The effect of treatment on survival in patients with advanced laryngeal carcinoma

Total laryngectomy vs. non-surgical organ preservation in advanced laryngeal cancer: a metanalysis

OBJECTIVE

To compare the oncological results and the functional outcomes of patients undergoing Total Laryngectomy (TL) with the non-surgical treatment (organ preservation protocol) in the treatment of advanced laryngeal carcinomas through systematic review and meta-analysis.

METHODS

A literature survey strategy was employed in order to perform a systematic review of the available evidence. Success rate and functional outomes after oncological treatment of patients with advanced laryngeal carcinomas was evaluated through systematic review and metanalysis, comparing TL and organ preservation protocol.

RESULTS

The surgical treatment was associated with better survival outcomes. When stratifying by T stage, while patients with T4 staging have less risk of mortality with TL, there is no difference between the different treatments for patients with T3 tumors. Surgery is related to a lower chance of recurrence, late dysphagia and feeding tube dependence.

CONCLUSION

Patients with T4 tumors should undergo TL as their treatment of choice. For patients with T3 tumors, there is no differences on the risk of mortality according to the therapeutic option, however, there is a greater chance of recurrence and dysphagia when surgery is not performed.

Factors Associated with Total Laryngectomy Utilization in Patients with cT4a Laryngeal Cancer

BACKGROUND

Despite recommendations for upfront total laryngectomy (TL), many patients with cT4a laryngeal cancer (LC) instead undergo definitive chemoradiation, which is associated with inferior survival. Sociodemographic and oncologic characteristics associated with TL utilization in this population are understudied.

METHODS

This retrospective cohort study utilized hospital registry data from the National Cancer Database to analyze patients diagnosed with cT4a LC from 2004 to 2017. Patients were stratified by receipt of TL, and patient and facility characteristics were compared between the two groups. Logistic regression analyses and Cox proportional hazards methodology were performed to determine variables associated with receipt of TL and with overall survival (OS), respectively. OS was estimated using the Kaplan-Meier method and compared between treatment groups using log-rank testing. TL usage over time was assessed.

RESULTS

There were 11,149 patients identified. TL utilization increased from 36% in 2004 to 55% in 2017. Treatment at an academic/research program (OR 3.06) or integrated network cancer program (OR 1.50), male sex (OR 1.19), and Medicaid insurance (OR 1.31) were associated with increased likelihood of undergoing TL on multivariate analysis (MVA), whereas age > 61 (OR 0.81), Charlson-Deyo comorbidity score ≥ 3 (OR 0.74), and clinically positive regional nodes (OR 0.78 [cN1], OR 0.67 [cN2], OR 0.21 [cN3]) were associated with decreased likelihood. Those undergoing TL with post-operative radiotherapy (+/- chemotherapy) had better survival than those receiving chemoradiation (median OS 121 vs. 97 months; p = 0.003), and TL + PORT was associated with lower risk of death compared to chemoradiation on MVA (HR 0.72; p = 0.024).

CONCLUSIONS

Usage of TL for cT4a LC is increasing over time but remains below 60%. Patients seeking care at academic/research centers are significantly more likely to undergo TL, highlighting the importance of decreasing barriers to accessing these centers. Increased focus should be placed on understanding and addressing the additional patient-, physician-, and system-level factors that lead to decreased utilization of surgery.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Investigating miR-9 as a mediator in laryngeal cancer health disparities

Background

For several decades, Black patients have carried a higher burden of laryngeal cancer among all races. Even when accounting for sociodemographics, a disparity remains. Differentially expressed microRNAs have been linked to racially disparate clinical outcomes in breast and prostate cancers, yet an association in laryngeal cancer has not been addressed. In this study, we present our computational analysis of differentially expressed miRNAs in Black compared with White laryngeal cancer and further validate microRNA-9-5p (miR-9-5p) as a potential mediator of cancer phenotype and chemoresistance.

Methods

Bioinformatic analysis of 111 (92 Whites, 19 Black) laryngeal squamous cell carcinoma (LSCC) specimens from the TCGA revealed miRNAs were significantly differentially expressed in Black compared with White LSCC. We focused on miR-9-5 p which had a significant 4-fold lower expression in Black compared with White LSCC (p<0.05). After transient transfection with either miR-9 mimic or inhibitor in cell lines derived from Black (UM-SCC-12) or White LSCC patients (UM-SCC-10A), cellular migration and cell proliferation was assessed. Alterations in cisplatin sensitivity was evaluated in transient transfected cells via IC50 analysis. qPCR was performed on transfected cells to evaluate miR-9 targets and chemoresistance predictors, ABCC1 and MAP1B.

Results

Northern blot analysis revealed mature miR-9-5p was inherently lower in cell line UM-SCC-12 compared with UM-SCC-10A. UM -SCC-12 had baseline increase in cellular migration (p < 0.01), proliferation (p < 0.0001) and chemosensitivity (p < 0.01) compared to UM-SCC-10A. Increasing miR-9 in UM-SCC-12 cells resulted in decreased cellular migration (p < 0.05), decreased proliferation (p < 0.0001) and increased sensitivity to cisplatin (p < 0.001). Reducing miR-9 in UM-SCC-10A cells resulted in increased cellular migration (p < 0.05), increased proliferation (p < 0.05) and decreased sensitivity to cisplatin (p < 0.01). A significant inverse relationship in ABCC1 and MAP1B gene expression was observed when miR-9 levels were transiently elevated or reduced in either UM-SCC-12 or UM-SCC-10A cell lines, respectively, suggesting modulation by miR-9.

Conclusion

Collectively, these studies introduce differential miRNA expression in LSCC cancer health disparities and propose a role for low miR-9-5p as a mediator in LSCC tumorigenesis and chemoresistance.

Surgical Management of Advanced Glottic Cancer

In advanced glottic cancer, it is widely known that definitive chemoradiation can result in comparable survival outcomes to primary surgery. This deserves consideration given the immense effects total laryngectomy (TL) has on patients. It is important to consider that not all advanced glottic tumors should be treated in the same way, and surgical management remains a critical consideration for optimization of local control and survival outcomes. Advances in organ preservation surgery and the more developed understanding of the survival benefits of TL in extensive T4 disease further support the importance of surgery in the management of advanced glottic cancer.

Salvage surgery in laryngeal cancer after radiotherapy and partial surgery - comparative results

Objective

The study is a retrospective comparison of the usefulness of salvage surgery between a group of previously radiotherapy-treated patients (RTPs) and a group of patients who previously underwent partial surgery with both local and ± nodal recurrence.

Study Design

Retrospective study.

Setting

Multi-center academic hospital.

Materials and Methods

The former group was comprised 30 previously RTPs, whereas the latter group consisted of 20 patients after partial laryngeal surgery with optional subsequent adjuvant radiotherapy (PSPs). Treatment efficacy was compared in both groups in relation to overall survival (OS) and the locoregional control rate (LCR). Local and ± nodal recurrence was considered primary treatment failure. All patients underwent total laryngectomy.

Results

The updated 5-year OS in the PSPs was 31%, while the percentage of the updated 5-year LCR was 42%. In the RTPs the updated 5-year OS was 21%, and the percentage of 5-year LCR was 38%. No statistically significant differences were found in terms of the comparison of OS or the comparison of LCR results in both groups (P = 0.427, P = 0.704, respectively).

Conclusions

Based on the analysis, it was found that irrespective of the initial treatment, salvage surgery was associated with decreased survival and cure rates (by 50%) compared to the group of patients with advanced laryngeal cancer who underwent primary total laryngectomy.

Survival Analysis in Patients with Laryngeal Cancer: A Retrospective Cohort Study

INTRODUCTION

The worldwide incidence rate of laryngeal cancer is declining. However, the 5-year survival for these patients has decreased in recent years from 66% to 63%. This may be due to changes in the treatment of the disease. The present study aimed to evaluate the survival rate of patients with LC according to the stage of the disease and the treatment applied. For this purpose, surgical versus organ preservation protocols (OPP) based on chemoradiotherapy were evaluated.

