Clinical predictors of larynx preservation after multiagent concurrent chemoradiotherapy

Factors associated with total laryngectomy following organ-preserving treatment of laryngeal SCC

Objectives

A subset of laryngeal squamous cell carcinoma (LSCC) patients undergoing larynx preserving treatment ultimately require total laryngectomy (TL) for oncologic or functional reasons. This study aims to identify TL risk factors in these patients.

Methods

Retrospective cohort study using Veterans Affairs (VA) database. T1-T4 LSCC cases treated with primary radiotherapy (XRT) or chemoradiotherapy (CRT) were assessed for TL and recurrence. Binary logistic and Cox regression and Kaplan-Meier analyses were implemented.

Results

Of 5390 cases, 863 (16.0%) underwent TL. On multivariable analysis, age (adjusted odds ratio: 0.97 [0.96-0.98]; p < .001) and N3 disease (0.42 [0.18-1.00]; p = .050) were associated with reduced risk of TL, whereas current alcohol use (1.22 [1.04-1.43]; p = .015) and >T1 disease (T2, 1.76 [1.44-2.17]; p < .001; T3, 2.06 [1.58-2.68]; p < .001; T4, 1.79 [1.26-2.53]; p = .001) were associated with increased risk of TL. However, N2 (adjusted hazard ratio: 1.30 [1.10-1.55]; p = .003) and N3 (2.02 [1.25-3.26]; p = .004) disease were associated with an increased risk for local recurrence. Compared to XRT, treatment with CRT was associated with reduced risk for local recurrence after adjusting for other factors (0.84 [0.70-0.99]; p = .044). Those who do not receive TL following local recurrence have poorer disease-specific survival (log-rank, p < .001). In patients without local recurrence, N2 disease was associated with a fourfold increase in risk of TL (4.24 [1.83-9.82]; p < .001).

Conclusion

Advanced nodal stage was associated with reduced rates of salvage TL in the setting of local recurrence, and subsequent worse prognosis after recurrence. Conversely, advanced nodal stage may increase the risk for functional salvage TL in patients without recurrence.

Level of Evidence

Level 3.

Functional Larynx Preservation in Patients With Locally Advanced Squamous Cell Carcinoma of the Larynx and Hypopharynx Treated With Induction Chemotherapy vs. Concurrent Chemoradiation Alone

Objectives

Chemoradiation therapy (CRT) has been established as a standard treatment for locally advanced hypopharynx/larynx squamous cell carcinoma (SCC) but the role of induction chemotherapy (IC) remains unclear. The primary outcome of this study is to determine whether functional larynx-preservation survival (FLPS) is improved with the addition of IC in these patients. Secondary outcomes were overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and laryngectomy rates.

Methods

Records for patients with AJCC 8th edition clinical stage III-IVB laryngeal and hypopharyngeal SCC treated with CRT +/- IC from 2005-2019 were reviewed. FLPS was defined as time until death, progression, laryngectomy, or non-functional larynx. Kaplan-Meier curves were generated for FLPS, OS, PFS, and DMFS. Outcomes were compared using the stratified log-rank test. Laryngectomy rates were compared using Fisher’s exact test.

Results

We included 52 patients with laryngeal and 38 with hypopharyngeal SCC (n=90); 19 patients with laryngeal SCC and 19 with hypopharyngeal SCC received IC (median three cycles). There were no differences in the three-year FLPS (61% vs 67.8%; p=0.88), OS (73.9% vs 86.2%; p=0.42), PFS (53.6% vs 62.6%; p=0.44), or DMFS (65.2% vs 71.5%, p= 0.85) between patients who did and did not receive IC all patients. Laryngectomy rates did not differ with and without IC (18.4 % vs 7.7%; p=0.19).

Conclusion

In this study of advanced laryngeal and hypopharyngeal SCC, IC did not improve three-year FLPS, OS, PFS, or laryngectomy rates compared to CRT alone. A large prospective series would provide a more robust understanding of the role of IC in this group of patients. 

Investigation of the affective factors on the survival rate of patients with laryngeal cancer using Cox proportional hazards and Lin -Ying's additive hazards models

Background: Determining the factors affecting survival and appropriate treatment methods leads to improving the survival rate and quality of life in cancer patients; therefore this study was aimed to determine the effective factors on the survival rate of patients with Laryngeal cancer in Kerman city, Iran.

Methods: This retrospective cohort study included 370 patients with Laryngeal cancer who referred to the hospitals of Kerman city, Iran during 2008 to 2018. Data were analyzed using Cox Proportional Hazards and Lin-Ying’s Additive Hazards models. Data analysis was done using SAS software version 9.4. The P-value of less than 0.05 was considered as statistically significant.

