Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection

Therapeutic Modalities in Head-Neck Neoplasia and Prognostication: A Review

Neoplasia of the head and the neck necessitates intervention, surgical or otherwise, as the site and stage of the pathology may dictate. The various therapeutic modalities employed and prognosis has been reviewed.

Prognostic significance of human papillomavirus status and treatment modality in hypopharyngeal cancer

BACKGROUND

Management of hypopharynx cancer is often extrapolated from larynx cancer. This report analyses treatment patterns and survival limited to hypopharynx cancer using the National Cancer Database (NCDB).

METHODS

There are 9314 patients diagnosed with hypopharynx cancer between 2004 and 2016. The association between treatment modality and survival was analyzed using Kaplan-Meier survival curves and multivariable Cox regression.

RESULTS

Five-year overall survival ranged from 45% for stage I to 21% for stage IVB. Treatment modality did not influence survival in stage I/II. For stage III/IV, chemoradiation and surgery + adjuvant therapy were equivalent. Surgery yielded improved survival for T4 disease. Human papillomavirus (HPV)-positive tumors were present in 21% and were associated with improved hazard ratio of death (0.60, p = <0.0001).

CONCLUSIONS

Survival is superior for T4 hypopharynx cancer managed with surgery, while treatment modality does not impact outcomes for other T-stages. HPV-positive tumors are associated with improved survival regardless of treatment.

Salvage surgery for residual or recurrent laryngeal squamous cell carcinoma after (Chemo)radiotherapy: Oncological outcomes and prognostic factors

Nonsurgical primary treatment of early and advanced laryngeal squamous cell carcinoma, employing radiotherapy with or without chemotherapy, is considered a standard of care in many centers throughout the world. When patients have persistent or recurrent disease after non-surgical treatment, salvage surgery is frequently the only remaining potentially curative treatment. Depending on the extent of the residual/recurrent disease, different surgical salvage options are at the surgeon's disposal. In selected cases with limited local disease, salvage transoral laser microsurgery, transoral robotic surgery and open partial laryngectomies can be employed to achieve cure while preserving laryngeal function. For more advanced cases total laryngectomy is necessary. Identifying situations with unacceptable results from surgical salvage may guide future therapies.

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.

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

Purpose To update the guideline recommendations on the use of larynx-preservation strategies in the treatment of laryngeal cancer. Methods An Expert Panel updated the systematic review of the literature for the period from January 2005 to May 2017. Results The panel confirmed that the use of a larynx-preservation approach for appropriately selected patients does not compromise survival. No larynx-preservation approach offered a survival advantage compared with total laryngectomy and adjuvant therapy as indicated. Changes were supported for the use of endoscopic surgical resection in patients with limited disease (T1, T2) and for initial total laryngectomy in patients with T4a disease or with severe pretreatment laryngeal dysfunction. New recommendations for positron emission tomography imaging for the evaluation of regional nodes after treatment and best measures for evaluating voice and swallowing function were added. Recommendations Patients with T1, T2 laryngeal cancer should be treated initially with intent to preserve the larynx by using endoscopic resection or radiation therapy, with either leading to similar outcomes. For patients with locally advanced (T3, T4) disease, organ-preservation surgery, combined chemotherapy and radiation, or radiation alone offer the potential for larynx preservation without compromising overall survival. For selected patients with extensive T3 or large T4a lesions and/or poor pretreatment laryngeal function, better survival rates and quality of life may be achieved with total laryngectomy. Patients with clinically involved regional cervical nodes (N+) who have a complete clinical and radiologic imaging response after chemoradiation do not require elective neck dissection. All patients should undergo a pretreatment baseline assessment of voice and swallowing function and receive counseling with regard to the potential impact of treatment options on voice, swallowing, and quality of life. Additional information is available at www.asco.org/head-neck-cancer-guidelines and www.asco.org/guidelineswiki .

Radiotherapy Alone or With Chemotherapy in the Management of Carcinoma of the Supraglottic Larynx: A 25-Year Community Hospital Experience

OBJECTIVES

The purpose of this study was to retrospectively review outcomes for patients treated with definitive radiotherapy for carcinoma of the supraglottic larynx at a community hospital and to compare our results with the literature.

MATERIALS AND METHODS

Treatment records of 46 patients with localized carcinoma of the supraglottic larynx treated from January 1987 through January 2012 were reviewed. Overall, 18 (39%) presented with stage I or II disease, whereas 28 (61%) presented with stage III to IV. In total, 30 patients (65%) were treated using hyperfractionation, whereas 16 (35%) received once-daily fractionation. Twelve patients (26%) received concurrent chemotherapy with weekly cisplatin. The Kaplan-Meier method was used to assess outcomes.