METHODS

A retrospective cohort study was conducted in a tertiary hospital. The study included adult patients with a clinical diagnosis of primary LC. Patients with LC and systemic metastases and those with synchronous tumors at diagnosis were excluded. Univariate and multivariate analyses were performed to determine the association between exposure to LC treatment and the time to event (death). Overall survival (OS), cause-specific survival (CSS), and disease-free survival (DFS) were calculated.

RESULTS

Patients with advanced tumors (stages III and IV) had almost three times the risk of LC death than those in the initial tumor stages (I and II) [HR CCS = 2.89 (95%CI 1.30-6.39)]; [HR OS = 2.01 (95%CI 1.35-2.98)]. Patients who underwent surgical treatment had a higher chance of survival than those who were treated according to OPP [HR = 0.62; 95%CI (0.38-1.02)] in CSS, 0.74 [95%CI (0.50-1.90)] in OS, and 0.61 [95%CI (0.40-0.91)] in DFS.

DISCUSSION

OPP changed the management of patients with advanced stages of LC, establishing CRT as an alternative to surgery. Our data did not reveal clinically relevant differences in OS between patients treated with OPP and those who underwent surgery; however, we reported differences in the DFS rate after five years of follow-up in favor of the surgery-treated group of patients.

CONCLUSION

Surgical treatment improves CSS and DFS at five years in patients with initial LC with respect to radiation therapy alone. Furthermore, surgical treatment associated with complementary radiation therapy offers better CSS and DFS in patients with advanced LC.

Primary radiation therapy for advanced-stage laryngeal cancer: A laryngo-esophageal dysfunction disease-free survival

Objectives

To evaluate the outcomes of advanced-stage laryngeal squamous cell carcinoma (SCC) patients treated with functional-preservation strategy with a specific focus on laryngo-esophageal dysfunction disease-free survival (LEDDFS).

Methods and materials

A retrospective review was conducted of stage III-IVB laryngeal SCC patients who were treated with curative-intent radiotherapy (RT) (2007-2018). Patients were preferentially managed with upfront chemoradiation (CCRT); except for those with cN2-3, cT4, or large volume cT3 (induction chemotherapy followed by RT or CCRT is an option), and those who were unfit or declined chemotherapy (received altered RT). The primary endpoint was 3-year LEDDFS, and secondary endpoints were 3-year local failure (LF), regional failure (RF), distant metastasis (DM), overall survival (OS), disease-free survival (DFS), and acute and late toxicities. Cox proportional hazard tests were used for multivariable analysis (MVA).

Results

A total of 213 cases were included. With a median follow-up of 37 months, the 3-year LEDDFS was 50%, while the 3-year OS, DFS, LF, RF, and DM were 81%, 74%, 9%, 5%, and 7%, respectively. On MVA, cT4-category was the only predictor of inferior LEDDFS (HR: 0.47, [95% CI: 0.29-0.74], p < .01). The most common grade ≥ 3 acute and late radiation therapy oncology group (RTOG) toxicity were esophageal toxicity: 16.7% and 29.6%, respectively.

Conclusions

Primary RT resulted in favorable oncologic and functional outcomes in only half of the advanced-stage laryngeal cancer patients. Future clinical trials are required to investigate further treatment options aiming to improve the oncologic and maintain functional outcomes with utilization of LEDDFS as the primary endpoint.

Level of evidence

4.

Outcomes of organ preservation treatment in advanced laryngeal carcinoma: A retrospective analysis from a single institution

Chemoradiation is the standard treatment for patients with locally advanced laryngeal carcinoma with intact cartilage and functional larynx. The aim of this retrospective study was to assess overall survival (OS) and disease-free survival (DFS) of patients with locally advanced (stage III and stage IV) squamous cell carcinoma of the larynx who have been treated with definitive radical radiotherapy (RT) with or without chemotherapy in a tertiary cancer center in India between January 1, 2006 and December 31, 2015. Data were collected using structured proforma. The patients were treated with RT alone, induction chemotherapy (IC) followed by RT, concurrent chemoradiation therapy (CCRT) or IC followed by CCRT. Response assessment was conducted at 3-4 months post-treatment. Patient-, tumor- and treatment-related factors were documented and were associated with DFS and OS. Survival curves were generated using the Kaplan-Meier method and the statistical significance of survival curves was assessed using the log-rank test. Prognostic factors were assessed using the Cox proportional hazards regression model. A total of 630 patients were included in the present study. The most common age group at presentation was 50-70 years (n=477; 75.7%) and 95.4% (n=601) patients were male. The most common stage at presentation was stage III (n=367, 58.1%). The median follow-up period for the entire group of was 59 months (range, 2-175 months). A complete response after treatment was seen in 549 patients (87.1%). Salvage surgery was performed for 11 patients with residual disease. A total of 134 patients (21.3%) had developed locoregional and distant relapses, and salvage surgery was performed for 31 out of 102 patients with locoregional relapse. The 5-year OS was 48.7% and the 5-year DFS was 45.7%. The stage-wise OS rates were 58.9, 34.9 and 30.4% (P=0.001) and the stage-wise DFS rates were 56.3, 32.0 and 21.7 (P=0.001) for stage III, IVa and IVb, respectively. Results from the present study demonstrated the feasibility of delivery of chemoradiation protocols with good results in a developing country.

The impact of operability status on outcomes in patients with T4 larynx cancer undergoing larynx preservation

BACKGROUND

Large analyses of T4 larynx cancer (LC) have raised concerns that larynx preservation (LP) contributes to reduced survival compared with laryngectomy (LGX). The role of operability has not been previously considered as a confounder.

METHODS

We queried the National Cancer Database for T4M0 LC diagnosed 2004-2015. Patients were categorized as undergoing LGX, chemoradiotherapy but operable (LP-operable), and chemoradiotherapy inoperable (LP-inoperable). Overall survival (OS) was estimated by Kaplan-Meier. Cox multivariate analysis (MVA) identified variables associated with OS.

RESULTS

We identified 1405 LGX, 164 LP-operable and 1969 LP-inoperable patients. Compared with LGX, MVA demonstrated worse OS among LP-inoperable (HR 1.28 95%CI 1.17-1.40, p < 0.01) but not LP-operable patients (HR 1.12 95%CI 0.91-1.39, p = 0.28).

CONCLUSIONS

LP-operable patients did not have significantly worse OS than those undergoing LGX.

Outcomes of surgical versus non-surgical treatment of resectable T4a laryngeal and hypopharyngeal carcinoma

Objective

Surgery is the recommended treatment for resectable T4a laryngeal and hypopharyngeal carcinoma. Non-surgical treatment is an option in a select few patients.

Method

This retrospective study was undertaken to assess the treatment outcomes in patients with resectable T4a carcinoma of the larynx and hypopharynx who received either surgical or non-surgical treatment at our institute and to assess factors influencing these outcomes.

Results

A total of 120 patients were included in the study. They were divided into groups A, B and C based on the presence of extralaryngeal spread through laryngeal membrane, cartilage or both. The overall survival was better among patients who received surgery than those who received non-surgical treatment in the three groups. The factor influencing overall survival was the treatment given in the form of surgical versus non-surgical treatment.

Conclusion

Surgery is the preferred treatment for T4a laryngeal and hypopharyngeal carcinoma, even in patients with extralaryngeal spread without cartilage erosion.

Imaging response assessment for predicting outcomes after bioselection chemotherapy in larynx cancer: A secondary analysis of two prospective trials

BACKGROUND AND PURPOSE

Bioselection with induction chemotherapy in larynx cancer is associated with excellent larynx preservation and disease-specific survival but requires visual inspection of the primary tumor. We retrospectively compare clinical and imaging response in bioselected patients to develop predictive models of surgeon-assessed response (SR), laryngectomy-free survival (LFS), and overall survival (OS) in bioselected patients.

