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

Current Status of Partial Laryngeal Surgery for Advanced Laryngeal Cancer: When and Why?

PURPOSE OF REVIEW

This paper aims to evaluate the evolution and current status of partial laryngeal surgery in the treatment of advanced laryngeal cancer (LC). Specifically, recent progress in the selection of both patients and tumors, together with surgical and rehabilitation innovations, have contributed to balancing oncological control with the maintenance of quality of life in naïve and radiorecurrent patients. The main aspect is represented by the recognized role of open partial horizontal laryngectomies (OPHLs) in this new era of laryngeal cancer treatment.

RECENT FINDINGS

Recent advancements highlight OPHLs' efficacy for conservative management of intermediate to advanced stages of LC. Innovations such as supratracheal partial laryngectomy have expanded surgical options, offering a modular approach to complex cases. Improved understanding of tumor biology, enhanced imaging techniques, and more precise preoperative planning have led to better patient outcomes, emphasizing the importance of a conservative function-preserving surgical treatment. These advancements reflect a broader trend towards individualized treatment plans that prioritize both survival and quality of life. OPHLs play an important role in current management of intermediate/advanced LC, effectively balancing oncological control with the preservation of laryngeal functions. Critical factors include meticulous patient and tumor selection, the impact of surgical and technological refinements on functional outcomes, and the necessity of a multidisciplinary approach in treatment planning. Current evidence justifies the use of these interventions in many intermediate T-stage laryngeal tumors, even at risk of upstaging on pathological examination. The oncological results, the preservation of laryngeal function and the laryngectomy-free survival achieved with OPHLs appear to be highly competitive with those of non surgical organ-preservation protocols, aiming to introduce a new standard in the LC treatment.

Clinical Relevance of Resection Margins in Patients with Total Laryngectomy or Laryngopharyngectomy

BACKGROUND

Laryngeal and hypopharyngeal cancer is complex and resection margins are therefore constrained. The aim of this study was to investigate the clinical relevance of resection margins in laryngeal and hypopharyngeal surgery.

METHODS

A retrospective cohort study was performed for patients treated with a total laryngectomy (TL) or laryngopharyngectomy (TLP) for laryngeal or hypopharyngeal squamous cell carcinoma (LSCC and HSCC, respectively). Within the groups primary LSCC, recurrent LSCC, primary HSCC, and recurrent HSCC the relationship between the status of the resection margin according to the Royal Collage of Pathology and the recurrence and survival rates were investigated.

RESULTS

Positive resection margins were found in 54% for primary LSCC, 29% for recurrent LSCC, 62% for primary HSCC, and 44% for recurrent HSCC. For primary and recurrent LSCC, there was a linear association between total recurrence and narrowing margins (p = 0.007 resp. p = 0.008). Multivariate survival analysis for primary and recurrent LSCC showed a significantly worse disease free and disease-specific survival in case of positive margins compared to clear margins.

CONCLUSION

Similar survival rates were recorded for close and clear margins for primary and recurrent LSCC. This may suggest that a margin > 5 mm is not clinically relevant in terms of survival. Therefore, a margin of 1-5 mm should be accepted in certain subsites. Margins < 1 mm are related to significantly worse outcomes and should be avoided.

Multicentric Study on Oncological Outcomes and Prognostic Factors of Open Partial Horizontal Laryngectomies

Objective: In recent years, the number of open preservation surgeries for the treatment of laryngeal Cancer has increased. This surgery aims to maintain laryngeal function and ensure oncological radicality, thereby avoiding a total laryngectomy (TL) that could significantly impact the patient's quality of life. The purpose of this study was to assess the oncologic results of OPHL I and II and to identify prognostic factors that could impact patient survival and local failure rates. Methods: This study was conducted on 182 patients with laryngeal squamous cell carcinoma treated with OPHLs between 2005 and 2015. The survival rates of a group of patients treated with TL between 2004 and 2014 were taken into consideration to compare survival outcomes. Results: The disease-specific survival in pT2 and pT3 tumors in relation to the type of surgery showed no statistically significant difference between OPHLs and TL (P = .54 and P = .63, respectively). The 5-year T-recurrence-free survival showed that pT4 tumors, perineural/vascular positive invasion, and OPHL IIb + ARY-treated tumors were associated with a higher risk of tumor recurrence (P < .0001, P = .0005 and P = .016 respectively). Conclusions: OPHLs represent an excellent alternative to TL considering the characteristics of the tumor and the general conditions of the patient.