RESULTS

The median follow-up for the living patients was 6.7 years (range, 1.7 to 23.1 y). At 5 years, the local-regional control (LRC), ultimate LRC, laryngeal preservation, and overall survival (OS) rates were 70%, 82%, 65%, and 53%, respectively. At 5 years, disease-free survival and cause-specific survival rates were 75% and 76%, respectively. The 5-year OS rates by American Joint Committee on Cancer stage were as follows: I to II, 61%; III, 51%; and IV, 44%. For those receiving concurrent chemotherapy, there was no improvement in 5-year LRC (83% vs. 66%; P=0.4081) or OS (55% vs. 50%; P=0.7697). For those receiving hyperfractionation, there was no improvement in 5-year LRC (75% vs. 63%; P=0.3369) or OS (55% vs. 50%; P=0.4161).

CONCLUSIONS

Our outcomes are similar to those reported in the literature. Neither hyperfractionation nor chemotherapy appeared to confer a benefit for disease control or OS possibly owing to small sample size and the inherent bias of a retrospective review.

Salvage Transoral Laser Microsurgery for Radiorecurrent Laryngeal Cancer: Indications, Limits, and Outcomes

Purpose of Review

The aim of this report is to identify relevant literature reports on salvage transoral laser microsurgery (TLM); to consider its oncologic and functional outcomes, as well as reported complications; and to address indications and limitations of salvage TLM.

Findings

The weighted average of local control after first salvage TLM was 57%. Repeated TLM procedures for second or third recurrences were required in up to 41% of cases, resulting in a weighted average of local control with TLM alone of 67%. The rate of definite laryngeal preservation was 73%. The ultimate local control rate, including cases that required total laryngectomy, was 90%. The overall complication rate after salvage TLM was 14%.

Summary

Salvage TLM of radiorecurrent laryngeal cancer yields excellent oncologic outcomes. Serious complications are scarce, hospitalization times are short, and functional outcomes in terms of voice and swallowing are favorable when compared to open conservation laryngeal surgery. The key to success is an optimal patient selection.

An update on larynx cancer

Answer questions and earn CME/CNE Laryngeal cancer remains one of the most common tumors of the respiratory tract. Fortunately, significant advancements have been made over the past decade in the treatment of laryngeal cancer. Although surgery has been the historical mainstay for localized disease and still is an integral part of treatment, nonsurgical options like radiation and systemic therapy have emerged as viable options. In addition, in the metastatic setting, novel agents are showing promise for this patient population. The care for patients with laryngeal cancer continues to evolve and truly requires a multidisciplinary team-based approach. Unique morbidities, such as loss of natural voice, respiration, and airway protection during swallowing, are observed with this disease and require special consideration. CA Cancer J Clin 2017;67:31-50. © 2016 American Cancer Society.

Prognostic significance of hyoid bone invasion in advanced base of tongue carcinoma treated by chemoradiation

OBJECTIVES

To examine the prognostic influence of hyoid bone invasion in advanced base of tongue squamous cell carcinoma treated with chemoradiation.

METHODS

We retrospectively reviewed pre-treatment imaging (CT/MRI) for the presence or absence of hyoid bone invasion in patients with advanced (clinical T3 or T4a stage) base of tongue squamous cell carcinoma treated with chemoradiation from January 2001 to January 2011. We compared patients with hyoid bone invasion to those without based on the following metrics: 1-, 2- and 5-year locoregional recurrence-free survival, disease-free survival, disease-specific survival and overall survival.

RESULTS

Eleven of thirty-seven patients had hyoid invasion present on pre-treatment imaging. Average follow-up was 45 months. Patients with hyoid bone invasion were found to have lower percentages in all survival metrics measured compared to patients without, respectively, with statistical significance achieved in the following: 2-year locoregional recurrence-free survival: 36.4% versus 86.4% (P = 0.006), 5-year locoregional recurrence-free survival: 12.5% versus 63.6% (P = 0.05), 2-year disease-free survival: 36.4% versus 77.3% (P = 0.05), 5-year disease-free survival: 12.5% versus 63.3% (P = 0.05) and the Kaplan-Meier curve for locoregional recurrence-free survival (P = 0.0075).

CONCLUSIONS

Hyoid bone invasion by base of tongue squamous cell carcinoma may indicate a poorer prognosis despite treatment. Hyoid bone invasion may be a possible indication for intensification of treatment and/or may indicate a necessity for increasing the degree of post-treatment surveillance monitoring and imaging.

Phase II study of concurrent chemoradiotherapy with S-1 in patients with stage II (T2N0M0) squamous cell carcinoma of the Pharynx or Larynx

OBJECTIVE

The goals of treatment for head and neck cancer are cure and organ-function preservation. For organ preservation, primary treatment via radiotherapy alone is thought to be insufficient for Stage II squamous cell carcinoma of the larynx, oropharynx or hypopharynx. The objective of the present study was to investigate the efficacy and safety of concurrent chemoradiotherapy with S-1 for patients with Stage II squamous cell carcinoma of the pharynx or larynx for primary organ preservation.