MATERIALS AND METHODS

In a secondary analysis of patients on two single-institution bioselection trials, model building used a regularized regression model (elastic-net) and applied nested cross-validation. Logistic regression-based model was used to predict SR and Cox proportional hazard-based models were used to predict LFS and OS.

RESULTS

In 115 patients with a median age of 57 years, most patients had supraglottic tumors (73.0%) and T3/T4 disease (94.8%). Definitive treatment was chemoradiation in 76.5% and laryngectomy in 23.5%. Change in primary tumor (OR = 5.78, p < 0.001) and N-classification (OR = 1.64, p = 0.003) predicted SR (AUC 0.847). Change in tumor volume (HR = 0.58, p < 0.001) predicted LFS (c-index 0.724). N-classification (HR = 1.48, p = 0.04) and pre-chemotherapy tumor volume (HR = 1.30, p = 0.174) predicted OS (c-index 0.552).

CONCLUSIONS

Imaging offers a non-invasive opportunity to evaluate response to induction chemotherapy, complementary to surgeon assessment. Further evaluation of approaches to bioselection that optimize generalizability of this paradigm are needed, and clinical trials utilizing imaging to predict outcomes including LFS are warranted.

SERS Based Lateral Flow Assay for Rapid and Ultrasensitive Quantification of Dual Laryngeal Squamous Cell Carcinoma-Related miRNA Biomarkers in Human Serum Using Pd-Au Core-Shell Nanorods and Catalytic Hairpin Assembly

Non-invasive early diagnosis is of great significant in disease pathologic development and subsequent medical treatments, and microRNA (miRNA) detection has attracted critical attention in early cancer screening and diagnosis. However, it was still a challenge to report an accurate and sensitive method for the detection of miRNA during cancer development, especially in the presence of its analogs that produce intense background noise. Herein, we developed a surface-enhanced Raman scattering (SERS)-based lateral flow assay (LFA) biosensor, assisted with catalytic hairpin assembly (CHA) amplification strategy, for the dynamic monitoring of miR-106b and miR-196b, associated with laryngeal squamous cell carcinoma (LSCC). In the presence of target miRNAs, two hairpin DNAs could self-assemble into double-stranded DNA, exposing the biotin molecules modified on the surface of palladium (Pd)-gold (Au) core-shell nanorods (Pd-AuNRs). Then, the biotin molecules could be captured by the streptavidin (SA), which was fixed on the test lines (T1 line and T2 line) beforehand. The core-shell spatial structures and aggregation Pd-AuNRs generated abundant active "hot spots" on the T line, significantly amplifying the SERS signals. Using this strategy, the limits of detections were low to aM level, and the selectivity, reproducibility, and uniformity of the proposed SERS-LFA biosensor were satisfactory. Finally, this rapid analysis strategy was successfully applied to quantitatively detect the target miRNAs in clinical serum obtained from healthy subjects and patients with LSCC at different stages. The results were consistent with the quantitative real-time PCR (qRT-PCR). Thus, the CHA-assisted SERS-LFA biosensor would become a promising alternative tool for miRNAs detection, which showed a tremendous clinical application prospect in diagnosing LSCC.

Clinical profile and treatment outcome of laryngeal cancer in a Nigerian Tertiary hospital

Background

Laryngeal cancer is one of the most common malignancies of the upper aerodigestive tract worldwide, and its management may sometimes be challenging, especially in developing countries due to late presentation, poverty and limited resources.

Aim

This study aims to highlight the clinical profile and treatment outcome of laryngeal cancer in our centre.

Patients and Methods

This was a retrospective review of patients who were managed for laryngeal cancer between January 2011 and December 2020.

Results

There were 90 (89.1%) males and 11 (10.9%) females, with a male-to-female ratio of 8.2:1. The age ranged from 22 to 82 years, with a mean age of 57.2 ± 12.7 years. Fifty patients (49.5%) presented more than 1 year after the onset of the symptoms. Squamous cell carcinoma (SCCA) was the only histological diagnosis observed in our patients. The laryngeal cancer was transglottic in location in 45 (44.6%) patients, while 50 (49.5%) patients presented with Stage III disease. Twenty-one (20.8%) patients had total laryngectomy. Amongst the patients managed, 17 (17.0%) were still on follow-up. Up to 37 (37.0%) were referred for radiotherapy elsewhere after chemotherapy. Forty-one of the patients (40.0%) died during the course of their management. There was a statistically significant association between having definitive surgical management and survival beyond 5 years (Chi-square test = 8.635, P = 0.003).

Conclusion

Majority of the patients presented late with transglottic SCCA. Surgical extirpation of the lesion was associated with better prognosis in our patients.

Treatment Results for Stage III Laryngeal Cancer: Analysis of a Populational Database Using Propensity Scores

Introduction Treatment of stage III laryngeal cancer suffered a major paradigm change with surgery being substituted by radiation therapy with chemotherapy.

Objective To evaluate the oncological outcome of different treatment modalities for stage III laryngeal cancer using a population database.

Methods A population database representing patients treated in the state of São Paulo, Brazil, was analyzed. Demographic, clinical and treatment variables were included, and the outcomes of interest were disease-specific and overall survival. Propensity score with nearest neighbor matching was used to compensate for imbalances in treatment groups.

Results We retrieved data from 1,804 patients. In multivariate analysis, age, female gender, payment source, clinical N stage (cN) stages, and treatment modality were significant for disease-specific and overall survival. Patients submitted to surgery treatment had a significantly better disease-specific (p < 0.001) and overall survival (p < 0.001) compared with chemoradiation. Propensity score matching was based on cN stage, gender, age, topography, and payment modality, and allowed the pairing of 685 patients from each treatment modality. There was a significant difference in disease-specific survival favoring surgery-based treatment (p = 0.017).

Conclusion The treatment choice has a significant impact on survival in patients with stage III laryngeal cancer with surgery-based treatment being superior to chemoradiotherapy (CRT).

Patterns of Failure After Definitive Treatment of T4a Larynx Cancer

OBJECTIVE

Recurrence is known to predict laryngeal squamous cell cancer (LSCC) survival. Recurrence patterns in T4a LSCC are poorly characterized and represent a possible explanation for observed survival discrepancies by treatment rendered.

STUDY DESIGN

Retrospective database review.

SETTING

Veterans Affairs national database.

METHODS

Patients with T4a LSCC between 2000 and 2017 were identified and stratified by treatment (chemoradiotherapy [CRT] vs total laryngectomy + neck dissection + adjuvant therapy [surgical]). Primary outcomes were locoregional and distant recurrence. Secondary outcomes of overall mortality, larynx cancer mortality, and noncancer mortality were evaluated in Cox and Fine-Gray models.

RESULTS

A total of 1043 patients had comparable baseline demographics: 438 in the CRT group and 605 in the surgical group. Patients undergoing CRT had higher proportions of node positivity (64.6% vs 53.1%, P < .001). Locoregional and distant recurrence were less common in the surgical group (23.0% vs 37.2%, P < .001; 6.8% vs 13.3%, P < .001, respectively); however, distant metastatic rates did not differ within the N0 subgroup (P = .722). On multivariable regression, surgery demonstrated favorable locoregional recurrence (hazard ratio [HR], 0.49; 95% CI, 0.39-0.62; P < .001), distant recurrence (HR, 0.47; 95% CI, 0.31-0.71; P < .001), overall mortality (HR, 0.75; 95% CI, 0.64-0.87; P < .001), and larynx cancer mortality (HR, 0.69; 95% CI, 0.56-0.85; P < .001).

