Patterns of care for cancer of the larynx in the United States

Effect of Radiological Tumor Thickness on Prognosis of Early Glottic-Squamous Cell Carcinoma Treated With Radiation

OBJECTIVES

Tumor depth of invasion is a known prognostic factor in several head and neck cancers, but data on early laryngeal squamous cell carcinoma (SCC) are sparse. In this study, we aim to determine whether radiological tumor thickness serves as a prognostic factor in early SCC of the glottis treated with radiation.

METHODS

One hundred thirty-two adult patients (age >18 years) underwent pretreatment computed tomography (CT) and were treated with radiation for pathologically proven early stage (T1 or T2) glottic SCC. Thirty-eight were excluded because the tumor could not be correctly identified on the CT scan, and an additional three patients because of insufficient data.

RESULTS

The final cohort consisted of 91 patients, 84 (90.3%) men and 7 (9.7%) women aged 39.86-86.53 (mean 65.55 ± 12.76) years. Mean tumor thickness was 0.59 ± 0.19 cm in patients with T1 tumors and 0.79 ± 0.21 cm in patients with T2 tumors. The optimal cutoff value for 5-year disease-free survival (DFS), using the Youden index (sensitivity: 81.2%, specificity 65.3%), was 0.7 cm. A significant advantage in 5-year overall survival (OAS) and 5-year DFS for tumor thickness of <0.7 cm (P = 0.01 and P < 0.01, respectively) was found, these findings were consistent also when each stage was examined separately (T1 vs T2).

CONCLUSION

Radiological tumor thickness appears to significantly predict OAS and DFS in early glottic SCC patients.

IMPLICATION FOR PRACTICE

Tumor thickness may be considered as an auxiliary aid in deciding follow-up time and frequency, proper treatment, and determining prognosis.

BNIPL is a promising biomarker of laryngeal cancer: novel insights from bioinformatics analysis and experimental validation

BACKGROUND

Laryngeal cancer (LC) is a malignant tumor with high incidence and mortality. We aim to explore key genes as novel biomarkers to find potential target of LC in clinic diagnosis and treatment.

METHODS

We retrieved GSE143224 and GSE84957 datasets from the Gene Expression Omnibus database to screen the differentially expressed genes (DEGs). Hub genes were identified from protein-protein interaction networks and further determined using receiver operating characteristic curves and principal component analysis. The expression of hub gene was verified by quantitative real time polymerase chain reaction. The transfection efficiency of BCL2 interacting protein like (BNIPL) was measured by western blot. Proliferation, migration, and invasion abilities were detected by Cell Counting Kit-8, wound-healing, and transwell assays, respectively.

RESULTS

Total 96 overlapping DEGs were screened out from GSE143224 and GSE84957 datasets. Six hub genes (BNIPL, KRT4, IGFBP3, MMP10, MMP3, and TGFBI) were identified from PPI network. BNIPL was selected as the target gene. The receiver operating characteristic curves of BNIPL suggested that the false positive rate was 18.5% and the true positive rate was 81.5%, showing high predictive values for LC. The expression level of BNIPL was downregulated in TU212 and TU686 cells. Additionally, overexpression of BNIPL suppressed the proliferation, migration, and invasion of TU212 and TU686 cells.

CONCLUSION

BNIPL is a novel gene signature involved in LC progression, which exerts an inhibitory effect on LC development. These findings provide a novel insight into the pathogenesis of LC.

Determining the Efficacy of Surgical Versus Non-Surgical Management in T3M0 Laryngeal Cancer With Cord Fixation

OBJECTIVE

Survival of laryngeal cancer is decreasing; thus, optimal treatment selection is paramount. Specifically, T3 disease survival appears similar with surgical or non-surgical management; however, the implications of vocal cord fixation on treatment selection and survival are unknown. This study seeks to determine if surgical treatment of patients with T3M0 laryngeal cancer with vocal cord fixation is associated with superior survival compared to non-surgical treatment.

METHODS

The National Cancer Database (NCDB) was queried for all T3M0 laryngeal carcinoma cases from 2004 to 2015, whose treatment included surgery or radiation therapy. Cases were stratified by cord fixation status and overall survival was compared using multivariable methods based on surgical versus non-surgical management.

RESULTS

Non-surgical management was more common, regardless of cord fixation status (84% in fixed and 79% in mobile). Cord fixation itself did not influence survival; however, surgical management had a significant survival benefit in the fixed cohort (HR = 0.843; 95% CI: 0.738, 0.962).

CONCLUSION

In this large observational cohort study of T3M0 laryngeal cancer, those with fixed cords had superior survival when managed surgically.

Superior loco-regional control after primary surgery compared to chemo-radiotherapy for advanced stage laryngeal cancer

Objective

The optimal strategy to treat loco-regionally advanced squamous cell carcinoma of the larynx (LSCC) remains to be defined. The goal of this single institution retrospective study was to report on oncologic outcome of advanced LSCC treated with curative intent.

Methods

Patients diagnosed and treated for stage T3-T4a LSCC between 2001 and 2014 were retrospectively analyzed. Time-to-event endpoints were calculated beginning from the date of histologic diagnosis, which were analyzed with log-rank test and Cox proportional hazard models.

Results

The cohort was divided into two subgroups: primary radiotherapy with concomitant cisplatin (CRT) (n=30, 38%) and primary surgery (n=48, 62%). Median follow-up was 56 months. Locoregional control (LRC) for the primary surgery and CRT were 95% and 50% in 5 years, respectively (p<0.01). Progression free survival (PFS) for the primary surgery and CRT were 61% and 38% in 5 years, respectively (p=0.23). The overall survival (OS) after primary surgery and CRT in 5 years were 63% vs. 65%, respectively (p=0.93). The 5-years LRC was significantly superior after surgery compared to RT for cT3 primaries (100% vs 50%, p= 0.0022). No significant differences were observed in the remaining subgroups regarding cT stage and PFS or OS.

Conclusion

Our series demonstrated superior LRC after primary surgery followed by risk-adapted adjuvant (C)RT compared to primary CRT in cT3 LSCC, but no significant difference in PFS or OS in locally-advanced LSCC. The optimal patient selection criteria for the ideal treatment for loco-regionally advanced LSCC still needs to be defined.

Non-Squamous Cell Carcinoma of the Larynx: A State-of-the-Art Review

(1) Background: Non-squamous cell laryngeal carcinoma includes endothelial tumors, such as minor salivary gland tumors, lymphoepithelial tumors, neuroendocrine tumors, soft and hard tissue sarcomas, and malignant melanomas. (2) Methods: A state-of-the-art review using the MEDLINE/PUBMED, Google Scholar, Ovid Medline, Embase, and Scopus electronic databases was performed. (3) Conclusions: In order to optimize overall treatment outcomes, a multidisciplinary, patient-centered approach to the management of non-SCC of the larynx must be adopted universally; a national or international registry on non-SCC laryngeal cancer can be useful to improve understanding about the behavior of this kind of tumor.

