www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Translation
and
adaptation
of
the
Radiotherapy
Edema
Rating
Scale
to
Brazilian
Portuguese
夽
Débora
dos
Santos
Queija
a,∗,
Lica
Arakawa-Sugueno
b,
Bruna
Mello
Chamma
c,
Marco
Aurélio
Vamondes
Kulcsar
d,e,
Rogério
Aparecido
Dedivitis
d,faUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,CursodePós-Graduac¸ãoemFisiopatologiaExperimental,SãoPaulo,
SP,Brazil
bUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,Ciências,SãoPaulo,SP,Brazil cUniversidadeBrazCubas,MogidasCruzes,SP,Brazil
dUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,DepartamentodeCirurgia,SãoPaulo,SP,Brazil eInstitutodoCâncerdoEstadodeSãoPaulo(ICESP),Servic¸odeCirurgiadeCabec¸aePescoc¸o,SãoPaulo,SP,Brazil
fUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,GrupodeTumoresdeLaringeeHipofaringedoServic¸odeCirurgiade
Cabec¸aePescoc¸o,SãoPaulo,SP,Brazil
Received5January2017;accepted28March2017 Availableonline9May2017
KEYWORDS
Edema; Headandneck neoplasms; Radiotherapy; Pharynx; Larynx
Abstract
Introduction:Internallymphedemaisoneofthesequelaeofheadandneckcancertreatment thatcanleadtovaryingdegreesofswallowing,speech,andrespirationalterations.The Radio-therapyEdemaRatingScale,developedbyPattersonetal.,isatoolusedtoevaluatepharyngeal andlaryngealedema.
Objective:To translateinto Brazilian Portuguese, toculturally adaptand test thisscalein patientsundergoingtreatmentforheadandneckcancer.
Methods:Theprocessfollowedtheinternationalguidelinesandtranslationstepsbytwohead and neck surgeons and back-translation performed independently by two North-American natives.Thefinalversionofthetestwasevaluatedbasedontheassessmentof18patientsby twoheadandnecksurgeonsandtwospeechtherapistsusingthescalesinBrazilianPortuguese. Results:Thetranslationandculturaladaptationweresatisfactorilyperformedbythemembers ofthecommitteeincharge.
夽 Pleasecitethisarticleas:QueijaDS, Arakawa-SuguenoL, ChammaBM,KulcsarMA,DedivitisRA.Translationand adaptationofthe
RadiotherapyEdemaRatingScaletoBrazilianPortuguese.BrazJOtorhinolaryngol.2018;84:344---50.
∗Correspondingauthor.
E-mails:dqueija@uol.com.br,queijad@gmail.com(D.S.Queija).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2017.03.014
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen
Conclusion: The translation and adaptation into Brazilian Portuguese of the Radiotherapy EdemaRatingScalewassuccessfullyperformedandshowedtobeeasytoapply.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Edema;
Neoplasiasdecabec¸a epescoc¸o;
Radioterapia; Faringe; Laringe
Traduc¸ãoeadaptac¸ãoparaoportuguêsbrasileirodaEscaladeClassificac¸ãodoEdema daRadioterapia
Resumo
Introduc¸ão: Olinfedemainternoéumadassequelasdotratamentoparaocâncerdecabec¸ae pescoc¸o,podendolevaraalterac¸õesdegrauvariadonadeglutic¸ão,vozerespirac¸ão.AEscala doEdemadaRadioterapia(RadiotherapyEdemaRatingScale),elaboradaporPattersonetal., éumaferramentadeavaliac¸ãodoedemadefaringeelaringe.
Objetivo: Traduzir,paraoportuguêsbrasileiro,adaptarculturalmenteetestarestaescalaem pacientessubmetidosaotratamentoparaocâncerdecabec¸aepescoc¸o.
Método: O processo seguiu as diretrizes internacionais e as etapas de traduc¸ão por dois cirurgiões de cabec¸a e pescoc¸o e aretrotraduc¸ãode forma independente pordois nativos norte-americanos.Otestedaversãofinalparaavaliac¸ãofoirealizadoapartirdaavaliac¸ãode 18pacientespordoismédicoscirurgiõesdecabec¸aepescoc¸oeduasfonoaudiólogaspormeio daaplicac¸ãodasescalasemportuguês.
Resultados: Atraduc¸ãoeadaptac¸ãoculturalforamexecutadassatisfatoriamentepelos mem-brosdocomitêresponsável.