CONCLUSION

T4a LSCC survival discrepancies between surgical and nonsurgical treatment are influenced by varying recurrence behaviors. Surgery was associated with superior disease control and improved survival. Beyond the known benefit in locoregional control with surgery, there may be a protective effect on distant recurrence that depends on regional disease burden.

Knockdown of circ_0001883 may inhibit epithelial-mesenchymal transition in laryngeal squamous cell carcinoma via the miR-125-5p/PI3K/AKT axis

Laryngeal squamous cell carcinoma (LSCC) is a malignant tumor with increasing incidence and poor prognosis. Circular RNAs (circRNAs) are known to modulate tumorigenesis and cancer development that may function through microRNAs (miRs). The aim of the present study was to investigate the functional roles of circ_0001883 in LSCC and the underlying molecular mechanism. The expression of circ_0001883 was upregulated and measured using reverse transcription-quantitative PCR (RT-qPCR) and RNase R. miR-125b-5p expression was downregulated in LSCC tissues and cells as determined using RT-qPCR. Subsequently, knockdown of circ_0001883 inhibited LSCC cell migration, invasion and epithelial-mesenchymal transition (EMT), which were tested by wound healing assays, Transwell assays and western blotting, respectively. Bioinformatics analysis predicted that circ_0001883 was a sponge of miR-125b-5p, which was verified using a dual-luciferase reporter assay. Knockdown of circ_0001883 played a functional role by sponging miR-125b-5p. Additionally, circ_0001883 and miR-125b-5p influenced phosphorylation of PI3K and AKT, detected via western blotting. In an in vivo study, knockdown of circ_0001883 reduced tumor volume and weight in mice, along with enhanced miR-125b-5p and E-cadherin expression levels, and decreased N-cadherin, phosphorylated (p)-PI3K/PI3K and p-AKT/AKT ratios. In conclusion, knockdown of circ_0001883 inhibited cell migration, invasion and EMT of LSCC by sponging miR-125b-5p. This is hypothesized to be via the PI3K/AKT signaling pathway, which suggested that circ_0001883 has potential for LSCC therapy.

WISP1 aggravates cell metastatic potential by abrogating TGF--Smad2/3-dependent epithelial-to-mesenchymal transition in laryngeal squamous cell carcinoma

Laryngeal squamous cell cancer (LSCC) is a common carcinoma with high morbidity and mortality. Metastasis constitutes the major cause of death and poor prognosis among patients with LSCC. Recent evidence confirms critical function of Wnt1-inducible signaling protein 1 (WISP1) in several cancers. However, its contribution in LSCC metastasis remains unclear. Specimens of tumor tissues and adjacent normal mucosa were collected from patients with LSCC. The mRNA and protein levels were determined using quantitative real-time PCR and Western blot, respectively. RNA interference was applied to silence the expression of WISP1 and TGF-β, and recombinant adenovirus was used to overexpress WISP1 in human LSCC cell line TU212 cells. Cell invasion and migration were determined by transwell assay. High expression of WISP1 was observed in LSCC tissues, especially in those from metastatic groups. Ectopic expression of WISP1 enhanced invasion and migration of TU212 cells. On the contrary, WISP1 knockdown reduced numbers of invasive and migrated cells. Additionally, elevation of WISP1 depressed the expression of epithelial marker E-cadherin and increased levels of mesenchymal marker vimentin in TU212 cells, whereas WISP suppression yielded the opposite effects. Further analysis corroborated that WISP1 overexpression enhanced activation of TGF-β-Smad signaling by increasing expression of TGF-β1, p-Smad2, and p-Smad3, which was abrogated following WISP1 down-regulation. Moreover, TGF-β1 exposure facilitated LSCC cell invasion and migration. Notably, blockage of the TGF-β-Smad pathway by si-TGF-β overturned WISP-1-evoked epithelial-to-mesenchymal transition (EMT), and subsequent cell invasion and migration. These findings highlight the pro-metastatic function of WISP1 in LSCC by regulating cell invasion and migration via TGF-β-Smad-mediated EMT, supporting a promising invention target for LSCC therapy.

Impact of treatment modality on survival in patients with stage IV laryngeal cancer: A population-based propensity score analysis

INTRODUCTION

The treatment of advanced stage laryngeal suffered a major shift away from surgery and towards larynx-preservation alternatives after the publication of major clinical trials. But its applicability in real-world situations is not consensual.

MATERIALS AND METHODS

We reviewed a population-based database from Brazil regarding patients treated for laryngeal cancer and selected those with stage IV disease at presentation. Survival analysis was realized by the Cox proportional hazards method and propensity scores were used to compensate for non-random allocation to different treatment arms.

RESULTS

A total of 5577 patients were included in the analyses, with 4243 staged as CS IVa, 1010 as CS IVb and 324 as CS IVc. In univariate and multivariate analysis, gender, cT stage, cN stage, cM stage and treatment modality were significant predictors of disease-specific survival. In patients with CS IVa, age, gender, payment modality, location within the larynx, cT and cN stages and treatment modality were significant. After propensity score adjustment, treatment modality remained significant, favoring primary surgery with disease-specific survival (HR: 0.5041, 95% CI: 0.4494-0.5644, p < 0.001) and overall survival (HR: 0.5485, 95% CI: 0.4955-0.6072, p < 0.001) as outcomes of interest. Patients staged as cT4a cN0 were selected and analyzed as a distinct subset. In multivariate analysis, treatment modality was the only variable with significant prognostic impact with improved outcome for surgery-based treatment (HR: 2.521, 95% CI: 1.897-3.350, p < 0.001).

CONCLUSIONS

The extrapolation of clinical trials to the real-world facilities must be carefully weighted. The setting of trial conduction may influence its outcome and may not be reproducible. Our results show that patient selection and the facilities of clinical trials may play a significant role in the success of non-surgical approaches to non-metastatic stage IV laryngeal cancer.

Current Role of Total Laryngectomy in the Era of Organ Preservation

In this article, we aimed to discuss the role of total laryngectomy (TL) in the management of patients with larynx cancer (LC) in the era of organ preservation. Before the 1990s, TL followed by radiotherapy (RT) was the standard treatment for patients with locally advanced LC. Over the last 30 years, various types of larynx preservation (LP) programs associating induction or concurrent chemotherapy (CT) with RT have been developed, with the aim of treating locally advanced LC patients while preserving the larynx and its functions. Overall, more than two-thirds of patients included in a LP program will not require total laryngectomy (TL) and will preserve a functional larynx. However, despite these advances, the larynx is the only tumor site in the upper aero-digestive tract for which prognosis has not improved during recent decades. Indeed, none of these LP protocols have shown any survival advantage compared to primary radical surgery, and it appears that certain LC patients do not benefit from an LP program. This is the case for patients with T4a LC (extra-laryngeal tumor extension through the thyroid cartilage) or with poor pretreatment laryngeal function and for whom primary TL is still the preferred therapeutic option. Moreover, TL is the standard salvage therapy for patients with recurrent tumor after an LP protocol.

Updates on larynx cancer epidemiology

Objective

Laryngeal cancer is an important oncologic entity, whose prognosis depends on establishing appropriate preventive and diagnostic measures, especially in populations at higher risk.

Methods

Epidemiologic information including worldwide incidence, prevalence, burden of health loss (disability-adjusted life year; DALYs) and mortality of larynx cancer was obtained from the Global Health Data Exchange (GHDx) database.

Results

The current incidence, prevalence and mortality of laryngeal cancer are estimated at 2.76 cases/year per 100,000 inhabitants, 14.33 cases/year per 100,000 inhabitants and 1.66 deaths/year per 100,000 inhabitants, respectively, averaging 3.28 million DALYs each year. Incidence and prevalence have increased by 12% and 24%, respectively during the past 3 decades, whilst mortality has declined by around 5%. The epidemiologic burden of this malignancy is approximately 5-fold higher in males and increases in parallel with ageing, peaking after 65 years of age. Both incidence and mortality rates are higher in Europe and lower in Africa, but the ratio between deaths and incidence is the highest in Africa. Incidence has gradually declined in Europe during the past 3 decades, whilst it has increased in South-East Asia and Western Pacific. Cigarette smoking and alcohol abuse contribute for about 90% of overall worldwide mortality for laryngeal cancer.