Outcomes after definitive surgery for mandibular osteoradionecrosis

OBJECTIVES

To analyze charges, complications, survival, and functional outcomes for definitive surgery of mandibular osteoradionecrosis (ORN).

MATERIALS AND METHODS

Retrospective analysis of 76 patients who underwent segmental mandibulectomy with reconstruction from 2000 to 2009.

RESULTS

Complications occurred in 49 (65%) patients and were associated with preoperative drainage (odds ratio [OR] 4.40, 95% confidence interval [CI] 1.01-19.27). The adjusted median charge was $343 000, and higher charges were associated with double flap reconstruction (OR 8.15, 95% CI 2.19-30.29) and smoking (OR 5.91, 95% CI 1.69-20.72). Improved swallow was associated with age <67 years (OR 3.76, 95% CI 1.16-12.17) and preoperative swallow (OR 3.42, 95% CI 1.23-9.51). Five-year ORN-recurrence-free survival was 93% while overall survival was 63% and associated with pulmonary disease (HR [hazard ratio] 3.57, 95% CI 1.43-8.94).

CONCLUSIONS

Although recurrence of ORN is rare, surgical complications are common and charges are high. Poorer outcomes and higher charges are associated with preoperative factors.

Stage Migration and Survival Trends in Laryngeal Cancer

BACKGROUND

During the last two decades, significant advancements in the treatment of laryngeal cancer have occurred. Although survival of head and neck cancer patients has improved over time, the temporal trend of laryngeal cancer survival is an area of controversy.

METHODS

From 2004 to 2016, 77,527 patients who had laryngeal cancer treated with curative intent in the United States were identified in the National Cancer Database. Relative and observed survival rates were assessed for temporal trends. Multinomial logistic regression investigated the relationship between American Joint Committee on Cancer (AJCC) stage and increasing calendar year.

RESULTS

No significant improvement in 2- or 5-year observed survival (OS) or relative survival (RS) was observed. The 5-year RS ranged from 61.72 to 63.97%, and the 5-year OS ranged from 54.26 to 56.52%. With each increasing year, the proportion of stage 4 disease increased, with risk for stage 4 disease at the time of diagnosis increasing 2.2% annually (adjusted odds ratio [aOR], 1.022; 95% confidence interval [CI], 1.017-1.028; p < 0.001). This increase was driven by a 4.7% yearly increase in N2 disease (aOR, 1.047; 95% CI, 1.041-1.053; p < 0.001), with an annual 1.2% increase in T3 disease (aOR, 1.012; 95% CI, 1.007-1.018; p < 0.001) and a 1.2% increase in T4 disease (aOR, 1.012; 95% CI, 1.005-1.018; p < 0.001).

CONCLUSION

Despite advances in the field, laryngeal cancer survival in the United States is not improving over time. This may be due to an increase in the proportion of stage 4 disease, driven primarily by increasing nodal disease. To achieve survival improvement commensurate with scientific and technologic advances, efforts should be made to diagnose and treat laryngeal cancer at earlier stages to prevent further stage migration.

Long Non-Coding RNA TRPM2-AS Promotes Cell Migration and Invasion by Serving as a ceRNA of miR-138 and Inducing SOX4-Mediated EMT in Laryngeal Squamous Cell Carcinoma

Background

Laryngeal squamous cell carcinoma (LSCC) is a common type of malignant tumors of larynx, and in this study, we aimed to evaluate the functional role of long non-coding RNA TRPM2-AS in LSCC.

Methods

The expression levels of TRPM2-AS in LSCC tissues and cell lines were detected by RT-qPCR analysis. In vitro functional assays, including MTT assay and transwell assay, were performed to explore the biological effects of TRPM2-AS on LSCC cells. The expression levels of EMT-relevant proteins were detected by Western blot analysis. The interaction between TRPM2-AS and miR-138 in LSCC, predicted by bioinformatic method, was verified by dual-luciferase reporter assay.

Results

We observed that TRPM2-AS was highly expressed in human LSCC tissues and cell lines. LSCC patients with advanced clinical stage exhibited higher intratumoral TRPM2-AS expression. The results of functional assays demonstrated that TRPM2-AS knockdown remarkably inhibited the proliferation, migration and invasion of LSCC cells, whereas TRPM2-AS overexpression showed opposite effects. In mechanism, we further observed that TRPM2-AS directly bound to miR-138 and served as competing endogenous RNA (ceRNA), thereby increasing SOX4 expression and promoting EMT in LSCC. The oncogenic effects of TRPM2-AS in LSCC cells were partly diminished by miR-138 restoration.

Conclusion

In short, our findings provided first evidence that TRPM2-AS is highly expressed and exerts its oncogenic role in LSCC partly by miR-138/SOX4 axis.

Which risk factors are associated with stomal recurrence after total laryngectomy for laryngeal cancer? A meta-analysis of the last 30 years

Introduction

Stomal recurrence is a troublesome complication after total laryngectomy. Despite a large number of studies having been performed, there is still controversy about which risk factors are most significant for the development of stomal recurrence.

Objective

The objective of the present meta-analysis was to analyze the potential factors leading to stomal recurrence after total laryngectomy.

Methods

PubMed, Web of Science, Cochrane Library, and Ovid databases were systematically searched using multiple search terms. Eighteen studies with 6462 patients were identified. The quality of evidence was assessed by The National Institute for Health and Clinical Excellence.

Results

The results showed that, tumor subsite (supraglottic vs. subglottic, RR = 0.292, 95% CI 0.142–0.600, p = 0.001; glottic vs. subglottic, RR = 0.344, 95% CI 0.175–0.676, p = 0.002), T stage (RR = 0.461, 95% CI 0.286–0.742, p = 0.001), preoperative tracheotomy (RR = 1.959, 95% CI 1.500–2.558, p < 0.001) were the high-risk factors associated with the development of stomal recurrence.

Conclusion

From the results of our study, tumor subsite, T stage and preoperative tracheotomy were the significant risk factors for stomal recurrence. Methodologically high-quality comparative investigations are needed for further evaluation.

