Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

The Prognostic and Diagnostic Value of [18F]FDG PET/CT in Untreated Laryngeal Carcinoma

This study aims to determine the diagnostic accuracy of staging PET/CT and neck MRI in patients with laryngeal carcinoma and to assess the value of PET/CT in predicting progression-free survival (PFS) and overall survival (OS). Sixty-eight patients who had both modalities performed before treatment between 2014 and 2021 were included in this study. The sensitivity and specificity of PET/CT and MRI were evaluated. PET/CT had 93.8% sensitivity, 58.3% specificity, and 75% accuracy for nodal metastasis, whereas MRI had 68.8%, 61.1%, and 64.7% accuracy, respectively. At a median follow-up of 51 months, 23 patients had developed disease progression and 17 patients had died. Univariate-survival analysis revealed all utilized PET parameters as significant prognostic factors for OS and PFS (p-value < 0.03 each). In multivariate analysis, metabolic-tumor volume (MTV) and total lesion glycolysis (TLG) predicted better PFS (p-value < 0.05 each). In conclusion, PET/CT improves the accuracy of nodal staging in laryngeal carcinoma over neck MRI and adds to the prognostication of survival outcomes through the use of several PET metrics.

Competing risk models versus traditional Cox models for prognostic factors' prediction and care recommendation in patients with advanced laryngeal squamous carcinoma: a population-based study

PURPOSE

To explore the prognostic factors and the optimal treatment modalities for patients with stage IVA laryngeal squamous cell carcinoma (LSCC), so as to improve the survival rate of patients.

METHODS

Patients with stage IVA LSCC between 2004 and 2019 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. We used competing risk models to build nomograms for predicting cancer-specific survival (CSS). The effectiveness of the model was assessed using the calibration curves and the concordance index (C-index). The above results were compared with the nomogram established by Cox regression analysis. The patients were grouped into low-risk and high-risk groups by competing risk nomogram formula. And the Kaplan-Meier (K-M) method and log-rank test were used to make sure that these groups had a survival difference.

RESULTS

Overall, 3612 patients were included. Older age, black race, a higher N stage, a higher pathological grade, and a larger tumor size were independent risk factors for CSS; married marital status, total/radical laryngectomy, and radiotherapy were protective factors. The C-index was 0.663, 0.633, and 0.628 in the train set and 0.674, 0.639, and 0.629 in the test set of the competing risk model, and 0.672, 0.640, and 0.634 in the traditional Cox nomogram for 1, 3, and 5 years. In overall survival and CSS, the prognosis of the high-risk group was poorer than that of the low-risk group.

CONCLUSION

For patients with stage IVA LSCC, a competing risk nomogram was created to help screen risk population and guide clinical decision-making.

PET-CT detection of local residual laryngeal carcinoma after definitive (chemo)radiotherapy

BACKGROUND

Positron emission tomography and computed tomography (PET-CT) is currently recommended in evaluating the treatment response after (chemo)radiotherapy ([C]RT). In the larynx, post-treatment changes and physiological uptake make image interpretation more challenging compared to other head and neck sites. Previous research has not addressed imaging factors specifically in the larynx that would help in distinguishing the residual disease and explain the unique challenges of that anatomic area. The study cohorts are small and heterogenous. Our objective was to investigate the ability of PET-CT in diagnosing local residual laryngeal carcinoma, and to uncover imaging factors that could be used in differentiating the residual disease from post-treatment and physiological changes. In the same study cohort, we also aimed to uncover prognostic factors for local residual or recurrent disease.

METHODS

Our retrospective study cohort included 73 patients with T2-T4 laryngeal carcinoma undergoing (C)RT with curative intention, and post-treatment non-contrast-enhanced PET-CT at 2-6 months. Findings were compared between local residual and non-residual disease. Local residual disease was defined as a persistent tumor growth with no evidence of remission in between, confirmed by biopsy, and evident within 6 months from the end of RT. PET-CT was evaluated using a 3-step scale: negative, equivocal, and positive.

RESULTS

Nine (12%) had a local residual tumor and 11 (15%) developed local recurrence, based on the biopsy. The median follow-up of surviving patients was 64 months (range, 28-174). In univariate analysis, primary tumor diameter greater than 2.4 cm (median value), and vocal cord fixation were prognostic for local residual or recurrent disease. Sensitivity, specificity, PPV, and NPV were 100%, 75%, 36%, and 100%, respectively, when the equivocal interpretation was grouped with the positive interpretation. All local residuals, and 28% (18/64) non-residuals, had a primary tumor area SUV_max of over 4.0 (p < 0.001). CT showed a persistent mass at the primary tumor area in 56% of residuals, and in 23% of non-residuals (p > 0.05). By combining SUV_max>4.0 and mass, specificity improved to 91%.

CONCLUSIONS

NPV of post-treatment PET-CT in laryngeal carcinoma is high, but equivocal and positive results have low PPV and require further diagnostics. All local residuals had SUV_max over 4.0. The combination of SUV_max over 4.0 and mass on CT increased specificity, but the sensitivity was low.

Head and neck cancer treatment in the era of molecular medicine

Head and neck cancers are a heterogeneous group of highly aggressive tumors and collectively represent the sixth most common cancer worldwide. Most head and neck cancers are squamous cell carcinomas (HNSCCs). Current multimodal treatment concepts combine surgery, chemotherapy, irradiation, immunotherapy, and targeted therapeutics. Recent scientific advancements have enabled a more precise molecular characterization of HNSCC and revealed novel therapeutic targets and prognostic/predictive biomarkers. Notably, HNSCC is characterized by complex relations between stromal, epithelial, and immune cells within the tumor microenvironment (TME). The TME consists of different subsets of immune cells that infiltrate the tumors and interact with the tumor cells or with each other. Understanding multiple pivotal factors in HNSCC tumorigenesis and tumor progression may help define novel targets and develop more effective therapies for patients. This review provides a comprehensive overview of the latest advances in the molecular biology of HNSCC and their effects on clinical oncology; it is meant for a broad readership in the head and neck cancers field.

Chemoradiation for Locoregionally Advanced Laryngeal Cancer

Laryngeal preservation with combined modality therapy involving radiotherapy and chemotherapy is usually the treatment of choice for patients with good performance status and with locoregionally advanced laryngeal cancer with a functional larynx. Surgical management with total laryngectomy with neck dissection, followed by adjuvant radiation or chemoradiation, is recommended for patients not eligible for laryngeal preservation. This article provides an overview of the current therapeutic approaches used to treat locoregionally advanced laryngeal cancer and outlines other currently investigated therapies.

Non-surgical organ preservation in laryngeal and hypopharyngeal cancers: an audit from the clinic

BACKGROUND

There is increasing concern regarding efficacy of organ preservation protocol in laryngeal and hypopharyngeal cancers.

METHOD

This study retrospectively assessed disease-related and functional outcomes of 191 patients with non-metastatic laryngeal or hypopharyngeal squamous cell carcinoma treated with curative intent (radiotherapy with or without chemotherapy).

RESULTS

Seventy-six patients (39.8 per cent) had a primary cancer in the larynx, and 115 patients (60.2 per cent) had a primary cancer in the hypopharynx. The median follow up was 39 months. The 3-year time to progression, overall survival, local control and laryngectomy free survival was 56.2 per cent, 76.3 per cent, 73.2 per cent and 67.2 per cent, respectively. At the time of analysis, 83 patients (43.5 per cent) were alive and disease free at their last follow up and did not require tube feeding or tracheostomy. The laryngo-oesophageal dysfunction-free survival was 61 per cent at 3 years.

CONCLUSION

Organ conservation protocols remain the standard of treatment in appropriately selected patients with laryngeal and hypopharyngeal cancers.

Salvage surgery in laryngeal cancer after radiotherapy and partial surgery - comparative results

Objective

The study is a retrospective comparison of the usefulness of salvage surgery between a group of previously radiotherapy-treated patients (RTPs) and a group of patients who previously underwent partial surgery with both local and ± nodal recurrence.

Study Design

Retrospective study.

Setting

Multi-center academic hospital.

Materials and Methods

The former group was comprised 30 previously RTPs, whereas the latter group consisted of 20 patients after partial laryngeal surgery with optional subsequent adjuvant radiotherapy (PSPs). Treatment efficacy was compared in both groups in relation to overall survival (OS) and the locoregional control rate (LCR). Local and ± nodal recurrence was considered primary treatment failure. All patients underwent total laryngectomy.