Conclusions

Laryngeal cancer still poses a high clinical and societal burden, with an escalating temporal trend not expected to reverse soon.

Association of clinical factors with survival outcomes in laryngeal squamous cell carcinoma (LSCC)

AIM

Treatment strategies in laryngeal squamous cell cancer (LSCC) straddle the need for long term survival and tumor control as well as preservation of laryngeal function as far as possible. We sought to identify prognostic factors affecting LSCC outcomes in our population.

METHODS

Clinical characteristics, treatments and survival outcomes of patients with LSCC were analysed. Baseline comorbidity data was collected and age-adjusted Charlson Comorbidity Index (aCCI) was calculated. Outcomes of overall survival (OS), progression-free survival (PFS) and laryngectomy-free survival (LFS) were evaluated.

RESULTS

Two hundred and fifteen patients were included, 170 (79%) underwent primary radiation/ chemoradiation and the remainder upfront surgery with adjuvant therapy where indicated. The majority of patients were male, Chinese and current/ex-smokers. Presence of comorbidity was common with median aCCI of 3. Median OS was 5.8 years. On multivariable analyses, high aCCI and advanced nodal status were associated with inferior OS (HR 1.24 per one point increase in aCCI, P<0.001 and HR 3.52; p<0.001 respectively), inferior PFS (HR 1.14; p = 0.007 and HR 3.23; p<0.001 respectively) and poorer LFS (HR 1.19; p = 0.001 and HR 2.95; p<0.001 respectively). Higher tumor (T) stage was associated with inferior OS and LFS (HR 1.61; p = 0.02 and HR 1.91; p = 0.01 respectively).

CONCLUSION

In our Asian population, the presence of comorbidities and high nodal status were associated with inferior OS, PFS and LFS whilst high T stage was associated with inferior LFS and OS.

Severe late dysphagia after multimodal treatment of stage III/IV laryngeal and hypopharyngeal cancer

Background

Long-term side effects after radiotherapy for organ preservation ‘could deteriorate’ the laryngeal function. This study intended to identify the incidence of severe late dysphagia following the multimodal treatment for stage III/IV laryngeal and hypopharyngeal cancer ‘to evaluate the function of larynx’.

Methods

The medical records of patients successfully treated for laryngeal and hypopharyngeal cancer with a multimodal approach, including radiotherapy, were retrospectively analyzed. ‘Functional larynx was defined as tolerable oral diet without severe late dysphagia or tracheostoma’.

Results

The study included 99 patients with a median follow-up period of 72 months. ‘Tracheostomy during the follow-up period was required in only one patient due to aspiration pneumonia, and dysphagia is the main determinant for functional larynx’. The probability of maintaining functional larynx was 63% for 10 years, when the treatment was started with radiotherapy or concurrent chemoradiotherapy. In upfront surgery (operation first and adjuvant radiotherapy/concurrent chemoradiotherapy) group, 37% of patients required total laryngectomy as primary treatment and 43% of patients could maintain laryngeal function for 10 years. And severe late dysphagia in the latter group developed mainly after laryngeal preservation surgery. The patients aged ≥65 years showed significantly higher incidence of dysphagia. Severe late dysphagia was very rare in laryngeal cancer successfully cured with radiotherapy/concurrent chemoradiotherapy (1/25, 4%); however, it gradually increased over time in hypopharyngeal cancer patients showing a statistically significant difference from laryngeal cancer patients (P = 0.040).

Conclusion

Severe late dysphagia occurred in 19.2% of patients treated for laryngeal and hypopharyngeal cancers, regardless of whether treatment started with radiotherapy/concurrent chemoradiotherapy or surgery.

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.

Association of Positive Initial Margins With Survival Among Patients With Squamous Cell Carcinoma Treated With Total Laryngectomy

Importance

Frozen-section analysis of margin status is routinely performed during total laryngectomy for squamous cell carcinoma; in the case of positive initial frozen margins, re-resection to negative margins can often be accomplished. Some evidence suggests that positive initial margins may be associated with worse survival among patients with head and neck cancer even when final margins are negative, but the significance of positive initial frozen margins in total laryngectomy is poorly understood.

Objective

To determine the association between disease-free survival and positive initial margins among patients treated with total laryngectomy for squamous cell carcinoma.

Design, Setting, and Participants

In this retrospective cohort study conducted at a tertiary care center, records of 237 consecutive patients treated with total laryngectomy for squamous cell carcinoma from February 2008 to July 2016 were reviewed for demographic characteristics, disease staging, pathologic markers, and outcomes. Margins were considered to be positive if they contained invasive carcinoma, carcinoma in situ, or severe dysplasia. Data analysis was performed from March to June 2018.

Interventions

All patients had undergone total laryngectomy for squamous cell carcinoma.

Main Outcomes and Measures

Variables associated with disease-free survival were analyzed using a univariable and multivariable Cox proportional hazards model.

Results

Among all 225 patients (184 [92%] male; mean age, 63.9 years; range, 30-92 years) who underwent total laryngectomy and had negative final margins, 127 patients underwent primary total laryngectomy and 98 underwent salvage total laryngectomy, with mean (SEM) follow-up of 29.3 (1.8) months. Initial frozen margins were positive in 40 of 225 patients (18%); positive initial margins occurred in 21 of 127 patients who underwent primary total laryngectomy (17%) and in 19 of 98 patients who underwent salvage total laryngectomy (19%). On multivariable analysis, only salvage laryngectomy was associated with significantly worse disease-free survival (hazard ratio [HR], 3.35; 95% CI, 1.76-6.36). Among 98 patients who underwent salvage total laryngectomy, positive lymph nodes, lymphovascular invasion, extracapsular nodal extension, and adjuvant therapy were associated with worse disease-free survival on univariable analysis, but no factors remained significant on multivariable analysis. Among 127 patients who underwent primary total laryngectomy, positive nodes, lymphovascular invasion, extracapsular nodal extension, and positive initial margins were associated with worse disease-free survival; however, only positive initial margins were associated with significantly worse disease-free survival on multivariable analysis (HR, 5.01; 95% CI, 1.55-16.2).

Conclusions and Relevance

In this study, positive initial margins were associated with worse disease-free survival among patients who underwent primary total laryngectomy despite negative margins on final pathologic examination. This finding may indicate aggressive tumor behavior in the context of primary laryngeal squamous cell carcinoma.

Combining use of Phillyrin and autophagy blocker alleviates laryngeal squamous cell carcinoma via AMPK/mTOR/p70S6K signaling

Phillyrin (PHN), one of the major active constituents of Forsythia suspensa and F. koreana, has been reported to produce antioxidant, antibacterial, anti-obesity and anti-inflammatory effects. However, no study has demonstrated the role of PHN in laryngeal squamous cell carcinoma (LSCC). We aimed to investigate the effects of PHN on the proliferation and apoptosis of HEp-2 cells. In the present study, PHN alone showed little effect on HEp-2 cell proliferation and apoptosis. Subsequent tests showed that PHN could largely enhance the level of autophagy on HEp-2 cells. Combining use of PHN and autophagy blockers including 3-methyladenine (3-MA) and chloroquine (CQ) significantly inhibited HEp-2 cell proliferation in a dose- and time-dependent manner and induced apoptosis after 24 h in a dose-dependent manner. Additionally, we found that the possible underlying molecular mechanism of PHN-induced autophagy might be through the AMPK/mTOR/p70S6K signaling pathway. Taken together, our study indicates that combining use of PHN and autophagy blockers may serve as a novel strategy in LSCC treatment.