Olfactory function in laryngectomised patients: tracheo-oesophageal versus oesophageal speech

Objective

This study aimed to evaluate olfactory function in patients rehabilitated with oesophageal (ES) voice or tracheo-oesophageal (TES) prosthesis to further verify whether there were differences in smell alterations depending on voice rehabilitation modality.

Methods

A total of 40 patients who had undergone total laryngectomy participated in the study. Speech rehabilitation was achieved through TES in 20 patients (Group A) or ES in 20 patients (Group B). Olfactory function was evaluated using the Sniffin' Sticks test.

Results

At olfactory evaluation, in Group A, 4/20 patients (20%) were anosmic, whereas 16/20 patients (80%) were hyposmic; in Group B, 11/20 patients (55%) were anosmic whereas 9/20 patients (45%) were hyposmic. A significant difference (p = 0.04) was found at global objective evaluation.

Conclusions

The study shows that the rehabilitation with TES contributes to maintaining a functioning, albeit limited, sense of smell.

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

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

Outcomes of Laryngeal Cancer Surgery after Open Partial Horizontal Laryngectomies with Lateral Cervical Approach

Background: Open partial horizontal laryngectomies (OPHL) are one of the surgical techniques used for the conservative management of laryngeal cancers. The aims of this study are to analyze the oncological and functional results of a group of patients affected by laryngeal squamous cell carcinoma (LSCC) treated with OPHL, performed using a minimally invasive technique. Methods: This is a prospective case−control study. We enrolled 17 consecutive patients with LSCC treated with OPHL through a lateral cervical approach (LCA). Patients were evaluated using their Penetration Aspiration Scale score (liquid, semiliquid and solid) and Voice Handicap Index (VHI) at three different endpoints: 15 days (T1), 3 months (T2), and 6 months (T2) after surgery. Results: The functional outcomes of the LCA are stackable with that of the classical anterior cervical approach in terms of respiration, swallowing, and speech. One-way ANOVA was performed to evaluate the variances of PAS and VHI scores at the three different observation points. No statistically significant differences were observed between OPHL- PAS scores for liquid (p = 0.1) at the three different observation points. A statistically significant improvement was observed in the OPHL- PAS score for semisolids and solids (p < 0.00001) between T1 and T3 (p = 0.0001) and for solids between T2 and T3 (p < 0.00001). The improvement of VHI-10 was statistically significative (p < 0.00001) at the three different observation points (T1−T2 and T2−T3). Conclusion: The LCA is a potential approach for laryngeal surgery in selected cases. The preoperative staging and planning are of the utmost importance to ensure oncological radicality. The main advantage of this approach is the preservation of the healthy tissues surrounding the larynx and the functional and oncological outcomes are stackable with the classic anterior cervical approach.

Prevalence of HPV Infection and p16INK4a Overexpression in Surgically Treated Laryngeal Squamous Cell Carcinoma

Background: The mucosal high-risk (HR) human papillomavirus (HPV) is associated with oropharyngeal carcinogenesis. Aims of this study were to evaluate the prevalence of HR-HPV infection in laryngeal squamous cell carcinoma (LSCC) from different subsites, and the clinico-biological meaning of p16 overexpression. Methods: Ninety-seven LSCCs submitted to primary surgery (n = 75) or to post-irradiation salvage laryngectomy (n = 22) were evaluated for HR-HPV DNA and RNA using Luminex-based assays. p16 immunohistochemistry was performed. Results: HR-HPV DNA from HPV16 was detected in seven cases (8.75%), without significant differences between supraglottic and glottic lesions. HPV RNA was never detected. p16 overexpression correlated with HR-HPV DNA, but the kappa agreement score was poor. HPV DNA showed no impact on prognosis. p16 overexpression was associated with a better survival (OS, RFS) in primarily operated cases, while an inverse association with OS was observed in the salvage surgery group. Conclusions: HR-HPV infection appears to have a marginal role in LSCC independent of the anatomical subsite. p16 expression is deregulated in LSCC independent of HPV but displays a prognostic role in patients submitted to primary surgery. The negative predictive role of p16 overexpression in patients undergoing salvage surgery deserves more investigations for validation and elucidation of its clinical relevance.

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.

pT3 N0 Laryngeal Squamous Cell Carcinoma: Oncologic Outcomes and Prognostic Factors of Surgically Treated Patients

Objectives/Hypothesis

To assess the disease control, survival rates, and prognostic factors of exclusive surgical treatment for patients with pT3 N0 laryngeal squamous cell carcinoma (LSCC).

Study Design

Multicentric retrospective cohort study.