Results

The updated 5-year OS in the PSPs was 31%, while the percentage of the updated 5-year LCR was 42%. In the RTPs the updated 5-year OS was 21%, and the percentage of 5-year LCR was 38%. No statistically significant differences were found in terms of the comparison of OS or the comparison of LCR results in both groups (P = 0.427, P = 0.704, respectively).

Conclusions

Based on the analysis, it was found that irrespective of the initial treatment, salvage surgery was associated with decreased survival and cure rates (by 50%) compared to the group of patients with advanced laryngeal cancer who underwent primary total laryngectomy.

Surgical Treatment of Early Glottic Cancer

The incidence of all head and neck malignancies is rising worldwide, with carcinoma of the larynx constituting approximately 1% of all cancers. Early glottic cancer responds quite favorably to surgical intervention due to its early presentation, coupled with the low rate of regional and distant metastases. This article focuses on various approaches to the surgical treatment of early glottic cancer. Details include the clinical and radiological evaluation of laryngeal cancer, the goals of treatment, current surgical options for early disease, approach to surgical resection margins and management of nodal disease, and complications associated with each treatment modality.

CT radiomics nomogram predicts pathological response after induced chemotherapy and overall survival in patients with advanced laryngeal cancer: A single-center retrospective study

Purpose

This study aimed to develop a radiomics nomogram to predict pathological response (PR) after induction chemotherapy (IC) and overall survival (OS) in patients with advanced laryngeal cancer (LC).

Methods

This retrospective study included patients with LC (n = 114) who had undergone contrast computerized tomography (CT); patients were randomly assigned to training (n = 81) and validation cohorts (n = 33). Potential radiomics scores were calculated to establish a model for predicting the PR status using least absolute shrinkage and selection operator (LASSO) regression. Multivariable logistic regression analyses were performed to select significant variables for predicting PR status. Kaplan–Meier analysis was performed to assess the risk stratification ability of PR and radiomics score (rad-score) for predicting OS. A prognostic nomogram was developed by integrating radiomics features and clinicopathological characteristics using multivariate Cox regression. All LC patients were stratified as low- and high-risk by the median CT radiomic score, C-index, calibration curve. Additionally, decision curve analysis (DCA) of the nomogram was performed to test model performance and clinical usefulness.

Results

Overall, PR rates were 45.6% (37/81) and 39.3% (13/33) in the training and validation cohorts, respectively. Eight features were optimally selected to build a rad-score model, which was significantly associated with PR and OS. The median OS in the PR group was significantly shorter than that in the non-PR group in both cohorts. Multivariate Cox analysis revealed that volume [hazard ratio, (HR) = 1.43], N stage (HR = 1.46), and rad-score (HR = 2.65) were independent risk factors associated with OS. The above four variables were applied to develop a nomogram for predicting OS, and the DCAs indicated that the predictive performance of the nomogram was better than that of the clinical model.

Conclusion

For patients with advanced LC, CT radiomics score was an independent biomarker for estimating PR after IC. Moreover, the nomogram that incorporated radiomics features and clinicopathological factors performed better for individualized OS estimation.

Validation of a prognostic model for predicting larynx preservation outcome (TALK score) in a Southern European population

OBJECTIVE

Larynx preservation is the current standard for locally advanced (LA) laryngeal/hypopharyngeal tumors, but not all patients respond as expected. TALK score model measures four variables (T-staging, albumin levels, liquor consumption and Karnofsky score) to determine which cases are best suited to preservation treatment scheme. We aimed to validate this prognostic model in a Southern European population.

METHODS

We retrospectively evaluated 175 patients diagnosed from July 2008 to December 2015 with LA laryngeal/hypopharyngeal carcinoma and treated with a laryngeal preservation scheme comprising induction chemotherapy followed by concomitant chemotherapy and radiotherapy. We applied the TALK score model to predict larynx preservation rate.

RESULTS

Of the 175 patients evaluated, 96.6% were men, 98.3% were smokers and 77.1% misused alcohol. Tumors were laryngeal 66.3% vs 33.7% in hypopharynx, and all were either stage III (37.7%) or stage IV (62.3%). TALK prognostic subgroups were: good risk 40.0%; intermediate risk 52.5%; and poor risk 7.5%. With a median follow-up of 40.1 months, larynx preservation rate, laryngectomy-free survival and overall survival at 3 years was 84.5%, 63.7% and 68.2%, respectively. Although TALK score was not predictive of 3-year larynx preservation rate (good risk 85.5%; intermediate risk 83.1%; poor risk 91.6%), it was predictive of 3-year overall survival (good risk 81.9%; intermediate risk 62.9%; poor risk 33.5%) and 3-year laryngectomy-free survival (good risk 75.6%; intermediate risk 59.6%; poor risk 30.7%).

CONCLUSION

TALK model could predict OS and laryngectomy-free survival, helping clinicians to decide which patients should avoid laryngeal preservation and undergo laryngectomy after diagnosis.

A novel 3D-printed laryngoscope with integrated working channels for laryngeal surgery

Background

For the surgical treatment of early-stage laryngeal cancer, the use of transoral laser microsurgery (TLM) has emerged as the gold standard. However, this procedure requires a straight line of sight to the operating field. Therefore, the patient's neck needs to be brought into a hyperextended position. In a considerable number of patients, this is not possible due to anomalies in the cervical spine anatomy or soft tissue scarring, e.g., after radiation. In these cases, adequate visualization of relevant laryngeal structures cannot be ensured using a conventional rigid operating laryngoscope, which may negatively affect the outcome of these patients.

Methods

We present a system based on a 3D-printed prototype of a curved laryngoscope with three integrated working channels (sMAC). The curved profile of the sMAC-laryngoscope is specifically adapted to the nonlinear anatomy of the upper airway structures. The central working channel provides access for flexible video endoscope imaging of the operating field while the two remaining channels provide access for flexible instrumentation. In a user study (n = 11), visualization and reachability of relevant laryngeal landmarks as well as the feasibility of basic surgical procedures with the proposed system were examined in a patient simulator. In a second setup, the system was evaluated for its applicability in a human body donor.

Results

All participants of the user study were able to visualize, reach and manipulate the relevant laryngeal landmarks. Reaching those took significantly less time in the second attempt compared to the first one (27.5 s ± 5.2 s vs. 39.7 s ± 16.5 s, p = 0.008) indicating a significant learning curve for handling the system. Instrument changes were performed quickly and reliably by all participants (10.9 s ± 1.7 s). All participants were able to bring the bimanual instruments into position for a vocal fold incision. Relevant laryngeal landmarks could be visualized and reached in the human body donor setup.

Conclusion

Possibly, the proposed system may develop into an alternative treatment option for patients with early-stage laryngeal cancer and restricted mobility of the cervical spine in the future. Further improvements of the system could include finer end effectors and a flexible instrument with a laser cutting tool.

Management of Locally Advanced Laryngeal Cancer-From Risk Factors to Treatment, the Experience of a Tertiary Hospital from Eastern Europe

Laryngeal cancer is an important oncological entity in which prognosis depends on the establishment of appropriate preventive and diagnostic measures, especially in high-risk populations. We present a retrospective two-year study (January 2021 to December 2022) with 152 patients diagnosed with laryngeal cancer from a tertiary hospital in Romania. The average age of the patients was 62 years old for both sexes, with a range from 44 to 83 years. The most frequent symptom was dysphonia with or without dyspnea in 142 cases (93.42%), followed by dyspnea alone in nine patients (5.92%) and dysphagia in one case (0.66%). Surgical treatment in this study consisted of partial laryngectomy (CO₂ laser transoral tumor ablation, supraglottic horizontal laryngectomy or hemilaryngectomy), or total laryngectomy. The main treatment was total laryngectomy (63%). For the eight patients with initial organ preservation treatment, the average time of recurrence was about two-and-a-half years. For the four patients who underwent a total circular pharyngo-laryngectomy, the upper digestive tract needed to be rebuilt with a salivary bypass tube or with a tubed myocutaneous flap from the major pectoralis muscle. One strong point is characteristic of the study group in gathering patients with advanced stages of laryngeal carcinoma candidates for salvage surgery and extended reconstruction methods. The development of new prevention protocols is mandatory in Eastern European countries.

Treatment and outcome among patients with laryngeal squamous cell carcinoma in S tockholm—A population‐based study

Objective

Survival of patients with advanced laryngeal squamous cell carcinoma (LSCC) remains poor and management protocols warrant further development. We thus investigated treatment and outcome-related factors for LSCC in Stockholm, Sweden.

Methods

In a retrospective setting, 520 patients with LSCC diagnosed during 2000-2014, were included. Data on stage, treatment, and outcome were correlated with recurrence-free and overall survival (RFS and OS, respectively).