Organ Preservation Protocols in T4 Laryngeal Cancer: a Review of the Literature

Population-based studies indicate that chemoradiation has become the most popular treatment for advanced laryngeal cancers; however, by extrapolating trial results to the general population, several issues have emerged, such as reduced overall survival, non-functional laryngeal preservation, and poor response to treatment. Although included in these trials, T4 laryngeal and hypopharyngeal cancers with cartilage invasion formed a small percentage of these patients and questions over whether they were appropriately staged remain unanswered. Literature on the use of chemoradiation in this set of patients, including the challenges, treatment considerations, and factors predicting response to treatment and outcomes, was reviewed. Current evidence indicates that all patients of T4 laryngeal and hypopharyngeal cancer are not suitable candidates for organ preservation; this modality should be offered only to select patients with good performance status and access to rehabilitative care and regular follow-up in order to achieve good results.

The Treatment of Laryngeal Cancer

Successful management of laryngeal cancer depends on careful pretreatment evaluation of patient and disease factors to arrive at accurate staging, leading to appropriate treatment selection for patients with this highly impacting disease. Surgical modalities, including transoral laser microsurgery, open partial laryngectomy, and total laryngectomy, offer options, alone or in combination with radiation and chemotherapy. Treatment strategy for laryngeal cancer should strive for cure while maintaining the best quality of life possible for the patient. Achieving the goals of initial and salvage treatment for laryngeal cancer depends on executing a plan of care determined by the expertise of the multidisciplinary team.

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

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

Management of locally advanced T3-4 glottic laryngeal carcinomas

OBJECTIVES

To assess five-year local control and ultimate local control rates of patients treated for locally advanced T3-4 glottic carcinoma with surgery only, radiotherapy only, or surgery plus radiotherapy. Cancer-specific survival, overall survival and rates of malignancy development were also assessed.

METHODS

A retrospective review was conducted on patients from 1967 to 2015, with analysis of local control, ultimate local control, overall survival and cancer-specific survival performed using Kaplan-Meier and Cox regression.

RESULTS

Of 169 eligible patients, the majority (59 per cent) were treated with surgery plus radiotherapy, with laryngectomy being the most common surgical procedure. Local control and ultimate local control rates were higher with surgery only (94.1 per cent) and surgery plus radiotherapy (87.9 and 86.8 per cent respectively), compared to radiotherapy only (46.8 and 52.4 per cent) (both p < 0.001). Cancer-specific survival, overall survival and malignancy development did not differ between groups.

CONCLUSION

Surgery, with or without radiotherapy, offers significantly higher five-year local control and ultimate local control for patients with advanced glottic carcinoma, compared to radiotherapy only.

Effects of Different Treatment Strategies and Tumor Stage on Survival of Patients with Advanced Laryngeal Carcinoma: A 15-Year Cohort Study

Background

Laryngeal cancer is the second most common cancer in the head and neck. Since laryngeal cancer management is a complex process, there is still no standard strategy to treat this disease in order to increase the survival rate of the patients especially among those with advanced form of the disease.

Methods

A cohort study was undertaken to analyze factors predicting survival of the patients in advanced stage laryngeal cancer in the Southern Iran among all patients newly diagnosed with laryngeal cancer between 2000 and 2015.

Results

Data of a total number of 415 patients who have had been diagnosed with advanced laryngeal cancer during this period was used for analysis. The patients' 1-, 3-, 5-, and 10-year survival rates were 81%, 62%, 53%, and 38%, respectively. Multivariable Cox regression analyses indicated a significant relationship between patients' survival and age at diagnosis (P < 0.001), disease stage (P = 0.002), tumor grade (P = 0.008), positive L. node (P = 0.008), and type of treatment (P < 0.001). As expected, treatment strategy was identified as the most effective factor in survival of the patients. According to the results, patients who undergone surgical treatment experienced a longer survival than those who received other treatments.

Conclusion

This study showed that the survival of patients depends on several factors, among which, treatment strategy is the most important. Combination of total laryngectomy plus chemoradiation provides superior local control and better survival compared to either radiotherapy or chemoradiation in patients with advanced laryngeal cancer.

Efficacy comparison between primary total laryngectomy and nonsurgical organ-preservation strategies in treatment of advanced stage laryngeal cancer: A meta-analysis

BACKGROUND

We aimed to provide a pooled analysis of controlled trials comparing long-term survival after primary laryngectomy and primary organ preservation methods in patients with T3-4 laryngeal cancer.

METHODS

We performed random-effects meta-analyses on overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), and locoregional control (LRC).

RESULTS

Fifteen studies met the selection criteria including 6288 patients (2696 patients who underwent primary laryngectomy and 3592 patients who underwent primary nonsurgical organ preservation therapy). There was a significant difference between the groups with respect to OS (HR 0.71, 95% CI 0.57-0.89, P = .003). However, a subgroup analysis found OS was not significantly worse for patients with T3 laryngeal cancer who received primary organ preservation compared with patients who underwent primary laryngectomy (HR 0.96, 95% CI 0.45-2.03, P = .91). There was no significant difference for DFS (HR 0.63, 95% CI 0.39-1.04, P = .07) in two groups. Patients with laryngeal cancer who underwent primary laryngectomy had a better DSS (HR 0.47, 95% CI 0.25-0.88, P = .02) and LRC (HR 0.56, 95% CI 0.390.80, P = .001) than patients who underwent primary nonsurgical organ preservation therapy.

CONCLUSION

Our results support total laryngectomy for patients with T4 laryngeal cancer and show that primary organ preservation for laryngeal cancer has no advantage and also did not decrease the rate of OS in patients with T3 laryngeal cancer when compared with primary total laryngectomy.

TIMP-3 Increases the Chemosensitivity of Laryngeal Carcinoma to Cisplatin via Facilitating Mitochondria-Dependent Apoptosis

Laryngeal carcinoma is a type of head and neck carcinoma with a high incidence and mortality. Chemotherapy treatments of human laryngeal carcinoma may fail due to the development of chemoresistance. Tissue inhibitor of metalloproteinase 3 (TIMP-3) has been shown to be implicated in a number of pathological processes typical for cancer. The present study aims to investigate the involvement of TIMP-3 in the chemoresistance of laryngeal carcinoma. We showed that TIMP-3 expression was significantly decreased in chemoresistant laryngeal carcinoma tissues compared with chemosensitivity tissues. Patients with low TIMP-3 expression exhibited poorer overall survival than those with high TIMP-3 expression. Moreover, cisplatin-resistant Hep-2 cells (Hep-2/R) were associated with the inhibition of mitochondrial membrane potential (MtMP) depolarization after cisplatin challenge. In addition, cisplatin resulted in a more pronounced mitochondrial cytochrome c release into the cytoplasm in Hep-2 cells than in their resistant variants. Overexpression of TIMP-3 by an adenovirus encoding TIMP-3 cDNA remarkably enhanced cisplatin-induced apoptosis, cytochrome c release, and caspase activation in Hep-2/R cells, thereby sensitizing cancer cells to cisplatin. On the other hand, downregulation of TIMP-3 markedly inhibited cisplatin-induced apoptosis in Hep-2 cells through attenuating mitochondria-dependent pathway activation. Taken together, these results demonstrate that decreased TIMP-3 expression may contribute to cisplatin resistance via inhibition of mitochondria-dependent apoptosis, indicating that forced TIMP-3 expression may be a useful strategy to improve the efficacy of cisplatin to treat laryngeal carcinoma.

Tumor volume as a predictor of survival in T3 glottic carcinoma: A novel approach to patient selection

BACKGROUND

The optimal treatment for T3 glottic cancers continues to be debated. Organ preservation has become the standard of care, but not all tumors respond equally. The purpose of this was to investigate the long-term survival outcomes of organ preservation protocols based on tumor volume.