Conclusão:Atraduc¸ãoeadaptac¸ãodaEscaladoEdemadaRadioterapiaparaoportuguêsfoi bemsucedidaedefácilaplicac¸ão.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
The head and neck encompasses an extensive lymphatic networkandmorethan300lymphnodes(one-thirdofthe lymphnodesinthebody).1Thetreatmentforheadandneck cancer involves multimodal therapies that result in increasedsurvivalrates;however,theyareaccompaniedby theriskofsecondarycomplications,suchassecondary lym-phedema.The tumor,surgery,andradiotherapy canbreak downlymphaticstructuresandblocklymphflow,resulting in soft tissue edema. Muscle contraction and soft tissue compression facilitate lymphatic flow throughmovement. However, the damage caused by surgery and radiothe-rapyadverselymodifiesthismechanism,leadingtoreduced movementandlymphflow.1---4
Lymphaticdysfunctionoccurswhenanylymphatic struc-tureorthatsurroundingsofttissueisdamagedbycancerand itstreatment,limitingthecapacityofthelymphaticsystem totransportthelymphvolumecarriedtothetissues. Lym-phedemais aswellingthatdevelopsduring aperiodofat leastthreemonthsafterheadandneckcancertreatment, beyondtheperiodwhenacuteedemaoccurs.5---7
When thelymphedemadevelops,the lymphaticsystem maybeabletorepairorcompensateforthedamagedone, resulting in visible swelling reduction. If the damage is severeorthereisnointervention,theaccumulated protein-rich lymphatic fluid can trigger a chronic inflammatory
response,resultinginafibroscleroticprocesswhereinfatty orfibroustissuesmaydevelop.1,7
Headandneckcancerlymphedemamayaffectexternal (face,submental andneck)andinternal structures(upper aerodigestivetract,tongue,epiglottis)orboth(compound). Internal lymphedema may impair chewing, swallowing, speech,andvoice.8Bothtypescanprogressovertimeand, whenidentifiedandtreatedearly,swellingregressionand prevention of late effects, such as fibrosis, may be the result.9Therefore,itisimportanttoassessforlymphedema aspartoftheclinicalroutineoftheevaluationofheadand neckcancerpatients.1,3,6,8,10,11
Fewmeasurestoevaluateedemaandlymphedemahave beendevelopedoverthelastfewyears.Concernaboutthese aspectshasbeen increasing inthe lastdecade, aiming to identify,andmonitortheevolutionofalterationsand treat-mentresults.11---14
The Radiotherapy Edema Rating Scale, developed by Patterson et al.,15 is the most comprehensive tool that evaluates and stages, in a simple and objective man-ner, 11 structures and two spaces of the pharynx and larynx through endoscopy. The scale showed good intra-rater(Kappa=0.84)andmoderateinter-rater(Kappa=0.54) reliability.
Theaimofthisstudyistocarryoutthetranslationofthe RadiotherapyEdemaRatingScaleintoBrazilianPortuguese anditscross-culturaladaptation.
Methods
Thisstudyrepresentstheinitialphaseoftheclinicalstudy project,approvedbytheEthicsCommitteeoftheinstitution whereitwasperformed,undernumber528/14.Todevelop the work using the scale, permission was granted by the author,whoauthorizedthetranslation.
Because thisscale evaluates structuresstrictly related toanatomy,thetranslationwasperformedbytwoheadand necksurgeonswithexperienceinheadandneckedemaand lymphedema,whowereproficientintheEnglishlanguage, basedontheNomina Anatomica.16 The processwasbased oninternationalguidelines.
Subsequently, a consensus developed between the translators regarding a Brazilian Portuguese version and subsequentback-translationperformedbytwonative speak-ersoftheEnglishlanguage,independently.Followingthat, the comparison of the back-translation with the original scalewasperformed,analyzingaspectsrelatedto concep-tual,semanticandcontentequivalence andlatercreation ofatranslatedversionbythecommittee,whichconsisted ofthetranslatorsandback-translators.
Eighteen patients submitted to surgical and/or radio-chemotherapytreatmentwereevaluatedbynasoendoscopy, which wasrecorded onDVD for furtherevaluation by the committee.
Thefinalversionwasappliedbyfourhealth profession-als(twoheadandnecksurgeonsandtwospeechtherapists, withbroadexperienceinheadandneckcancerand interpre-tationofvideoendoscopicimagesofthepharynxandlarynx). Due to similar interpretations, the evaluators achieved consensus.
Results
The translation of the Radiotherapy Edema Rating Scale (Table 1) was performed independently by twohead and necksurgeonsproficientintheEnglishlanguage.15
The two translations (Tables 2 and 3) were analyzed jointlybythetwotranslators,whoreachedaconsensusfor itsfinalversioninBrazilianPortuguese(Table4).Therewas aquestionregardingthetermcricopharyngealprominence, which in Portuguese referstothe cricopharyngealbar,an alterationrelatedtotheanatomyofpatientssubmittedto Table1 RadiotherapyEdemaRatingScale(originaltoolintheEnglishlanguage).