Results

Five-year OS for all patients was 65%. Five-year RFS for T1a, T1b, T2, T3, and T4 glottic LSCC was 90%, 91%, 77%, 47%, and 80%, respectively. The corresponding figures for T1, T2, T3, and T4 supraglottic LSCC were 64%, 66%, 64%, and 86%.

Conclusion

Patients with a T3 glottic LSCC had unexpectedly poor survival, especially when compared with patients with a T4 tumor. Patients with T4 disease were primarily treated with laryngectomy and postoperative radiotherapy (RT)/chemoradiotherapy (CRT), while most patients with T3 LSCC were treated with RT/CRT.

Treatment outcomes and cost comparisons for older adults with T4 laryngeal squamous cell cancer

BACKGROUND

To evaluate treatment modalities of T4 larynx cancer in older adults using SEER-Medicare.

METHODS

The database was queried for patients aged 66 and older with nonmetastatic T4 laryngeal squamous cell cancer from 2006 to 2015. Treatment modalities compared were surgery plus chemoradiation (SCR), surgery plus radiation (SR), chemoradiation (CR), surgery (S), and radiation (R). Multivariate analysis and Kaplan-Meier methods were used to explore the relationship of treatment modality and survival. Total cancer-related costs were calculated.

RESULTS

A total of 438 patients met inclusion criteria. Patients receiving CR or SR had similar CSS to SCR (HR 1.36 and HR 1.24, respectively). Those receiving S (HR 2.00) or R (HR 2.41) had significantly worse CSS. Similar findings were observed for OS. Cancer care-related costs were not significantly different but highest in SCR ($162215) and lowest in R ($121421).

CONCLUSION

Older patients with T4 larynx cancer had similar survival rates when treated with CR, SR, and SCR. Average total health care costs were not significantly different between modalities. Patients not eligible for triple-modality could consider these other treatment options.

Relationship between dysphagia and surgical treatment for supraglottic laryngeal carcinoma: A meta-analysis

OBJECTIVE

To systematically evaluate differences in swallowing disorder-related manifestations in patients with supraglottic laryngeal cancer, who underwent traditional open partial horizontal laryngectomy (OPHL) and endoscopic supraglottic laryngectomy (ESL).

METHODS

A systematic review of the literature and a meta-analysis were performed. The CNKI, Wan Fang, PubMed, EMBASE, Cochrane Library, Web of Science, and Clinical Trials databases for clinical studies data sources were investigated. The efficiency of recovery, postoperative swallowing function, and complications related to dysphagia were investigated to compare the effects of surgical procedures.

RESULTS

The meta-analysis included 8 studies with 281 patients. ESL surgery played a positive role in the recovery of patients. Preservation of the anterior epiglottic space, ventricular band, and arytenoid cartilage without destroying the external framework of the larynx can effectively reduce the risk of aspiration pneumonia in patients.

CONCLUSIONS

ESL has advantages in postoperative recovery and retention of swallowing function in patients with supraglottic laryngeal cancer.

Radiomics analysis of CT imaging improves preoperative prediction of cervical lymph node metastasis in laryngeal squamous cell carcinoma

OBJECTIVES

To investigate the role of CT radiomics for preoperative prediction of lymph node metastasis (LNM) in laryngeal squamous cell carcinoma (LSCC).

METHODS

LSCC patients who received open surgery and lymphadenectomy were enrolled and randomized into primary and validation cohorts at a ratio of 7:3 (325 vs. 139). In the primary cohort, we extracted radiomics features from whole intratumoral regions on venous-phase CT images and constructed a radiomics signature by least absolute shrinkage and selection operator (LASSO) regression. A radiomics model incorporating the radiomic signature and independent clinical factors was established via multivariable logistic regression and presented as a nomogram. Nomogram performance was compared with a clinical model and traditional CT report with respect to its discrimination and clinical usefulness. The radiomics nomogram was internally tested in an independent validation cohort.

RESULTS

The radiomics signature, composed of 9 stable features, was associated with LNM in both the primary and validation cohorts (both p < .001). A radiomics model incorporating independent predictors of LNM (the radiomics signature, tumor subsite, and CT report) showed significantly better discrimination of nodal status than either the clinical model or the CT report in the primary cohort (AUC 0.91 vs. 0.84 vs. 0.68) and validation cohort (AUC 0.89 vs. 0.83 vs. 0.70). Decision curve analysis confirmed that the radiomics nomogram was superior to the clinical model and traditional CT report.

CONCLUSIONS

The CT-based radiomics nomogram may improve preoperative identification of nodal status and help in clinical decision-making in LSCC.

KEY POINTS

• The radiomics model showed favorable performance for predicting LN metastasis in LSCC patients. • The radiomics model may help in clinical decision-making and define patient subsets benefiting most from neck treatment.

Survival outcomes for patients with T3N0M0 squamous cell carcinoma of the glottis treated with definitive radiation alone versus chemoradiation

BACKGROUND

Given the poor lymphatics of the glottis, we evaluated omission of chemotherapy in patients treated definitely for T3N0M0 squamous cell carcinoma (SCC) of the glottis.

METHODS

We performed survival analysis of patients with T3N0M0 SCC of the glottis identified in the National Cancer Database treated with radiation alone versus chemoradiation.

RESULTS

A total of 3785 patients were identified. Patients age ≥70 and those with comorbidities were less likely to receive chemotherapy (odds ratio [OR] 0.30, 95% CI [0.25-0.37] and 0.48 [0.31-0.76], respectively). Five-year OS was lower in patients treated with radiation versus chemoradiation (33.8% [30.3%-37.2%] vs. 58.0% [55.8%-60.0%]). In patients <70 with no comorbidities this difference persisted (51.0% [44.5%-57.0%] versus 66.7% [64.0%-69.3%]).

CONCLUSION

Overall survival was higher in patients treated with chemoradiation compared to radiation alone, even when controlling for age and comorbidities. Radiotherapy with chemotherapy omission is not appropriate in patients with T3N0M0 SCC of the glottis.

Risk Factors for Feeding Tube Dependency in Patients Undergoing Function Preservation Surgery for Advanced-Stage Laryngohypopharyngeal Cancer

Dysphagia and feeding tube dependency commonly occur in patients with laryngeal or hypopharyngeal cancer (LHC) during and after treatment, often leading to poor functional outcomes. Therefore, we examined the factors related to feeding tube dependency among advanced-stage LHC patients undergoing curative surgery. This study included 69 consecutive patients who underwent conservative surgery for previously untreated, advanced-stage LHC (squamous cell carcinoma) between 2006 and 2016. Persistent feeding tube dependency was defined as 1 year or more after treatment completion. Binary logistic regression analysis was used to determine the factors associated with reactive prolonged and persistent feeding tube dependency. Cox proportional hazard regression analysis was used to determine the association between feeding tube dependency and survival. None of the study patients had a prophylactic feeding tube, but 15 (21.7%) patients had reactive feeding tube placement for 3 months or more. A total of 9 (13.0%) patients had persistent feeding tube dependency. Univariate analysis showed that age, tracheostomy, and common terminology criteria for adverse events (CTCAE) ≥ 3 were significantly associated with reactive prolonged and persistent feeding tube dependency (all P < 0.05). In the multivariate analysis, advanced age and CTCAE ≥ 3 remained the independent factors of reactive prolonged and persistent feeding tube dependency (all P < 0.05). Feeding tube dependency was not associated with overall survival or disease-free survival (P > 0.1). Feeding tube dependency might be related to clinical factors, such as age and severe adverse events, in the patients undergoing function-preserving surgery for advanced-stage LHC.

Association of Primary Tumor Volume With Survival in Patients With T3 Glottic Cancer Treated With Radiotherapy: A Study of the Canadian Head & Neck Collaborative Research Initiative

Importance

The association of primary tumor volume with outcomes in T3 glottic cancers treated with radiotherapy with concurrent chemotherapy remains unclear, with some evidence suggesting worse locoregional control in larger tumors.

Objective

To evaluate the association of primary tumor volume with oncologic outcomes in patients with T3 N0-N3 M0 glottic cancer treated with primary (chemo)radiotherapy in a large multi-institutional study.

Design, Setting, and Participants

This multi-institutional retrospective cohort study involved 7 Canadian cancer centers from 2002 to 2018. Tumor volume was measured by expert neuroradiologists on diagnostic imaging. Clinical and outcome data were extracted from electronic medical records. Overall survival (OS) and disease-free survival (DFS) outcomes were assessed with marginal Cox regression. Laryngectomy-free survival (LFS) was modeled as a secondary analysis. Patients diagnosed with cT3 N0-N3 M0 glottic cancers from 2002 to 2018 and treated with curative intent intensity-modulated radiotherapy (IMRT) with or without chemotherapy. Overall, 319 patients met study inclusion criteria.