Methods

Multicentric retrospective case series of previously untreated patients with pT3 R0N0 LSCC, who received exclusive surgery between 2011 and 2019. Tumor location; subsite involvement; grading; and lymphatic, vascular, and perineural invasion were reported. Overall survival (OS), disease‐specific survival (DSS), and disease‐free survival (DFS) were measured.

Results

Fifty‐four patients (mean age 67.1; male sex 83.3%; mean follow‐up period 37 months) underwent total laryngectomy (48.1%) or partial laryngectomy (51.9%). Ipsilateral or bilateral neck dissection was performed in 46 (85.2%) cases. Perineural invasion was more frequent in case of supraglottic involvement than glottic involvement (85.7% vs. 14.3%, P = .03). Five (9.3%) patients experienced recurrence (3 local recurrences, 1 nodal recurrence, 1 distant recurrence). Rate of recurrence differed between glottic (0%), supraglottic (80%), and transglottic (20%) tumors (P = .01), with a lower risk yielded by glottic involvement (odds ratio [OR], 0.05, 95% confidence interval [95% CI], 0.01–0.56, P = .01). A higher risk was recorded in case of perineural invasion (OR, 66.0, 95% CI, 1.41–3085.3, P = .03). The OS, DSS, and DFS were 79.6%, 96.3%, and 90.7%, without differences regarding the type of surgery. The DFS was lower in case of supraglottic involvement when compared to purely glottic LSCC (83.9% vs. 100%, P = 0.02).

Conclusions

Exclusive surgery is a safe option for patients with pT3 R0N0 LSCC. Adjuvant treatments or closer follow‐up monitoring might be considered in case of supraglottic involvement or perineural invasion.

Level of Evidence

4 Laryngoscope, 131:2262–2268, 2021

Role of Clinical-Demographic Data in Survival Rates of Advanced Laryngeal Cancer

Background and Objectives: Laryngeal cancer is one of the most common cancers in the upper aerodigestive tract, and tobacco and alcohol habits are the most relevant risk factors. The role of these risk factors in the incidence of laryngeal carcinomas is well known, yet only a few studies have been conducted on their role as risk factors of prognosis. The aim of the study was to assess the impact of clinical–demographic data on overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) in patients with advanced-stage laryngeal cancer (Stage III–IV) who underwent total laryngectomy. Materials and Methods: This retrospective study was carried out on patients with Stage III–IV laryngeal squamous cell carcinoma treated with total laryngectomy between 2004 and 2014. For each patient, clinical and anamnestic data were collected and collated in a database, including alcohol and smoking habits. Results: Considering the variable age, family history, alcohol, grading, subsite, stage, pT stage, pN stage, and adjuvant therapy, no statistical significance was found for five-year OS. Smoking was the only variable that was statistically significant (p = 0.0043). A relevant difference was noted in the five-year DFS between pN-negative and pN-positive tumors (74.3% vs. 55.26%, respectively; p = 0.056), and a statistically significant difference was found between non- and ≤20 cigarettes/day smokers and heavy smokers (77.78% vs. 53.66%, respectively; p = 0.021). The five-year disease-specific survival rate was 68.83%, and a significant difference was detected for the smoking and pN stage variables. Heavy smokers (43.90% died vs. 16.67% of the non- and ≤20 cigarettes/day smokers; p = 0.0057) and pN-positive (42.1% died vs. 20.51% of the pN-negative patients; p = 0.042) patients had a worse prognosis. Conclusion: Smoking in our study was found to be an important independent risk factor for worse OS and DSS in patients with advanced laryngeal cancer.

Early glottic cancer recurrence: A critical review on its current management

INTRODUCTION

Recurrent early glottic cancer (rEGC) poses several issues in terms of timely diagnosis, correct re-staging, and treatment. We want to critically review the latest evidence about rEGC considering its epidemiology, biology, diagnostic challenges, and treatment strategies.

METHODS

A systematic search of the literature using PubMed from 1990 to October 31, 2020 was performed.

RESULTS

There are many different treatment options available (open surgery, transoral mini-invasive surgery, radiotherapy), and many factors related to the patient's status and previous treatments must be considered when planning the best management strategy for rEGC. While its overall prognosis remains satisfactory, it is of the utmost importance to appreciate all the clinical implications derived from the choice of the initial therapeutic modality, and from a correct primary and recurrent staging.

CONCLUSION

The balance between oncological and voice and swallowing functions represents the fundamental principle underlying rEGC management. Future studies should focus on molecular profiling of rEGC, and on the results of the emerging radiation delivery techniques and mini-invasive procedures.

