Swallowing function after transoral laser microsurgery (TLM) ± adjuvant therapy for advanced-stage oropharyngeal cancer

OBJECTIVES/HYPOTHESIS

To perform a longitudinal description of swallowing function following transoral laser microsurgery (TLM) ± adjuvant therapy for advanced-stage oropharyngeal cancer (OPC) and identify prognostic factors associated with swallowing performance.

STUDY DESIGN

Retrospective analysis and longitudinal descriptive study of swallowing outcomes.

METHODS

Patients treated with TLM for AJCC stage III-IV OPC at Washington University from 1996 to 2008 were included. A search of medical records and direct patient contact were performed to obtain swallowing function at multiple time points. Persistently poor swallowing at 2 year after surgery was the primary outcome measure. Two year swallowing outcomes stratified by tumor site and T stage are presented.

RESULTS

One hundred eighteen patients met criteria for the study (median follow-up 53.9 months). There were 44 T1's, 41 T2's, 23 T3's and 10 T4's. Forty seven percent received radiotherapy and 41% received chemoradiotherapy. Ninety-eight percent underwent neck dissection. Patients tolerated TLM well with 82% enjoying good swallowing at 1 month after surgery. During adjuvant therapy, at 3 months, good swallowing dropped to 55%. At 1 and 2 years after TLM, 89% and 88% of patients had good swallowing function, respectively. At 2 years, 9 patients had persistently poor swallowing function. 93% of patients with T1 through T3 enjoyed good swallowing at 2 years. T4 base of tongue disease was associated with persistently poor swallowing function in multivariate analyses (P = 0.0023), with 40% having good swallowing at 2 years. Preexisting comorbidities and conversion to an open procedure were associated with delayed return of swallowing function, but not with persistently poor swallowing. Seven patients developed late-onset swallowing dysfunction.

CONCLUSIONS

Treatment of advanced stage OPC with TLM ± adjuvant therapy results in excellent swallowing outcomes for patients with either T1 to T3 tonsil or T1 to T3 base of tongue resections. A detailed, longitudinal swallowing profile is presented to assist in preoperative counseling.

State-of-the-Art Endoscopic Management of Larynx and Pharynx Cancer

Program Description: Transoral treatment of larynx and pharynx cancer has been done for over a century. Despite substantial technical innovations such as enhanced imaging, innovative laser technologies, and robotics guidance systems, radiotherapy and/or chemotherapy dominate the treatment strategy at many institutions. In part, this is due to limited familiarity with recent novel endoscopic surgical approaches. Outcomes data on transoral microsurgical management for advanced oropharynx and larynx cancer will be presented to illustrate the efficacy of surgical management of these diseases. Robotics and laser photoangiolysis of laryngeal cancer are two emerging technologies that can enhance endoscopic surgery. These novel and innovative treatment technologies can potentially be combined in the future to expand the indications for endoscopic surgery. This miniseminar will highlight advantages and disadvantages of endoscopic techniques and update the attendees on state-of-the-art procedural innovations.

Educational Objectives: 1) Understand outcomes data on transoral laser microsurgery for advanced oropharyngeal and laryngeal cancer. 2) Understand the emerging role of robotics in endoscopic surgical management of larynx and pharynx cancer. 3) Understand concepts of photoangiolysis in treatment of aerodigestive tract malignancy.

Human papillomavirus and oropharynx cancer: biology, detection and clinical implications

OBJECTIVES

To review evidence for the role of human papillomavirus (HPV) in the etiology of oropharyngeal cancers, methods of viral detection, and the resulting clinical implications.

STUDY DESIGN

Contemporary review.

METHODS

Published journal articles identified through PubMed and conference proceedings were reviewed.