Exposures

Tumor volume as measured on diagnostic imaging by expert neuroradiologists.

Main Outcomes and Measures

Primary outcomes were OS and DFS; LFS was assessed as a secondary analysis, and late toxic effects as an exploratory analysis determined before start of the study.

Results

The mean (SD) age of participants was 66 (12) years and 279 (88%) were men. Overall, 268 patients (84%) had N0 disease, and 150 (47%) received concurrent systemic therapy. The mean (SD) tumor volume was 4.04 (3.92) cm3. With a mean (SD) follow-up of 3.85 (3.04) years, there were 91 (29%) local, 35 (11%) regional, and 38 (12%) distant failures. Increasing tumor volume (per 1-cm3 increase) was associated with significantly worse adjusted OS (hazard ratio [HR], 1.07; 95% CI, 1.03-1.11) and DFS (HR, 1.04; 95% CI, 1.01-1.07). A total of 62 patients (19%) underwent laryngectomies with 54 (87%) of these within 800 days after treatment. Concurrent systemic therapy was associated with improved LFS (subdistribution HR, 0.63; 95% CI, 0.53-0.76).

Conclusions and Relevance

Increasing tumor volumes in cT3 glottic cancers was associated with worse OS and DFS, and systemic therapy was associated with improved LFS. In absence of randomized clinical trial evidence, patients with poor pretreatment laryngeal function or those ineligible for systemic therapy may be considered for primary surgical resection with postoperative radiotherapy.

A preliminary analysis of prognostic genes in advanced laryngeal squamous cell carcinoma patients with postoperative radiotherapy

Advanced laryngeal squamous cell carcinoma (LSCC) has a high mortality rate, and the prognosis is poor. However, the underlying molecular biological mechanisms bringing about the development and progression of advanced LSCC are not entirely clarified. This study aimed to find out the potential biomarkers to predict the prognosis in advanced LSCC patients who had undergone postoperative radiotherapy alone. The next-generation sequencing of RNA was performed to detect the mRNAs expression profiling in 10 advanced LSCC samples, comprised of 5 samples from LSCC patients with favorable outcome and 5 samples from paired patients with poor outcome. Then bioinformatics analysis including Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway were used to find out functional core genes that were significantly different between the two groups. 1630 differentially expressed genes (DEGs) were confirmed to have significant differences between the two groups. 53 GO terms and 19 pathways which were closely related to the DEGs were identified. Finally, 52 intersection DEGs which were both related to the top three GO terms and pathways were identified. The expression of several core genes was confirmed with RT-qPCR in tissues from another 75 patients. RT-qPCR confirmed that the genes of c-JUN, LYN, PIK3R2, and TNFAIP3 were significantly differentially expressed between the two groups, which was in accordance with the RNA sequencing data. The DEGs identified above may be potential prognostic markers for advanced LSCC patients with postoperative radiotherapy, and may provide essential guidance for following-up.

Establishment of prognostic nomogram for T1N0M0 glottic squamous cell carcinoma: an SEER database analysis

OBJECTIVES

The study aimed to construct prognostic models for OS and CSS in patients with T1N0M0 glottic SCC. In addition, we used PSM to re-assess the effect of surgery alone and radiation alone.

METHODS

The Surveillance, Epidemiology, and End Results database was searched for patients with confirmed T1N0M0 glottic SCC. Patients with complete data were randomly divided into the training and the validation cohort (7:3), Cox-regression analysis was performed to identified significant predictors of OS and CSS. PSM was used to mimic randomized controlled the trials. Kaplan-Meier survival method and log-rank tests were utilized for survival analysis.

RESULTS

A total 1827 patients met the inclusion criteria. Survival analysis indicated that the patients who underwent the primary site surgery had a better OS (P = 0.002) and CSS (P = 0.008), compared with non-surgery patients. Cox-regression analysis proved that age, marital status, T1 stages, surgery, radiation, sequential treatments, and chemotherapy had significant effects on OS. While age, marital status, histologic grade, surgery, radiation, sequential treatments, and chemotherapy were substantially associated with CSS. Patients who received primary site surgery had a better OS and CSS, compared with non-surgical patients. Patients receiving radiation had a better CSS than non-radiation patients. However, patients who received sequential treatments or chemotherapy had a worse OS and CSS, compared with controlled groups. Predictive nomogram models were established to predict patients' prognosis with good consistency between the actual observation and the nomogram prediction. Before PSM, patients who underwent surgery alone had a better OS and CSS than those who received radiation alone. After PSM, patients receiving surgery still had a better OS than those receiving radiation. However, there were no statistically significant differences in CSS.

CONCLUSIONS

Nomogram models were developed to predict OS and CSS in patients with T1N0M0 glottic SCC. Primary site surgery could definitely increase OS and CSS, while radiation could significantly increase CSS. Using PSM, surgery alone could significantly enhance OS, as compared to radiation alone. Chemotherapy should not be recommended for early glottic carcinoma.

Surgical prevention of pharyngocutaneous fistula in salvage total laryngectomy: a systematic review and network meta-analysis

PURPOSE

To compare the efficacy of different reconstructive techniques in preventing pharyngocutaneous fistula (PCF) after salvage total laryngectomy (STL).

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model according to the PRISMA-NMA guidelines.

RESULTS

A total of 1694 patients with a median age of 64 years (n = 1569, 95% CI: 62-66 years) were included. If compared to primary pharyngeal closure alone, only a pedicled flap onlay (PFO) showed a statistically significant reduction in PCF rate (OR: 0.35, CI: 0.20-0.61). PFO seemed to perform better than other treatments according to the rank probabilities test (39.9% chance of ranking first).

CONCLUSIONS

A pedicled flap placed with an overlay technique might be preferred over a patch reconstruction to prevent PCF after STL.

Survival outcomes in patients with T3-4aN0M0 glottic laryngeal squamous cell carcinoma and evaluation of postoperative radiotherapy

This study aimed to evaluate the clinical outcomes of patients with T3-4aN0M0 glottic laryngeal squamous cell carcinoma (LSCC) treated with laryngectomy, and to assess the postoperative radiotherapy (PORT) results in terms of the survival of T3-T4aN0M0 patients with negative margins. This was a retrospective review of 369 T3-4aN0M0 glottic LSCC cases. The 5-year cancer-specific survival (CSS) and overall survival (OS) rates were 67.5 and 66.7%, respectively. Patients who received total laryngectomy had worse survival [5-year CSS, 62.5%; disease-free survival (DFS), 56.2%] than those who underwent partial laryngectomy (5-year CSS, 79.3%; DFS, 65.4%). More advanced-stage cancer is a predictor of poor survival. There was no significant difference in CSS or DFS between patients with positive margins following rescue therapy and those with negative margins. Furthermore, no difference in the survival rates was observed between patients with negative margins who received PORT and those who did not (5-year DFS: 59.1 vs. 63.8%, P=0.057 and CSS: 62.5 vs. 69.5%, P=0.074). For T3-4aN0M0 glottic LSCC patients, surgical treatment remained a good option, as it can achieve satisfactory oncological outcomes. However, PORT did not increase survival in surgically managed pT3-4aN0M0 LSCC patients with negative margins.

Role of Neck Dissection in Organ-Preservation for Glottic Squamous Cell Carcinoma

The surgical approach to the neck in laryngeal cancer depends on the tumor site and stage. Clinical practice guidelines recommend elective neck dissection in ≥ T2 N0 and all supraglottic cancers; however, there is no evidence supporting these recommendations. The objective is to evaluate the results of bilateral elective neck dissection in patients with glottic cancer who underwent supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP). Thirty-five patients diagnosed with ≥ T2 N0 laryngeal squamous cell carcinoma (LSCC) in a single-center retrospective study. Right-sided neck dissections yielded 900 lymph nodes, none of which were positive for metastatic disease. Left-sided neck dissections yielded 949 lymph nodes, one of which was positive for malignancy. Prelaryngeal (Delphian) neck dissection was performed in all patients. Out of 50 lymph nodes removed; one was positive for malignancy. Median overall survival was 172 months, and the 60-month overall survival was 87.3%. The 60-month disease-specific survival was 97.1%. Bilateral neck dissection and Delphian node dissection showed a low rate of metastasis (2.8%). Radical neck dissection may thus represent overtreatment; however, this surgical procedure could be justified to prevent regional recurrences.