Clinical effect of postoperative chemoradiotherapy in resected advanced laryngeal squamous cell carcinoma

Laryngeal squamous cell carcinoma (LSCC) is one of the most prevalent types of head and neck malignancies. Advanced LSCC has failed to demonstrate a satisfactory prognosis, despite the progresses in the diagnosis and treatment, and the optimal treatment modality continues to be debated. To evaluate the clinical utility and survival outcomes of adjuvant chemoradiotherapy (CRT) for patients with resected advanced LSCC, a retrospective analysis of 232 patients with LSCC who had undergone total laryngectomy and neck dissection between 2005 and 2010 was conducted. Of the 232 eligible patients, 167 patients (72%) received surgery alone, whereas 65 patients (28%) received surgery + adjuvant CRT. In the overall cohort, the 5- and 10-year overall survival (OS) rates were 55.2 and 48.3%, respectively. Multivariate analysis revealed that the clinical stage was significantly associated with OS. However, the N classification was an independent indicator in disease-free survival and laryngeal cancer-specific survival. In those patients with stage IV disease, patients receiving adjuvant CRT exhibited a markedly improved survival benefit compared with patients receiving surgical treatment only, following propensity score matching of the data (P<0.05). The application of adjuvant CRT confers additional survival benefits in comparison with surgery-only treatment regimens for advanced LSCC. However, additional prospective studies are required.

Pituitary tumor-transforming 1 expression in laryngeal cancer and its association with prognosis

The purpose of the present study was to investigate the association between the expression of pituitary tumor-transforming 1 (PTTG1) and the expression of matrix metalloproteinase (MMP)-2 and MMP-9 in laryngeal carcinoma tissues, and to elucidate the association between PTTG1 expression and the prognosis of patients with laryngeal cancer. Immunohistochemical staining was used to detect PTTG1 expression in laryngeal cancer and normal tumor-adjacent laryngeal tissues. Western blotting was used to determine the levels of PTTG1 and MMP-2 and -9 in laryngeal carcinoma tissues and to assess their correlation. In addition, the associations between PTTG1 expression and the clinical parameters of laryngeal cancer and patient survival were determined. The immunohistochemistry results revealed that the positive expression rates of PTTG1, MMP-2 and MMP-9 in the laryngeal cancer tissues were significantly higher than those in the carcinoma-adjacent normal laryngeal tissues (all P<0.05). In addition, expression levels of PTTG1, MMP-2 and MMP-9 were significantly associated with lymph node metastasis, histological grade and clinical stage (P<0.05). Furthermore, the levels of PTTG1 were positively correlated with the levels of MMP-2 and MMP-9 in laryngeal cancer tissues (P<0.05). In summary, the expression levels of PTTG1, MMP-2 and MMP-9 are closely associated with the biological behaviors of laryngeal cancer tissues, showing that they serve important roles in the occurrence and development of laryngeal cancer, and may be useful as biological indicators of laryngeal tissue invasion, metastasis and patient prognosis.

RNA-Seq profiling of circular RNAs in human laryngeal squamous cell carcinomas

Abnormal expression of non-coding circular RNAs (circRNAs) have been reported in many types of tumors. circRNA have been suggested to be an ideal candidate biomarker for diagnostic and therapeutic implications in cancers. The aim of this study was to assess the circRNA expression profile of laryngeal squamous cell carcinomas (LSCC). The biopsy samples from patients with LSCC were obtained intra-operatively. The circRNA expression was performed using secondary sequencing. Among 10 patients with LSCC, 2 were well differentiated, 3 were moderately differentiated and 5 were adjunctive samples with normal and LSCC tissues. A total of 21,444 distinct circRNA candidates were detected. Among them, we defined the statistical criteria for selecting aberrant-expressed circRNA using a q-value of < 0.001 with a fold change of > 2.0 or < 0.5. A total of 29 circRNA were upregulated and 19 circRNA were downregulated significantly in the LSCC tissues. The intersection of these dysregulated circRNAs of normal-well differentiated set and normal-moderately differentiated set was then assessed to narrow the upregulated and downregulated circRNAs down to 18 and 5 respectively. Furthermore, an association of the circRNA-miRNA-mRNA was investigated, showing that 20 dysregulated circRNA successfully predicted an interaction with several cancer-related miRNAs. Finally, a further KEGG analysis showed that PPAR, Axon guidance, Wnt and Cell cycle signaling pathway were key putative pathways in the process of LSCC. hsa_circ:chr20:31876585–31,897,648 was found to be able to differentiate most of LSCC from the matching normal tissues. This observational study demonstrated dysregulation of circRNA in LSCC, which may have an impact on development of potential biomarkers in this disease. Validation of down-regulation of hsa_circ:chr20:31876585–31,897,648 in LSCC compared to each adjunctive tissue by Q-RT-PCR, indicating that hsa_circ:chr20:31876585–31,897,648 may be a novel promising tumor suppresser in LSCC.

lncRNA-NKILA/NF-κB feedback loop modulates laryngeal cancer cell proliferation, invasion, and radioresistance

Laryngeal cancer is one of the most common head and neck malignant tumors and is commonly resistant to X‐ray‐based radiotherapy. NF‐κB interacting lncRNA (NKILA) has been reported to serve as a tumor suppressor in several cancers through combining with NF‐κB: IκB complex thereby inhibiting NF‐κB activation. Herein, we demonstrated a low NKILA expression in laryngeal cancer and its correlation with shorter overall survival in patients with laryngeal cancer. NKILA serves as a tumor suppressor in laryngeal cancer by suppressing laryngeal cancer cell viability and migration, whereas promoting cell apoptosis; NKILA knockdown reverses the cytotoxicity of X‐ray radiation on laryngeal cancer cells through combining with NF‐κB: IκB complex to inhibit IκB phosphorylation, inhibit p65 nuclear translocation, and finally inhibit NF‐κB activation. NF‐κB binds to the promoter region of NKILA to activate its transcriptional activity, upregulated NKILA then inhibits IκB phosphorylation and NF‐κB activation, thus forming a negative feedback loop to sensitize laryngeal cancer cell to X‐ray radiation. In conclusion, NKILA can serve as a promising agent of enhancing the cytotoxicity of X‐ray radiation on laryngeal cancer and addressing the radioresistance of laryngeal cancer.