RESULTS

HPV-associated squamous cell carcinomas represent a distinct disease entity from carcinogen-associated squamous cell carcinomas. HPV oncoproteins lead to mucosal cell transformation through well-defined mechanisms. Different methods of detecting HPV exist with variable levels of sensitivity and specificity for biologically active virus. Although virus is detected in a number of head and neck subsites, studies demonstrate improved outcomes in HPV-associated carcinoma of the oropharynx only. The cell cycle regulatory protein p16 is upregulated by biologically active HPV and serves as a biomarker of improved response to therapy.

CONCLUSIONS

HPV-associated squamous cell carcinoma of the oropharynx is a biologically distinct entity from carcinogen-associated carcinoma. Understanding the molecular mechanisms behind the improved outcomes in patients with HPV-associated oropharyngeal carcinoma may lead to novel therapeutics for patients with carcinogen-associated carcinomas.

p16 positive oropharyngeal squamous cell carcinoma:an entity with a favorable prognosis regardless of tumor HPV status

BACKGROUND

In the human papillomavirus (HPV) era, the best way to assess oropharyngeal squamous carcinomas (SCC) for risk stratification is not clear. Many recommend use of both p16 immunohistochemistry and HPV in situ hybridization (ISH). A significant minority of tumors are p16 positive and HPV ISH negative, the significance of which is unclear.

METHODS

Two hundred thirty-nine oropharyngeal SCC were tested by immunohistochemistry for p16 and by ISH for high-risk HPV. For p16 positive, HPV ISH negative cases, PCR was conducted for HPV. The findings were correlated with pathologic and clinical findings.

RESULTS

Of the 239 cases, 187 (78%) were positive for p16. Of these, 139 (74%) were positive for HPV by ISH. Of the remaining 48 cases, 45 had material for PCR. Nineteen were positive for HPV, leaving a group of 26 p16 positive and HPV undetectable SCCs. In the p16 positive cohort, there was no difference in survival between HPV ISH positive and negative cases. Comparing the HPV ISH positive and HPV ISH and PCR negative SCC, there was again no difference in survival. p16 positive, HPV negative SCC still had significantly better survival than p16 negative SCC in univariate and multivariate analysis.

CONCLUSIONS

Outcomes for p16 positive, HPV negative oropharyngeal SCC are not significantly different from p16 positive, HPV positive tumors and are significantly better than for p16 negative tumors. These results suggest that p16 immunohistochemistry alone is the best test to use for risk stratification in oropharyngeal SCC.

Transoral laser microsurgery (TLM) +/- adjuvant therapy for advanced stage oropharyngeal cancer: outcomes and prognostic factors

OBJECTIVES/HYPOTHESIS

Document survival, prognostic variables, and functional outcomes of patients with AJCC stage III or IV oropharyngeal cancer, treated with transoral laser microsurgery (TLM) +/- adjuvant therapy.

STUDY DESIGN

Analysis of prospectively assembled data pertaining to the above-described patient cohort.

METHODS

Patients treated with TLM for AJCC stage III or IV oropharyngeal cancer at Washington University School of Medicine from 1996 to 2006 were followed for a minimum of 2 years. Recurrence, survival, functional, and human papilloma virus data were analyzed.

RESULTS

Eighty-four patients met inclusion criteria. Mean follow-up was 52.6 months. Overall AJCC stages were: III 15% and IV 85%. T stages were T1-2, 74%; T3-4, 26%. Eighty-three patients underwent neck dissection, 50 received adjuvant radiotherapy, and 28 received adjuvant chemoradiotherapy. Overall survival at 2 and 5 years was 94% and 88%, respectively. Disease-specific survival at 2 and 5 years was 96% and 92%, respectively. Six patients recurred (7%): locally (one), regionally (four), and distant (five). T stage, positive margins, and p16 status significantly impacted survival. The addition of adjuvant chemotherapy in high-risk patients did not significantly impact survival. Five patients (6%) had major surgical complications, but without mortality. Eighty-one percent of patients had acceptable swallowing function at last follow-up. Immediately postoperatively, 17% required G-tubes, which dropped to 3.4% of living patients at 3 years.

