhaps 4 months. CT scans are particularly helpful in evaluating for nodal involvement and bone invasion while MRI scans are useful for soft-tissue and intracranial extension. Current research is investigating the use of PET scans for the post-therapy follow-up of head and neck cancers. It has been reported that this study is more accurate for detecting recurrence than MRI scans.137

Figure 21-18. Oral candidiasis.

Long-term follow-up for endocrine complications requires appropriate laboratory monitoring as abnormalities can occur late.

Thyroid function tests including TSH are obtained every 6 months post-treatment for up to 5 years for all patients who received radiation to the thyroid gland area. Clinical hypothyroidism develops in approximately 5 percent of adults and a bit higher in children irradiated to the thyroid region. There is a 20 to 25 percent incidence of chemical hypothyroidism which increases to 66 percent in patients who have also undergone a hemithyroidec-tomy. If the TSH rises above a normal range, the patients are started on thyroid hormone replacement therapy irrespective of the T3 and T4 values, which very well may be within normal limits. The thyroid gland is a very radiosensitive organ and should be routinely monitored after radiation therapy. If the hypothalamic-pituitary axis has been irradiated as well, then a complete endocrine screening should also be similarly obtained.

Patients who receive radiation to the oral cavity or oropharyngeal areas should be seen routinely by the dental service for an indefinite time. The fluoride prophylaxis routine which was initiated prior to treatment should be continued. No gingival surgery or tooth extraction should occur without the dentist knowing the history of the prior radiation therapy volume and dosage as well as the potential risks for osteoradionecrosis subsequent to the planned dental surgery. During the follow-up evaluation, the radiation oncologist will need to pay special attention to eliciting history of mandibular or tooth pain. An examination should be carried out to look for any exposed bone in the oral cavity. These findings may suggest the development of osteoradionecrosis and necessitate a thorough work-up including detailed radiologic evaluation.

Some patients who received radiation to the cervical spine may develop Lhermitte's syndrome, a benign, transient myelopathy thought to be due to demyelination, that can appear from 1 to 3 months after radiation therapy and can last for up to 9 months or more with an average of 3 to 4 months. The syndrome is characterized by the development of a symmetrical instantaneous, shooting, electrical sensation radiating down the spine and extremities with neck flexion. There are no other associated neurologic problems. This is self-limited and requires no therapy. However, if these symptoms should develop for the first time 9 to 12 months after radiation therapy, one must be very concerned that this may be a harbinger for the development of radiation myelitis.

The patient should be evaluated for trismus, which may be due to either post-radiation fibrosis versus recurrence or progression of tumor. Routine daily range of motion exercises must be encouraged for the jaw, tongue, neck, and shoulders to minimize post-treatment functional deficits from fibrosis and scarring.

Occasionally, a patient who received high-dose radiation therapy to the head and neck, particularly with chemotherapy, may develop chronic dysphagia secondary to fibrosis. This will require an esopha-goscopy to rule out tumor. If benign stricture is noted within the cervical or upper thoracic esophagus, then occasional dilatation procedures are indicated and can be most helpful.

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