Functional outcomes of supraglottic squamous cell carcinoma treated by transoral laser microsurgery compared with horizontal supraglottic laryngectomy in patients younger and older than 65 years

The treatment of supraglottic carcinoma remains a controversial issue. Five accepted surgical and non-surgical oncological treatments have been currently established: standard horizontal supraglottic laryngectomy (HSL), supraglottic CO2 laser microsurgery (TLM), transoral robotic surgery, radiotherapy alone and radiotherapy in combination with chemotherapy. Some studies have shown that complications of head and neck surgeries increase significantly in patients over 65 years compared to younger patients. We designed a retrospective analysis to assess the rate of complications and functional outcomes of patients treated by TLM and HSL in cases of T1-T3 supraglottic squamous cell carcinomas (SCC) in a tertiary University Hospital. Results were compared between patients younger and older than 65 years. We found significant differences in the rate of aspiration pneumonia (p = 0.026), mean time to decannulation (p = 0.001) and mean hospital stay (p = 0.007) in patients treated by TLM, which was higher and longer in the group of patients over 65 years of age. Regarding HPL, we only found significant differences in the mean time to decannulation (p = 0.001), which was longer in the group of patients younger than 65 years. According to our results, TLM or HPL can both be a safe surgical option for patients older than 65 years, but previous evaluation of lung function before surgery is mandatory because of an increased risk of aspiration pneumonia in patients with lung problems, especially when treated by TLM. Concerning functional outcomes in patients older than 65 years, TLM reduces the postoperative rate of tracheostomy, mean time required for decannulation and mean hospital stay compared with HPL. However, no significant difference in the occurrence of aspiration pneumonia, dysphagia or in the mean length of NGT feeding was found.

What is the price of functional surgical organ preservation in local-regionally advanced supraglottic cancer? Long-term outcome for partial laryngectomy followed by radiotherapy in 32 patients

Aims and background

To achieve the goal of organ preservation, both a chemoradiotherapy and a conservative surgical approach can be proposed. The aim of the study was to review all patients treated in our Institute with conservative surgery and postoperative radiotherapy for locally advanced supraglottic tumor.

Methods and study design

A retrospective analysis of 32 patients treated between 2000 and 2010 was performed. Overall survival, disease-free survival and late laryngeal toxicity were evaluated. The impact of surgical procedures, radiotherapy characteristics and addition of chemotherapy on late laryngeal toxicity was studied.

Results

The median follow-up was 38 months. Overall survival and disease-free survival at 5 years were 73% and 66%, respectively. Three (9%) patients experienced local recurrence (after 22, 25 and 40 months, respectively) and were treated with total laryngectomy. The larynx preservation rate was 93%. Severe treatment-related late laryngeal toxicity (grade 3 and 4 laryngeal edema, laryngeal stenosis, presence of tracheotomy at last follow-up because of treatment-related toxicity, and the need for enteral nutrition) was experienced by 34% of patients. The functional larynx preservation rate was 81%. The statistically significant risk factors for severe late toxicity were: female gender, extension of the surgical procedure, removal of one arytenoid and association with concomitant chemotherapy.

Conclusions

We confirmed literature data on the feasibility and efficacy of a surgical organ preservation strategy. However, the high incidence of severe late toxicity requires further studies to improve patient selection and to reduce side effects.

AHNS Series: Do you know your guidelines? Review of current knowledge on laryngeal cancer

The following article is part of a series in an initiative by the American Head and Neck Society's Education Committee and will review clinical practice guidelines for head and neck oncology. The primary goal is to increase awareness of current best practices pertaining to head and neck surgery and oncology. This manuscript is a review of current knowledge in laryngeal cancer with a focus on anatomy, epidemiology, diagnosis, evaluation, and treatment.

Aggressiveness pattern and second primary tumor risk associated with basaloid squamous cell carcinoma of the larynx

Basaloid squamous cell carcinoma (BSCC) is a rare, aggressive and distinct variant of squamous cell carcinoma (SCC) of the upper respiratory and digestive tract. We have evaluated disease specific survival (DSS) and overall survival (OS) through Kaplan-Meier method and mortality risk through univariate statistical analysis of Cox in 42 cases of BSCC and other 42 of laryngeal SCC (LSCC) matched for both age and sex. We demonstrated that laryngeal BSCC is a more aggressive tumor than LSCC as is associated to higher nodal recurrence of pathology (5 vs 2 patients, overall risk, OR 2.7), a reduced survival (median survival 34 vs 40 months, OR 3.2 for mortality); in addition, basaloid patients have a higher risk to be affected by second primary tumors (13 vs 3 patients, OR 5.8) and a higher probability to die for this second tumor (Hazard Risk, HR 4.4). The analysis of survival shows an increased mortality risk concurrent with the parameters assessed by univariate analyses that assume a predictive and statistical significance in second tumor and grading in basaloid LSSC.

Contemporary management of advanced laryngeal cancer

The treatment of advanced laryngeal cancer has undergone a paradigm shift in recent years, with an increase in chemoradiation for organ preservation and a decrease in primary surgery. This review will summarize the contemporary management of advanced laryngeal cancer and discuss treatment‐related toxicity and strategies to improve outcomes.

Level of Evidence

NA.

Treatment, short-term outcomes, and costs associated with larynx cancer care in commercially insured patients

OBJECTIVES/HYPOTHESIS

To examine associations between treatment, complications, and costs in patients with laryngeal cancer.

STUDY DESIGN

Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data.

METHODS

We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression.

RESULTS

Chemoradiation was significantly associated with supraglottic tumors (relative risk ratio [RRR] = 5.9 [4.4-7.8]), pretreatment gastrostomy (RRR = 4.0 [2.7-6.1]), and alcohol abuse (RRR = 0.5 [0.3-0.9]). Treatment-related complications occurred in 23% of patients, with medical complications in 22% and surgical complications in 7%. Chemoradiation (odds ratio [OR] = 3.7 [2.6-5.2]), major surgical procedures (OR = 4.9 [3.5-6.8]), reconstruction (OR = 7.7 (4.1-14.7)], and advanced comorbidity (OR = 9.7 [5.7-16.5] were associated with acute complications. Recurrent/persistent disease occurred in 23% of patients and was associated with high-volume care (OR = 1.4 [1.1-1.8]). Salvage surgery was performed in 46% of patients with recurrent/persistent disease and was less likely for supraglottic disease (OR = 0.5 [0.4-0.8]) and after chemoradiation (OR = 0.4 [0.2-0.6]). Initial treatment and 1-year overall costs for chemoradiation were higher than all other treatment categories, after controlling for all other variables including complications and salvage. High-volume care was associated with significantly lower costs of care for surgical patients but was not associated with differences in costs of care for nonoperative treatment.

CONCLUSIONS

In commercially insured patients <65 years old with laryngeal cancer, chemoradiation was associated with increased costs, an increased likelihood of treatment-related medical complications, and a reduced likelihood of surgical salvage. Higher-volume surgical care was associated with lower initial treatment and 1-year costs of care. These data have implications for discussions of value and quality in an era of healthcare reform.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:91-101, 2018.

How phenotype guides management of non-conventional squamous cell carcinomas of the larynx?

Although the majority of laryngeal malignancies are the conventional squamous cell carcinomas (SCC), a wide variety of malignant epithelial tumors can affect the larynx. Current treatment guidelines are designed to guide clinicians in management of conventional laryngeal SCC. Less is known about the biological behavior and responsiveness to therapy and overall outcomes of other malignant epithelial lesions. Because a spectrum of disease biology is represented by these rare phenotypes, an understanding of the basic biology can help direct management to optimize clinical outcome in this group of patients. This review provides a critical analysis of literature relating to the diagnosis, management, and outcome of patients with non-conventional squamous malignant epithelial neoplasms of the larynx. Particular attention is paid to features which are at variance with the conventional SCC and how these impact on management of these rare tumors.