Results: The mean age at the time of diagnosis was 58.16±10.60 years. About 92% of the patients were men. The patient’s 1, 3, 5, 7 and 10-years of overall survival rates were equal to 82.38%, 60.68%, 55.98%, 49.83%, and 30.91%, respectively. Age at the diagnosis (p=0.001), radiotherapy (p=0.001), chemotherapy (p=0.015), surgery (p=0.031), and smoking (p=0.001) were found to have significant effect on the patient’s survival rate in the Cox model. These variables were significant in the Lin-Ying model too.

Conclusion: Treatment is an important factor in controlling the disease and survival of cancer patients, and choosing the best treatment depends on the condition of the patient and the disease level.

Organ preservation in patients with advanced laryngeal tumours. Results of induction chemotherapy versus chemoradiotherapy in actual clinical practice

INTRODUCTION AND OBJECTIVES

A high percentage of patients with locally advanced larynx carcinomas are candidates for inclusion in organ preservation protocols. The objective of this study is to compare the results of two schemes of preservation, induction chemotherapy versus chemoradiotherapy, in patients with locally advanced larynx carcinomas in the context of actual clinical practice.

METHODS

Our retrospective study included 157 patients with locally advanced tumours of the larynx (T3-T4) treated with induction chemotherapy (n = 121) or chemoradiotherapy (n = 36).

RESULTS

From 121 patients who began treatment with induction chemotherapy, 6 died due to toxicity, 37 were treated with surgery, and 78 completed the preservation scheme; 36 patients received treatment with chemoradiotherapy. There were no significant differences in 5-year disease-specific survival between both treatments: 68.9% in induction chemotherapy versus 75.7% in chemoradiotherapy (p = 0.259). In 45.9% of patients the laryngeal function was preserved. Patients treated with chemoradiotherapy had a tendency to have better 5-year laryngeal dysfunction-free survival than patients treated with induction chemotherapy (55.6% versus 44.8%, p = 0.079).

CONCLUSION

Patients included in a protocol of organ preservation achieved a 5-year laryngeal dysfunction-free survival of 45.9%. There were no significant differences in disease-specific survival among patients treated with induction chemotherapy or chemoradiotherapy.

Onset of hypothyroidism after total laryngectomy: Effects of thyroid gland surgery and preoperative and postoperative radiotherapy

Background

To determine time of onset and risk of hypothyroidism after total laryngectomy (TL) with and without (hemi)thyroidectomy in relation to treatment regimen, that is, preoperative radiotherapy (RT‐TL), postoperative radiotherapy (TL‐RT), and postoperative re‐irradiation (RT‐TL‐RT).

Methods

Retrospective review of 128 patients treated by RT‐TL (51 patients), TL‐RT (55 patients), and RT‐TL‐RT (22 patients). Risk of hypothyroidism was determined by multivariable Cox regression analysis and euthyroid survival was calculated using Kaplan‐Meier method.

Results

Hypothyroidism developed in 69 (54%) patients. The median onset of hypothyroidism was later (P < .01) and the risk of hypothyroidism was lower (hazard ratio 0.49; P = .014) in the TL‐RT group compared to both other treatment regimens. Euthyroid survival did not differ between the treatment regimens. Two years euthyroid survival was 24% with and 61% without (hemi)thyroidectomy (P < .001).

Conclusions

Patients treated with TL‐RT have later onset of hypothyroidism. Higher risk for hypothyroidism is associated with salvage TL after radiotherapy and (hemi)thyroidectomy.

Clinical Predictors of Laryngeal Preservation Rate in Stage III-IV Laryngeal Cancer and Hypopharyngeal Cancer Patients Treated with Organ Preservation

Purpose: To determine factors affecting laryngeal preservation rate in laryngeal and hypopharyngeal cancer patients treated with organ preservation. Material and Methods: Retrospective study examining stage III to IV laryngeal and hypopharyngeal cancer patients who have been treated with organ preservation. Conventional radiation must be applied in all patients with minimum dose of 45 Gray. Weekly or triweekly chemotherapy can be adding during radiation. Salvage surgery should be considered in residual disease or local recurrence. Kaplan-Meier was used for survival analysis and, Log rank test and Cox proportional hazard test were used for uni and multivariate analysis. Results: From January 2010 to October 2014, there were 69 patients treated with laryngeal preservation and 53 patients received radiation dose 61-70 Gray. After completing radiation, we found that 44 patients have no residual tumor within 6 months and 33 patients can preserve their functional larynx later with complete response (median follow up 6 mo, range 0-46.3 mo). The 1-year, 2-year and 3-year laryngeal preservation rate was 49%, 36 % and 32 % respectively. On univariate analysis, lower nodal stage (p = 0.008), stage III disease (p = 0.046), tumor volume <10 ml (p = 0.005), no true vocal cord involvement (p = 0.016), dose 61-70 Gray (p < 0.001) and no interruption of treatment (p = 0.017) have better laryngeal preservation rates. ECOG performance status 2, higher nodal stage, stage IV, presence of true vocal cord involvement, upper airway obstruction before/during radiation and radiation dose below 61-70 Gray had an effect on worse overall survival when evaluated with univariate analysis statistical significance. Conclusion: For factors that affected laryngeal preservation in our study were nodal stage, group stage, tumor volume, true vocal cord involvement, radiation dose and treatment break time more than one week with statistical significance.