METHODS

Previously untreated patients with Stage II squamous cell carcinoma of the larynx, oropharynx or hypopharynx received three courses of S-1 (40 or 50 mg twice a day; 2 weeks of administration followed by 1 week of rest every 3 weeks) during conventional radiotherapy (a single daily fraction of 1.8 Gy) to a total dose of 70.2 Gy. The primary endpoint was the local control rate at 3 years.

RESULTS

From August 2009 to October 2012, 37 patients were evaluated for the study. The overall response rate was 100%. The 3-year local control rate was 89.0% (95% confidence interval, 78.9-99.2%), and the 3-year overall survival rate was 97.2% (95% confidence interval, 91.8-100%). Mucositis and dermatitis in the radiation field were the most common acute adverse events observed. The rates of Grade 3 mucositis and dermatitis were 27 and 35%, respectively. No patients experienced Grade 4 acute adverse events. The treatment completion rate was 89.2%.

CONCLUSION

Concurrent chemoradiotherapy with S-1 was safe and effective in improving local control for Stage II squamous cell carcinoma of the pharynx or larynx.

Prediction of concurrent chemoradiotherapy outcome in advanced oropharyngeal cancer

The aim of this study was to investigate human papillomavirus (HPV) infection as a predictor of concurrent chemoradiotherapy (CCRT) response and indicator of planned neck dissection (PND) for patients with advanced oropharyngeal squamous cell carcinoma (OPSCC; stage III/IV). Overall, 39 OPSCC patients (32 men, 7 women; median age 61 years, range 39–79 years) were enrolled. The primary lesion and whole neck were irradiated up to 50.4 Gy, and subsequently the primary site and metastatic lymph nodes were boosted with a further 16.2 Gy. Although several chemotherapy regimens were employed, 82.1% of OPSCC patients received the combination of nedaplatin and 5-fluorouracil. HPV-related OPSCC (16 cases) was defined as both HPV DNA-positive status by polymerase chain reaction and p16^INK4a overexpression by immunohistochemistry. Patients with N2 and N3 disease received PND 2–3 months after CCRT completion. Compared to non-responders, CCRT responders showed significantly lower nodal stage (N0 to N2b) and HPV-positive status in univariate analysis. Patients with HPV-related OPSCC had longer time to treatment failure (TTF) than those with HPV-unrelated OPSCC (p=0.040). Three-year TTF was 81.3 and 47.8% in the HPV-related and HPV-unrelated groups, respectively. There were also significant differences in disease-free survival (DFS) between the two OPSCC patient groups (p=0.042). Three-year DFS was 93.8 and 66.7% in patients with HPV-related and HPV-unrelated OPSCC, respectively. Multivariate logistic analysis showed a lower risk of TTF event occurrence in HPV-related OPSCC (p=0.041) than in HPV-unrelated OPSCC. Thus, HPV testing in addition to nodal stage was useful for predicting CCRT response, especially in advanced OPSCC. Because patients who received PND showed moderate locoregional control, PND is an effective surgical procedure for controlling neck lesions in patients with advanced HPV-unrelated disease.

Prognostic significance of HIF-1a, CA-IX, and OPN in T1-T2 laryngeal carcinoma treated with radiotherapy

OBJECTIVES/HYPOTHESIS

To examine the prognostic value of hypoxia inducible factor HIF-1a, CA-IX, and OPN on clinical outcome in patients with T1-T2 supraglottic laryngeal squamous cell carcinoma (LSCC) treated with primarily radiotherapy (RT).

STUDY DESIGN

Retrospective cohort study.

METHODS

Tumor tissue sections of 60 patients with T1-T2 supraglottic LSCC treated with primarily radiotherapy were assessed immunohistochemically for expression of HIF-1a, CA-IX, and OPN. The relationship of protein expression and classical clinical parameters with clinical outcome was studied, using Cox regression and Kaplan-Meier survival analyses.

RESULTS

Neither HIF-1a nor CA-IX was of prognostic significance toward local control or overall survival in T1-T2 supraglottic LSCC. Cox regression survival analysis showed no relation between HIF-1a or CA-IX expression and local control (HR [hazard ratio] 1.07, CI [95% confidence interval] 0.29-3.87; HR 0.34, CI 0.04-2.58). Furthermore, OPN expression was not associated with local control (HR 1.37, CI 0.45-4.17) and overall survival (HR 0.99, CI 0.44-2.21). Our earlier findings in T1-T2 glottic LSCC (Schrijvers et al., 2008) could not be confirmed.

CONCLUSION

The absence of prognostic significance for HIF-1a and CA-IX toward local control in supraglottic LSCC, unlike glottic LSCC, suggests that supraglottic LSCC might represent another biological entity.

Survival Differences between Organ Preservation Surgery and Definitive Radiotherapy in Early Supraglottic Squamous Cell Carcinoma

Objective

Single-modality treatment, either with organ preservation surgery (OPS) or definitive radiation (RT), is the treatment of choice for patients with early supraglottic squamous cell carcinoma (SGC). However, studies comparing the effectiveness of these 2 techniques are lacking. This study compares the survival outcomes in early SGC patients treated with OPS versus RT.