Downregulation of Survivin by shRNA Inhibits Invasion and Enhances the Radiosensitivity of Laryngeal Squamous Cell Carcinoma

Radiotherapy is an important treatment modality for laryngeal carcinoma, however, some patients with early stage laryngeal carcinomas showed resistance to radiotherapy. Survivin overexpression is associated with radioresistance of laryngeal squamous cell carcinoma. We speculated that the inhibition of survivin expression might improve the radiosensitivity of laryngeal carcinoma. We assessed the effect of survivin expressions by shRNA on the radiosensitivity of laryngeal squamous cell carcinoma in vitro and in vivo. After transfection of shRNA-targeting survivin, MTS assay showed that the survival rates of radiation groups were reduced with the prolongation of culture time (p < 0.05). In addition, shRNA-targeting survivin abrogated radiation-induced G2 phase arrest and amplified radiation-induced apoptosis. In vivo, shRNA transfection also sensitized tumor xenograft to radiotherapy. Radioresistance of laryngeal squamous cell carcinoma may be associated with increased expression of survivin, and survivin suppression may enhance the radiosensitivity of laryngeal squamous cell carcinoma.

Surgical vs Nonsurgical Treatment Modalities for T3 Glottic Squamous Cell Carcinoma

Importance

Further investigation is needed in the outcomes of currently available treatment for T3 glottic squamous cell carcinoma (SCC), a unique type of laryngeal cancer.

Objective

To compare overall survival (OS) and functional outcomes among patients with T3 glottic SCC receiving nonsurgical and surgical management.

Design, Setting, and Participants

This secondary analysis used data from the Surveillance, Epidemiology, and End Results (SEER) registry and Medicare databases. All patients with T3 glottic SCC who received a diagnosis from January 1, 1992, to December 31, 2010, were included. Data were analyzed from April 2014 to August 2015.

Interventions

Surgery with or without adjuvant radiotherapy and/or chemotherapy.

Main Outcomes and Measures

Five-year OS and functional outcomes.

Results

Among the 487 patients identified with T3 glottic SCC (418 men [85.8%]; 69 women [14.2%]; median age, 74.3 [interquartile range, 70.4-80.6] years), the 5-year OS for nonsurgical management, surgery alone, and surgery plus adjuvant treatment were 36% (95% CI, 30%-42%), 41% (95% CI, 30%-53%), and 41% (95% CI, 32%-51%), respectively. Multivariable analyses revealed an adjusted hazard ratio for OS of 0.68 (95% CI, 0.49-0.94) for patients receiving surgery alone vs nonsurgical management and 0.75 (95% CI, 0.57-0.98) for patients receiving surgery plus adjuvant treatment vs nonsurgical management. Gastrostomy tube dependence was highest in patients receiving surgery plus adjuvant treatment (30 of 98 patients [30.6%]). Tracheostomy dependence was highest in patients receiving chemoradiotherapy (34 of 92 patients [37.0%]).

Conclusions and Relevance

Overall survival showed a statistically significant and clinically meaningful improvement in patients with T3 glottic SCC who underwent surgery compared with a nonsurgical treatment. Furthermore, the data suggest that adjuvant and nonsurgical treatment result in a dysfunctional larynx; however, this association needs further study.

Laryngeal Preservation in Glottic Cancer

Objective

When total laryngectomy is not required, organ preservation surgery or radiotherapy is considered the standard of care for primary glottic cancer. These accepted treatment options are available for early and advanced glottic cancers due to equivalent locoregional control and survival rates. However, in today’s climate of accountable care, the financial burden of treatment choices continues to increase in significance. We therefore compared hospital charges and treatment-related morbidity between organ-preserving surgery and radiation with or without chemotherapy—herein, (chemo)radiation—in the primary treatment of glottic cancer.

Study Design

Nationwide Inpatient Sample Database was analyzed to assess clinical and financial information.

Setting

Population-based analysis.

Subjects

Patients (N = 5499) with primary glottic cancer undergoing treatment with laryngeal preservation strategies.

Methods

Patients were subdivided by ICD-9 codes into 3 treatment groups: endoscopic resection, open partial laryngectomy, and (chemo)radiation. Treatment-related outcomes, charges, and length of hospitalization were analyzed among treatment groups.

Results

When adjusting for sex, age, race, comorbidity, and primary payer, (chemo)radiotherapy was associated with increased direct charges ( P < .001; coefficient, $23,658.99; 95% confidence interval [95% CI]: $10,227.15-$37,090.84) and length of hospitalization ( P < .001; hazard ratio, 0.593; 95% CI: 0.502-0.702) when compared with endoscopic surgery. As compared with open surgery, endoscopic surgery was associated with reduced hospital charges ( P = .012; coefficient, $11,967.01; 95% CI: $2,784.17-$21,249.85) and duration of hospitalization ( P < .001; hazard ratio, 0.749; 95% CI: 0.641-0.876).

Conclusions

This analysis suggests that increased utilization of endoscopic surgery in patients with primary glottic cancer not requiring total laryngectomy may lead to reduced financial burden and duration of hospitalization when compared with open surgery or (chemo)radiation therapy.

Efficacy Comparison Between Total Laryngectomy and Nonsurgical Organ-Preservation Modalities in Treatment of Advanced Stage Laryngeal Cancer: A Meta-Analysis

It remains unclear whether the efficacy of nonsurgical organ-preservation modalities (NOP) in the treatment of advanced-stage laryngeal cancer was noninferiority compared with that of total laryngectomy (TL). The objective of this study was to compare the curative effects between TL and NOP in the treatment of advanced-stage laryngeal cancer through a meta-analysis.Clinical studies were retrieved from the electronic databases of PubMed, Embase, Wanfang, and Chinese National Knowledge infrastructure. A meta-analysis was performed to investigate the differences in the curative efficacy of advanced-stage laryngeal cancer between TL and the nonsurgical method. Two reviewers screened all titles and abstracts, and independently assessed all articles. All identified studies were retrospective.Sixteen retrospective studies involving 8308 patients (4478 in the TL group and 3701 in the nonsurgical group) were included in this meta-analysis. The analysis results displayed the advantage of TL for 2-year and 5-year overall survival (OS)(OR 2.79, 95% CI 1.85-4.23 and OR 1.52, 95% CI 1.09-2.14) as well as in 5-year disease-specific survival (DSS)(OR 1.79, 95% CI 1.61-1.98), but no significant difference in 2-year DSS was detected between the 2 groups (OR = 2.09,95% CI0.69-6.40). Additionally, there were no significant differences between TL and NOP for 5-year local control (LC) either (OR = 1.75, 95% CI 0.87-3.53). When we carried out subgroup analyses, the advantage of TL was especially obvious in T4 subgroups, but not in T3 subgroups.This is the first study to compare the curative effects on advanced-stage laryngeal cancer using meta-analytic methodology. Although there was a trend in favor of TL for OS and DSS, there is no clear difference in oncologic outcome between TL and NOP. Therefore, other factors such as tumor T-stage and size, lymph node metastasis, and physical condition are also important indicators for treatment choice.

