Effectiveness and feasibility of selective intra-arterial low dose of cisplatin infusion and concomitant radiotherapy for patients with advanced laryngeal cancer with impaired renal function: A retrospective cohort study

BACKGROUND

Chemoradiation therapy with high-dose cisplatin is the standard regimen against advanced squamous cell carcinoma of the larynx (SCC-L). However, patients with renal dysfunction are ineligible for this regimen. We investigated the effectiveness and feasibility of selective intra-arterial low-dose cisplatin infusion and radiotherapy (modified [m]-RADPLAT) for patients with impaired renal function.

METHODS

We retrospectively reviewed the data of 77 patients with SCC-L who received m-RADPLAT.

RESULTS

Fourteen and 63 patients had creatinine clearance (CrCl) values of 30 ≤ CrCl < 60 mL/min and ≥60 mL/min, respectively. The m-RADPLAT regimen led to no significant changes in serum creatinine or CrCl values post-treatment. The 5-year local control, overall survival, and laryngectomy-free survival rates of the CrCl < 60 and ≥60 groups were 90.0% and 90.5%, 100% and 81.8%, and 100% and 79.0%, respectively. Grade 3 or higher toxicity rates were not significantly different between the groups.

CONCLUSIONS

The m-RADPLAT regimen yielded favorable survival rates and clinical outcomes in patients with impaired renal function.

Radiation for Early Glottic Cancer

Multidisciplinary evaluation of early-stage glottic cancer facilitates optimal treatment with either surgery or radiation therapy. Standard of care radiation treatment of early-stage glottic cancer continues to be three-dimensional opposed lateral fields to include the whole larynx. Modern radiation treatment techniques are allowing studies to examine the efficacy and toxicity of altered doses and treatment volumes. Advanced techniques, such as stereotactic body radiation therapy or single-vocal cord irradiation, are not yet considered standard of care for early-stage glottic cancer and should be performed at institutions with clinical trials to ensure adequate expertise and quality assurance.

Mobility of the arytenoid cartilage in glottic carcinoma: a CT image study

BACKGROUND

Laryngeal carcinomas cause vocal cord (VC) mobility problems. Other than evaluation through flexible laryngoscopy, rare reports concerning CT findings for the motion of the VC or arytenoid cartilage (AC) are found.

AIMS/OBJECTIVES

To explore a novel evaluation of the mobility of the AC in glottic carcinoma.

MATERIAL AND METHODS

In 39 patients with glottic carcinoma grouped upon lesion locations and AC mobilities, laryngeal CT scans were collected during inspiration and phonation. AC static position and motion data were compared between paired lesion and control sides.

RESULTS

No significant difference showed in the group with glottic carcinoma invading the anterior 2/3 of VC. In the abnormal mobility group, significant AC position changes and weaker motion of most measurements were proved on the lesion side. Lesion invading the posterior 1/3 of VC also resulted in an adducted, medially rotated and forward-tilted AC, rotation of axial angle (RAA) was the only motion item that decreased significantly.

CONCLUSIONS AND SIGNIFICANCE

In most glottic cancer cases, CT and laryngoscope had similar judgments for AC mobility. For lesions extending to the cartilaginous VC with laryngoscopically confirmed normal mobility, CT measurement of RAA showed the feasibility of being an indicator for the earliest motion problem.

Early-stage vocal cord cancer treated with hypofractionated radiotherapy to the larynx with or without concurrent chemotherapy

BACKGROUND

We report outcomes among patients with T2 and select T3 glottic squamous cell carcinoma (SCC) treated with radiotherapy.

METHODS

We reviewed T2 and T3 (only paraglottic space invasion) N0 M0 glottic SCC patients treated with curative-intent hypofractionated larynx radiotherapy, with or without concurrent systemic therapy.