Study Design

Secondary data analysis.

Setting

Surveillance, Epidemiology and End Results database.

Subjects and Methods

This study included adult patients with early-stage (T1N0, T2N0) SGC undergoing single-modality treatment with either OPS (with or without neck dissection [ND]) or RT between 1988 and 2008. Survival analysis was used to compare the overall survival (OS) and disease-specific survival (DSS) between patients treated with OPS+ND, OPS alone, and RT.

Results

A total of 2631 T1/T2 N0 SGC patients were identified, of whom 167 (6%) were treated with OPS+ND, 186 (7%) with OPS only, and 2278 patients (87%) with definitive RT only. In stage I (T1N0) SGC patients, a significantly better 5-year DSS was noted for both OPS+ND (81% vs 68%, hazard ratio [HR] = 0.61, P = .03) and OPS only (82% vs 68%, HR = 0.70, P = .05) when compared with definitive RT. For stage II (T2N0) patients, only OPS+ND resulted in a significantly better 5-year DSS (86% vs 60%, HR = 0.31, P < .001) when compared with patients treated with RT.

Conclusions

Patients with early SGC who underwent OPS+ND had better OS and DSS than patients undergoing RT alone. OPS+ND may be considered a viable and preferred treatment option in these patients.

Results of 226 patients with T3 laryngeal carcinoma after treatment with transoral laser microsurgery

BACKGROUND

The purpose of this study was to assess the feasibility of transoral laser microsurgery (TLM) in treatment of pT3 laryngeal cancer.

METHODS

We conducted a retrospective case series study of 226 patients with pT3 glottic (n = 122; 54%) or supraglottic laryngeal carcinoma (n = 104; 46%). All patients were treated by TLM in combination with neck dissection (63%) and with postoperative radiotherapy (18%). Our main outcome measures were local control, organ preservation, functional outcome, overall survival, recurrence-free survival, and disease-specific survival.

RESULTS

Median follow-up period was 57.8 months. The 5-year organ-preservation and local control rates for all patients were 87% and 71.4%, respectively. The 5-year overall, recurrence-free, and disease-specific survival were 64.4%, 63.0%, and 83.3%, respectively.

CONCLUSION

Results are comparable to partial or total laryngectomy, while being superior to primary chemo(radio)therapy. TLM results in low morbidity, rapid recovery, and good function and can be a valid option for organ-preserving surgery of pT3 glottic and supraglottic cancer.

Causes of death of patients with laryngeal cancer

Despite remarkable advances in the care of patients with laryngeal cancer over the past several decades, including a growing awareness of therapeutic complications and attention to quality of life, little is known about the causes of mortality in this population. In addition to the laryngeal malignancy itself, acute and late or chronic treatment-associated causes, second primary cancers, intercurrent disease and psychosocial factors are all responsible for patient morbidity and mortality. We examine the current literature related to the causes of death in patients with laryngeal cancer, in the hope of guiding future interventions to improve the longevity and quality of life of individuals with this cancer.

Organ preservation in T4a laryngeal cancer: is transoral laser microsurgery an option?

The main objective of this study is to assess the feasibility of transoral laser microsurgery (TLM) in the treatment of T4a laryngeal cancer and to report the oncological and functional outcomes. This is a retrospective case-series study, held in a single-institute, academic tertiary referral center. Seventy-nine patients with previously untreated T4a glottic (n = 31, 39 %) or supraglottic laryngeal carcinoma (n = 48, 61 %) were included in this study. Five patients (6 %) were treated exclusively by TLM, 16 (20 %) had TLM and unilateral neck dissection, 27 (35 %) had TLM and bilateral neck dissection. Adjuvant (chemo)radiotherapy was additionally administered in 26 (33 %) cases following TLM and neck dissection, and in 5 (6 %) cases after TLM without neck dissection. The main outcome measures included organ preservation, local control, functional outcome, overall, recurrence-free, and disease-specific survival. The median follow-up period was 49 months, 5 year organ preservation rate and local control rate were 80.0 and 67.2 %, 5 year overall, recurrence-free and disease-specific survival were 55.8, 61.9 and 71.8 %. The 5 year overall survival rates were 62.5 % in pN0 cases and 57.2 % in cases with pN-positive neck disease. With respect to survival, these results are comparable to total laryngectomy, while being superior to primary (chemo)radiotherapy. TLM results in a low morbidity, rapid recovery and good function and can be a valid option for organ preserving surgery of pT4a glottic and supraglottic cancer.