Detection of O6-methylguanine-DNA methyltransferase gene promoter region methylation pattern using pyrosequencing and the effect of methylation pattern on survival, recurrence, and chemotherapy sensitivity in patients with laryngeal cancer

AIM

To determine the methylation pattern of the promoter region of the O6-methylguanine-DNA methyltransferase (MGMT) gene in laryngeal cancer and normal laryngeal mucosa samples using pyrosequencing, and to determine the relationship between the methylation pattern of MGMT, and tumor stage, survival, recurrence, and chemosensitivity in patients with laryngeal cancer.

MATERIALS AND METHODS

Laryngeal cancer and normal laryngeal mucosa specimens were obtained from our paraffin block archives, and then subjected to pyrosequencing. Different cut-off values were used to detect methylation. Clinicopathological data for the patients that provided specimens were obtained from archive records.

RESULTS

When 5% was used as the cut-off value, 78% of the laryngeal cancer specimens (64 of 82), and 27.3% of normal laryngeal mucosa specimens (3 of 11) were considered methylated. When 10% was used as the cut-off value, 47% of the laryngeal cancer specimens (39 of 82), and none of the normal laryngeal mucosa specimens were considered methylated. There was not a significant relationship between the methylation status of MGMT, and clinicopathological parameters, including age, tumor stage, histopathological differentiation, chemoradiotherapy protocol used, recurrence, or disease-free survival.

CONCLUSION

Pyrosequencing is a reliable semiquantitative technique that can be used to detect the methylation pattern. Methylation was common in the laryngeal cancer specimens, but there was not a significant relationship between the methylation status of MGMT and clinicopathological parameters.

Evaluation of swallowing function after supracricoid laryngectomy as a primary or salvage procedure

The primary functional issues following conservative therapy for advanced laryngeal cancer concern swallowing. Here, we evaluated the recovery of swallowing after supracricoid partial laryngectomy (SCL) in patients with primary or recurrent laryngeal cancer. We evaluated the swallowing recovery in 27 SCL patients through oropharyngoesophageal scintigraphy, and we evaluated their quality of life using EORTC questionnaires. Four patients underwent total laryngectomy during follow-up. Patients who retained their larynges were able to feed without nutritional support and without tracheostoma. The only significantly different parameter between the primary and salvage cases was the time elapsed to the removal of nasogastric/PEG tubes, which was longer in salvage cases. SCL has been demonstrated as a valuable option for primary and recurrent laryngeal cancer patients. The present data demonstrate good functional results, particularly in terms of swallowing after previous treatments and in primary settings. The combination of oropharyngoesophageal scintigraphy and questionnaires appears to be an adequate, standardizable approach to assessing swallowing function after SCL.

Study of the Histopathologic Characteristics and Surface Morphologies of Glottic Carcinomas With Anterior Vocal Commissure Involvement

This article explores the features and the role of the anterior vocal commissure (AVC) structure and the surface morphologies of glottic carcinomas with AVC involvement to provide a reference for the selection of transoral carbon dioxide (CO2) laser surgery. A total of 31 cases of glottic carcinomas with AVC involvement from May 2012 to January 2014 were included. All patients underwent electronic laryngoscopic examinations and computed tomography scans to determine the surface morphology. After surgery, the tumor specimens were resected integrally, and axial serial sections parallel to the plane of vocal cords were taken to explore the features and possible invasion paths of the glottic carcinomas with AVC involvement. The rates of involvement of the supraglottis and subglottis were 71.4% and 14.8%, respectively, via the AVC. The involvement of the superficial layer of the unilateral or bilateral vocal cords without involvement of the vocal muscle in the AVC region (IVM) or the cartilage was present in 15 cases (48.4%). The involvement of the superficial layer of the unilateral and bilateral vocal cords occurred in 16 cases (51.6%) with the IVM in 13 cases and the involvement of the intermediate lamina of the thyroid cartilage (ITC) in 8 cases. The involvement of the ITC was associated with the involvement of the vocal muscle of the AVC region (P < 0.05). Among the pushing carcinomas, 15 of 21 (71.4%) presented with well-defined tumor mass, and 8 of 10 (80.0%) infiltrating carcinomas presented with multiple tumor nests that were often surrounded by fibrosis (P < 0.05). The AVC is an important path of invasion of subglottic in glottic carcinomas but less so for suparglottic. The Broyles' ligaments acted as a barrier against the spread of the tumors to the thyroid cartilage, but this role was obviously weaken by the involvement of the vocal muscle of the AVC region. The infiltrating carcinomas presented with multiple tumor nests in fibrous tissue. When CO2 laser microsurgery is considered as a treatment option, these facts should be kept in mind.

Silencing SOX2 Expression by RNA Interference Inhibits Proliferation, Invasion and Metastasis, and Induces Apoptosis through MAP4K4/JNK Signaling Pathway in Human Laryngeal Cancer TU212 Cells

SRY (sex determining region Y)-box 2 (SOX2) plays an important role in tumor cell metastasis and apoptosis. Laryngeal squamous cell carcinoma (LSCC), responsible for 1.5% of all cancers, is one of the most common head and neck malignancies. Accumulating evidence shows that SOX2 is overexpressed in several human tumors, including lung cancer, esophageal carcinoma, pancreatic carcinoma, breast cancer, ovarian carcinoma and glioma. Our study aimed to investigate the silencing effects of SOX2 expression using RNA interference (RNAi) on various biological processes in laryngeal cancer TU212 cells, including proliferation, apoptosis, invasion and metastasis. We also studied the involvement of the MAPK/JNK signaling pathway in the biological effects of SOX2 siRNA in TU212 cells. We found that silencing SOX2 decreased the proliferation, migration, and invasion of TU212 cells, and induced apoptosis. This effect of silencing SOX2 could be reversed by silencing MAP4K4. Therefore, we consider SOX2 as a key regulator of the upstream MAP4K4/JNK signaling pathways that could be a potential therapeutic target in the treatment of patients with or prevention of laryngeal cancer.