CONCLUSIONS

In this population, our findings validate TLM +/- adjuvant therapy as a highly effective strategy for survival, locoregional control, and swallowing recovery in AJCC stage III and IV oropharyngeal cancer. Our finding also show that p16 positivity improves survival.

Microvascular flap reconstruction of major pharyngeal resections with the intent of laryngeal preservation

OBJECTIVE

To determine the functional outcome in patients undergoing pharyngeal reconstruction with free tissue transfer with the intent of functional laryngeal preservation.

DESIGN

Retrospective medical record review.

SETTING

Academic tertiary care hospital.

PATIENTS

The study population comprised 45 patients who underwent a major pharyngeal resection with or without a partial laryngeal resection (2 patients died perioperatively, leaving 43 to evaluate). The majority (n = 35 [81%]) had advanced (T3 or T4) primary tumors at presentation and underwent subsequent reconstruction using free tissue transfer at a tertiary care hospital.

MAIN OUTCOME MEASURES

The rate of functional larynx preservation, best swallow score based on the Functional Outcome Swallowing Scale, and need for tracheostomy. Thirteen independent variables relevant to function and 6 postoperative outcome variables were studied following treatment, and their correlation with laryngeal function was determined.

RESULTS

Of the 43 patients, 35 (81%) had T3 (n = 9) or T4 (n = 26) squamous cell carcinoma at presentation. There was 100% flap survival. Thirty-one patients (72%) tolerated an oral diet, with 24 (56%) achieving an exclusively oral diet. Only a history of gastroesophageal reflux disease had a statistically significant correlation with poor swallowing; having had a cranial nerve removed did not achieve statistical significance (P = .06). The majority of patients had their best swallow by 10 months. Of the 43 patients, 42 (97%) achieved native laryngeal speech and 36 (84%) were decannulated. The need for a tracheostomy did not correlate with any of the preoperative independent variables.

CONCLUSIONS

Free tissue transfer allows for successful reconstruction of complex pharyngeal defects that functionally threaten the remaining larynx. In properly selected patients, functional laryngeal preservation, decannulation, and use of laryngeal speech can be reliably achieved. Excellent swallowing function can less reliably be predicted.

Determinants of success in endoscopic cerebrospinal fluid leak repair

OBJECTIVES

To identify factors influencing success in endoscopic repair of CSF leaks of the anterior skull base.

METHODS

Through retrospective chart review, 24 endoscopic closures of anterior skull base CSF leaks were analyzed for factors correlating with initial repair outcome.

RESULTS

Thirteen patients with either spontaneous leaks or iatrogenic leaks arising from FESS were repaired with significantly lower recurrence rate (8%) than 11 patients with leaks induced by skull base procedures (45%). However, in the latter group, only 14% recurred when the dural defect was directly visualized, whereas leaks always recurred when bony dehiscences were patched in the absence of visible dural defects. Such defects were least frequently localized in patients with craniotomy-induced leaks. A trend toward morbid obesity was also noted among repair failures.

CONCLUSIONS

Direct visualization of the dural defect is essential for endoscopic repair of anterior skull base CSF leaks, with craniotomy-induced leaks being the most challenging to localize. Obesity is another likely factor contributing to repair failure.

Laryngeal transplantation in 2005: a review

There is no good surgical, medical or prosthetic solution to the problems faced by those with a larynx whose function is irreversibly damaged by tumor or trauma. Over the past 10 years, the pace of research designed to establish laryngeal transplantation as a therapeutic option for these persons has increased steadily. The biggest milestone in this field was the world's first true laryngeal transplant performed in Cleveland, Ohio in 1998. The recipient's graft continues to function well, in many respects, even after 7 years. However, it has also highlighted the remaining barriers to full-scale clinical trials. Stimulated by these observations, several groups have accumulated data which point to answers to some of the outstanding questions surrounding functional reinnervation and immunomodulation. This review seeks to outline the progress achieved in this field by 2005 and to point the way forward for laryngeal transplantation research in the 21st century.