Defining targets to improve care delivery for T4 larynx squamous cell carcinoma

Objective

United States oncology trends consistently demonstrate that nearly half of T4a larynx carcinoma patients are treated with larynx preservation, despite national guidelines favoring laryngectomy. This study identifies clinical decision-making drivers and defines patient subsets that should become targets for care improvement.

Methods

Retrospective analysis of patients with cT4 squamous cell carcinoma of the larynx from US National Cancer Database 2005-2016. Demographic data and survival rates between clinical pathways were compared. Survival was estimated by Kaplan-Meier method with statistical comparisons assessed by log-rank test.

Results

Of 11,556 patients with cT4 disease, laryngectomy (TL) was the initial treatment for 4627 (40%) patients. Larynx preservation via chemoradiation (CRT) occurred for 4307 patients. TL and CRT patients had similar Charlson-Deyo comorbidity indices and insurance status. TL patients had higher total tumor size, lower N3 rates and were more often seen at academic institutions (p < .0001). N0 surgery patients with adjuvant treatment demonstrated superior median survival (MS) compared to CRT (surgery + radiation MS: 69 months, surgery + chemoradiation MS: 66, CRT MS: 37.7), p < .0001. MS for N1/N2 disease patients was 56.5 months for surgery + radiation and 35.5 months for surgery + CRT, superior to CRT, MS 30.8 months, p < .0001. Tri-modality N3 patients with up front surgery had similar MS compared to CRT (surgery + chemoradiation 21.3 months vs. CRT 16.1), p = .95.

Conclusion

National quality improvement initiatives are needed to promote guideline adherence and improve survival in advanced larynx cancer. Targets for such initiatives should be patients with limited or no nodal disease burden, that meet clear T4a imaging criteria.

Level of Evidence

Level IV, non-randomized controlled cohort.

Prognostic impact of the number of metastatic lymph nodes after surgery in locally advanced hypopharyngeal cancer

Background

Postoperative chemoradiotherapy (CRT) is a standard therapy for patients with high-risk factors for head and neck squamous cell carcinoma, including positive margin and extra-nodal extension (ENE). However, the prognostic impact of the number of pathological metastatic lymph nodes (pLNs) in hypopharyngeal carcinoma (HPC) is unclear. Thus, this study aimed to investigate postoperative prognostic factors for locally advanced hypopharyngeal squamous cell carcinoma (LA-HPSCC) with a focus on the number of pLNs.

Methods

We retrospectively analyzed medical records of 99 consecutive patients with LA-HPSCC who underwent total pharyngo-laryngo-esophagectomy (TPLE) and bilateral neck dissection (ND) between December 2002 and May 2019.

Results

The median follow-up time for all censored patients was 63.2 months. The median overall survival (OS) was 101.0 months (95% confidence interval [CI] 48.1–134.9). patients had pLNs ≥ 3. Forty-six (45.5%) patients were diagnosed with ENE. Twenty (20.2%) patients received postoperative CRT. The multivariate analysis revealed that pLNs ≥ 3 (median OS: 163.2 vs. 31.8 months, hazard ratio [HR] 2.39, 95% CI 1.16–4.94, p < 0.01) and ENE (median OS: 161.0 vs. 26.3 months, HR 4.60, 95% CI 2.26–9.36, p < 0.01) were significantly associated with poor prognosis and that postoperative CRT (HR 0.34, 95% CI 0.16–0.72, p < 0.01) was significantly associated with better prognosis. The cumulative incidence of distant metastasis was higher in patients with pLNs ≥ 3 than in those with pLNs < 3 (p < 0.01).

Conclusion

pLNs ≥ 3 and ENE were significant poor prognostic factors for patients with LA-HPSCC who underwent TPLE and bilateral ND.

Reliability of a Multidisciplinary Multiparametric Approach in the Surgical Planning of Laryngeal Squamous Cell Carcinomas: A Retrospective Observational Study

(1) Background: Endoscopy and morphological imaging are the mainstay of the diagnostic work up of laryngeal squamous cell carcinomas (LSCCs), which can be integrated in a multidisciplinary discussion to obtain a shared pretreatment staging. (2) Methods: A retrospective evaluation of patients, managed at a tertiary university hospital in Italy and submitted to major laryngeal surgery, has been performed. Four different stagings have been defined and compared: epTN (based on endoscopy and physical ENT examination); radTN (based on CT scan); cTN (based on multidisciplinary integration of the two above); pTN based on pathology on surgical samples. Oncological outcomes have been assessed. (3) Results: Three-year relapse free and disease specific survival were 88% and 92.5%, respectively, without significant differences between partial surgeries (n = 13) and total laryngectomies (n = 32). As for the pretreatment staging, and in particular the T classification, the cTN has been revealed as more reliable than epTN and radTN alone in predicting the final pT (Cohen kappa coefficient: 0.7 for cT, 0.44 for radT, 0.32 for epT). In the partial surgery group, we did not record any positive margin nor local recurrence, with a 100% overall and disease-specific survival. (4) Conclusions: The multidisciplinary approach is fundamental in the definition of the primary lesion in LSCC, in particular in order to safely perform surgical preservation of laryngeal function, which is associated with a higher laryngectomy-free survival than irradiation but to a lower salvageability in case of recurrence.

Anterolateral thigh free flap reconstruction of pharyngoesophageal defect caused by radiotherapy for laryngeal cancer: A case report

Salvage total laryngectomy is a common treatment option for patients with recurrent or residual laryngeal cancer after primary radiotherapy. If the tumor is limited to the larynx at the time of surgery, there is usually sufficient mucosa for primary closure of the hypopharynx. We present an unusual case of pharyngoesophageal defect caused by radiotherapy. Since the remaining mucosa of the posterior wall was insufficient for primary closure, the defect was reconstructed with an anterolateral thigh (ALT) free flap.

Bioradiotherapy with Cetuximab May Reduce the Risk of Neck Node Relapse in Locoregionally Advanced Laryngeal Glottic Carcinoma: May HER1-Profile Be Useful in the Bioselection of Patients?

The aim of the study was to evaluate survival in patients with advanced glottic laryngeal squamous cell carcinoma treated by bioradiotherapy (BioRT) with cetuximab and eventual salvage surgery (group A, n = 66) or upfront surgery (total laryngectomy or near-total laryngectomy) with or without postoperative radiotherapy (PORT) (group B, n = 66). The predictive role of HER1 expression in the bioselection of tumors was evaluated. Relapse-free (RFS), metastasis-free (MFS), overall (OS) survivals, salvageability, and rates of larynx preservation were analyzed. The two groups were balanced by propensity score method on their baseline characteristics. No significant differences in RFS and OS were found, while MFS results were significantly higher in group A (p = 0.04). Group A showed a 22% reduction in the probability of nodal metastasis (p = 0.0023), mostly in tumors with higher HER1 expression. The salvageability with TL at 3 years was 54% after prior BioRT and 18% after prior upfront NTL (p < 0.05). BioRT with cetuximab showed a reduction in the risk of lymph node relapse, particularly in the case of HER1 positive tumors, and it allowed to achieve a higher rate of functional larynx preservation and a higher salvageability compared with upfront surgery. HER1 analysis could be clinically useful in the bioselection of tumors that may benefit from BioRT with cetuximab, particularly in those with neck node metastatic propensity.

Low expression of isocitrate dehydrogenase 1 (IDH1) R132H is associated with advanced pathological features in laryngeal squamous cell carcinoma

INTRODUCTION

Recent developments in genomic sequencing have led to the identification of somatic mutations in isocitrate dehydrogenase 1 (IDH1) in various malignancies. IDH1 R132H is the most common mutation of IDH1, which affects codon 132 and results in the conversion of amino acid residue arginine (R) to histidine (H). This study is designed to evaluate the association between the expression of IDH1 R132H and clinicopathological characteristics in laryngeal squamous cell carcinoma (LSCC).

METHODS

The expression pattern and clinical significance of IDH1 R132H were investigated in tissue microarrays (TMAs) of 50 LSCC tumors as well as adjacent normal tissues using immunohistochemistry. Then the exons of the 12 tumor samples with negative/weak positive staining were sequenced by applying polymerase chain reaction (PCR).

RESULTS

The results demonstrated that the cytoplasmic expression of IDH1 R132H was downregulated in tumor cells compared to adjacent normal tissues. A statistically significant association was found between a low level of cytoplasmic expression of IDH1 R132H protein and an increase in histological grade (p < 0.001), perineural invasion (p = 0.019), and lymph node involvement (p < 0.001). The exon4 sequencing results showed that only one sample was positive for IDH1 R132H mutation. IDH1 R132H expression was observed in 39 (78.0%) LSCC samples.