RESULTS

Of 71 patients, those who received concurrent chemotherapy (23/71; 32%) had worse prognostic factors, including impaired cord mobility (70% vs. 40%, p = 0.02) and larger median gross tumor volume (3.0 vs. 1.6 cm³ , p = 0.003). Over a median follow-up of 3.8 years, 2-year local control among patients with impaired cord mobility appeared higher for those who received chemotherapy (88% vs. 61%, p = 0.12), but the difference was not statistically significant. Acute and late toxicity rates were not higher among patients who received chemotherapy.

CONCLUSIONS

The addition of concurrent platinum-based chemotherapy to hypofractionated larynx radiotherapy among patients with early-stage glottic SCC with impaired cord mobility appears safe and worthy of additional investigation.

Comparative Treatment Outcome in T3N0 Glottic Cancer With and Without Vocal Fold Fixation Receiving Radiation Therapy and Concurrent Low-Dose Intra-Arterial Cisplatin Infusion

OBJECTIVES

Selective radiotherapy and concomitant intra-arterial cisplatin infusion (m-RADPLAT) with a lower cisplatin dosage have been performed for organ and function preservation in patients with locally advanced squamous cell carcinoma of the larynx (SCC-L), and results showing a lower rate of adverse events have been reported. This study evaluated the treatment outcomes of patients with T3N0 glottic SCC-L with or without vocal fold fixation (VFF) who were treated with m-RADPLAT.

METHODS

We retrospectively reviewed the data of 33 patients with T3N0 SCC-L who received m-RADPLAT.

RESULTS

The vocal fold in patients with VFF 3 months after completing m-RADPLAT resumed normal movement in 15 patients (83%) and persisted fixation in 3 (17%). The 3-year local control, laryngeal cancer-specific survival, and overall survival rates of patients with or without VFF were 88.9% and 86.7%, 94.1% and 93.3%, and 88.9% and 86.7%, respectively. Additionally, the 3-year freedom from laryngectomy, laryngectomy-free survival, and laryngo-esophageal dysfunction-free survival rates of patients with or without VFF were 94.4% and 86.7%, 88.9% and 73.3%, and 83.3% and 73.3%, respectively. Grade 3 or higher toxicities were observed in all patients: leukopenia in 4 patients (12%), neutropenia in 5 (15%), anemia in 2 (6%), thrombocytopenia in 3 (9%), and mucositis in 2 (6%).

CONCLUSIONS

This study demonstrated that m-RADPLAT yielded VFF improvement and a favorable survival while maintaining laryngeal function not only in patients with T3N0 glottic SCC-L without VFF but also in patients with VFF.

Novel predictive tools and therapeutic strategies for patients with initially diagnosed glottic cancer in the United States

OBJECTIVE

The objective of this study is to identify valuable prognostic factors, build clinical prediction nomograms, and recommend the optimal therapeutic strategy for patients with initially diagnosed glottic cancer.

METHODS

Patients were extracted from the SEER database. Cox regression analyses, survival analyses, an internal validation, the propensity score analysis, and the competing risk analysis were performed.

RESULTS

Nine overlapped factors were considered as valuable prognostic factors. Furthermore, nomograms were established for clinical prediction models to assess the 1-, 3-, and 5-year overall survival (OS) and cancer-specific survival (CSS). C-indexes, receiver operating characteristic curves, calibration curves, and decision curve analyses proved that nomograms showed better predictive accuracy, ability, and prognostic value compared to the American Joint Committee on Cancer stage. For patients in stage I, primary site surgery alone would acquire best OS and CSS. For patients in stage II, primary site surgery and/or radiation would gain better OS and CSS. For patients in stage III, radiation plus chemotherapy or primary site surgery (alone or plus radiation) would acquire better OS and CSS. Moreover, for patients in stage IV, primary site surgery plus radiation would gain better OS and CSS.

CONCLUSIONS

Nomograms could be useful for patients' counseling and guide therapeutic decision-making. Primary site surgery alone may likely be the optimal therapy for stage I glottic cancer, and primary site surgery and/or radiation may be the recommended therapy for stage II glottic cancer. The combination treatment would be the preferred choice for advanced-stage (stage III & IV) glottic cancer, and the role of chemotherapy needs to be further explored.

