Skeletal muscle status and malnutrition as predictors of short-term radiotherapy response and oral mucositis in head and neck cancer

Abstract

Objective: This study aimed to investigate whether baseline skeletal muscle status and malnutrition in patients with locally advanced head and neck cancer (HNC) are associated with short-term treatment outcomes and acute radiation oral mucositis (OM).

Methods: We retrospectively analyzed data from 68 patients with stage III–IV HNC treated at a single center with definitive radiotherapy (66–70 Gy) with or without chemotherapy (induction and/or concurrent) between July 2021 and July 2023. Malnutrition was diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria and Patient-Generated Subjective Global Assessment (PG-SGA). Short-term response was assessed at first post-treatment imaging after radiotherapy according to RECIST 1.1, and OM severity was graded using World Health Organization criteria. Univariate and multivariate logistic regression analyses evaluated the correlation between short-term response and grades III–IV OM.

Results: Of the 68 patients, 32.4% had a lower skeletal muscle index (SMI), 26.5% had lower hand grip strength (HGS), 20.6% (GLIM) and 58.8% (PG-SGA) had malnutrition. At the end of treatment, 64.7% of the patients achieved partial remission, and 35.3% achieved a stable condition. Low HGS was associated with low short-term efficacy (OR = 0.31, 95% CI = 0.10–0.95, p = 0.040); however, this difference did not reach statistical significance in the multivariate model. A total of 41.2% of patients had Grade III–IV OM; however, OM was not significantly associated with low SMI, HGS, or malnutrition.

Conclusion: Baseline skeletal muscle status and malnutrition did not consistently predict short-term treatment outcomes or severe radiation-induced OM in patients with locally advanced HNC. However, these results suggest a potential relationship between low HGS and treatment response. Further research with larger sample sizes and longitudinal evaluations is needed to clarify muscle and nutritional status impact on multidimensional outcomes in this patient population.

Keywords

head and neck cancer / malnutrition / oral mucositis / radiotherapy / skeletal muscle

References

[1] Crowder SL, Douglas KG, Yanina PM, et al. Nutrition impact symptoms and associated outcomes in post-chemoradiotherapy head and neck cancer survivors: a systematic review. J Cancer Surviv. 2018; 12(4): 479–494.

[2] Choi SY, Cheong HK, Lee MK, et al. Metabolic Diseases and Risk of Head and Neck Cancer: A Cohort Study Analyzing Nationwide Population-Based Data. Cancers (Basel). 2022; 14(13): 3277.

[3] Grossberg AJ, Chamchod S, Fuller CD, et al. Association of Body Composition With Survival and Locoregional Control of Radiotherapy-Treated Head and Neck Squamous Cell Carcinoma. JAMA Oncol. 2016; 2(6): 782-789.

[4] Cramer JD, Burtness B, Le QT, Ferris RL. The changing therapeutic landscape of head and neck cancer. Nat Rev Clin Oncol. 2019; 16(11): 669-683.

[5] Brizel DM, Esclamado R. Concurrent chemoradiotherapy for locally advanced, nonmetastatic, squamous carcinoma of the head and neck: consensus, controversy, and conundrum. J Clin Oncol. 2006; 24(17): 2612-2617.

[6] Talwar B, Donnelly R, Skelly R, et al. Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016; 130(S2): S32-S40.

[7] Lalla RV, Bowen J, Barasch A, et al. Mucositis Guidelines Leadership Group of the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014; 120(10): 1453–1461.

[8] Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017; 36(1): 11-48.

[9] Swartz JE, Pothen AJ, Wegner I, et al. Feasibility of using head and neck CT imaging to assess skeletal muscle mass in head and neck cancer patients. Oral Oncol. 2016; 62: 28-33.

[10] Norman K, Stobäus N, Gonzalez MC, Schulzke JD, Pirlich M. Hand grip strength: outcome predictor and marker of nutritional status. Clin Nutr. 2011; 30(2): 135-142.