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 .

Effectiveness of ultrasonography and computed tomography in assessing thyroid cartilage invasion in laryngeal and hypopharyngeal cancers

OBJECTIVE

To evaluate the adequacy of ultrasonography (US) and computed tomography (CT) in the assessment of thyroid cartilage invasion in patients with airway cancer.

MATERIALS AND METHODS

Sixty-two consecutive patients referred to our institute underwent US and CT to stage laryngeal (n = 27) or hypopharyngeal (n = 35) cancer in this prospective study. Two radiologists, who were blinded to the patients' clinical histories and histopathology, evaluated thyroid cartilage invasion on US and CT separately and independently. Fifty-eight of the 64 patients (90%) underwent surgery. The histopathologic findings were used as the standard of reference for comparison and statistical analysis.

RESULTS

For thyroid cartilage invasion, the detection rate on CT and US was 98%. CT achieved a sensitivity of 91% and a specificity of 75%, while US attained a sensitivity of 98% and a specificity of 75%. The difference between CT and US in terms of sensitivity was not statistically significant.

CONCLUSION

US and CT have high diagnostic performance in evaluating thyroid cartilage invasion. US is more sensitive than CT in diagnosing invasion of the thyroid cartilage; however, the difference is not statistically significant. US can be used to solve the diagnostic dilemma of the presence or absence of cartilage invasion when CT is inconclusive, as CT is more widely used in staging laryngeal and hypopharyngeal cancers.

Comparative effectiveness of surgical and nonsurgical therapy for advanced laryngeal cancer

BACKGROUND

The treatment of patients with advanced stage laryngeal cancer includes surgery or concurrent chemoradiation (CRT). Although CRT has become more common in recent years, to the authors' knowledge, the effectiveness of complete CRT in improving survival over surgery has not been studied.

METHODS

The authors examined patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare claims-linked data set with locoregional laryngeal cancer who were diagnosed between 1997 and 2007. Multivariate Cox proportional hazard analyses were conducted to compare overall and cause-specific 5-year survival rates between treatment modalities, adjusting for patient sociodemographic and clinical characteristics. A propensity score-matched subcohort also was used to compare survival.

RESULTS

Of the 3212 patients in the study cohort, 42% underwent surgery and 18% underwent CRT. Only approximately one-quarter of patients who were treated with CRT completed the courses. In adjusted analyses, the authors were unable to reject the null hypothesis of no difference in 5-year all-cause or cause-specific mortality risk between patients treated with surgery and patients undergoing complete CRT (hazards ratio, 1.25 [95% confidence interval, 0.91-1.71; P = .16] and hazard ratio, 1.41 [95% confidence interval, 0.9-2.2; P = .14], respectively). Older age, not currently married, Medicaid eligibility, and prior cancer history were found to be associated with a higher risk of mortality (P<.05).

CONCLUSIONS

Patients with advanced laryngeal cancer who underwent complete CRT were found to have overall and cause-specific survival rates similar to those of patients undergoing surgery. However, a substantial percentage of patients who initiated CRT did not complete the course. Although CRT provides organ preservation, the benefits and trade-offs of CRT and total laryngectomy should be discussed fully with patients. The importance of completing the full course of CRT should be emphasized. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2845-2856. © 2016 American Cancer Society.

Clinical Assessment and Treatment of the Dysfunctional Larynx after Radiation

Objective

To review the pathophysiology of early and late radiation-related tissue changes, methods to differentiate these changes from disease recurrence, and treatment of these changes in the irradiated larynx.

Data Sources

Peer-reviewed publications.

Review Methods

PubMed database search.

Conclusions/Implications for Practice

Early and late radiation-related changes in the larynx manifest variably between individual patients. Severe radiation-related tissue changes in the larynx and recurrent malignancy share many clinical characteristics, and the presence of malignancy must be considered in these patients. Positron emission tomography may help select patients who need operative biopsy to rule out recurrence. In patients with a cancer-free but dysfunctional larynx, both surgical and nonsurgical treatment options, including hyperbaric oxygen, are available for attempted salvage. Further investigation is needed before hyperbaric oxygen can be considered standard-of-care treatment for these patients.