Laser Microsurgery Versus Radiotherapy Versus Open Partial Laryngectomy for T2 Laryngeal Carcinoma: A Systematic Review of Oncological Outcomes

INTRODUCTION

The aim of the current systematic review is to update the pooled survival outcome of patients with T2 glottic carcinoma treated with either laser surgery (CO₂ transoral laser microsurgery [CO₂ TOLMS]), radiotherapy (RT), or open partial laryngectomy (OPL).

METHODS

A systematic search was performed using the MEDLINE database, Scopus, and Google scholar. The inclusion criteria were studies of patients with T2N0 glottic tumor, treated with either primary CO₂ TOLMS, definitive curative RT, or primary OPL, and with reported oncological outcome at 5 years calculated with a Kaplan-Meier or Cox regression method.

RESULTS

The results of the current review show that local control (LC) is higher with OPL 94.4%, while there are no differences in LC at 5-year posttreatment for patients treated with RT, compared to those treated with CO₂ TOLMS (respectively, 75.6% and 75.4%). Primary treatment with OPL and CO₂ TOLMS results in higher laryngeal preservation than primary treatment with RT (respectively 95.8%, 86.9%, and 82.4%).

CONCLUSION

First-line treatment with OPL and CO₂ TOLMS should be encouraged in selected T2 patients, because it results in higher laryngeal preservation and similar LC compared to primary treatment with RT. The involvement of the anterior commissure in the craniocaudal plane and T2b impaired vocal cord mobility have a poorer prognosis and LC compared to patients with T2a tumors for both CO₂ TOLMS and RT.

Elevated peripheral inflammatory markers are related with the recurrence and canceration of vocal fold leukoplakia

OBJECTIVE

To evaluate the predictive value of preoperative peripheral inflammatory markers in patients with vocal fold leukoplakia.

METHODS

A retrospective study was performed of the patients diagnosed with vocal fold leukoplakia and who accepted carbon dioxide (CO₂) laser resection in our center in the last 10 years. We calculated the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and monocyte-to-lymphocyte ratio (MLR) after collecting and analyzing the clinical, histopathological and laboratory data. The potential relation between blood indexes and clinical events as recurrence or canceration was evaluated.

RESULTS

A total of 589 patients were involved, including 300 cases without recurrence (group A), 198 with recurrence but not canceration (group B) and 91 transformed into squamous cancer (group C). Baseline analysis of NLR, PLR, and MLR showed no difference among the three groups before the first surgery. But all the indexes significantly elevated in groups B (P < 0.001, < 0.001, 0.023, respectively) and C (P = 0.009, 0.004, 0.007, respectively) in the last operation. The receiver-operating curve (ROC) analysis showed NLR as a potential marker of canceration of leukoplakia (AUC = 0.837) and the cutoff value was 2.505. When regrouping with pathological outcomes, severe dysplasia and squamous cell carcinoma (SCC) groups both revealed a higher level of NLR, PLR, and MLR comparing to the no dysplasia, mild dysplasia, and moderate dysplasia groups. NLR, PLR, and MLR in high-risk group (moderate, severe dysplasia and carcinoma) also elevated comparing to low-risk group (no dysplasia, mild dysplasia) (P = 0.039, 0.011, 0.007, respectively).

CONCLUSIONS

The peripheral inflammatory markers NLR, PLR, and MLR are closely connected with the development of vocal fold leukoplakia. NLR may be a potential marker to predict the poor outcomes (recurrence or canceration) of patients in first surgery.

Limitations and Opportunities in Open Laryngeal Organ Preservation Surgery: Current Role of OPHLs

The current trend for treatment of intermediate-early advanced laryngeal cancer is essentially oriented toward preservation of organ and laryngeal function, and with a good potential for treating the disease. This goal can be achieved by adopting open laryngeal organ preservation surgery (OLOPS), at present mainly represented by open partial horizontal laryngectomies (OPHLs). An approach using rigorous selection criteria based on both the general condition of the patient and the local and regional extent of the disease gives excellent oncological and functional results in untreated patients. Similar outcomes, albeit slightly worse, are also obtainable in radio-recurrent and laser-recurrent patients. Troublesome postoperative management and the inconsistency of functional recovery are the main limitations for extensive application of this therapeutic strategy. The future direction is represented by simplification of the indications identifying iso-prognostic sub-categories within the T-stage, wider consensus on rehabilitation protocols, hybrid approaches to the larynx, and open minimally invasive access.