Results of transoral laser microsurgery for supraglottic carcinoma in 277 patients

The objective of the study was to evaluate the oncological and functional results of transoral laser microsurgery (TLM) in patients with supraglottic laryngeal squamous cell carcinoma. Between June 1980 and December 2006, 277 patients with squamous cell supraglottic carcinoma of all stages were treated by primary carbon dioxide laser microsurgery. All treatments were performed with curative intention. The goal was the complete tumor removal with preservation of functionally important structures of the larynx. The administered treatment was exclusively TLM with or without selective or modified radical neck dissection in 215 cases (78 %); TLM with postoperative radiotherapy was performed in 62 cases (22 %). Data were analyzed using the Kaplan–Meier method. The median follow-up was 65 months. We achieved a 5-year local control rate of 85 % for pT1/pT2, 82 % for pT3, and 76 % for pT4. The 5-year overall, recurrence-free and disease-specific survival rates for stages I and II were 76, 81, and 92 %, for stages III and IVa 59, 65, and 81 %, respectively. With respect to local control and survival, these results are comparable with the results achieved by conventional partial and total resection of the larynx, while being superior to primary (chemo)radiotherapy. Transoral laser microsurgery results in a low morbidity, rapid recovery, and superior function compared with standard therapy.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall

PURPOSE

To analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall.

METHODS AND MATERIALS

Between 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up.

RESULTS

The 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%).

CONCLUSIONS

Local-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.

Prognostic factors for supraglottic laryngeal carcinoma: Importance of the unfit patient

BACKGROUND

The purpose of this study was to define prognostic factors for supraglottic laryngeal cancer that may influence management.

METHODS

This ethics-approved study captured information on patients who presented with supraglottic laryngeal cancer between 1967 and 2008. Endpoints were local/ultimate failure and cancer-specific survival (CSS). Analysis was performed using chi-square, Fisher exact test, and logistic regression. Kaplan-Meier and Cox regression analysis were used to describe time-to-event data.

RESULTS

Three hundred sixty-nine patients were analyzed. Two hundred seventeen patients received radiotherapy, 30 were treated with surgery, and 122 were treated with radiotherapy and surgery. The 5-year ultimate local control and CSS rates were 79.5% and 62.8%. Treatment type was a univariate predictor for outcome; however, it was not an independent predictor for ultimate local control or CSS.

CONCLUSIONS

This study highlights the fact that by documenting information it is possible to define prognostic factors. It also shows the importance of adjusting for clinical predictors such as patients being unfit for surgery.

Accelerated Radiotherapy With Carbogen and Nicotinamide for Laryngeal Cancer: Results of a Phase III Randomized Trial

Purpose

To report the results from a randomized trial comparing accelerated radiotherapy (AR) with accelerated radiotherapy plus carbogen inhalation and nicotinamide (ARCON) in laryngeal cancer.

Patients and Methods

Patients with cT2-4 squamous cell laryngeal cancer were randomly assigned to AR (68 Gy within 36 to 38 days) or ARCON. To limit the risk of laryngeal necrosis, ARCON patients received 64 Gy on the laryngeal cartilage. The primary end point was local control. Secondary end points were regional control, larynx preservation, toxicity, disease-free survival, and overall survival. In a translational side study, the hypoxia marker pimonidazole was used to assess the oxygenation status in tumor biopsies.

Results

From April 2001 to February 2008, 345 patients were accrued. After a median follow-up of 44 months, local tumor control rate at 5 years was 78% for AR versus 79% for ARCON (P = .80), with larynx preservation rates of 84% and 87%, respectively (P = .48). The 5-year regional control was significantly better with ARCON (93%) compared with AR (86%, P = .04). The improvement in regional control was specifically observed in patients with hypoxic tumors and not in patients with well-oxygenated tumors (100% v 55%, respectively; P = .01). AR and ARCON produced equal levels of toxicity.

Conclusion

Despite lack of benefit in local tumor control for advanced laryngeal cancers, a significant gain in regional control rate, with equal levels of toxicity, was observed in favor of ARCON. The poor regional control of patients with hypoxic tumors is specifically countered by ARCON treatment.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Laser surgery for early to moderately advanced glottic, supraglottic, and hypopharyngeal cancers

Current practice standards for the treatment of early to moderately advanced laryngeal and hypopharyngeal cancer demand both achievement of cure and preservation of laryngeal structure and function to the greatest extent possible. The oncologic and functional results of transoral laser microsurgery (TLM) for early glottic cancer appear to be comparable to those of radiotherapy, with a higher rate of laryngeal preservation and a lower cost. TLM for early and moderately advanced supraglottic and hypopharyngeal cancers offers similar results with regard to survival and local control to those obtained with open surgical approaches. In addition, functional results of TLM are superior to those of open approaches because tracheotomies are usually avoided, rehabilitation of swallowing is faster, and hospital stay is shorter. TLM, when applicable, has become the preferred modality for surgical treatment of most early to moderately advanced cancers of the larynx and selected tumors of the hypopharynx.

Transoral laser microsurgery for T3 laryngeal tumors: Prognostic factors

BACKGROUND

The objective of this study was to evaluate the outcomes of transoral laser microsurgery (TLM) in T3 laryngeal carcinomas and to identify prognostic factors for survival and laryngeal preservation.