Radiotherapy versus open surgery versus endolaryngeal surgery (with or without laser) for early laryngeal squamous cell cancer

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 2, 2002 and previously updated in 2004, 2007 and 2010.Radiotherapy, open surgery and endolaryngeal excision (with or without laser) are all accepted modalities of treatment for early-stage glottic cancer. Case series suggest that they confer a similar survival advantage, however radiotherapy and endolaryngeal surgery offer the advantage of voice preservation. There has been an observed trend away from open surgery in recent years, however equipoise remains between radiotherapy and endolaryngeal surgery as both treatment modalities offer laryngeal preservation with similar survival rates. Opinions on optimal therapy vary across disciplines and between countries.

OBJECTIVES

To compare the effectiveness of open surgery, endolaryngeal excision (with or without laser) and radiotherapy in the management of early glottic laryngeal cancer.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 8); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 18 September 2014.

SELECTION CRITERIA

Randomised controlled trials comparing open surgery, endolaryngeal resection (with or without laser) and radiotherapy.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified only one randomised controlled trial, which compared open surgery and radiotherapy in 234 patients with early glottic laryngeal cancer. The overall risk of bias in this study was high.For T1 tumours, the five-year survival was 91.7% following radiotherapy and 100% following surgery and for T2 tumours, 88.8% following radiotherapy and 97.4% following surgery. There were no significant differences in survival between the two groups.For T1 tumours, the five-year disease-free survival rate was 71.1% following radiotherapy and 100.0% following surgery, and for the T2 tumours, 60.1% following radiotherapy and 78.7% following surgery. Only the latter comparison was statistically significant (P value = 0.036), but statistical significance would not have been achieved with a two-sided test.Data were not available on side effects, quality of life, voice outcomes or cost.We identified no randomised controlled trials that included endolaryngeal surgery. A number of trials comparing endolaryngeal resection and radiotherapy have terminated early because of difficulty recruiting participants. One randomised controlled trial is still ongoing.

AUTHORS' CONCLUSIONS

There is only one randomised controlled trial comparing open surgery and radiotherapy but its interpretation is limited because of concerns about the adequacy of treatment regimens and deficiencies in the reporting of the study design and analysis.

Treatment and survival in 10,429 patients with localized laryngeal cancer: a population-based analysis

BACKGROUND

The objectives of this study were to identify factors associated with treatment differences, characterize changes in treatment patterns over time, and compare survival across treatment types in patients who received treatment for localized laryngeal cancer.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of patients who were treated from 1995 to 2009 for localized laryngeal cancer. Four treatment groups were defined: (1) radiation only, (2) local surgery only, (3) local surgery and radiation, and (4) open surgery with or without radiation. Variations in treatment rates between these groups were evaluated according to demographic factors, and differences in treatment rates across time were calculated. Associations between treatment and mortality were assessed using Kaplan-Meier methods. Cox proportional hazards regression models were used to adjust for potential confounding covariates.

RESULTS

In total, 10,429 patients with localized laryngeal cancer were identified. Most patients (57%) were treated with radiation only; 25% with local surgery and radiation, 9% with local surgery only, and 9% with open surgery with or without radiation. Race, age, and registry were associated with differences in treatment. Receipt of single-modality treatment increased and receipt of combined-modality treatment decreased over the study period. Better survival was observed with white race, younger age, and treatment with local surgery. Survival differences associated with treatment type were observed within 3 years of diagnosis and persisted beyond 5 years after diagnosis.

CONCLUSIONS

Although treatment patterns became more adherent to treatment guidelines over time, we identified survival differences associated with treatment type that warrant further investigation into treatment decision-making for patients with localized laryngeal cancer.

Overexpression of SOX2 promotes migration, invasion, and epithelial-mesenchymal transition through the Wnt/β-catenin pathway in laryngeal cancer Hep-2 cells

SOX2 is a high-mobility group box containing transcription factor essential for the maintenance of embryonic stem cells. Recent evidence indicates that SOX2 overexpression correlates with metastasis and poor prognosis in patients with laryngeal squamous cell cancer. To investigate how SOX2 contributes to this aggressive phenotype, we introduced the human SOX2 gene into a low SOX2-expressing human laryngeal cancer cell line Hep-2. Cell migration and invasion were determined by the Transwell assay with or without Matrigel coating. The epithelial-mesenchymal transition (EMT)-related markers were assayed by Western blot analysis or immunofluorescence. Our results showed that exogenous expression of SOX2 in Hep-2 cells substantially promoted their migratory and invasive capabilities in culture. Moreover, Hep-2 cells stably overexpressing SOX2 underwent EMT phenotype, as evidenced by mesenchymal morphology, decreased expression of epithelial marker (E-cadherin), and increased expression of mesenchymal markers (N-cadherin, vimentin, fibronectin, and α-smooth muscle actin). Strikingly, Western blot analysis and immunofluorescence also showed that overexpression of SOX2 resulted in substantial increase and nuclear accumulation of β-catenin in Hep-2 cells. However, small interfering RNA targeting β-catenin significantly attenuated the reduced expression of E-cadherin and increased cell migration and invasion abilities in SOX2-overexpressing cells, suggesting that SOX2-induced EMT process, migration, and invasion are dependent on β-catenin activation. Taken together, our findings underscore a novel role for SOX2 in laryngeal cancer migration and invasion.

Oncologic results of the surgical salvage of recurrent laryngeal squamous cell carcinoma in a multicentric retrospective series: emerging role of supracricoid partial laryngectomy

BACKGROUND

Several studies in the last decade evaluated conservative surgical procedures and, in particular, supracricoid operations as an alternative to total laryngectomy for the salvage of recurrences of laryngeal squamous cell carcinoma (SCC) after a first attempt of organ preservation.

METHODS

The clinical records of 68 consecutive patients primarily treated by irradiation or endoscopic surgery and surgically salvaged by total laryngectomy or supracricoid partial laryngectomy in 2 large university hospitals in Italy from 2004 to 2010 were reviewed.

RESULTS

The survival was not affected by the primary treatment or by salvage modality. The only parameter always keeping a prognostic value is the involvement of resection margins of salvage surgery. Patients with early relapse seem to have a worse prognosis than patients with a delayed relapse (p = .05 at Cox multivariate analysis and p = .048 at Wilcoxon test for overall survival [OS] from the primary treatment).

CONCLUSION

Supracricoid operations, if the indications are careful, can prove reliable salvage procedures.