Salvage open partial horizontal laryngectomy after failed radiotherapy: A multicentric study

OBJECTIVES

The primary aim of the present study was to report our multi-institutional experience in surgical salvage with open partial horizontal laryngectomies (OPHL) after failed radiotherapy (RT) for laryngeal squamous cell carcinoma (LSCC). Secondary aims were to analyze the prognostic meaning of the main clinical and pathological parameters in relation to the oncologic outcome and to compare our results with the available literature.

STUDY DESIGN

A retrospective multicenter analysis of surgical oncological outcomes.

METHODS

We retrospectively review the clinical charts of 70 recurrent LSCC patients after primary RT failure undergone salvage OPHL.

RESULTS

At last follow-up, 46 patients (65%) were disease-free; six (9%) were alive with disease; nine (12%) died because of the disease; and nine (12%) died without evidence of disease. The final local control, overall survival, disease-specific survival, and laryngectomy-free survival were 87%, 75%, 87%, and 91%, respectively. Twelve patients (17%) experienced postoperative complications, whereas 18 patients (25%) experienced late sequelae. In five patients (7%), decannulation was not possible because of postoperative laryngeal stenosis.

CONCLUSION

In selected patients, when proper selection criteria for conservation laryngeal surgery are adopted, OPHL can be considered for salvage after RT failure.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:431-436, 2020.

Free bipaddled anterolateral thigh flap for simultaneous reconstruction of large larynx and prelaryngeal skin defects after resection of the local recurrent laryngeal cancer invading the cricoid cartilage and prelaryngeal skin: A case report

RATIONALE

After total or near-total laryngectomy and resection of prelaryngeal skin, laryngeal defects and prelaryngeal skin defects often remain a great challenge for head and neck surgeons when considering simultaneous reconstruction of. In this case report, a free bipaddled anterolateral thigh (ALT) was used for such defects reconstruction.

PATIENT CONCERNS

For this 50-year-old male patient whose recurrent tumor invaded the cricoid cartilage and the prelaryngeal skin, supracricoid partial laryngectomy with a cricohyoidepiglottopexy would no longer be an option. However, the patient had a strong requirement of preserving lung-power speech, making total laryngectomy and chemoradiotherapy not acceptable.

DIAGNOSIS

Pathologic result demonstrated well-differentiated squamous cell carcinoma. A PET-CT of the whole body showed extralaryngeal extension of the tumor invading the cricoids cartilage and prelaryngeal ribbon muscles and skin. Meanwhile, the video-laryngoscpy showed smooth laryngeal mucosa.

INTERVENTIONS

A near-total laryngectomy and resection of prelaryngeal skin were performed. The resultant defects were reconstructed with a free bipaddled ALT flap.

OUTCOMES

The patient is 18 months postsurgery with no locoregion tumor recurrence, taking oral feeds, partial lung-power speech and not decannulated. Laryngostenosis was shown by the videolaryngoscopy, MRI and CT scan.

LESSONS

A free bipaddled ALT flap could be utilized for simultaneous reconstruction of large larynx and prelaryngeal skin defects, and allows partial laryngeal function preservation in selected local recurrent laryngeal cancer invading the cricoid cartilage and prelaryngeal skin.

Oncologic and functional outcomes of salvage supracricoid partial laryngectomy

BACKGROUND

Supracricoid partial laryngectomy (SCL) can have a positive impact on patients' quality of life by circumventing dysphagia and voice problems resulting from creation of a permanent stoma after conventional total laryngectomy (TL) surgery.

AIMS/OBJECTIVES

The aim of this study was to investigate the oncologic and functional outcomes of salvage SCL for recurrent laryngeal carcinoma.

MATERIAL AND METHODS

Forty-five patients that underwent salvage surgery for recurrent laryngeal carcinoma between January 2004 and May 2015 after initial treatment failure were included in this retrospective study.

RESULTS

Overall survival and disease free survival were non-significantly higher in the salvage SCL group (n = 14) than in the salvage TL group (n = 31) (87.5 versus 56.5%, 53.4 versus 41.9%). Multivariate analyses showed only positive resection margin to be significantly associated with survival and recurrence (HR 9.974, p = .007, and HR 9.196, p = .002, respectively). In the salvage SCL group, 92.8% achieved successful decannulation and all patients returned to an oral diet. All patients in the salvage TL group sustained a permanent stoma and conversation was possible only through esophageal voice or a voice prosthesis. 74.2% of patients in the group were able to tolerate an oral diet.

CONCLUSIONS AND SIGNIFICANCE

Salvage SCL showed comparable oncologic outcomes and favorable functional outcomes relative to the classic salvage TL. This study could provide a sufficient basis of SCL as salvage treatment for recurrent laryngeal carcinoma in selected patients.