METHODS

This study aimed to provide a retrospective analysis of 147 consecutive patients, evaluating their overall survival, disease-specific survival, laryngectomy-free survival, and function preservation rate.

RESULTS

Five-year overall, disease-specific, and laryngectomy-free survivals were 53.1%, 70.2%, and 62.3%, respectively. Disease-specific survival differed between glottic and supraglottic tumors (86.3% vs 61.8%; p = .015). Function preservation was 65.5% in supraglottic and 49.1% in glottic tumors (p = .002). Disease-specific survival was not related to pre-epiglottic involvement, cord fixation, or focal cartilage infiltration (p > .05). Vocal cord fixation and cartilage infiltration were independent negative prognostic factors for organ preservation (odds ratio [OR] = 0.184; 95% confidence interval [CI] = 0.082-0.411; p = .000 and OR = 0.331; 95% CI = 0.139-0.789; p = .013, respectively).

CONCLUSION

Our conclusion is that TLM is a good alternative in a large number of T3 laryngeal tumors, with adequate survival and organ preservation rates above 60%.

[Occult metastases in patients with supraglottic larynx cancer]

The treatment of patients with supraglottic laryngeal cancer still remains a controversal issue. The study comprised 193 patients with a supraglottic laryngeal carcinoma treated in the period 1986-2003. All patients had primary surgery. They all had clinically and ultrasonografically negative findings in the neck (N0). Bilateral selective neck dissection at the level II-III was performed in all patients at the time of primar surgery. Postoperative radiotherapy was given to all patients with verified occult metastases (60 Gy). The occult cervical node metastases were found in 18% (35/193). Ipsilateral occult metastases were more common (77%, 27/35), but both bilateral and contralateral spread was also seen (14%, 5/35 and 9%, 3/35, respectively). Only in two (1%) did metastases develop subsequently. The 5-years survival rate was 86%.

Predictors of outcome for advanced-stage supraglottic laryngeal cancer

BACKGROUND

The objective of this study was to report our experience in the management of patients with advanced-stage supraglottic laryngeal carcinoma and to identify factors predictive of outcome.

METHODS

In total, 181 patients with advanced-stage supraglottic laryngeal carcinoma were treated at Memorial Sloan-Kettering Cancer Center between 1984 and 1998. Sixty-nine (38%) patients were treated by surgery +/- postoperative radiotherapy (SRT), 93 (52%) by chemoradiotherapy (CTRT), and 19 (10%) by radiotherapy alone (RT). Survival outcomes were calculated using the Kaplan-Meier method. Predictors of outcome were identified using multivariate analysis.

RESULTS

The-5 year overall survival (OS) and disease-specific survival (DSS) were 53% and 71%, respectively. Patients treated with SRT and CTRT had comparable outcomes. The main independent predictors of OS and DSS were age greater than 60 years and stage of the neck at presentation.

CONCLUSION

Regardless of index treatment, age over 60 years and clinical stage of the neck at presentation were the main independent predictors of OS and DSS.

Chemoselection as a strategy for organ preservation in patients with T4 laryngeal squamous cell carcinoma with cartilage invasion

OBJECTIVES/HYPOTHESIS

High rates of overall survival (OS) and laryngeal preservation were achieved in two sequential phase II clinical trials in patients with stage III/IV laryngeal squamous cell carcinoma (SCC). Patients were treated with chemoradiation after a >50% primary tumor response to one cycle of neoadjuvant chemotherapy (IC). We analyzed outcomes for T4 patients with cartilage invasion from both studies.

STUDY DESIGN

Retrospective.

METHODS

Records from 36 patients with T4 SCC of the larynx with cartilage invasion alone (n = 16) or cartilage invasion and extralaryngeal spread (n = 20) were retrospectively reviewed. All were treated with one cycle of cisplatin (100 mg/m(2)) [or carboplatin (AUC 6)] and 5-fluorouracil (1,000 mg/m(2)/d for 5 days) (P+5FU). Those achieving >50% response at the primary tumor received chemoradiation (70 Gy; 35 fractions with concurrent cisplatin-100 mg/m(2) [carboplatin (AUC 6)] every 21 days for 3 cycles), followed by adjuvant P+5FU for complete histologic responders (CHR). Patients with <50% response after IC underwent total laryngectomy and postoperative radiation.

RESULTS

Twenty-nine of 36 patients (81%) had >50% response following IC. Of these, 27 received definitive chemoradiation, 23 (85%) obtained CHR, with 58% laryngeal preservation rate. The 3-year OS was 78%, and the disease-specific survival was 80% (median follow-up 69 months). Following chemoradiation, 8/11 (73%) patients with an intact larynx had >75% understandable speech, 6/36 (17%) were g-tube dependent and 6/36 (17%) were tracheostomy dependent.