Prognostic risk factors for initially diagnosed T2N0M0 glottic cancer: competing risk analysis and propensity-score matched cohort analysis

BACKGROUND

Prognostic risk factors of patients with initially diagnosed T2N0M0 glottic cancer remain unclear. This study was aimed to conduct a comprehensive analysis to identify valuable prognostic risk factors for initially diagnosed T2N0M0 glottic cancer.

METHODS

Data of patients with initially diagnosed T2N0M0 glottic cancer were extracted from the Surveillance, Epidemiology, and End Results database. Survival analyses and Cox regression analyses were conducted to evaluate overall survival (OS) and cancer-specific survival (CSS). In consideration of competing events, the competing risk (CR) analysis was applied. Furthermore, propensity-score matching (PSM) was applied to mimic randomized-controlled trials and reduce selection bias.

RESULTS

A total of 923 eligible patients met the inclusion criteria. Survival analyses showed that age, marital status, primary site surgery, and radiation were independent predictors of OS. Besides, age, marital status, primary site surgery, radiation, and chemotherapy were independent predictors of CSS. Cox regression analyses and the CR analysis were basically consistent with this result. In addition, an internal validation and PSM were performed to explore the role of chemotherapy.

CONCLUSION

We conducted a comprehensive analysis to prove that age, marital status, primary site surgery, radiation, and chemotherapy may be valuable prognostic risk factors for initially diagnosed T2N0M0 glottic cancer. Primary site surgery and radiation should be recommended, whereas chemotherapy was likely not suitable so far. Furthermore, we constructed a CR nomogram to predict survival rates.

Outcomes after radiation therapy for T2N0/stage II glottic squamous cell carcinoma

BACKGROUND

We report outcomes for patients with T2N0M0 glottic squamous cell carcinoma (SCC) treated with radiation therapy (RT).

METHODS

Patients who received definitive RT for T2 glottic SCC from 2000 through 2013 were retrospectively reviewed.

RESULTS

One hundred and thirteen patients were analyzed (median follow-up time 91 months; 85 patients received three-dimensional conformal radiotherapy [3D-CRT] and 28 received intensity-modulated radiation therapy [IMRT]). Fractionation was conventional (58%) or altered (42%); 20 patients (18%) received concurrent chemotherapy. Five-year local control was 83% for the 3D-CRT vs 81% for the IMRT group (P = .76). The ultimate locoregional control at 5 years was 100% for IMRT vs 91% for 3D-CRT (P = .1). The 5-year overall survival (OS) was 78% for 3D-CRT vs 81% for IMRT (P = .83). On multivariate analysis, younger age was the only independent predictor of improved OS (P = .0002).

CONCLUSIONS

Oncologic and survival outcomes were excellent for patients with T2N0 glottic cancer. Patients treated with IMRT and 3D-CRT had no statistically significant differences in all investigated endpoints.

Radiotherapy in the management of glottic squamous cell carcinoma

INTRODUCTION

Our purpose is to review the role radiotherapy (RT) in the treatment of glottic squamous cell carcinoma (SCC).

METHODS

A concise review of the pertinent literature.

RESULTS

RT cure rates are Tis- T1N0, 90% to 95%; T2N0, 70% to 80%; low-volume T3-T4a, 65% to 70%. Concomitant cisplatin is given for T3-T4a SCCs. Severe complications occur in 1% to 2% for Tis-T2N0 and 10% for T3-T4a SCCs. Patients with high-volume T3-T4 SCCs undergo total laryngectomy, neck dissection, and postoperative RT. Those with positive margins and/or extranodal extension receive concomitant cisplatin. The likelihood of local-regional control at 5 years is 85% to 90%. Severe complications occur in 5% to 10%.