ENT COBRA ONTOLOGY: the covariates classification system proposed by the Head & Neck and Skin GEC-ESTRO Working Group for interdisciplinary standardized data collection in head and neck patient cohorts treated with interventional radiotherapy (brachytherapy)

PURPOSE

Clinical data collecting is expensive in terms of time and human resources. Data can be collected in different ways; therefore, performing multicentric research based on previously stored data is often difficult. The primary objective of the ENT COBRA (COnsortium for BRachytherapy data Analysis) ontology is to define a specific terminological system to standardized data collection for head and neck (H&N) cancer patients treated with interventional radiotherapy.

MATERIAL AND METHODS

ENT-COBRA is a consortium for standardized data collection for H&N patients treated with interventional radiotherapy. It is linked to H&N and Skin GEC-ESTRO Working Group and includes 11 centers from 6 countries. Its ontology was firstly defined by a multicentric working group, then evaluated by the consortium followed by a multi-professional technical commission involving a mathematician, an engineer, a physician with experience in data storage, a programmer, and a software expert.

RESULTS

Two hundred and forty variables were defined on 13 input forms. There are 3 levels, each offering a specific type of analysis: 1. Registry level (epidemiology analysis); 2. Procedures level (standard oncology analysis); 3. Research level (radiomics analysis). The ontology was approved by the consortium and technical commission; an ad-hoc software architecture ("broker") remaps the data present in already existing storage systems of the various centers according to the shared terminology system. The first data sharing was successfully performed using COBRA software and the ENT COBRA Ontology, automatically collecting data directly from 3 different hospital databases (Lübeck, Navarra, and Rome) in November 2017.

CONCLUSIONS

The COBRA Ontology is a good response to the multi-dimensional criticalities of data collection, retrieval, and usability. It allows to create a software for large multicentric databases with implementation of specific remapping functions wherever necessary. This approach is well-received by all involved parties, primarily because it does not change a single center's storing technologies, procedures, and habits.

Supracricoid partial laryngectomy for radiorecurrent laryngeal cancer: a systematic review of the literature and meta-analysis

PURPOSE

The objective of the current systematic review with meta-analysis was to report the pooled survival outcomes of supracricoid partial laryngectomy in the setting of radiorecurrent laryngeal cancer to investigate if and when an organ-sparing surgical treatment is adequate.

METHODS

The search included all original papers from 1990 to December 2017. The search terms included the following: cricohyoepiglottopexy; cricohyoidopexy; cricohyopexy; horizontal laryngectomy; and partial, subtotal, supracricoid, and supraglottic laryngectomy. Inclusion criteria were as follows: (1) data clearly distinguish results of partial laryngeal procedures; (2) clear description of tumor stage and selection criteria; (3) clear description or derivability of local control and survival rates.

RESULTS

Eleven out of 270 papers were analyzed, and a total of 251 cases were included. Two-year LC, 3-year DFS, and 5-year OS were 92, 80, and 79%, respectively. Heterogenicity evaluated with the I² parameter was 14, 0, 0%, respectively. The larynx preservation rate was 85.2%, the decannulation rate was 92.1%, and swallowing recovery was 96.5% (PEG dependence and the aspiration pneumonia rate were 3.5 and 6.4%, respectively).

CONCLUSIONS

SCPL is oncologically sound, guaranteeing a high percentage of success. The homogeneity of data should encourage the use of SCPL as salvage treatment for recurrent LSCC.

Supracricoid laryngectomy for recurrent laryngeal cancer after chemoradiotherapy: a systematic review and meta-analysis

Residual or recurrent laryngeal cancer after irradiation is a difficult clinical problem with a rate that ranges from 13% to 36% of cases. Supracricoid laryngectomy (SCL) with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP) provide reliable oncological and functional results for selected primary and recurrent patients with glottic and supraglottic carcinomas. We conducted a systematic review and meta-analysis to assess the oncological and functional outcomes of patients treated with open partial horizontal laryngectomy types IIa and IIb (CHEP, CHP) in terms of the recurrence of squamocellular cancer of the larynx after radiotherapy failure. The databases searched included MEDLINE, PubMed and EMBASE (from January 1990 to December 2015, English language). The meta-analysis was performed with a mixed random effects model using the DerSimonian and Laird method. The heterogeneity was measured with the I² statistic. Fourteen papers out of 276 were included and comprised a total of 291 patients. The five-year overall survival was 80.2% (CI 0.719-0.885; I² = 62%; p = 0.003), and the 5-year disease-free survival was 89.5% (CI 0.838-0.952; I² = 52%; p = 0.022). The indications for SCL after the failure of radiation therapy (RT) were similar to those specified for previously untreated patients. We therefore hypothesised that careful assessment of tumour extension might be responsible for the high 5-year OS and 5-year DFS. The early postoperative recovery outcomes indicated that the mean time until decannulation was 35.6 days (CI 24.3-46.9; I² = 95%; p < 0.001), and the mean time until nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG) removal was 28.3 days (CI 22.7-33.8; I² = 86%; p< = 0.001). These data are according to authors who prefer the initial removal of the NGT and the initiation of oral alimentation with a tracheostomy tube to protect and clean the airways and permit the suction of any residual food that might be present.