CONCLUSION

These findings indicate that low cytoplasmic expression of IDH1 R132H may have clinical significance in LSCC patients and is associated with more aggressive tumor behavior and progression of the disease, which can help improve potential treatment in patients with LSCC. Further investigations are needed to understand the biological function of IDH1 R132H and larger sample size to confirm our findings.

Advances in nanomaterials for the diagnosis and treatment of head and neck cancers: A review

Nanomaterials (NMs) have increasingly been used for the diagnosis and treatment of head and neck cancers (HNCs) over the past decade. HNCs can easily infiltrate surrounding tissues and form distant metastases, meaning that most patients with HNC are diagnosed at an advanced stage and often have a poor prognosis. Since NMs can be used to deliver various agents, including imaging agents, drugs, genes, vaccines, radiosensitisers, and photosensitisers, they play a crucial role in the development of novel technologies for the diagnosis and treatment of HNCs. Indeed, NMs have been reported to enhance delivery efficiency and improve the prognosis of patients with HNC by allowing targeted delivery, controlled release, responses to stimuli, and the delivery of multiple agents. In this review, we consider recent advances in NMs that could be used to improve the diagnosis, treatment, and prognosis of patients with HNC and the potential for future research.

Salivary bypass tube in total laryngectomy: Systematic review and meta-analysis

The aim of this study is to determine whether the preventive positioning of a salivary bypass tube (SBT) after total laryngectomy (TL) reduces the incidence of postoperative pharyngocutaneous fistula (PCF) and pharyngeal stenosis (PS). This study was conducted in conformity with the PRISMA statement. 1960 patients with a median age of 62.0 years were included. A SBT was placed in 980 (50%) patients (SBT group). The cumulative PCF incidence in the SBT group was 15.8% (95% CI: 9.3-23.6). The measured pooled OR comparing PCF incidence in patients with SBT compared to those without was 0.40 (95% CI: 0.24-0.65). The pooled PS incidence in the SBT group was 12.3% (95% CI: 5.4-21.6). The measured pooled OR comparing PS incidence in patients with SBT compared to those without was 0.43 (95% CI: 0.24-0.65). PCF and PS could be prevented by the intra-operative placement of a SBT.

Deriving prognostic significance from a molecular subtype model of laryngeal carcinoma

BACKGROUND

This study explored whether laryngeal carcinoma could be divided into different subtypes based on molecular differences using a molecular subtype-prediction model.

METHODS

We extracted data from the Cancer Genome Atlas and Gene Expression Omnibus databases and then performed unsupervised cluster analysis to identify discrete molecular subtypes of laryngeal carcinoma. Significance analysis of microarrays was performed to detect differentially expressed genes for each subtype, and gene set enrichment analysis and the GenCliP3 software were used to label gene functions and identify key pathways.

RESULTS

We categorized 126 patients into C1 and C2 molecular subtypes associated with pathologic grade. The C2 subtype appeared more aggressive, with a worse prognosis. The most significant enrichment pathway of the C2 subtype was the Hedgehog pathway, and GLI1 was a core gene.

CONCLUSIONS

Laryngeal carcinoma can be divided into two subtypes based on differences in molecular expression, which could identify key molecules associated with prognosis.

Prognostic value of computed tomography scan detection of cartilage invasion in advanced laryngeal cancer treated with primary total laryngectomy

Background

We sought to determine whether detection of cartilage invasion (CI) by computed tomography predicts oncologic outcomes after primary total laryngectomy.

Methods

Retrospective cohort study comparing oncologic outcomes between radiologic versus pathologic diagnosis.

Results

Assessment of clear CI versus gestalt CI resulted in 84% versus 48% specificity, 90.9% versus 80.3% positive predictive value (PPV), 60.6% versus 80.3% sensitivity, 44.7% versus 48% negative predictive value (NPV), respectively. Disease‐free survival (DFS) was similar between cT4a and cT3/cT2 patients (p = 0.87). DFS trended towards superiority among pT3/pT2 versus pT4a patients (p = 0.18). DFS was similar among patients with CI on radiologist gestalt versus no CI (p = 0.94). Histologically confirmed CI was associated with a hazard ratio (HR) of 1.46 (p = 0.27), gestalt CI 1.13 (p = 0.70), and clear CI 1.61 (p = 0.10) for DFS.

Conclusion

Gestalt determination of CI results in high sensitivity but low specificity, while clear determination of CI results in moderate sensitivity and high specificity.

Randomized trial of laryngeal organ preservation evaluating two cycles of induction chemotherapy with platinum, docetaxel, and a novel Bcl-xL inhibitor

BACKGROUND

Single cycle induction chemotherapy (IC) with platinum and 5-flurouracil (PF) and treatment based on clinical response predicts organ preservation in laryngeal cancer. Other agents offer intriguing alternatives with potentially increased ease of administration, reduced risk for severe toxicities, and increased platinum sensitivity.

METHODS

We report the results of a phase II bioselection trial in advanced resectable laryngeal cancer utilizing an IC regimen of two cycles of platinum plus docetaxel (TP) with a Bcl-2 inhibitor. The primary endpoint was organ preservation rate at 12 weeks post chemoradiation.

RESULTS

Fifty-four patients were enrolled. Response to IC was 72%. The organ preservation rate was 59% with a laryngectomy free survival of 46%. Induction related grade ≥3 toxicities were observed in 56% of patients with two grade 5 events.

CONCLUSIONS

Two cycles of TP IC plus a Bcl-2 inhibitor did not improve laryngeal preservation compared to a single cycle of PF.

Revisiting the Concept of Non- and Minimally Invasive Interventions in Early Glottic Cancer – Part II: Single Therapy Should be Favored over the Combination of Transoral Laser Microsurgery and Radiotherapy, Regarding the Postinterventional Voice Quality

Introduction  Early glottic cancer (EGC) is associated with a high cure rate. Hence, patients and physicians also focus on the impact of the proposed treatment on the speaking function of the preserved larynx.

Objectives  The present study assessed the impact of single-modality treatment (transoral laser microsurgery [TLM], or radiotherapy) or combination therapy for EGC on postinterventional voicing and explored factors which might explain the related perceptions.

Methods  A total of 108 patients filled in the voice handicap index 10 questionnaire, 1 and 2 years postinterventionally. Non-parametric tests were used for the respective statistical analyses.

Results  Sixty-four patients were treated with TLM, 15 with radiotherapy, and 29 with both modalities. Transoral microsurgery and radiotherapy were associated with postinterventional dysphonia, which attenuated between the first and second postintervention year ( p  = 0.000). No association between sociodemographic parameters and the attenuation of postinterventional dysphonia was identified for either treatment modality. Transoral microsurgery and radiotherapy resulted in comparable postinterventional voicing, in the first ( p  = 0.940) and second ( p  = 0.196) postintervention years. The addition of TLM to radiotherapy resulted in worse voice quality in the second, compared with the first postintervention year ( p  = 0.000), demonstrating a detrimental effect on speech intelligibility in noise ( p  = 0.000).

Conclusion  Single therapy should be favored over the combination of TLM and radiotherapy for EGC in terms of retaining better postinterventional voice quality. Postinterventional dysphonia should be taken into account, during preinterventional counseling, as it may exert leverage on the quality of patients' lives. Patients and physicians should acknowledge the optimal time of voice function return, which seems to be extending up to two years posttreatment.

Swallowing Outcomes in Open Partial Horizontal Laryngectomy Type I and Endoscopic Supraglottic Laryngectomy: A Comparative Study

Background: Effective swallowing represents the main challenge in supraglottic laryngectomy. This study aimed to assess swallowing outcome comparing endoscopic supraglottic laryngectomy (ESL) and open partial horizontal laryngectomy type I (OPHL I). Methods: A retrospective study was carried out on 20 patients that underwent supraglottic laryngectomy from 2015 to 2021: 10 underwent ESL (group A) and 10 underwent OPHL I (Group B). Patients underwent fiberoptic endoscopic evaluation of swallowing (FEES) 3 months and 12 months after surgery and videofluoroscopy swallowing studies (VFSS) 12 months after surgery. A Swallowing Outcome After Laryngectomy (SOAL) questionnaire was administered to patients to assess their life quality. Results: A naso-gastric tube was placed in two patients of Group A and in all patients of Group B. Tracheostomy was performed in two patients of Group A and in all patients in Group B and it has been closed in 100% of them. According to Donzelli’s scale, FEES and VFSS showed better results in Group A at 3 months, while at 12 months they did not show statistically significant differences between ESL and OPHL I in terms of laryngeal penetration and aspiration. The SOAL questionnaire showed satisfactory life quality. Conclusion: Swallowing evaluation by FEES and VFSS did not demonstrate statistically significant differences at 12 months post-op between two surgeries, although ESL showed less cases of laryngeal penetration and aspiration at 3 months post-op. Anyway, good results of any surgery depend on careful patient selection and the surgeon’s experience.