Laryngeal preservation in stage III/IV resectable laryngo-hypopharyngeal squamous cell carcinoma following concurrent chemoradiotherapy with capecitabine/cisplatin

Concurrent chemoradiotherapy has become the standard of care for advanced head and neck cancers in organ preservation strategies. However, the optimal regimen for concurrent chemoradiotherapy to maximise treatment response and minimise toxicity has not been determined. The purpose of the present clinical study was to review our experience with concurrent chemoradiotherapy by using the capecitabine and cisplatin (XP) regimen with the aim of organ preservation in patients with locoregionally advanced laryngo-hypopharyngeal squamous cell carcinoma (LHSCC). Thirty-one patients with stage III/IV resectable LHSCC treated with concurrent chemoradiotherapy using the XP regimen were enrolled in the present study. The patients fulfilled the criteria for total laryngectomy when surgery was selected. The primary endpoint of this study was disease-free survival with a functional larynx, which was indicated by the following conditions: survival, disease-free status at all sites and retention of a functional larynx. Following concurrent chemoradiotherapy, 23 patients (74.2%) exhibited complete response (CR) at the primary site and 18 (69.2%) exhibited CR at the lymph nodes. CR at the primary site and lymph nodes was identified in 19 patients (61.3%). The Kaplan-Meier 2- and 3-year cumulative disease-free survival rates were 71.5 and 59.6%, respectively. Anatomical laryngeal preservation was feasible in 27 patients (87.1%) during the 36-month follow-up period. Permanent gastrostomy was required in 1 disease-free patient with an intact larynx. For the entire cohort, the 2- and 3-year cumulative disease-free survival with a functional larynx was 58.5 and 50.7%, respectively. The most frequent grade 3–4 haematological and non-haematological toxicities of concurrent chemoradiotherapy were leucopenia and mucositis, which developed in 4 (12.9%) and 8 (25.8%) patients, respectively. There was no treatment-related death. Concurrent chemoradiotherapy with the XP regimen resulted in functional laryngeal preservation accompanied by disease-free survival and the toxicities were more tolerable and manageable compared to those reported by previous studies.

Chemoradiation for patients with large-volume laryngeal cancers

BACKGROUND

Patients with T4 laryngeal cancers, including those with large-volume (cartilage or tongue-base invasion) lesions, are often excluded from organ-preservation trials due to expectations of inferior outcome in terms of survival and function. We hypothesize that such patients indeed have acceptable survival and function when treated with organ-preservation strategies.

METHODS

Retrospective analysis of prospectively collected data of a cohort of patients with T4 laryngeal cancer was carried out. Follow-up ranged from 0.18 to 15.6 years. All T4 laryngeal cancer patients who were enrolled in the University of Chicago concomitant chemoradiotherapy protocols from 1994 to the present were reviewed. This study was composed of 80 newly diagnosed T4 laryngeal cancer patients. Efficacy of treatment was determined through evaluations of survival and function. Survival was evaluated via Kaplan-Meier methods. Swallowing function was evaluated by an oropharyngeal motility (OPM) study and swallowing scores were assigned. Higher scores reflected increasing swallowing dysfunction.

RESULTS

Fifty-five of 80 patients (~69%) had documented large-volume tumor. Two- and 5-year overall survivals were 60.0% and 48.7%, respectively. Disease-specific 2- and 5-year survivals for the group were 80.1% and 71.3%, and 79.4 and 74.3%, respectively, for the 55 patients with large volume status. Progression-free survival rates were 52.6% and 47.6%. Forty-four of 65 patients (~68%) with OPM data had a Swallowing Performance Status Scale (SPSS) score of ≤5, indicating various degrees of swallowing abnormalities not requiring a gastrostomy tube. This is a functional-preservation rate of 67.7%.

CONCLUSIONS

Chemoradiation for patients with T4 laryngeal cancer appears to be an effective and reasonable option, particularly in light of the satisfactory survival and function-preservation rates.

Treatment-induced changes in vocal cord mobility and subsequent local recurrence after organ preservation therapy for laryngeal carcinoma

BACKGROUND

As multidisciplinary cancer treatment evolves, strategies to identify patients needing early resection/salvage are necessary. Some have suggested that vocal cord function after organ-preservation treatment may be an indicator.

METHODS

A retrospective review was performed of patients presenting with fixed or impaired vocal cord function at a tertiary center. Local recurrence rates were examined in patients with and without improved/normal mobilization after treatment.

RESULTS

Sixty-nine patients met the inclusion criteria, with 35 patients having vocal cord fixation and 34 patients with impaired mobility. After treatment, 44 patients had normalization of vocal cord function, while 25 patients did not, with 2-year local control rates of 70% and 77%, p = .23, respectively. No difference in local control was found between patients with normalized/improved cord function (n = 53) and those who remained the same/worsened (n = 16; p = .81).

CONCLUSION

Therapy-induced changes in vocal cord mobility did not correlate with local recurrence. Other criteria are needed to identify patients most likely to benefit from early surgical resection/salvage after organ preservation.