Role of epithelial-mesenchymal transition markers E-cadherin, N-cadherin, β-catenin and ZEB2 in laryngeal squamous cell carcinoma

Epithelial-mesenchymal transition (EMT) allows neoplastic cells to gain the invasive phenotype and become migratory, which is required for cancer progression and metastasis. In the present study, the expression of EMT-associated biomarkers and their association with clinicopathological parameters in laryngeal squamous cell carcinoma (LSCC) was investigated. E-cadherin, N-cadherin, β-catenin and zinc finger E-box binding homeobox 2 (ZEB2) protein expression was evaluated with immunohistochemistry in a cohort of 76 patients with operable LSCC. The association between these transition markers, clinicopathological parameters and their prognostic impact in LSCC was analyzed. Immunohistochemical analysis revealed that EMT-associated proteins were differentially expressed between LSCC and adjacent non-neoplastic laryngeal tissue. Negative E-cadherin expression and positive N-cadherin, β-catenin and ZEB2 expression were associated with a later tumor (T) stage, decreasing tumor differentiation and a reduced overall survival (OS) time (OS: E-cadherin, P=0.016; N-cadherin, P=0.003; β-catenin, P=0.002; ZEB2, P=0.0003). E-cadherin/β-catenin co-expression was significantly associated with the majority of clinicopathological parameters assessed, including lymph node metastases, T stage and tumor cell differentiation (P=0.004, P=0.005, and P<0.001, respectively). Multivariate analysis indicated that T stage and the positive expression of β-catenin and ZEB2 were independent risk factors for OS in LSCC (P=0.014, P=0.025 and P=0.003, respectively). It was concluded that EMT mediates tumor progression, and reduces OS time in patients with LSCC. E-cadherin/β-catenin co-expression may be associated with clinicopathological parameters. T stage, and the positive co-expression of β-catenin and ZEB2 may be independent predictors of prognosis in LSCC.

Salvage Surgery after Radiation Failure in T1/T2 Larynx Cancer: Outcomes following Total versus Conservation Surgery

Objective

After radiation failure for early T-stage larynx cancer, national guidelines recommend salvage surgery. Total laryngectomy and conservation laryngeal surgery with an open or endoscopic approach are both used. Beyond single-institution studies, there is a lack of evidence concerning the outcomes of these procedures. We aim to study whether treatment with conservation laryngeal surgery is associated with poorer outcomes than treatment with total laryngectomy as salvage surgery after radiation failure for T1/T2 larynx cancers.

Study Design

A retrospective study was conducted of adult squamous cell larynx cancer cases in the National Cancer Database diagnosed from 2004 to 2012.

Setting

Commission on Cancer cancer programs in the United States.

Methods

Demographic, facility, tumor, and survival variables were included in the analyses. Multivariate survival regressions as well as univariate Kaplan-Meier analyses were conducted.

Results

Slightly more than 7% of patients receiving radiotherapy for T1/T2 larynx cancers later received salvage surgery. Salvage with partial laryngectomy was not associated with diminished survival as compared with total laryngectomy. However, positive surgical margins were associated with worse outcomes (hazard ratio, 1.782; P = .001), and a larger percentage of patients receiving partial laryngectomy had positive margins than those receiving total laryngectomy. Facility characteristics were not associated with differences in salvage surgery type or outcomes.

Conclusion

In recognition of the inherent selection bias, patients who experienced recurrences after radiation for T1/T2 larynx cancer and underwent conservation salvage laryngeal surgery demonstrated clinical outcomes similar to those of patients undergoing salvage total laryngectomy. Increased rates of positive surgical margins were observed among patients undergoing salvage conservation surgery.