Ratingofedema
Structures Normal Mild Moderate Severe
Baseoftongue
Posteriorpharyngealwall Epiglottis Pharyngoepiglotticfolds Aryepiglotticfolds Interarytenoidspace Cricopharyngealprominence Arytenoids
Falsevocalfolds Truevocalfolds Anteriorcommissure
Spaces Normal Mildlyreduced Moderatelyreduced Severelyreduced Vallecullae
Pyriformsinus
Table2 RadiotherapyEdemaRatingScale(TranslatorA).
Classificac¸ãodoedema
Estruturas Normal Discreto Moderado Intenso
Basedalíngua
Paredeposteriordefaringe Epiglote Pregasfaringo-epiglóticas Pregasariepiglóticas Membranainteraritenóidea Áreapós-cricóide Aritenóides Bandasventriculares Pregasvocais Comissuraanterior
Espac¸os Normal Reduc¸ãodiscreta Reduc¸ãomoderada Reduc¸ãointensa Valécula
Table3 RadiotherapyEdemaRatingScale(TranslatorB).
Classificac¸ãodoedema
Estruturas Normal Discreto Moderado Severo
Basedalíngua
Paredeposteriordefaringe Epiglote
Pregasfaringo-epiglóticas Pregasariepiglóticas Espac¸ointeraritenóideo Árearetrocricóidea Aritenóides Pregasvestibulares Pregasvocais Comissuraanterior
Espac¸os Normal Discretamentereduzida Moderadamentereduzida Severamentereduzida Valécula
Seiospiriformes
Table4 FinalversionoftheRadiotherapyEdemaRatingScale(consensusbetweentranslatorsAandB). Classificac¸ãodoedema
Estruturas Normal Discreto Moderado Severo
Basedalíngua
Paredeposteriordefaringe Epiglote
Pregasfaringo-epiglóticas Pregasariepiglóticas Espac¸ointeraritenóideo Árearetrocricóidea Aritenóides Pregasvestibulares Pregasvocais Comissuraanterior
Espac¸os Normal Discretamentereduzida Moderadamentereduzida Severamentereduzida Valécula
Seiospiriformes
Table5 Radiotherapyedemarating(independentback-translation).
Ratingofedema
Structures Normal Mild Moderate Severe
Baseofthetongue Posteriorpharyngealwall Epiglottis Pharyngoepiglotticfolds Aryepiglotticfolds Interarytenoidspace Cricopharyngealprominence Arytenoids
Falsevocalfolds Vocalfolds
Anteriorcommissure
Spaces Normal Slightlyreduced Moderatelyreduced Severelyreduced Valleculla
totallaryngectomy.Toclarifythisdoubt,wecontactedthe authorand asked whether the term would correspond to thecricopharyngealprominence.Theauthorconfirmedour hypothesis.
Basedonthislastversion,theback-translationwas car-riedoutindependently bytwobilingualtranslators.Inthe case of the term that raised doubts in the translators,it wasunderstoodintheback-translationaspost-cricoidarea. Thus,theversionsweresimilartoeachother withoutany impairmenttotheoriginalversion.Thecommitteechoseto retainthe originalversion, withthetermcricopharyngeal prominence(Table5).
Theauthorschosetotranslatethepyriformsinus struc-ture as seio piriforme because, although the Nomina indicates the term ‘‘pyriformrecess,’’ the term piriform sinusiswidelyused.
The examinationswere then performed by ahead and necksurgeoninthe18patientsrecruitedforthestudy.
Thetoolwasappliedbythegroupconsistingoftwohead andnecksurgeonsandtwospeechtherapists(whohad expe-rienceininterpretingnasoendoscopyresults)inaconsensus, tothe18 patients at the institutionwhere the study was carriedout (Tables 6 and 7). Because this is a scale that evaluates anatomical structures, we did not observe any difficultiesinunderstandingandapplyingthetool.
Discussion
The techniques of edema and lymphedema assessment throughimagesaretoolsthatofferamoreaccuratechoice of the structures involved both with the disease and the treatment. The evaluation of internal edema secondary to treatment in head and neck cancer is a tool that can contribute not only to its diagnosis but also to its evolution.