CONCLUSIONS

RT is a good treatment option for patients with Tis-T2N0 and low-volume T3-T4a glottic SCCs. Patients with higher volume T3-T4 cancers are best treated with surgery and postoperative RT.

Predictors of chemotherapy and its effects in early stage squamous cell carcinoma of the larynx

BACKGROUND

Squamous cell carcinoma (SCC) of larynx is a common head and neck cancer. For cases that are node negative, the role of definitive concurrent chemoradiation is unclear and not supported by guidelines but used at provider discretion. To address this knowledge gap, we examined the oncological outcomes with additional chemotherapy and factors correlated with the chemotherapy administration.

METHODS

We queried the National Cancer Database for patients with early stage (T2N0M0) laryngeal SCC treated nonsurgically. Multivariable logistic regression identified predictors of chemotherapy. Multivariable Cox regression evaluated predictors of survival. Propensity matching accounted for indication biases.

RESULTS

We identified 7181 patients meeting the eligibility criteria, of which 1568 (22%) patients received chemotherapy in addition to radiation. Predictors of chemotherapy use included younger age, Caucasian race, more remote year of treatment, higher grade, sites other than glottis, treatment at a community cancer center, and use of intensity-modulated radiation therapy. Median overall survival was not significantly different in the two arms analyzed-65 months (95% confidence interval [CI] 60, 72months) with chemotherapy compared to 70 months without chemotherapy (95% CI 66, 75 months, P<.37). Predictors for survival on propensity-matched multivariable analysis were increased age, male sex, less education, lower income, higher comorbidity score, receipt of treatment at a community center, and nonglottic sites.

CONCLUSIONS

This study shows no clear survival benefit with chemotherapy in early stage disease. Although this implies that chemotherapy should not be routinely delivered, individualized judgment and prospective studies are recommended as the biology behind this interesting finding is undefined.

LEVEL OF EVIDENCE

2C (Outcomes Research).

Organ preservation following radiation therapy and concurrent intra-arterial low dose cisplatin infusion for advanced T2 and T3 laryngeal cancer: Long-term clinical results from a pilot study

BACKGROUND

This pilot study evaluated the long-term outcomes of patients with advanced T2 or T3 squamous cell carcinoma of the larynx (SCC-L) who were treated with selective intra-arterial cisplatin and concomitant radiotherapy (RADPLAT).

METHODS

We retrospectively investigated the data of 49 patients with advanced T2 or T3 SCC-L who received a RADPLAT regimen with low-dose cisplatin.

RESULTS

The 5-year locoregional control, disease-specific survival, and overall survival rates were 83.3%, 88.1%, and 82.6%, respectively, while the 5-year freedom from laryngectomy, laryngectomy-free survival, and laryngo-esophageal dysfunction-free survival rates were 89.6%, 79.4%, and 77.1%, respectively. The incidences of grade 3-4 hematologic and nonhematologic toxicities were 18% and 6%, respectively. Although two patients (4%) developed late toxicities within 5 years following RADPLAT, no other events were noted beyond 5 years.

CONCLUSION

This pilot study demonstrated that RADPLAT is feasible and safe and yielded favorable survival outcomes and functional laryngeal preservation in patients with advanced T2 or T3 SCC-L.

LEVEL OF EVIDENCE

3.

Addition of Chemotherapy Is Associated With Decreased Survival in Early-Stage (T1-2N0M0) Glottic Squamous Cell Carcinoma Treated With Definitive Radiotherapy

Purpose

The role of chemoradiation (CRT) in treating patients with early-stage glottic squamous cell carcinoma (SCC), especially for T2N0M0 glottic SCC with impaired vocal cord mobility, remains unexplored. We sought to evaluate the impact of CRT on survival in early-stage glottic SCC by using the SEER database.