Caspase Inhibition Enhances Ischemic Tolerance of Fasciocutaneous Flaps

OBJECTIVES/HYPOTHESIS

To demonstrate the significance of apoptosis in ischemia-reperfusion injury in revascularized fasciocutaneous flaps and test the hypothesis that pharmacologic inhibition of caspases prolongs the allowable primary ischemia time of these flaps.

STUDY DESIGN

Animal study using the epigastric flap in adult male Sprague-Dawley rats.

METHODS

Fifty-nine rats were treated with the caspase inhibitor (Q-VD-OPH) reconstituted in dimethylsulfoxide (DMSO) (n = 20, 8 mg/kg:0.8 mL/kg), DMSO alone (n = 19, 0.8 mL/kg), or saline (n = 20, 0.8 mL/kg). Treatment was given as a single intraperitoneal injection 30 minutes before starting primary ischemia. Epigastric flaps were subjected to increasing ischemia times followed by reperfusion. The flaps were harvested and analyzed 7 days later, and viability was assessed. Probit statistical analysis was used to determine the critical ischemia time. This was defined as the time point when 50% of the flaps in each group were expected to survive.

RESULTS

The calculated critical ischemia times were 8.92 hours (95% confidence interval 7.19-10.47 h) for the saline group, 16.35 hours (95% confidence interval 11.82-19.89 h) for the DMSO group, and 21.73 hours (95% confidence interval 19.39-25.37 h) for the DMSO with Q-VD-OPH group. These differences were significantly different from each other.

CONCLUSIONS

Pretreatment of fasciocutaneous flaps with a free radical scavenger alone or in combination with a caspase inhibitor significantly increases the flap's tolerance of primary ischemia. The added benefit of the caspase inhibitor suggests that apoptosis plays an important role in ischemia-reperfusion injury in soft tissue flaps.

Management of Stage IV Glottic Carcinoma: Therapeutic Outcomes

OBJECTIVES/HYPOTHESIS

The best therapeutic approach for the treatment of stage IV glottic carcinoma is controversial.

STUDY DESIGN

A retrospective study.

METHODS

A retrospective study of Tumor Research Project data was performed using patients with stage IV glottic squamous cell carcinoma treated with curative intent by five different treatment modalities from 1955 to 1998 at Washington University School of Medicine and Barnes-Jewish Hospital (St. Louis, MO).

RESULTS

Ninety-six patients with stage IV glottic carcinoma were treated by five modalities: total laryngectomy (TL) (n = 13), total laryngectomy with neck dissection (TL/ND) (n = 18), radiation therapy alone (RT) (n = 7) (median dose, 69.5 Gy), total laryngectomy combined with radiation therapy (TL/RT) (n = 10), and total laryngectomy and neck dissection combined with radiation therapy (TL/ND/RT) (n = 48). The overall 5-year observed survival (OS) rate was 39%, and the 5-year disease-specific survival (DSS) rate was 45%. The 5-year DSS rates for the individual treatment modalities included the following: TL, 58.3%; TL/ND, 42.9%; RT, 50.0%; TL/RT, 30.0%; and TL/ND/RT, 43.9%. There was no significant difference in DSS for any individual treatment modality (P =.759). The overall locoregional control rate was 69% (66 of 96). The overall recurrence rate was 39% with recurrence at the primary site and in the neck at 19% and 17%, respectively. Recurrence was not related to treatment modality. The 5-year DSS after treatment of locally recurrent cancer (salvage rate) was 30% (3 of 10) and for recurrent neck disease (28 of 67) was 42%. The incidence of delayed regional metastases was 28%; of distant metastasis, 12%; and of second primary cancers, 9%. There was no statistically significant difference in survival between node-negative (N0) necks initially treated (5-y DSS, 31%) versus N0 necks observed and later treated if necessary (5-y DSS, 44%) (P =.685).

