Hyperfractionated radiotherapy for T2 glottic cancer for preservation of the larynx

Radiotherapy versus partial laryngectomy in the management of early glottic cancer with anterior commissure involvement: A propensity score matched study with 256 patients

OBJECTIVES

The study was intended to compare the outcomes for T1-T2N0M0 glottic squamous cell carcinoma with anterior commissure involvement who had undergone partial laryngectomy (PL) or radiotherapy (RT).

MATERIALS AND METHODS

We retrospectively analyzed 256 patients who were treated by RT (n = 70) or PL (n = 186). Patients received prophylactic irradiation of the neck in RT group whereas PL was not associated with lymphadenectomy. Propensity score matching (PSM) was used to eliminate the baseline variations.

RESULTS

The average age of the RT group (67 years) was significantly higher than that of the PL (59 years). Local recurrence was noted in 14 patients of the RT group and 22 of the PL. While regional recurrence was noted in only 1 patient of the RT group and 23 of the PL. After PSM, the 5-year overall survival (82.8% vs. 83.9%, p = 0.302), 5-year cancer-specific survival (88.3% vs. 89.7%, p = 0.793), 5-year local relapse-free survival (79.3% vs. 84.5%, p = 0.127) were not significantly different between two groups. However, 5-year regional relapse-free survival in the RT group was significantly better than that in the PL (100% vs. 87.1%, p = 0.014). In the PL group, infection, granuloma, laryngeal stenosis, chylous leakage, and pharyngeal fistula were reported in six, 11, 12, one, and two patients, respectively.

CONCLUSIONS

RT resulted in comparable rates of survival, local control, and larynx preservation compared to PL. However, RT was associated with higher regional control rate. The complication rates were extremely low in RT group.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Oncologic and functional outcomes of patients treated with transoral CO2 laser microsurgery or radiotherapy for T2 glottic carcinoma: a systematic review of the literature

PURPOSE OF REVIEW

To give an overview of the laryngeal preservation and functional outcomes of patients treated with transoral CO2 laser microsurgery (TLM) or radiotherapy for T2 glottic carcinoma. This information supports physicians and patients in treatment counselling and choices.

RECENT FINDINGS

A recent systematic review showed that local control rates at 5-year did not differ between radiotherapy and TLM for T2 glottic tumours. However, there is a lack of comparative data on laryngeal preservation as well as functional outcomes in T2 glottic carcinoma.

SUMMARY

Laryngeal preservation for T2 tumours in this review is higher for patients treated primarily with TLM (88.8 vs. 79.0%). It is important to differentiate between tumours with normal and impaired mobility (T2a and T2b) because the latter showed poorer prognosis for both TLM and radiotherapy. Involvement of the anterior commissure does not result in significantly lower oncological results, if adequately staged and treated. More studies are needed to support these data and to compare the functional outcomes between TLM and radiotherapy for T2 glottic carcinoma.

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.

Co-Inhibition of GLUT-1 Expression and the PI3K/Akt Signaling Pathway to Enhance the Radiosensitivity of Laryngeal Carcinoma Xenografts In Vivo

In the present study, we investigated the role of GLUT-1 and PI3K/Akt signaling in radioresistance of laryngeal carcinoma xenografts. Volume, weight, radiosensitization, and the rate of inhibition of tumor growth in the xenografts were evaluated in different groups. Apoptosis was evaluated by TUNEL assay. In addition, mRNA and protein levels of GLUT-1, p-Akt, and PI3K in the xenografts were measured. Treatment with LY294002, wortmannin, wortmannin plus GLUT-1 AS-ODN, and LY294002 plus GLUT-1 AS-ODN after X-ray irradiation significantly reduced the size and weight of the tumors, rate of tumor growth, and apoptosis in tumors compared to that observed in the 10-Gy group (p<0.05). In addition, mRNA and protein expression of GLUT-1, p-Akt, and PI3K was downregulated. The E/O values of LY294002, LY294002 plus GLUT-1 AS-ODN, wortmannin, and wortmannin plus GLUT-1 AS-ODN were 2.7, 1.1, 1.8, and 1.8, respectively. Taken together, these data indicate that GLUT-1 AS-ODN as well as the inhibitors of PI3K/Akt signaling may act as radiosensitizers of laryngeal carcinoma in vivo.