SOX2 promotes the migration and invasion of laryngeal cancer cells by induction of MMP-2 via the PI3K/Akt/mTOR pathway

SOX2 is a high mobility group box containing transcription factor that has been reported to be aberrantly overexpressed in various human malignancies, including laryngeal squamous cell carcinoma (LSCC). However, the potential role of SOX2 in LSCC migration and invasion remains to be elucidated. In the present study, we generated stable transformants of human LSCC cells constitutively overexpressing SOX2 and investigated the effects of SOX2 overexpression on migration and invasion in LSCC cells as well as the possible underlying mechanisms. We found that ectopic overexpression of SOX2 in LSCC cells enhanced their migratory and invasive ability in vitro, accompanied by increased expression and activity of matrix metalloproteinase (MMP)-2. Meanwhile, SOX2-induced cell migration and invasion were significantly abrogated by a neutralizing anti-MMP-2 antibody or small interfering RNA targeting MMP-2. Furthermore, overexpression of SOX2 induced phosphorylation of Akt and mammalian target of rapamycin (mTOR), which are downstream effectors of the PI3K pathway. Finally, LY294002, an inhibitor of PI3K, also markedly abolished SOX2-induced activation of the Akt/mTOR pathway and increased cell invasion and MMP-2 expression. Taken together, we conclude that SOX2 promotes migration and invasion of laryngeal cancer cells by inducing MMP-2 via the PI3K/Akt/mTOR pathway. Our findings suggest that SOX2 may serve as a potential therapeutic target for LSCC.

Management of locally advanced laryngeal cancer

Background

Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer.

Methods

Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center.

Results

A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis.

Conclusion

This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.

Combined modality treatment of laryngeal squamous cell carcinoma

Squamous cell carcinoma of the larynx is a major public health concern; it causes substantial morbidity and mortality, and arises chiefly as a result of tobacco and alcohol consumption. Early stage disease is best treated with radiation or surgery alone, but for patients with more locally advanced squamous cell carcinoma of the larynx, combined modality treatment has been shown to benefit selected patients, particularly when cisplatin-based chemotherapy and concurrent radiation therapy are employed, with or without altered fractionated radiation therapy. Substantial laryngectomy-associated quality-of-life decrements can be avoided in selected, potentially resectable patients with organ-sparing approaches, without sacrificing survival. Recently, trials have addressed the role of targeted systemic agents to the epidermal growth factor receptor, and other targets are under investigation. The addition of induction chemotherapy to concurrent chemoradiotherapy is a promising treatment strategy that warrants further evaluation, but has not yet emerged as a standard of care; the toxicity of such regimens must be balanced with the potential benefits on a case-by-case basis, and functional outcomes are often quite variable. Treatment planning, management and follow-up are complex, and thus should ideally be performed in a comprehensive, multidisciplinary fashion, in a center accustomed to a high volume of such cases. Future research directions are described herein.

High CCR6/CCR7 expression and Foxp3+ Treg cell number are positively related to the progression of laryngeal squamous cell carcinoma

Chemokine receptors CCR6 and CCR7 have been reported to play important roles in T cell migration and organ-specific metastasis of various tumors. In the present study, we evaluated the expression and clinical significance of CCR6, CCR7, their ligands and CD4+CD25+Foxp3+ regulatory T cells in laryngeal squamous cell carcinoma (LSCC) and metastatic lymph nodes (LNs). The expression of CCR6, CCR7 and their ligands mRNA (CCL20, CCL19/CCL21) as well as the CCR6 and CCR7 proteins were detected by real-time RT-PCR and immunohistochemistry (IHC), respectively. Flow cytometry was used to investigate the percentage of CD4+CD25+Foxp3+ regulatory T cells (Tregs) in peripheral blood mononuclear cells (PBMCs). Furthermore, a number of cytokines, including interleukin (IL)-2, IL-4, IL-10, IL-12p70, interferon (IFN)-γ and transforming growth factor (TGF)-β1 were detected by ELISA. The results showed that CCR6 and CCR7 were expressed in tumors in situ, metastatic LNs and CD4+CD25+Foxp3+ Tregs. It was hypothesized that the expression profile of CCR6, CCR7 and the proliferation of CD4+CD25+Foxp3+ Tregs affected the process of LN metastasis in LSCC patients. Therefore, the increased percentage of the Foxp3+ Tregs and the upregulation of Foxp3 expression on CCR6+ Tregs in LSCC patients may have accounted for the downregulation of antitumor immunity in these patients, which could be valuable for assessment of prognosis in LSCC treatment.

Prospective head and neck cancer research: a four-decade bibliometric perspective

BACKGROUND

It is unknown whether changes in study sponsorship have affected the proportion of prospective research on surgery, radiotherapy, and pharmacotherapy for head and neck squamous cell carcinoma (HNSCC) being published over time.

PATIENTS AND METHODS

We examined prospective studies from PubMed, Ovid MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1980, 1985, 1990, 1995, 2000, 2005, and 2010. Chi-squared tests were used to identify significant associations between sponsorship and authorship, treatments within study protocols, and presentation of results, whereas time-based trends were analyzed using the Cochran-Armitage test.

RESULTS

Among 309 articles, industry (70, 22.7%) and the U.S. government (65, 21%) were the most common sponsors. There was a significant increase in the proportion of industry-sponsored research (p for trend = .013) and a decline in U.S. government-sponsored research (p for trend = .001) over time. The inclusion of surgery in treatment protocols declined over the past four decades (p for trend = .003). Protocols incorporating pharmacotherapy were more likely to have industry support than those without pharmacotherapy (p = .001), whereas protocols with radiotherapy (p = .003) or surgery (p = .002) were less likely to have industry support.

CONCLUSION

Industry is the predominant sponsor of prospective HNSCC research, with an emphasis on pharmacotherapy.

Total Laryngectomy

Objective

The management of advanced laryngeal cancer is evolving, with increasing use of chemoradiation as initial treatment. Recent reports confirm a decline in total laryngectomies (TLs) in the United States. A study was undertaken to evaluate national and regional trends in TLs performed over the most recent decade for which data were available and to use multivariate analysis to characterize these trends in more detail.

Study Design

Population-based cohort study.

Setting

Healthcare Cost and Utilization Project–Nationwide Inpatient Sample from 1998 to 2008.

Subjects and Methods

All patients underwent radical or complete laryngectomy. Descriptive statistics and linear and multivariate regressions were performed on both raw case volumes and nationally extrapolated figures.

Results

In this nationally representative sample, 8288 TL cases met inclusion criteria between 1998 and 2008. The TL case volumes decreased by 27.3 per year ( P = .005) and showed increasing trends in high-volume centers. The number of hospitals performing TLs decreased by 12.3 per year ( P < .0005). The South and Midwest showed higher case volumes even after controlling for multiple covariates.

Conclusion

Total laryngectomy cases are decreasing and concentrating into high-volume centers. This study demonstrated unexplained regional variation in case volumes. These findings may affect patients, otolaryngology residency training, surgeons, and reimbursement.