CONCLUSION

The five treatment modalities had statistically similar survival, recurrence, and complication rates. The overall 5-year DSS for patients with stage IV glottic carcinoma was 45%, and the OS was 39%. The cumulative disease-specific survival (CDSS) was 0.4770 with a mean survival of 10.1 years and a median survival of 3.9 years. Patients younger than age 55 years had better survival (DSS) than patients 56 years of age or older (P =.0002). Patients with early T stage had better survival than patients with more advanced T stage (P =.04). Tumor recurrence at the primary site (P =.0001) and in the neck (P =.014) and distant metastasis (P =.0001) had a deleterious effect on survival. Tumor recurrence was not related to treatment modality. Patients with clear margins of resection had a statistically significant improved survival (DSS and CDSS) compared with patients with close or involved margins (P =.0001). Post-treatment quality of life was not significantly related to treatment modality. Patients whose N0 neck was treated with observation and appropriate treatment for subsequent neck disease had statistically similar survival compared with patients whose N0 neck was treated prophylactically at the time of treatment of the primary. A minimum of 7 years of follow-up is recommended for early identification of recurrent disease, second primary tumors, and distant metastasis. None of the standard treatment modalities currently employed has a statistical advantage regarding survival, recurrence, complications, or quality of life.

Intensity-modulated radiation therapy for oropharyngeal carcinoma: impact of tumor volume

PURPOSE

To assess the therapeutic outcomes in oropharyngeal cancer patients treated with intensity-modulated radiotherapy (IMRT) and analyze the impact of primary gross tumor volume (GTV) and nodal GTV (nGTV) on survival and locoregional control rates.

METHODS AND MATERIALS

Between February 1997 and September 2001, 74 patients with squamous cell carcinoma of the oropharynx were treated with IMRT. Thirty-one patients received definitive IMRT; 17 also received platinum-based chemotherapy. Forty-three patients received combined surgery and postoperative IMRT. The median follow-up for all patients was 33 months (range, 9-60 months). Fifty-two patients (70.3%) had Stage IV disease, 17 patients (23%) had Stage III, 3 patients (4.1%) had Stage II, and 2 patients (2.7%) had Stage I tumors. The mean prescription dose was 70 and 66 Gy, respectively, for the definitive and postoperative cohorts. The daily fraction dose was either 1.9 or 2 Gy, five times weekly. The GTV and/or nGTV were determined and derived using the Computational Environment for Radiotherapy Research, a free software package developed at Washington University. The mean GTV was 30.5 +/- 22.3 cm(3), and the mean nGTV was 23.2 +/- 20.6 cm(3).

RESULTS

Ten locoregional failures were observed. Six patients died of disease and three died of concurrent disease. Distant metastasis developed in 6 patients. The 4-year estimate of overall survival was 87%, and the 4-year estimate of disease-free survival was 81% (66% in the definitive vs. 92% in the postoperative RT group). The 4-year estimate of locoregional control was 87% (78% in the definitive vs. 95% in the postoperative RT group); the 4-year estimate of distant metastasis-free survival was 90% (84% in the definitive vs. 94% in the postoperative group). Multivariate analysis showed that GTV and nGTV were independent risk factors determining locoregional control and disease-free survival for definitive oropharyngeal IMRT patients. The worst late toxicities documented were as follows: 32 patients with Grade 1 and 9 with Grade 2 xerostomia; 2 with Grade 1 and 1 with Grade 2 skin toxicity; 3 with Grade 1 late mucositis; and 3 with Grade 1 trismus. Seventeen patients required gastrostomy tube placement.

CONCLUSION

IMRT is an effective treatment modality for locally advanced oropharyngeal carcinoma. The GTV and nGTV are the most important factors predictive of therapeutic outcome.