A comparison of the survival between laser surgery and radiation in T1aN0M0 glottic cancer: a population-based analysis and meta-analysis

OBJECTIVE

The objective of this study is to compare the overall survival (OS) and the cancer-specific survival (CSS) for patients of T_1aN₀M₀ glottic cancer who underwent laser surgery (LS) or radiation (RT).

METHODS

The data of the population-based analysis were extracted from the SEER database. The studies of the meta-analysis were identified through PubMed, EMBASE, and Cochrane databases. Cox regression analyses, the propensity score analysis (PSM), survival analyses, and the meta-analysis were performed.

RESULTS

In the population-based analysis, 2101 eligible patients were included. Multivariable Cox analyses indicated that patients accepting LS alone would obtain better OS (HR 0.77, 95% CI 0.61-0.98, p = 0.03) and CSS (HR 0.26, 95% CI 0.12-0.59, p = 0.001) than those of whom they accepted RT alone. Survival analyses before PSM and after PSM also indicated that patients who underwent LS alone would have better OS and CSS. In the meta-analysis, nine eligible studies were included. Results of the pooled effect showed that significant differences existed between LS and RT groups on OS (OR: 1.84, 95% CI 1.36-2.50, p < 0.001) and CSS (OR 3.84, 95% CI 1.17-12.52, p = 0.026), both distinctly favoring LS.

CONCLUSIONS

Compared with RT, LS may acquire better survivals for patients with T_1aN₀M₀ glottic cancer. Simultaneously, more multi-center randomized controlled trials would be warranted to prove the conclusion.

Primary Total Laryngectomy versus Organ Preservation for Locally Advanced T3/T4a Laryngeal Cancer

OBJECTIVE

Organ preservation (OP) treatment for advanced laryngeal cancer has increased compared to primary total laryngectomy. Our study compares oncologic and functional outcomes between these approaches.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary care institution.

METHODS

Retrospective review of patients receiving primary total laryngectomy or OP for laryngeal cancer between 1/1/2000 and 12/31/2018.

RESULTS

A total of 118 patients received primary total laryngectomy and 119 received OP. Overall survival was similar between total laryngectomy and OP. When stratified by T stage, disease-free survival was worse among T3 patients receiving OP versus total laryngectomy. In T3 patients, 28 OP patients experienced local recurrence (28.9%) compared to 3 total laryngectomy patients (7.1%; p < 0.01). In total, 20 OP patients with local recurrence received salvage surgery. These patients had similar overall survival to patients who underwent initial total laryngectomy (TL). About 14 OP patients with local recurrence did not receive salvage surgery. About 89 (75.4%) TL patients achieved normal diet as compared to 64 (53.8%) OP patients (p < 0.001). In TL patients, 106 (89.8%) received primary or secondary tracheoesophageal-prosthesis, 82 (77.4%) of whom achieved completely understandable speech.

CONCLUSIONS

There was no difference in survival by treatment in T4 patients, possibly because of strict patient selection. However, disease-free survival was worse in T3 patients receiving OP, likely due to a high local recurrence rate. Approximately 40% of patients with local recurrence were not eligible for salvage laryngectomy. TL patients had comparable swallowing and speech outcomes with OP patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Pilot Investigation on p75ICD Expression in Laryngeal Squamous Cell Carcinoma

We investigated the p75 Neurotrophin Receptor (p75NTR) expression and cleavage product p75NTR Intracellular Domain (p75ICD) as potential oncogenic and metastatic markers in human Laryngeal Squamous Cell Carcinoma (LSCC). p75NTR is highly expressed in Cancer Stem Cells (CSCs) of the laryngeal epithelia and it has been proposed as a marker for stemness, cell migration, and chemo-resistance in different squamous carcinomas. To investigate the clinical significance of p75NTR cleavage products in solid tumors, full-length and cleaved p75NTR expression was analyzed in laryngeal primary tumors from different-stage LSCC patients, diagnosed at the Policlinico Umberto I Hospital. Molecular and histological techniques were used to detect the expressions of p75NTR and p75ICD, and ATP Binding Cassette Subfamily G Member 2 (ABCG2), a CSC marker. We found regulated p75NTR cleavage during squamous epithelial tumor progression and tissue invasion. Our preliminary investigation suggests p75ICD expression and localization as possible features of tumorigenesis and metastaticity. Its co-localization with ABCG2 in squamous cells in the parenchyma invaded by the tumor formation allows us to hypothesize p75NTR and p75ICD roles in tumor invasion and CSC spreading in LSCC patients. These data might represent a starting point for a comprehensive analysis of p75NTR cleavage and of its clinical relevance as a potential molecular LSCC signature, possibly helping diagnosis, and improving prognosis and personalized therapy.

Intensity-Modulated Radiotherapy (IMRT) following Conservative Surgery of the Supraglottic Region: Impact on Functional Outcomes

Simple Summary

The present study has been suggested by the previous experience of our group showing that patients treated with conventional radiotherapy (named 3D conformal radiotherapy—3D-CRT) performed after conservative surgery (CS) for tumors of the supraglottic regions experienced a high rate of severe long-term toxicity. Therefore, we reported the toxicity profile of a similar cohort of patients treated with a high-precision radiotherapy technique (named intensity-modulated radiotherapy—IMRT). Moreover, to investigate the advantage of IMRT, we performed a comparison with a historical cohort treated with 3D-CRT. Results showed that patients treated with IMRT achieved a very low toxicity profile and comparison with 3D-CRT was in favor of IMRTs. Therefore, we believe that the results of the present study provide preliminary findings on the potential of IMRT in improving the toxicity profile of patients treated with surgical organ preservation strategies for laryngeal tumors.

Abstract

The aim of the present study was to investigate the role of intensity-modulated radiotherapy (IMRT) on the toxicity profile of patients treated with conservative surgery (CS) of the supraglottic (SG) region. Data on patients treated with CS and postoperative radiotherapy (PORT)-IMRT were prospectively collected. Results. In total, 20 patients were analyzed. Of these, six patients (35%) required the positioning of a temporary tracheostomy. The functional larynx preservation rate was 95%. Females had a higher risk of both endoscopic intervention and chondronecrosis, while the median age was significantly higher in patients requiring enteral nutrition. The incidence of long-term severe toxicities was lower in patients treated with IMRT than in the historical 3D-CRT cohort. Patients who had received PORT-IMRT achieved a lower rate of permanent laryngeal and swallowing dysfunctions. Overall, results from the comparison with the historical 3D-CRT cohort favor the IMRTs.

Precision Medicine in Head and Neck Cancers: Genomic and Preclinical Approaches

Head and neck cancers (HNCs) represent the sixth most widespread malignancy worldwide. Surgery, radiotherapy, chemotherapeutic and immunotherapeutic drugs represent the main clinical approaches for HNC patients. Moreover, HNCs are characterised by an elevated mutational load; however, specific genetic mutations or biomarkers have not yet been found. In this scenario, personalised medicine is showing its efficacy. To study the reliability and the effects of personalised treatments, preclinical research can take advantage of next-generation sequencing and innovative technologies that have been developed to obtain genomic and multi-omic profiles to drive personalised treatments. The crosstalk between malignant and healthy components, as well as interactions with extracellular matrices, are important features which are responsible for treatment failure. Preclinical research has constantly implemented in vitro and in vivo models to mimic the natural tumour microenvironment. Among them, 3D systems have been developed to reproduce the tumour mass architecture, such as biomimetic scaffolds and organoids. In addition, in vivo models have been changed over the last decades to overcome problems such as animal management complexity and time-consuming experiments. In this review, we will explore the new approaches aimed to improve preclinical tools to study and apply precision medicine as a therapeutic option for patients affected by HNCs.

Comparison of Survival Outcomes of Different Treatment Options for cT1-2, N0 Glottic Carcinoma: A Propensity Score–Weighted Analysis

Background

Treatments for cT1-2, N0 glottic squamous cell carcinoma (GLSCC) include endoscopic resection, open surgery, and radiotherapy. The purpose of this study was to compare the outcomes of three treatment modalities and provide reference data for treatment selection.

