A novel classification scheme for advanced laryngeal cancer midline involvement: implications for the contralateral neck

Advances and residual knowledge gaps in the neck management of head and neck squamous cell carcinoma patients with advanced nodal disease undergoing definitive (chemo)radiotherapy for their primary

PURPOSE

Substantial changes have been made in the neck management of patients with head and neck squamous cell carcinomas (HNSCC) in the past century. These have been fostered by changes in cancer epidemiology and technological progress in imaging, surgery, or radiotherapy, as well as disruptive concepts in oncology. We aimed to review changes in nodal management, with a focus on HNSCC patients with nodal involvement (cN+) undergoing (chemo)radiotherapy.

METHODS

A narrative review was conducted to review current advances and address knowledge gaps in the multidisciplinary management of the cN+ neck in the context of (chemo)radiotherapy.

RESULTS

Metastatic neck nodes are associated with poorer prognosis and poorer response to radiotherapy, and have therefore been systematically treated by surgery. Radical neck dissection (ND) has gradually evolved toward more personalized and less morbid approaches, i.e., from functional to selective ND. Omission of ND has been made feasible by use of positron-emission tomography/computed tomography to monitor the radiation response in cN+ patients. Human papillomavirus-driven oropharyngeal cancers and their cystic nodes have shown dramatically better prognosis than tobacco-related cancers, justifying a specific prognostic classification (AJCC) creation. Finally, considering the role of lymph nodes in anti-tumor immunity, de-escalation of ND and prophylactic nodal irradiation in combination are intense areas of investigation. However, the management of bulky cN3 disease remains an issue, as aggressive multidisciplinary strategies or innovative combined treatments have not yet significantly improved their prognosis.

CONCLUSION

Personalized neck management is an increasingly important aspect of the overall therapeutic strategies in cN+ HNSCC.

Should an elective contralateral neck dissection be performed in midline-reaching squamous cell carcinomas of the oral cavity and oropharynx?

OBJECTIVE

to compare the rate of occult contralateral neck metastases (OCNM) in oral and oropharyngeal squamous cell carcinomas (SCC) reaching or crossing the midline and to identify risk factors for OCNM.

MATERIALS AND METHODS

we conducted a single-center retrospective study of oral and oropharyngeal SCC with contralateral cN0 neck. The cohort was divided into a midline-reaching (MR; approaching the midline from up to 10 mm) group and a midline-crossing (MC; exceeding the midline by up to 10 mm) group. Clinical N-status was assessed by a radiologist specializing in head and neck imaging. All patients underwent contralateral elective neck dissection (END).

RESULTS

A total of 98 patients were included in this study, 59 in the MR group and 39 in the MC group. OCNM were present in 17.3% of patients, 20.3% in the MR group and 12.8% in the MC group (p = 0.336). In multivariable analysis, MR/MC status as well as distance from the midline (in mm) were not identified as risk factors for OCNM. Conversely, oropharyngeal primary and clinical N-status above N1 were significantly associated with a higher risk of OCNM, with odds ratios (OR) of 3.98 (95% CI = 1.08-14.60; p = 0.037) and 3.41 (95% CI = 1.07-10.85; p = 0.038) respectively.

CONCLUSION

in patients with oral and oropharyngeal SCC extending close to or beyond the midline, tumor origin and clinical N-status should carry the most weight when dictating the indications for contralateral END, rather than the midline involvement in itself.

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.

Delineation of neck node levels for patients with locally advanced supraglottic cancer receiving radical intensity-modulated radiotherapy: a cross-sectional study in Mainland China

Background: To survey the diversity of clinical target volumes (CTVs) for locally advanced supraglottic cancer (LA-SGC) with radical radiotherapy in mainland China. Methods: Radiation oncologists from 30 provinces and four representative cases (T2N1, T3N2b, T4N0, T4N2c) were included. Results: High risk (HR)-CTV included involved and the lower adjacent level was followed by most physicians (n = 160, 97.6%). In the N0-1 stage, whether contralateral levels II-III should be included in HR- or low risk (LR)-CTV was controversial. In the N2 stage, the bilateral levels II-IVb were included in LR-CTV (75-92.5% agreement). Levels Ib, V or VIb were included in CTV requiring certain conditions. Conclusion: Involved and lower adjacent levels were as HR-CTV. Whether bilateral levels II-IV are included in HR- or LR-CTV remain controversial.

Total Laryngectomy: A Review of Surgical Techniques

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.

Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

Unilateral versus bilateral nodal irradiation: Current evidence in the treatment of squamous cell carcinoma of the head and neck

Cancers of the head and neck region often present with nodal involvement. There is a long-standing convention within the community of head and neck radiation oncology to irradiate both sides of the neck electively in almost all cases to include both macroscopic and microscopic disease extension (so called elective nodal volume). International guidelines for the selection and delineation of the elective lymph nodes were published in the early 2000s and were updated recently. However, diagnostic imaging techniques have improved the accuracy and reliability of nodal staging and as a result, small metastases that used to remain undetected and were thus in the past included in the elective nodal volume, will now be included in high-dose volumes. Furthermore, the elective nodal areas are situated close to the parotid glands, the submandibular glands and the swallowing muscles. Therefore, irradiation of a smaller, more selected volume of the elective nodes could reduce treatment-related toxicity. Several researchers consider the current bilateral elective neck irradiation strategies an overtreatment and show growing interest in a unilateral nodal irradiation in selected patients. The aim of this article is to give an overview of the current evidence about the indications and benefits of unilateral nodal irradiation and the use of SPECT/CT-guided nodal irradiation in squamous cell carcinomas of the head and neck.