Other modalitiessuch aslymphoscintigraphy, magnetic resonanceimaging,computedtomography,ultrasonography, andfluorescenceimaging,scarcelymentionedinthe litera-tureoftheheadandneckregion,arealsousedinadditionto thelaryngologicalevaluationusingtheRadiotherapyEdema RatingScale. ThePatterson Scalecan beeasilyappliedin clinicalpractice,sincelaryngologicalexaminationispartof theroutineevaluationandfollow-upofpatientswithhead andneckcancer.1,14,17---22
Anotherpossibilityistoverifytheassociationof swallow-ingandvoicealterations withthepresenceof pharyngeal and laryngeal edema, which can be better quantified usingthe Radiotherapy Edema Rating Scale. The associa-tionbetweeninternaledemaandswallowingandbreathing alterations and their impact on quality of life using this scaleidentifiedastrongcorrelationbetweenedema sever-ity, especially in the region of the aryepiglottic folds, pharyngoepiglottic folds, epiglottis, arytenoids, and pyri-form sinus with swallowing symptoms, mainly of solid consistency.When compared to patients without internal edema,theimpactonfunctionandqualityoflifewasmore evident.10,22
Damagetothelymphatictissuescanleadtolymphedema and fibrosis, which may manifest as early or late effects of head and neck cancer treatment. Lymphedema and fibrosisarenotstaticprocesses.Lymphedemaisassociated
Table 6 Demographic, clinical and treatment characteristics. Variable Category n Age Min.---max. 36---82 Median 60 Mean±standard deviation 61.22±11.39 Gender Female 6 Male 12
Tumorlocation Mouth 7
Oropharynx 5
Larynx 1
Infraglottic 1
Thyroid 1
Face 2
Occultprimarytumor 1
Staging Tx 1 T1b 1 T2 10 T3 2 T4 2 N0 10 N1 2 N2 1 N2a 2 N2b 1 Treatment Surgery 8 Surgery+radiotherapy 4 Surgery+radio-chemo 5 Radio-chemotherapy 1 Neckdissection No 3 Yes 15 Typeofneck dissection Supraomohyoid 9 Radical 3 Modifiedradical 1 Jugular 1 Selective 1 Radiotherapy Min.---max. 3150---7000 Median 1575 Mean±standard deviation 3186±3292.57 Timeuntiltheend
oftreatment (months) Min.---max. 3---40 Median 6.5 Mean±standard deviation 11.94±12.12 Alcoholism No 18 Yes ---Smoking No 16 Yes 2 Tracheostomy No 17 Yes 1 Nasogastrictube No 17 Yes 1
Table7 Distributionofradiotherapyedemaclassification.
Patients Structures Spaces
BT PPW E PEF AEF IS CPP A FVF VF AC V PS 1 1 0 2 0 1 2 2 3 2 0 0 2 1 2 0 0 0 0 0 0 0 0 0 0 0 1 0 3 0 0 0 0 1 2 0 2 0 0 0 0 0 4 0 0 0 0 0 1 0 1 0 1 0 0 0 5 0 1 1 0 2 2 2 3 1 0 0 0 2 6 0 0 0 0 0 2 2 0 0 0 0 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 8 1 0 1 1 0 2 2 2 0 0 0 1 0 9 0 1 0 0 0 0 0 0 0 0 0 0 0 10 0 0 1 0 2 2 2 2 0 0 0 0 0 11 0 0 1 0 0 1 2 1 0 0 0 0 0 12 0 0 0 0 0 0 0 0 0 0 0 0 0 13 1 2 1 0 2 2 1 2 0 0 0 1 1 14 1 0 1 0 2 2 2 2 0 0 0 1 0 15 0 2 1 2 1 2 2 2 0 0 0 0 1 16 0 0 0 0 0 0 0 0 0 0 0 0 0 17 0 0 1 2 2 2 2 2 0 0 0 0 2 18 2 2 2 2 3 3 3 3 0 0 0 0 3
BT,baseofthetongue;PPW,posteriorpharyngealwall;E,epiglottis;PEF,pharyngoepiglotticfolds;AEF,aryepiglotticfolds;IS, Inter-arytenoidspace;CPP,cricopharyngealprominence;A,arytenoids;FVF,falsevocalfolds;VF,vocalfolds;AC,anteriorcommissure;V, valleculla;PS,pyriformsinus;degreeofedemaofstructures:0,normal;1,mildedema;2,moderateedema;3,severeedema;degree ofspacereduction:0,normal;1,mildlyreduced;2,moderatelyreduced;3,severelyreduced.
withongoing inflammationresultingin progressivefibrosis and adipose tissue deposition. With the development of fibrofatty tissue, manual lymphatic drainage and compressiontherapymaybelesseffective.Therefore,the evaluation of treatment effects may facilitate an earlier approachaimingtoavoidorminimizethesealterations.23
TheRadiotherapyEdemaRatingScaleisindicatedby sev-eralauthorsasavalidtoolforthecharacterizationofedema afterheadandneckcancertreatment.1,2,12,18,22
Conclusions
ThetranslationoftheRadiotherapyEdemaRatingScaleinto BrazilianPortuguesewascompatiblewiththeoriginal.The toolisaccessibleandeasytointerpretforhealth profession-alsexperiencedintheevaluationandtreatmentofheadand neckcancer.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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