Patients and Methods

We included patients with localized (T1-4N0M0) glottic SCC (N = 4,743) diagnosed between 2004 and 2014 and treated with definitive radiotherapy (RT) alone, CRT, or laryngectomy alone in the SEER database. Disease-specific mortality (DSM) was evaluated via multivariable regression using a competing risk model that accounts for other-cause mortality as a competing risk event for DSM. One-to-one propensity score matching between CRT and RT cohorts was also performed to facilitate comparison of cumulative DSM and other-cause mortality incidences stratified by T stage.

Results

After stratification by T stage, CRT was associated with increased DSM in T1-2N0M0 glottic SCC (adjusted hazard ratios [AHRs], 4.222 and 2.260 for T1 and T2 disease, respectively; P < .001 for both). For T2N0M0 glottic SCC with and without impaired vocal cord mobility, CRT resulted in significantly increased DSM compared with RT alone in both cohorts (AHR, 2.084; P = .046 and AHR, 2.412; P < .001, respectively). After propensity score matching, cumulative incidence plots demonstrated a statistically significant increase in DSM associated with CRT compared with RT alone for both T1 and T2 glottic SCC ( P < .001 and P = .003, respectively).

Conclusion

CRT for T1-2N0M0 glottic SCC was associated with increased DSM compared with RT alone. This pattern persisted upon further stratification on the basis of vocal cord mobility status for T2N0M0 glottic SCC. This finding warrants careful consideration of chemotherapy in early-stage glottic SCC.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 1 (Head and Neck Surgery)

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer. Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51-74%), moderate (75-84%), and high (≥85%). Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively. Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

Survival and Prognostic Factors for Outcome after Radiotherapy for T2 Glottic Carcinoma

Background: Local recurrence after radiotherapy for T2 glottic carcinoma remains an issue and identifying patients at risk for relapse is, therefore, important. This study aimed to assess the oncological outcomes and prognostic factors in a consecutive series of patients treated with radiotherapy for T2N0 glottic carcinoma. Methods: Patients with T2N0 glottic carcinoma treated with radiotherapy were included in this retrospective study. Five- and ten-year local control (LC), overall survival (OS), disease-specific survival (DSS), and laryngeal preservation (LP) rates were calculated with the Kaplan–Meier method. The impact of prognostic variables was evaluated with the log-rank test. Results: Ninety-four patients were included for analysis. LC, OS, DSS, and LP rates were 70.5, 63.7, 86.0, and 74.7%, respectively at five years and 65.8, 41.0, 75.6, and 72.4% at 10 years. In total, 46 scans were included in the analyses. Vertical involvement of the anterior commissure on imaging showed a significant impact on LC. Conclusions: In accordance with previously described surgical risk factors, we identified vertical involvement of the anterior commissure on imaging as a prognostic factor for radiation failure.

Optimized treatment strategy of radiotherapy for early glottic squamous cell carcinomas: An initial analysis

The purpose of this study was to evaluate the clinical outcomes of radiotherapy for patients with T1/T2 glottic carcinoma. Patients with T1/T2 glottic carcinoma histopathologically diagnosed with squamous cell carcinoma and treated at our hospital between 2007 and 2015 were analyzed retrospectively. Our strategy for T1/T2 glottic carcinoma was as follows: radiotherapy alone with 2.25 Gy per fraction to a total of 25–28 fractions for patients with non-bulky T1 glottic carcinoma; concurrent chemoradiotherapy with oral S-1 and radiotherapy with 2 Gy per fraction to a total of 30 fractions for patients with T1 bulky/T2 favorable glottic carcinoma; or chemoradiotherapy with high-dose cisplatin and radiotherapy with 2 Gy per fraction to a total of 35 fractions for T2 unfavorable glottic carcinoma. Forty-eight patients were eligible. The median follow-up period among surviving patients was 38 months (range, 11–107). The disease was T1a in 23%, T1b in 13%, and T2 in 65% of patients. The 3-year local control rate in all patients, T1a, T1b, and T2 was 96.7%, 100%, 100%, and 96.0%, respectively. Of the 46 patients, one with T2 glottic carcinoma developed recurrent disease at the primary site, and one with T2 glottic carcinoma had lymph node recurrences in the neck. Acute Grade 3 dermatitis occurred in 8 (17%) patients and late Grade 2 hypothyroidism occurred in 2 (4%) patients. This retrospective study shows that our optimized treatment strategy of radiotherapy depending on the stage of early glottic carcinoma is not only effective but also well-tolerated.