CONCLUSIONS

Our results suggest that chemo-selection is a feasible organ preservation alternative to total laryngectomy for patients with T4 laryngeal SCC with cartilage invasion.

Nodal control and surgical salvage after primary radiotherapy in 1782 patients with laryngeal and pharyngeal carcinoma

The purpose of this study was to evaluate the ultimate neck control after primary radiotherapy and surgical salvage in laryngeal and pharyngeal cancer patients. Some 1782 consecutive patients with squamous cell carcinoma were treated by radiotherapy. At presentation 26% of the patients had metastatic lymph nodes. A total of 298 primary or secondary nodal recurrences were seen, 159 were treated, and 53 (53/298 approximately 18%) were controlled. Isolated N-recurrence was fatal in 2.7% (36/1324) of the N0 patients. Univariate actuarial analysis of nodal control demonstrated that the region of origin, T-classification, T-size, N-classification, tumor stage, differentiation, hemoglobin, and radiation time were significant prognostic factors. In a Cox analysis the independent significant parameters were gender, region of origin, N-classification, and differentiation. The conclusions were that in patients with nodal recurrence a little over half were treated and of these a third of the nodal recurrences were controlled. Significant prognostic factors in multivariate analysis were gender, region of origin, N-classification, and tumor differentiation.

Durable long-term remission with chemotherapy alone for stage II to IV laryngeal cancer

PURPOSE

For patients with stage II to IV laryngeal cancer, radiation therapy (RT) either alone or with concurrent chemotherapy provides the highest rate of organ preservation but can be associated with functional impairment. Thus, we studied the use of induction chemotherapy with or without conservation laryngeal surgery (CLS). Our objectives were to study the sensitivity of laryngeal cancer to platinum-based chemotherapy alone and to highlight the efficacy of CLS in this setting.

PATIENTS AND METHODS

Thirty-one previously untreated patients with laryngeal cancer (T2-4, N0-1, M0), who were resectable with CLS, were enrolled. Patients received three to four cycles of paclitaxel, ifosfamide, and cisplatin (TIP) chemotherapy, and response was assessed histologically. Patients with partial response (PR) proceeded to CLS. Patients achieving pathologic complete response (pCR) received an additional three cycles of TIP and no other treatment.

RESULTS

Thirty patients were assessable for response. With TIP chemotherapy alone, 11 patients (37%) achieved pCR, 10 of whom (33%) remain alive with durable disease remission and no evidence of recurrence over a median follow-up time of 5 years. Nineteen patients (63%) treated with TIP alone achieved PR. The overall laryngeal preservation (LP) rate was 83%, and only five patients (16%) required postoperative RT. No patient required a gastrostomy tube or tracheotomy.

CONCLUSION

Chemotherapy alone in selected patients with T2-4, N0-1 laryngeal cancer can provide durable disease remission at 5 years. For patients with PR, CLS provides a high rate of LP. This prospective study suggests that chemotherapy alone may cure selected patients with laryngeal cancer, warranting further prospective investigation.

Functional organ preservation with definitive chemoradiotherapy for T4 laryngeal squamous cell carcinoma

BACKGROUND

Randomized trials established chemoradiotherapy as standard treatment for advanced laryngeal cancer. Patients with large-volume T4 disease (LVT4) were excluded from these trials. The purpose of this study was to report T4 laryngeal cancer patient outcome, including those with LVT4 disease, treated with chemoradiotherapy.

PATIENTS AND METHODS

This study is a retrospective subset analysis of 32 patients with T4 laryngeal carcinoma including LVT4 tumors treated on three consecutive protocols investigating paclitaxel (Taxol), 5-fluorouracil, hydroxyurea, and 1.5-Gy twice daily (BID) radiotherapy (TFHX).

RESULTS

Median follow-up is 43 months. Four-year locoregional control (LRC), disease-free survival (DFS), overall survival (OS), and laryngectomy-free survival (LFS) was 71%, 67%, 53%, and 86%, respectively. Four patients required laryngectomy for recurrent or persistent disease. Of disease-free patients with >or=1 year follow-up, 90% demonstrated normal or understandable speech. None required laryngectomy for complications. Among LVT4 patients, 4-year LRC, DFS, OS, and LFS was 71%, 65%, 56%, and 81%, respectively. Induction chemotherapy improved 4-year LRC (90% versus 46%, P = 0.03) and DFS (84% versus 42%, P = 0.03).

CONCLUSIONS

Promising control and functional outcomes are achieved with TFHX for T4 laryngeal patients. LVT4 disease had outcomes similar to patients with less advanced disease treated on Radiation Therapy Oncology Group 91-11. Induction chemotherapy improved outcomes, warranting further investigation.