Salvage total laryngectomy after conservation laryngeal surgery for recurrent laryngeal squamous cell carcinoma

The aim of the present study was to evaluate the oncological efficacy of salvage total laryngectomy in patients who had previously undergone supracricoid partial laryngectomy or transoral laser microsurgery for treatment of laryngeal squamous cell carcinoma. We retrospectively reviewed the medical, surgical and pathological records of 35 patients who underwent salvage total laryngectomy after recurrence of laryngeal cancer (following supracricoid partial laryngectomy or transoral laser microsurgery). Kaplan-Meier survival curves as well as univariate and multivariate analyses of prognostic factors were performed. No statistically significant differences were seen comparing the supracricoid partial laryngectomy group with the transoral laser microsurgery group for overall survival and disease-specific survival at 3 years (OS = 38% vs. 52%, p = 0.16; DSS = 40% vs. 61%, p = 0.057) or locoregional control at 2 years (LRC = 40% vs. 54%, p = 0.056). A trend indicating worse survival and locoregional control for supracricoid partial laryngectomy patients emerged. Preservation of the osteocartilaginous frame in transoral laser microsurgery could hypothetically result in better salvageability of anterior recurrences with extralaryngeal spread.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

Laringectomias supracricóides: revisão de literatura em protocolos de qualidade de vida

RESUMO: A Laringectomia Parcial Supracricóide (LPSC) é indicada para tratamento de tumores com estadiamento1 e 2 e certos casos de tumores avançados. É considerada pela literatura como apresentando resultados satisfatórios em ambas situações, preservação da laringe e funcionalidade. Este estudo tem como objetivo rever de forma sistemática a literatura voltada para qualidade de vida em voz de pacientes submetidos a LPSC, identificando-se os protocolos de qualidade de vida em câncer de cabeça e pescoço. Para a revisão de literatura sistemática exploratória foram considerados os seguintes bancos de dados: MEDLINE, SciELO, LILACS; PubMed. Utilizados descritores em português, inglês e espanhol. A seleção dos artigos seguiu critérios de inclusão, para aplicação de teste de Relevância. Esta revisão de literatura revelou que os protocolos específicos para pacientes oncológicos de cabeça e pescoço mais utilizados são o EORTC-C30/H&N35, UW-QOL e HNQOL. A LPSC embora seja considerada uma cirurgia que vise à preservação das funções de deglutição e fonação é apontada como tendo possibilidade de permanência de queixas em tais funções. A literatura afirma que os pacientes se declaram satisfeitos com a própria voz, tendo pouca dificuldade para se comunicar de forma inteligível. Estudos relacionam pacientes com dificuldades respiratórias após LPSC, inclusive com apneia obstrutiva do sono. Conclui-se que há necessidade de mais pesquisas que visem pontuar as dificuldades resultantes da LPSC e que utilizem protocolos específicos em cabeça e pescoço, para melhor mostrar o impacto da LPSC na qualidade de vida.

The prognostic role of E-cadherin and β-catenin overexpression in laryngeal squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Epithelial-to-mesenchymal transition (EMT) consists of a rapid and reversible change in the cellular phenotype toward the mesenchymal cell phenotype that facilitates cell migration and invasion of the tumor into surrounding tissues followed by metastasis. In the present study, we sought to determine the clinical significance of E-cadherin, N-cadherin, β-catenin, α-catenin, γ-catenin, caveolin-1, and vimentin in a cohort of patients with stage I to IVA laryngeal squamous cell carcinoma (LSCC) treated with surgery with or without adjuvant therapy using immunohistochemical analyses.

STUDY DESIGN

Individual retrospective cohort study.

METHODS

E-cadherin, N-cadherin, β-catenin, α-catenin, γ-catenin, caveolin-1, and vimentin immunohistochemical expression were evaluated in a cohort of 82 patients with stages I to IVA LSCC. The Fisher exact test was used for categorical variables, and the Mann-Whitney test where appropriate for continuous variables. Survival comparisons was performed using the log-rank test. A multivariate analysis using the Cox proportional hazards model was performed and considered all EMT markers.

RESULTS

In multivariate analysis, T stage was an independent risk factor for adverse disease-specific survival (DSS) and overall survival (OS) (P = .025 and .019, respectively). Cytoplasmic β-catenin overexpression was independently associated with a longer DSS (P = .0007), and E-cadherin overexpression was found to be an independent risk factor for poor OS (P = .030).

CONCLUSIONS

E-cadherin and β-catenin pathways could represent future therapeutic targets in the treatment of LSCC. However, validation of our results in prospective cohorts of patients with LSCCs is required before their clinical implementation.

LEVEL OF EVIDENCE

NA.

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.