[11] Wendrich AW, Swartz JE, Bril SI, et al. Low skeletal muscle mass is a predictive factor for chemotherapy dose-limiting toxicity in patients with locally advanced head and neck cancer. Oral Oncol. 2017; 71: 26-33.

[12] Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. J Cachexia Sarcopenia Muscle. 2019; 10(1): 207-217.

[13] Caputo MP, Rodriguez CS, Padhya TA, Mifsud MJ. Telehealth Interventions in Head and Neck Cancer Patients: A Systematic Review. Cancer Nurs. 2023; 46(5): E320-E327.

[14] Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009; 45(2): 228-247.

[15] Martin L, Birdsell L, Macdonald N, et al. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013; 31(12): 1539-1547.

[16] Chen LK, Woo J, Assantachai P, et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020; 21(3): 300-307.e2.

[17] Gökcan H, Selçuk H, Töre E, et al. The Nutritional Risk Screening 2002 tool for detecting malnutrition risk in hospitalised patients: perspective from a developing country. Turk J Gastroenterol. 2014; 25(6): 718-723.

[18] Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002; 56(8): 779-785.

[19] Wang J, Xu Q H, Xie H F, et al. Comparison of the Global Leadership Initiative on Malnutrition and the Patient-Generated Subjective global Assessment for diagnosing malnutrition in patients undergoing surgery for hepatobiliary and pancreatic malignancies. Nutr Hosp. 2024; 41(4): 835-842.

[20] Zhang Z, Wan Z, Zhu Y, Zhang L, Zhang L, Wan H. Prevalence of malnutrition comparing NRS2002, MUST, and PG-SGA with the GLIM criteria in adults with cancer: A multi-center study. Nutrition. 2021; 83:111072.

[21] Langius JA, Bakker S, Rietveld DH, et al. Critical weight loss is a major prognostic indicator for disease-specific survival in patients with head and neck cancer receiving radiotherapy. Br J Cancer. 2013; 109(5): 1093-1099.

[22] Jager-Wittenaar H, Dijkstra PU, Vissink A, van Oort RP, van der Laan BF, Roodenburg JL. Malnutrition in patients treated for oral or oropharyngeal cancer–prevalence and relationship with oral symptoms: an explorative study. Support Care Cancer. 2011; 19(10): 1675-1683.

[23] Ravasco P. Nutrition in Cancer Patients. J Clin Med. 2019; 8(8): 1211.

[24] van Rijn-Dekker MI, van den Bosch L, van den Hoek JGM, et al. Impact of sarcopenia on survival and late toxicity in head and neck cancer patients treated with radiotherapy. Radiother Oncol. 2020; 147: 103-110.

[25] Lønbro S, Dalgas U, Primdahl H, et al. Progressive resistance training rebuilds lean body mass in head and neck cancer patients after radiotherapy–results from the randomized DAHANCA 25B trial. Radiother Oncol. 2013; 108(2): 314-319.

[26] Zhang Z, Chen X, Yuan T. Precision radiotherapy for nasopharyngeal carcinoma. Prec Radiat Oncol. 2024; 8: 37-41.

[27] Liao W, Zhao Y, Zhang S. The evolution of prophylactic neck irradiation in nasopharyngeal carcinoma: Changing concepts and irradiation ranges. Prec Radiat Oncol. 2025; 9: 61-68.

[28] Pandu B, Khanna D, Palanisamy M, Jacob S, Maddipati T. Analyzing the patient isocenter positional accuracy with portal imaging acquired at different gantry angles and its dosimetrical impact on the dose delivery for head and neck cancers. Prec Radiat Oncol. 2024; 8: 77-84.

[29] Yan J, Sui J. Long-term survival after immunotherapy for uncontrolled locally advanced temporal bone squamous cell carcinoma followed by chemoradiotherapy: A case report. Prec Radiat Oncol. 2024; 8: 99-105.

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2026 The Author(s). Precision Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Shandong Cancer Hospital & Institute.