METHODS

A retrospective review of prospectively collected data from 1966 to 2016 was performed. Patients with T3 vocal cord cancer treated with radiation therapy (RT) at the University of Florida were included. Local control rates as well as survival rates were determined with a Kaplan Meier and Cox regression analysis. Survival was analyzed as a function of tumor volume and an optimal cut point was determined.

RESULTS

107/234 patients were included. 79% received RT and 21% chemo-RT. 5-year local control was 61.5% and 5-year disease specific survival was 79.3%. Tumor volume was a significant predictor of survival (p = 0.007). An optimal cut point for tumor volume was 2.5 cc. Patients with tumor volumes ≥2.5 cc had significantly worse (p < 0.05) tumor control rates (100% vs. 70.4%).

CONCLUSION

Tumor volume is a significant predictor of survival outcomes in T3 vocal cord cancers, but will need external validation. Tumors <2.5 cc have favorable outcomes. Those with higher volume tumors should be counselled appropriately and be considered for primary surgical management.

The functional role of microRNAs in laryngeal carcinoma

MicroRNAs are a class of non-coding, small RNAs, which modulate gene expression at the post-transcriptional level. Numerous studies have showed microRNAs are involved in the pathogenesis of laryngeal cancer through regulating tumor-related genes such as oncogenes or tumor suppressor genes. In this review, we summarize recent progress on the function of microRNAs in laryngeal cancer. We focus on potential use of microRNAs in laryngeal cancer diagnosis and prognosis.

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 .

Multidisciplinary Care of Laryngeal Cancer

Treatment of larynx cancer has changed dramatically over the past several years. Novel modalities of treatment have been introduced as organ preservation has been developed. In addition, new targeted therapies have appeared, and improvements in radiotherapeutic and surgical techniques have been introduced. Thus, a large variety of treatment options is increasing local control rates and overall survival; however, selecting the most appropriate treatment remains a challenging decision. This article focuses on the multidisciplinary care of early-stage and locally advanced larynx cancer and attempts to sum up different approaches. Moreover, it reviews state-of-the-art treatment in larynx preservation, which has been consolidated in recent years.

A change in the study evaluation paradigm reveals that larynx preservation compromises survival in T4 laryngeal cancer patients

BACKGROUND

Larynx preservation (LP) is recommended for up to low-volume T4 laryngeal cancer as an evidence-based treatment option that does not compromise survival. However, a reevaluation of the current literature raises questions regarding whether there is indeed reliable evidence to support larynx preservation for T4 tumor patients.

METHODS

In an observational cohort study of 810 laryngeal cancer patients, we evaluated the outcomes of all T4 tumor patients treated with primary chemo-radiotherapy (CRT) or primary radiotherapy alone (RT) compared with upfront total laryngectomy followed by adjuvant (chemo)radiotherapy (TL + a[C]RT). Additionally, we reevaluated the studies that form the evidence base for the recommendation of LP for patients with up to T4 tumors (Pfister et al., J Clin Oncol 24:3693-704, 2006).

RESULTS

The evaluation of all 288 stage III and IV patients together did not show a significant difference in overall survival (OS) between CRT-LP and TL + a(C)RT (hazard ratio (HR) 1.23; 95% confidence interval (CI): 0.82-1.86; p = 0.31) using a multivariate proportional hazard model. However, a subgroup analysis of T4 tumor patients alone (N = 107; 13.9%) revealed significantly worse OS after CRT compared with TL + a(C)RT (HR 2.0; 95% CI: 1.04-3.7; p = 0.0369). A reevaluation of the subgroup of T4 patients in the 5 LP studies that led to the ASCO clinical practice guidelines revealed that only 21-45 T4 patients had differential data on survival outcome. These data, however, showed a markedly worse outcome for T4 patients after LP.

CONCLUSIONS

T4 laryngeal cancer patients who reject TL as a treatment option should be informed that their chance of organ preservation with primary conservative treatment is likely to result in a significantly worse outcome in terms of OS. Significant loss of survival in T4 patients after LP is also confirmed in recent literature.

Contemporary management of advanced laryngeal cancer

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

Level of Evidence

NA.

Modifications in the treatment of advanced laryngeal cancer throughout the last 30 years

In the last decades, the treatment schemes for patients with locally advanced laryngeal cancer have changed significantly. These changes may have an impact in the survival of these patients. Our objective is to review the treatments administered to patients with locally advanced larynx tumors during a period of 30 years in our institution and to evaluate the prognostic impact of the changes in treatment protocols. Retrospective analysis of a cohort of 830 consecutive patients with T3 or T4 laryngeal carcinomas diagnosed and treated between 1985 and 2014 with a minimum follow-up of 1.5 years. During the study period, we witnessed a reduction in surgery as the initial treatment, as well as a substitution of induction chemotherapy by chemoradiotherapy as an organ preservation strategy. For patients with T3 tumors, there were no differences in cancer-specific survival by type of treatment, while patients with T4 tumors treated surgically showed significantly better survival than those treated with preservation strategies. Patients treated in the last decade (2005-2014) showed worse cancer-specific survival than those treated in the previous decade (1995-2004). The multivariate analysis showed significant differences in cancer-specific survival for larger tumors, positive nodal extension, and treatment with radiotherapy alone. The main changes in the management of advanced laryngeal carcinomas are the implementation of organ preservation strategies that reduce the use of surgery and the progressive of chemoradiotherapy as a standard treatment. These changes may have had a negative impact in survival of these patients.

Quantitative pretreatment CT volumetry: Association with oncologic outcomes in patients with T4a squamous carcinoma of the larynx

BACKGROUND

The purpose of this study was to determine the impact of CT-determined pretreatment primary tumor volume on survival and disease control in T4a laryngeal squamous cell carcinoma (SCC).

METHODS

We retrospectively reviewed 124 patients with T4a laryngeal cancer from 2000-2011. Tumor volume measurements were collected and correlated with outcomes.

RESULTS

Five-year overall survival (OS) for patients with tumor volume ≥21 cm³ treated with larynx preservation (n = 26 of 41) was significantly inferior compared to <21 cm³ (42% vs 64%, respectively; P = .003). Five-year OS for patients with tumor volumes ≥21 cm³ in the cohort treated with total laryngectomy followed by radiotherapy (RT; n = 42 of 83) was not statistically significant when compared to <21 cm³ (50% vs 63%, respectively; P = .058). On multivariate analysis, tumor volume ≥21 cm³ was a significant independent correlate of worse disease-specific survival (DSS; P = .004), event-free survival (P = .005), recurrence-free survival (RFS; P = .04), noncancer cause-specific survival (P = .02), and OS (P = .0002).

CONCLUSION

Pretreatment CT-based tumor volume is an independent prognostic factor of outcomes in T4a laryngeal cancer.

Survival Rates Using Individualized Bioselection Treatment Methods in Patients With Advanced Laryngeal Cancer

Importance

Use of chemoradiotherapy for advanced laryngeal cancer led to a major shift in treatment as an alternative to laryngectomy. Despite widespread adoption of chemoradiotherapy, survival rates have not improved and the original premise of matching neoadjuvant chemotherapy tumor response to determine subsequent treatment has not been followed.

Objective

To determine whether improved survival could be achieved by incorporating a single cycle of neoadjuvant chemotherapy to select patients with advanced disease for either laryngectomy or concurrent chemoradiotherapy.

Design, Setting, and Participants

An unselected cohort of 247 patients with laryngeal cancer in an academic institution between 2002 and 2012 was evaluated. Patients with limited disease (stages I and II) underwent endoscopic resection, radiotherapy, or chemoradiotherapy for deeply invasive T2 lesions. For patients with advanced disease (stages III and IV), neoadjuvant chemotherapy, concurrent chemoradiotherapy, or primary surgery was recommended. Overall survival (OS) and disease-specific survival (DSS) were analyzed. Median follow-up was 48 months. The study was conducted from January 1, 2002, to December 31, 2012; data analysis was completed December 1, 2015.