Methods

In all, 4274 patients with cT1-2, N0 GLSCC underwent these three treatment modalities from 2004 to 2015 were identified from the Surveillance, Epidemiology, and End Results-18 database. Overall survival (OS) and disease-specific survival (DSS) of patients treated with the three modalities were compared.

Results

In the entire cohort, there were no significant differences in 5-year OS and 5-year DSS among the three treatment groups. In subgroup analyses based on stage and age, endoscopic resection provided significantly better 5-year survival than radiotherapy for cT1, N0 patients aged &lt;65 years, with an OS rate of 89.0% vs. 82.3% (p = 0.009) and a DSS rate of 95.6% vs. 88.2% (p = 0.021). For 5-year DSS, open surgery also had better outcomes than patients who received radiotherapy (5-year DSS: 98.5% vs. 88.2%, respectively; p = 0.046).

Conclusions

To summarize, for cT1, N0 GLSCC patients younger than 65 years, surgical treatment (either endoscopic or open) appears to be superior to the radiotherapy, and endoscopic resection should probably be the first consideration.

Overview on Molecular Biomarkers for Laryngeal Cancer: Looking for New Answers to an Old Problem

Laryngeal squamous cell cancer (LSCC) accounts for almost 25-30% of all head and neck squamous cell cancers and is clustered according to the affected districts, as this determines distinct tendency to recur and metastasize. A major role for numerous genetic alterations in driving the onset and progression of this neoplasm is emerging. However, major efforts are still required for the identification of molecular markers useful for both early diagnosis and prognostic definition of LSCC that is still characterized by significant morbidity and mortality. Non-coding RNAs appear the most promising as they circulate in all the biological fluids allowing liquid biopsy determination, as well as due to their quick and characteristic modulation useful for non-invasive detection and monitoring of cancer. Other critical aspects are related to recent progress in circulating tumor cells and DNA detection, in metastatic status and chemo-refractoriness prediction, and in the functional interaction of LSCC with chronic inflammation and innate immunity. We review all these aspects taking into account the progress of the technologies in the field of next generation sequencing.

Outcomes of surgical versus non-surgical treatment of resectable T4a laryngeal and hypopharyngeal carcinoma

Objective

Surgery is the recommended treatment for resectable T4a laryngeal and hypopharyngeal carcinoma. Non-surgical treatment is an option in a select few patients.

Method

This retrospective study was undertaken to assess the treatment outcomes in patients with resectable T4a carcinoma of the larynx and hypopharynx who received either surgical or non-surgical treatment at our institute and to assess factors influencing these outcomes.

Results

A total of 120 patients were included in the study. They were divided into groups A, B and C based on the presence of extralaryngeal spread through laryngeal membrane, cartilage or both. The overall survival was better among patients who received surgery than those who received non-surgical treatment in the three groups. The factor influencing overall survival was the treatment given in the form of surgical versus non-surgical treatment.

Conclusion

Surgery is the preferred treatment for T4a laryngeal and hypopharyngeal carcinoma, even in patients with extralaryngeal spread without cartilage erosion.

Identification and Validation of Immune Infiltration Phenotypes in Laryngeal Squamous Cell Carcinoma by Integrative Multi-Omics Analysis

Background

Laryngeal squamous cell carcinoma (LSCC) is one of the world’s most common head and neck cancer. However, the immune infiltration phenotypes of LSCC have not been well investigated.

Methods

The multi-omics data of LSCC were obtained from the TCGA (n=111) and GEO (n=57) datasets. The infiltrations of the 24 immune cell populations were calculated using the GSVA method. Then LSCC samples with different immune cell infiltrating patterns were clustered, and the multi-omics differences were investigated.

Results

Patients were clustered into the high-infiltration and low-infiltration groups. The infiltration scores of most immune cells were higher in the high-infiltration group. Patients with high-infiltration phenotype have high N and TNM stages but better survival, as well as less mutated COL11A1 and MUC17. Common targets of immunotherapies such as PD1, PDL1, LAG3, and CTLA4 were significantly up-regulated in the high-infiltration group. The differentially expressed genes were mainly enriched in several immune-related GOs and KEGG pathways. Based on the genes, miRNAs, and lncRNAs differentially expressed in both the TCGA and GEO cohorts, we built a ceRNA network, in which BTN3A1, CCR1, miR-149-5p, and so on, located at the center. A predictive model was also constructed to calculate a patient’s immune infiltration phenotype using 16 genes’ expression values, showing excellent accuracy and specificity in the TCGA and GEO cohorts.

Conclusions

In this study, the immune infiltration phenotypes of LSCC and the corresponding multi-omics differences were explored. Our model might be valuable to predicting immunotherapy’s outcome.

Dual-energy CT may predict post-operative recurrence in early-stage glottic laryngeal cancer: a novel nomogram and risk stratification system

OBJECTIVES

To establish and validate a predictive model integrating with clinical and dual-energy CT (DECT) variables for individual recurrence-free survival (RFS) prediction in early-stage glottic laryngeal cancer (EGLC) after larynx-preserving surgery.

METHODS

This retrospective study included 212 consecutive patients with EGLC who underwent DECT before larynx-preserving surgery between January 2015 and December 2018. Using Cox proportional hazard regression model to determine independent predictors for RFS and presented on a nomogram. The model's performance was assessed using Harrell's concordance index (C-index), time-dependent area under curve (TD-AUC) plot, and calibration curve. A risk stratification system was established using the nomogram with median scores of all cases to divide all patients into two prognostic groups.

RESULTS

Recurrence occurred in 39/212 (18.4%) cases. Normalized iodine concentration in arterial (NICAP) and venous phases (NICVP) were verified as significant predictors of RFS in multivariate Cox regression (hazard ratio [HR], 4.2; 95% confidence interval [CI]: 2.3, 7.7, p < .001 and HR, 3.0; 95% CI: 1.5, 5.9, p = .002, respectively). Nomogram based on clinical and DECT variables was better than did only clinical variables. The prediction model proved well-calibrated and had good discriminative ability in the training and validation samples. A risk stratification system was built that could effectively classify EGLC patients into two risk groups.

CONCLUSIONS

DECT could provide independent RFS indicators in patients with EGLC, and the nomogram based on DECT and clinical variables was useful in predicting RFS at several time points.

KEY POINTS

• Dual-energy CT(DECT) variables can predict recurrence-free survival (RFS) after larynx-preserving surgery in patients with early-stage glottic laryngeal cancer (EGLC). • The model that integrates clinical and DECT variables predicted RFS better than did only clinical variables. • A risk stratification system based on the nomogram could effectively classify EGLC patients into two risk groups.

Deep learning approach of diffusion-weighted imaging as an outcome predictor in laryngeal and hypopharyngeal cancer patients with radiotherapy-related curative treatment: a preliminary study

OBJECTIVES

This preliminary study aimed to develop a deep learning (DL) model using diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps to predict local recurrence and 2-year progression-free survival (PFS) in laryngeal and hypopharyngeal cancer patients treated with various forms of radiotherapy-related curative therapy.

METHODS

Seventy patients with laryngeal and hypopharyngeal cancers treated by radiotherapy, chemoradiotherapy, or induction-(chemo)radiotherapy were enrolled and divided into training (N = 49) and test (N = 21) groups based on presentation timeline. All patients underwent MR before and 4 weeks after the start of radiotherapy. The DL models that extracted imaging features on pre- and intra-treatment DWI and ADC maps were trained to predict the local recurrence within a 2-year follow-up. In the test group, each DL model was analyzed for recurrence prediction. Additionally, the Kaplan-Meier and multivariable Cox regression analyses were performed to evaluate the prognostic significance of the DL models and clinical variables.

RESULTS

The highest area under the receiver operating characteristics curve and accuracy for predicting the local recurrence in the DL model were 0.767 and 81.0%, respectively, using intra-treatment DWI (DWI_intra). The log-rank test showed that DWI_intra was significantly associated with PFS (p = 0.013). DWI_intra was an independent prognostic factor for PFS in multivariate analysis (p = 0.023).

CONCLUSION

DL models using DWI_intra may have prognostic value in patients with laryngeal and hypopharyngeal cancers treated by curative radiotherapy. The model-related findings may contribute to determining the therapeutic strategy in the early stage of the treatment.

KEY POINTS

• Deep learning models using intra-treatment diffusion-weighted imaging have prognostic value in patients with laryngeal and hypopharyngeal cancers treated by curative radiotherapy. • The findings from these models may contribute to determining the therapeutic strategy at the early stage of the treatment.