Rational surgical neck management in total laryngectomy for advanced stage laryngeal squamous cell carcinomas

PURPOSE

Controversies exist in regard to surgical neck management in total laryngectomies (TL). International guidelines do not sufficiently discriminate neck sides and sublevels, or minimal neck-dissection nodal yield (NY).

METHODS

Thirty-seven consecutive primary TL cases from 2009 to 2019 were retrospectively analyzed in terms of local tumor growth using a previously established imaging scheme, metastatic neck involvement, and NY impact on survival.

RESULTS

There was no case of level IIB involvement on any side. For type A and B tumor midline involvement, no positive contralateral lymph nodes were found. Craniocaudal tumor extension correlated with contralateral neck involvement (OR: 1.098, p = 0.0493) and showed increased involvement when extending 33 mm (p = 0.0134). Using a bilateral NY of ≥ 24 for 5-year overall survival (OS) and ≥ 26 for 5-year disease-free survival (DFS) gave significantly increased rate advantages of 64 and 56%, respectively (both p < 0.0001).

CONCLUSIONS

This work sheds light on regional metastatic distribution pattern and its influence on TL cases. An NY of n ≥ 26 can be considered a desirable benchmark for bilateral selective neck dissections as it leads to improved OS and DFS. Therefore, an omission of distinct neck levels cannot be promoted at this time.

Significance of examined lymph nodes number and metastatic lymph nodes ratio in overall survival and adjuvant treatment decision in resected laryngeal carcinoma

OBJECTIVE

The value of adjuvant therapy in resected laryngeal cancer remains controversial. This large SEER-based cohort study aimed to investigate the existing parameters of lymph node status that could predict survival outcomes and the prognostic value of adjuvant treatment in resected laryngeal carcinoma.

METHODS

Population-based data from the US Surveillance, Epidemiology, and End Results (SEER-18) Program on patients after laryngectomy and lymphadenectomy (2004-2015) were analyzed. The optimal cut-off values for examined lymph nodes number (ELNs) and metastatic lymph nodes ratio (MLNR) were determined using the X-tile program. Associations of ELNs and MLNR with overall survival were investigated through Cox regression analysis. A survival-predicting model was then constructed to stratified patients. The prognostic value of adjuvant therapy was evaluated in different subgroups.

RESULTS

A total of 2122 patients with resected laryngeal cancer were analyzed. A novel survival-predicting model was proposed based on ELNs, MLNR, and other clinicopathological characteristics. Patients were stratified into three subgroups with the increasing risk of death. Only patients in the high-risk group who receiving adjuvant treatment had a significantly better survival outcome than those receiving surgery alone.

CONCLUSION

A new survival-predicting model was established in this study, which was superior in assessing the survival outcomes of patients with resected laryngeal cancer. Notably, this model was also able to assist in the decision making of adjuvant therapy for patients and physicians.

Volume de-escalation in radiation therapy: state of the art and new perspectives

PURPOSE

New RT techniques and data emerging from follow-up for several tumor sites suggest that treatment volume de-escalation may permit to minimize therapy-related side effects and/or obtain better clinical outcomes. Here, we summarize the main evidence about volume de-escalation in RT.

METHOD

The relevant literature from PubMed was reviewed in this article. The ClinicalTrials.gov database was searched for clinical trials related to the specific topic.

RESULTS

In Lymphoma, large-volume techniques (extended- and involved-field RT) are being successfully replaced by involved-site RT and involved-node RT. In head and neck carcinoma, spare a part of elective neck is controversial. In early breast cancer, partial breast irradiation has been established as a treatment option in low-risk patients. In pancreatic cancer stereotactic body radiotherapy may be used to dose escalation. Stereotactic radiosurgery should be the treatment choice for patients with oligometastatic brain disease and a life expectancy of more than 3 months, and it should be considered an alternative to WBRT for patients with multiple brain metastases.

CONCLUSION

Further clinical trials are necessary to improve the identification of suitable patient cohorts and the extent of possible volume de-escalation that does not compromise tumor control.

Surgical nodal management in hypopharyngeal and laryngeal cancer

Objective

The aim of this study is to compare pre-therapeutic staging of the loco-regional lymphatic basin and subsequent surgical management in cN0 versus cN+ hypopharyngeal and laryngeal cancer patients.

Methods

We analyzed all hypopharyngeal and laryngeal carcinoma patients treated surgically at a single quaternary medical care and cancer center between 2004 and 2014. We established two groups for patients who underwent neck dissection comparing patients with a low LNR (lymph node ratio) to one with a high LNR. Regarding the cN0 cohort, elective neck dissection was evaluated as a secondary predictor variable. Comorbidities, such as anemia and renal insufficiency, were analyzed as potentially influencing disease-free (DFS) and overall survival (OS).

Results

A total of 310 patients (185 glottic and 125 supraglottic/hypopharyngeal carcinoma) were included. Pre-therapeutic neck MRI-/CT-scan and concomitant neck ultrasound revealed cN+ status in 144 patients resulting in a significant over-staging in 63 patients (44%) who were rated as being pN0 after histological examination. 166 patients were staged cN0 and 21 underwent elective neck dissection (11 local advanced glottic and 10 supraglottic/hypopharyngeal carcinoma). Two cN0 patients showed occult cervical lymph node metastases (10%). Furthermore, we could detect a significant negative impact of the LNR divided by the number of dissected lymph nodes and OS.

Conclusion

The pre-therapeutic clinical evaluation of lymphatic outgrowth is over-staged. OS decreases with increasing LNR divided by the number of dissected lymph nodes. Renal insufficiency and anemia are significant negative factors, decreasing both OS and DFS.