Management and pitfalls of stage I/II glottic cancer

CONCLUSIONS

Once-daily radiotherapy for stage I glottic cancer and hyperfractionated radiotherapy for stage II glottic cancer achieved satisfactory results in terms of prognosis and laryngeal preservation. The treatment strategy for stage II glottal cancer with subglottal invasion needs to be reconsidered to further improve the outcome.

OBJECTIVES

Although early glottic carcinomas are highly curable by radiation therapy, the laryngeal preservation rate is not always sufficient. We reviewed the stage I/II glottal cancer treated in our institute during a recent 15-year period to improve the outcome and prognosis.

METHODS

In all, 113 cases of stage I/II glottic cancer (81 stage I cases and 32 stage II cases) were treated in Kyoto University hospital from 1994 to 2008. In 81 cases with stage I glottic cancer, radiation was performed for 66 cases, transoral laser excision (TLE) was performed for 14 cases, and hyperfractionated radiotherapy was done for one case. Among 32 cases with stage II glottic cancer, 24 cases were treated with hyperfractionated radiotherapy, 6 cases were treated with radiation, and one case with partial laryngectomy. Total laryngectomy was performed for one patient who suffered mixed connective tissue disease. Kaplan-Meier estimates were used for the analysis of survival rate and laryngeal preservation rate.

RESULTS

The 5-year overall survival rates were 88.4% in stage I cases and 89.1% in stage II cases. The 5-year disease-specific survival rates were 100% in stage I cases and 93% in stage II cases. The 5-year laryngeal preservation rates were 99% in stage I cases and 90% in stage II cases. Two cases of stage II glottal cancer with subglottal invasion failed to be controlled and the patients died from local recurrence and mediastinum lymph node metastasis, respectively.

Ten years single institutional experience of treatment for advanced laryngeal cancer in Kyoto University

CONCLUSION

It is important to suppress lymph node recurrence and distant metastasis to achieve better survival of advanced laryngeal cancer, especially supraglottic cancer.

OBJECTIVE

The therapeutic outcomes of 33 cases with advanced laryngeal cancer treated at Kyoto University Hospital between 2000 and 2008 were reviewed.

METHODS

Thirty-one males and two females were involved. Their ages ranged from 49 to 81 years (average 65.6 years). All tumors were squamous cell carcinoma, arising at the glottis in 21 cases and the supraglottis in 12 cases. Most glottic cancers (90.5%) and supraglottic cancers (83.3%) were classified as T3 or T4. Total laryngectomy with neck dissection was performed in the treatment of T3 or T4 cases. Two cases of T2 cancers were treated by radiotherapy (66-72 Gy) with neck dissection, and one case of T2 cancer was treated by radiotherapy (66 Gy). Partial laryngectomy with neck dissection was performed in one T3 case.

RESULTS

Five-year overall survival rates for stage III of glottic cancer, stage IV of glottic cancer, stage III of supraglottic cancer, and stage IV of supraglottic cancer were 100%, 40.9%, 100%, and 24.2%, respectively. Five-year disease-specific survival rates for stage III of glottic cancer, stage IV of glottic cancer, stage III of supraglottic cancer, and stage IV of supraglottic cancer were 100%, 56.3%, 100%, and 28.1%, respectively. No local recurrence occurred. Regional lymph node recurrence occurred in two cases- one patient with glottic cancer and one with supraglottic cancer. Both of them died of disease despite undergoing chemotherapy. One case initially had lung metastasis, and post-treatment distant metastasis occurred in the lung in four cases, in the skin in one, and in multiple organs in one case.

Radiotherapeutic management of laryngeal carcinoma

Authors discuss laryngeal lesions, metastases, and relevant anatomy. Outcome of surgical and radiotherapy in terms of voice preservation is discussed. Radiation techniques and outcomes for laryngeal cancer are presented along with discussion of interdisciplinary treatment. Authors review studies and quality of life outcomes of surviving laryngeal cancer patients.