Multidisciplinary Management of Laryngeal Carcinoma

The management of head and neck cancer has evolved into a multidisciplinary approach in which patients are evaluated before treatment and decisions depend on prospective multi-institutional trials, as well as retrospective outcome studies. The choice of one or more modalities to use in a given case varies with the tumor site and extent, as exemplified in the treatment of laryngeal squamous cell carcinomas. The goals of treatment include cure, laryngeal voice preservation, voice quality, optimal swallowing, and minimal xerostomia. Treatment options include transoral laser excision, radiotherapy (both definitive and postoperative), open partial laryngectomy, total laryngectomy, and neck dissection. The likelihood of local control and preservation of laryngeal function is related to tumor volume. Patients who have a relatively high risk of local recurrence undergo follow-up computed tomography scans every 3-4 months for the first 2 years after radiotherapy. Patients with suspicious findings on computed tomography might benefit from fluorodeoxyglucose positron emission tomography to differentiate post-radiotherapy changes from tumor.

Radiotherapy Alone for Early-Stage Squamous Cell Carcinoma of the Larynx and Hypopharynx

PURPOSE

To describe and illustrate examples of early-stage larynx and hypopharynx cancer that can be successfully treated with radiotherapy alone.

METHODS AND MATERIALS

Review of the NCCN and ASCO practice guidelines. Representative examples are included.

RESULTS

Early-stage larynx and hypopharynx cancer is defined by tumor extent based on physical and imaging examination.

CONCLUSIONS

Radiotherapy alone is appropriate treatment for properly selected early-stage squamous cell carcinoma of the larynx and hypopharynx. The NCCN and ASCO practice guidelines can be an aid to the clinician in identifying favorable cancers that can be successfully treated with radiotherapy alone with preservation of organ function.

Supraglottic laryngectomy: analysis of 267 cases

Horizontal supraglottic laryngectomy (HSL) allows the preservation of a functioning larynx and avoids permanent tracheotomy. In this retrospective study we report our experience with HSL and describe the functional and oncological results of the procedure. A total of 267 previously untreated patients with squamous cell carcinoma of the supraglottis underwent a supraglottic laryngectomy at our Department from January 1978 to May 2002. The main outcome measures were: local and regional control, disease-specific survival and laryngeal preservation rate. The overall recurrence rate was 29% (78/267). The local recurrence rate was 8% (22 patients) and the regional recurrence rate was 17% (45 patients). The 5-year disease-specific survival rate was 73%. The 5-year laryngeal preservation rate was 82%. Multivariate analysis showed two parameters that were independent predictors of a reduced disease specific survival: cervical lymph node metastases of class N3 (P = 0.0003) and primary tumour classified as T4 (P = 0.004). HSL provided, in our experience, an optimal locoregional oncological control for laryngeal preservation.

The role of laser microsurgery in the treatment of laryngeal cancer

PURPOSE OF REVIEW

Transoral laser microsurgery has developed in recent years into a surgical method that combines a minimally invasive approach with the surgical precision of laser and microscope. The outcomes of laser microsurgical treatment of laryngeal carcinomas are reviewed and compared with the results of competitive standard procedures.

RECENT FINDINGS

Laser microsurgery is widely acknowledged to have advantages in the treatment of early glottic carcinoma. In the treatment of glottic carcinoma causing impaired mobility or fixation of the vocal cord the role of laser surgery has not yet been definitively assessed. Based on published results, primary laser therapy can achieve local tumor control with a functional residual larynx in approximately 70-80% of cases. In patients with early or moderately advanced supraglottic carcinoma, laser microsurgery is comparable to open supraglottic laryngectomy in terms of local control and survival. With regard to organ preservation, laser microsurgery is comparable to open supraglottic laryngectomy but superior to radiotherapy. Microsurgery can preserve functionally important structures, allowing for early swallowing rehabilitation while avoiding tracheotomy.

SUMMARY

This review elucidates the role of laser microsurgical partial resections of the larynx in comparison with other treatment modalities.

Current surgical treatment of squamous cell carcinoma of the head and neck

Historically treatment of head and neck cancers involved surgical resection followed by radiation therapy for advanced tumors. Concurrent chemoradiation therapies have shown equal survival to surgical resection with better preservation of function. However, concurrent therapy does entail significant morbidity, and recent advances have been used to minimize that morbidity. Newer tumor specific medical therapies are anticipated to be less toxic while maintaining a high degree of efficacy. For resectable cancer, transoral laser microsurgery is a new trend in surgery for complete resection of tumors with preservation of function. Advanced reconstructive techniques that allow free transfer of soft tissue and bone from all over the body improve the functional and aesthetic outcomes following major ablative surgery. With successful surgical reconstruction, dental and prosthetic rehabilitation choices are enhanced. Advances in rehabilitation of speech following removal of the larynx have improved the quality of life post-laryngectomy patients. With these newer therapies and methods of reconstruction, each patient needs to be carefully evaluated to maximize the possibility of cure and level of function, and minimize the morbidity associated with treatment. Combined chemotherapy and radiation protocols are associated with increased acute and chronic toxicities that may affect the quality of life due to the impact upon oral disease and oral function. Oral care providers must be aware of advances in cancer management and implications for patient care to effectively care for these patients.