Conventional fractionation should not be the standard of care for T2 glottic cancer

Background

The aim of this study was to report outcomes and late toxicity following hypofractionated accelerated radiotherapy for T2 glottic cancers. We highlight the importance of hypofractionated treatments with shorter overall treatment times, in improving outcomes for T2 glottic cancers. We also compare the biologically effective dose of hypofractionated regimes, with conventional fractionation.

Methods

One hundred twelve patients with T2 glottic cancer were treated between January 1999 and December 2005. All patients were prescribed a hypofractionated accelerated radiotherapy dose of 52.5 Gray in 3.28 Gray per fraction, delivered over 22 days. Radiobiological calculations were used to assess the relationship of fraction size and overall treatment time on local control outcomes and late toxicity.

Results

The 5-year overall survival was 67%, the 5-year local control was 82%, and the 5-year disease-specific survival was 90%. The respective 5-year local control for T2a and T2b disease was 88.8 and 70.8% (p = 0.032). Severe late toxicity occurred in two patients (1.8%). Radiobiological calculations showed an increase in local control of nearly 12%, with a 10 Gray increase in biologically effective dose.

Conclusion

This study has demonstrated that accelerated hypofractionated regimes have improved local control and similar late toxicity compared with conventional fractionation schedules. This supports the use of hypofractionated regimes as the standard of care for early glottic laryngeal cancers.

Transoral laser microsurgery versus radiotherapy for T2 glottic squamous cell carcinoma: a systematic review of local control outcomes

BACKGROUND

Systematic reviews comparing treatment of early glottic cancer with transoral surgery or radiotherapy demonstrate similar oncological outcomes. Most studies of 'early-stage' laryngeal cancer include Tis, T1a, T1b and T2 cases. The data are dominated by patients with T1 and Tis tumours, although extrapolating these results and applying them for T2 cases may be inappropriate. No previous systematic reviews have focused on T2 cancers as a separate group.

OBJECTIVE OF REVIEW

This review compares local control outcomes for T2 glottic squamous cell carcinoma, treated with transoral microsurgery or external beam radiotherapy.

TYPE OF REVIEW

This is a systematic review of case series and comparison studies, focusing on oncological outcomes.

SEARCH STRATEGY

Independent searches of MEDLINE, EMBASE and the Cochrane Database were conducted by two authors, using the search terms: laryngeal/glottic/vocal cord combined with carcinoma/cancer/tumour and laser/microsurgery or radiotherapy. Studies of adult patients treated for primary T2N0 glottic squamous cell carcinoma (SCC) with laser surgery or curative radiotherapy were included.

EVALUATION METHOD

Full text of studies satisfying the inclusion criteria were reviewed with extraction of local control and survival data and laryngeal preservation rates. The primary endpoint is local control at 5 years.

RESULTS

Initial searches identified 3252 studies. Following full-text review of 183 papers, 59 studies met the inclusion criteria, all level IV evidence. A total of 48 studies specified 5-year local control for 1156 patients treated with transoral laser surgery and 3191 patients treated with radiotherapy. Weighted averages of local control at 5 years demonstrated similar results: 75.81% for radiotherapy versus 77.26% for transoral laser surgery.

CONCLUSIONS

The results of this review indicate no difference in 5-year local control between radiotherapy and transoral surgery for T2 glottic SCC. The data demonstrated higher rates of local failure for T2b compared with T2a cases, although outcomes were similar between laser excision and radiotherapy for each substage. Further research focusing upon functional outcomes for T2 glottic tumours is imperative to guide decision-making, ideally with subgroup analysis of T2a and T2b cases.