Interventions

Endoscopic resection, radiotherapy, chemoradiotherapy, neoadjuvant chemotherapy, concurrent chemoradiotherapy, and primary surgery.

Main Outcomes and Measures

Overall survival and DSS.

Results

Of the 247 patients, 191 (77.3%) were male; mean (SD) age was 59.6 (10.4) years. Of 94 patients with limited disease, 33 (35.1%) underwent endoscopic resection; 50 (53.2%), radiotherapy alone; and 11 (11.7%), chemoradiotherapy for deeply invasive T2 lesions. Of 153 patients with advanced disease, 71 (46.4%) received neoadjuvant chemotherapy; 50 (32.7%), concurrent chemoradiotherapy; and 32 (20.9%), surgery. Five-year OS and DSS was 75% (95% CI, 68%-81%) and 83% (95% CI, 77%-88%), respectively, for the entire cohort. The DSS was 92% (95% CI, 83%-97%) for patients with stage I or II and 78% (95% CI, 69%-84%) for patients with stage III or IV disease. For patients with advanced disease, 5-year OS and DSS ranged from 78% (95% CI, 55%-90%) and 91% (95% CI, 67%-98%), respectively, for surgery; to 76% (95% CI, 63%-85%) and 79% (95% CI, 67%-88%), respectively, for neoadjuvant bioselection; and to 61% (95% CI, 44%-75%) and 66% (95% CI, 48%-79%), respectively, for primary chemoradiotherapy. Propensity-adjusted, multivariable controlling for known prognostic factors DSS was significantly improved in the neoadjuvant group compared with the chemoradiotherapy group (hazard ratio [HR], 0.48; 95% CI, 0.29-0.80).

Conclusions and Relevance

Superior survival rates were achieved with a bioselective treatment approach using a single cycle of neoadjuvant chemotherapy. Good survival rates were also achieved in patients selected for primary surgery, and both neoadjuvant chemotherapy and primary surgery were better than survival rates with concurrent chemoradiotherapy, suggesting that the optimal individualized treatment approach for patients with advanced laryngeal cancer has not yet been defined.

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.

Long-term outcomes after multidisciplinary management of T3 laryngeal squamous cell carcinomas: Improved functional outcomes and survival with modern therapeutic approaches

BACKGROUND

The purpose of this study was to evaluate the long-term outcomes after initial definitive or adjuvant radiotherapy (RT) for T3 laryngeal cancers.

METHODS

We reviewed 412 patients treated for T3 laryngeal squamous cell cancer from 1985 to 2011.

RESULTS

The 10-year overall survival (OS) was 35%; disease-specific-survival (DSS) was 61%; locoregional control was 76%; and freedom from distant metastasis was 83%. Chemotherapy, age, performance status <2, node-negative status, and glottic subsite were associated with improved survival (all p < .03). Larynx preservation with induction and/or concurrent chemoradiotherapy (LP-CRT) had better laryngectomy-free survival than RT alone (LP-RT; hazard ratio [HR] = 0.62; 95% confidence interval [CI] = 0.47-0.81; p = .0005); 10-year laryngectomy-free survival rates of the LP-CRT cohort (37%) were higher than those of the LP-RT cohort (18%). The 5-year DSS and OS rates of the LP-CRT cohort (79% and 67%) were better after total laryngectomy with postoperative RT (TL-PORT; 61% and 50%) and LP-RT (64% and 46%; p < .006 for all).

CONCLUSION

In patients with T3 laryngeal cancers, LP-CRT provides better functional, oncologic, and survival outcomes than historical TL-PORT or LP-RT does. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1739-1751, 2016.

Up-Regulation of Angiotensin-Converting Enzyme (ACE) Enhances Cell Proliferation and Predicts Poor Prognosis in Laryngeal Cancer

Background

The angiotensin-converting enzyme (ACE, CD143) gene plays a crucial role in the pathology of many cancers. Previous studies mostly focused on the gene polymorphism, but the other functions of ACE have rarely been reported. The purpose of this study was to investigate the expression of ACE and its biological function, as well as its prognostic value, in laryngeal cancer.

Material/Methods

The expression of ACE was detected by quantitative real-time polymerase chain reaction (qRT-PCR) analysis in 106 patients with laryngeal cancer and 85 healthy people. Then the cell proliferation was estimated after the cell lines Hep-2 were transfected with pGL3-ACE and empty vector, respectively. In addition, the relationship between ACE expression and clinicopathologic characteristics was analyzed. Finally, Kaplan-Meier analysis was used to evaluate the overall survival of patients with different ACE expression, while Cox regression analysis was conducted to reveal the prognostic value of ACE in laryngeal cancer.

Results

Our results demonstrate that ACE is over-expressed in laryngeal cancer and thus promotes cell proliferation. The up-regulation of ACE was significantly influenced by tumor stage and lymph node metastasis. Patients with high ACE expression had a shorter overall survival compared with those with low ACE expression according to Kaplan-Meier analysis. The ACE gene was also found to be an important factor in the prognosis of laryngeal cancer.

Conclusions

Our study shows that the ACE gene was up-regulated, which promoted the cell proliferation, and it could be an independent prognostic marker in laryngeal cancer.

Expression of Th1- Th2- and Th17-associated cytokines in laryngeal carcinoma

T-helper (Th) 0 cell differentiation into Th1 or Th2 cells is dependent on a number of transcription factors that act at specific time points to regulate gene expression. Th17 cells, a subset of interleukin (IL)-17-producing T cells distinct from Th1 or Th2 cells, are considered to exhibit a critical function in inflammation and autoimmune diseases, as well as cancer development. In the present study, the expression of Th1-, Th2- and Th17-associated cytokines in laryngeal cancer and pericarcinoma tissues obtained from 57 laryngeal carcinoma patients was investigated. The association between Th1, Th2 and Th17 infiltration and tumor development was also evaluated. Reverse transcription-polymerase chain reaction and western blotting results revealed that the mRNA and protein expression of Th2 cytokines was lower, while the expression of Th1 and Th17 cytokines was higher in tumor tissues than in pericarcinoma tissues. Furthermore, the early stage cancer patients exhibited a higher level of interferon-γ, IL-2 and IL-17 mRNA expression than those at advanced stages. Cancer tissues exhibited higher Th17 cytokine expression than pericarcinoma tissues. By contrast, Th1 cytokine expression was increased in pericarcinoma tissues compared with cancer tissues. These results indicate that high expression of Th1- and Th17-associated cytokines in laryngeal carcinoma may contribute to suppression of cancer development and a relatively good prognosis.

Organ preservation with chemoradiation in advanced laryngeal cancer: The problem of generalizing results from randomized controlled trials

BACKGROUND

The primary goal of treatment in advanced laryngeal cancer is to achieve optimal oncologic outcomes while preserving function and quality of life. Combination of chemotherapy and radiation has been popularized as an alternative to surgery for patients facing total laryngectomy. However, survival analyses from large, population-based databases have not duplicated results reported from randomized trials.

METHODS

A comprehensive literature review was undertaken to try to better understand the reasons why results differ among randomized trials and population cohort studies.

RESULTS

A variety of reasons are discussed, including differences in patient staging, selection bias, complexity bias, inconsistent terminology, patient compliance and treatment expertise.

CONCLUSIONS

Personalized treatment considering all factors is critical for optimal outcomes. In general, evidence supports total laryngectomy for patients with T4 cancers. Definitive chemoradiotherapy strategies are acceptable alternatives for T3 cancers, provided that all resources for the administration of the treatment, follow-up and surgical salvage are available.