[Surgical treatment options in laryngeal and hypopharyngeal cancer]

In Austria, around ten new cases of laryngeal cancer can currently be expected per 100.000 persons each year whereas three out of 100.000 men develope hypopharyngeal cancer. Among women, the incidence in both types of carcinoma is lower by a factor of around 5. All in all, the rate of new cases seems to have been constant or to have slightly decreased in the last few years. Approximately 70% of all laryngeal cancer are glottic cancer, that is to say originating from the vocal cords. About 30% are supraglottic tumours, true subglottic cancers are very rare. The majority of hypopharyngeal tumours originate from the piriform sinuses. Vocal cord tumours lead to a typical symptom that can be early detected: hoarseness. Thus, voice problems in adults that persist for several weeks should therefore always checked by laryngoscopy. This leads to there being a real possibility of early diagnosis of laryngeal cancer, which means that today, approximately 60% of all laryngeal tumours can be diagnosed in stage I or II according to UICC or as intraepithelial lesions (former carcinoma in situ). In glottic cancer about 75% are diagnosed in these early stages, whereas in supraglottic tumours the rate is only about 30% and in hypopharyngeal cancer it is less then 15%. Surgery, radiation therapy, chemo- or immunotherapy are the principal types of oncological treatments currently available. The following conditions generally need to be met for curative surgical treatment options: Local tumour, no systemic metastasis Tumour has to be resectable in healthy margins mortality/morbidity Surgery must not lead to unreasonable mutilation Lack of other therapeutic alternatives having an equal or lesser impact In the following pages, indications for the surgical treatment of laryngeal and hypopharyngeal cancer will be discussed and the results of surgical therapy will be summarised briefly.

Therapeutic outcomes of laryngeal cancer at Kyoto University Hospital for 10 years

CONCLUSION

It is important to prevent regional lymph node recurrence and distant metastasis to achieve better survival of laryngeal cancer.

OBJECTIVE

Therapeutic outcomes of 130 cases with laryngeal cancer treated at Kyoto University Hospital between 1995 and 2004 were reviewed.

PATIENTS AND METHODS

In all, 121 males and 9 females were involved. Their ages ranged from 40 years to 92 years (average 66 years). All tumors were squamous cell carcinoma - arising at the glottis in 111 cases, the supraglottis in 18, and the subglottis in 1 case. Most glottic cancers (77.5%) were classified as stage I or II, while most supraglottic cancers (77.8%) were at stage III or IV. Stage I/II cancers were basically treated by conventional radiotherapy (60-66 Gy) and twice-daily hyperfractionated radiotherapy (70-74 Gy), respectively, attempting to preserve the larynx. Total laryngectomy with neck dissection was performed in the treatment of stage III/IV cases.

RESULTS

Five-year disease-specific survival rates were 100%, 96%, 100%, and 68% for stage I, II, III, and IV, respectively. Five-year laryngeal preservation rates were 98%, 100%, 86%, 0%, and 0% for T1a, T1b, T2, T3, and T4 of glottic cancer, respectively. Local recurrence occurred in five cases of stage I/II glottic cancer, which was successfully salvaged. Regional lymph node recurrence occurred in five cases including four patients with glottic cancer and one with supraglottic cancer. Two of them died of disease despite undergoing salvage therapy. Distant metastasis occurred in the lung in four cases including one glottic and three supraglottic cancer patients after initial treatment.

Surgical approach and results of treating two subcategories pT2 glottic carcinoma of the larynx

Background: T2 glottic carcinoma is a nonhomogenous localization of laryngeal carcinoma with two subcategories. The aim of the study was to retrospectively analyze the results of surgically treated pT2 glottic carcinomas and to determine the importance of subcategories of glottic carcinomas in diagnostics, surgical treatment, and patients? survival. Methods: During the period 1990-2000, 71/701 (10%) patients were diagnosed. with pT2 glottic carcinoma. All patients were treated with different surgical techniques. Results: Total laryngectomy was performed in 14/71 patients. Involvement of anterior commisure in local spreading of the cancer was found in 24/71 patients; total laryngectomy was performed in 13/24 and reconstructive surgery in 11/24. Selective resection of neck was done in 49 patients and metastases were found in 2 of these patients. Out of fifty-seven patients who had reconstructive laryngeal surgery local disease recurrence appeared in 8 patients. These 8 patients were treated with total laryngectomy. Overall 5-year survival was 90.1% with a slight difference between subcategories (89.1% subcategory I; 93.7% subcategory II) which was not statistically significant (p>0.05). Disease free 5-year survival was 83.6% with a difference between subcategories (81.1% subcategory I; 93.3% subcategory II) which was not statistically significant (p>0.05). Conclusion: Spreading of glottic carcinoma toward supraglottic and subglottic structures complicates exact preoperative evaluation of tumor size regardless to preoperative diagnostic procedures. Just owing to that, larger surgical resections performed bring more radicalness with less percentage of local recurrence and better effects on overall survival and disease free survival rate.