2859 - An Institutional Experience of Radiotherapy for Sialorrhea in Patients with Amyotrophic Lateral Sclerosis
Presenter(s)
L. Sandhu1, N. Oakley2, R. Neel2, J. Janecek2, L. E. Pater2, and B. Nelson3; 1University of Cincinnati - Barrett Cancer Center, Cincinnati, OH, United States, 2University of Cincinnati, Cincinnati, OH, 3Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH
Purpose/Objective(s): Approximately half of ALS patients develop sialorrhea, increasing aspiration risk and reducing quality of life and survival. Although noninvasive ventilation (NIV) prolongs survival, excessive sialorrhea limits tolerance and adherence, diminishing its benefit. Radiation therapy is an effective option for medically refractory cases or when anticholinergics are contraindicated. By reducing salivary production, it improves comfort and NIV compliance, supporting longer survival. While various dose schedules and targets have been reported, guidance on optimal delineation and response assessment remains limited. To our knowledge, this is the largest single-institution study of external beam radiation therapy (EBRT) for refractory sialorrhea.
Materials/Methods: This is a single-institution retrospective review of patients with ALS who received EBRT for medically refractory sialorrhea. Charts were reviewed for bulbar impairment prior to EBRT. Clinical surrogates including feeding tube placement, suctioning requirements, and dysarthria were noted. Our institutional standard is to irradiate one parotid gland to 15 Gy in 3 fractions with 3D conformal radiotherapy and re-evaluate symptoms 1-month post-EBRT for consideration of additional EBRT to further improve symptoms. A shorter course of radiation was offered to patients with poor performance status. All plans were reviewed in our treatment planning software. Charts were reviewed for treatment-related toxicity.
Results: Our cohort included 62 patients: 57% female, 98% Caucasian, median age of 66 years with median ECOG performance status of 2. Before EBRT, 53 (82%) patients were prescribed anticholinergics, and 5 (8%) patients had Botox injections with persistent symptoms. At the time of consultation, 46 (74%) patients required a feeding tube, 22 (35%) required suctioning, and 46 (70%) were nonverbal. 51 (86%) patients completed an initial course of radiation to a single parotid gland. The remaining patients stopped early due to preference or toxicity. Thirty-eight (61%) patients reported subjective improvement after the first course of EBRT. Twenty-eight (45%) patients elected to proceed with radiation to the contralateral parotid gland. On average, patients started the second course of EBRT 3.2 months from the initial course. Eight patients (13%) received a third course of radiation which targeted the bilateral submandibular glands. Overall, EBRT was well-tolerated. Twenty-one (19%) patients experienced acute sialadenitis/ parotitis, 6 (10%) patients had xerostomia, 2 (3%) had dysgeusia, 9 (15%) endorsed new/worsening mucinous/viscous secretions.
Conclusion: EBRT is an effective and well-tolerated treatment for sialorrhea in patients with ALS. Our institutional stepwise protocol may be a useful reference for other institutions seeking to offer this treatment.