Radiation therapy for T2N0 laryngeal cancer: A retrospective analysis for the impact of concurrent chemotherapy on local control

Daily fraction dose-adjusted radiotherapy policy to avoid prolonging the overall treatment time for early glottic squamous cell carcinoma: a single-institutional retrospective study

The objective of this study was to determine the outcomes of radical radiotherapy for early glottic squamous cell carcinoma (EGSCC) with the policy of increasing the fraction size during radiotherapy when the overall treatment time (OTT) was expected to be prolonged. Patients diagnosed with clinical T1-2N0M0 EGSCC, who were treated with radical radiotherapy between 2008 and 2019 at Hokkaido University Hospital, were included. Patients received 66 Gy in 33 fractions for T1 disease and 70 Gy in 35 fractions for T2 disease as our standard regimen (usual group [UG]). If the OTT was expected to extend for >1 week, the dose fraction size was increased from 2.0 to 2.5 Gy from the beginning or during radiotherapy (adjusted group [AG]). At this time, we performed a statistical analysis between UG and AG. In total, 116 patients were identified, and the treatment schedules of 29 patients were adjusted. The median follow-up was 60.9 months. In the T1 group, the cumulative 5-year local failure rate was 12.0% in the AG and 15.4% in the UG, and in the T2 group, the rate was 40.7% in the AG and 25.3% in the UG. There were no significant differences between the AG and UG. Similarly, no significant differences were observed for overall survival and progression-free survival rates. Our single-institutional retrospective analysis of EGSCC patients suggested that a method of adjusting the radiotherapy schedule to increase fraction size from the beginning or during the course may be effective in maintaining treatment outcomes.

Radiation for Early Glottic Cancer

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

Analysis of prognostic factors for Tis-2N0M0 early glottic cancer with different treatment methods

INTRODUCTION

In many regions, laryngeal carcinoma is a common upper respiratory tract cancer, most commonly involving the glottic region. The treatment of early glottic cancer includes radiotherapy, open surgery and laryngeal laser microsurgery. However, the preferred treatment for early glottic cancer is still controversial.

OBJECTIVES

To study the factors affecting the 5-year survival rate of T_is-2N₀M₀ early glottis cancer and to demonstrate the oncological safety of different treatments.

METHODS

144 patients with early glottic cancer were analyzed retrospectively. All patients were clinically node negative. 53 patients underwent open surgery, transoral CO₂ laser microsurgery in 46 cases and radiotherapy in 45 cases. The patients were followed up for 26 - 84 months, with an average follow-up period of 62.9 months.

RESULTS

The 5-year overall survival was 82.6%. The 5 year survival rates of open surgery, laser microsurgery and radiotherapy were 83.0%, 82.6% and 82.2%, respectively. There was no significant difference in 5-year survival rate among the three treatments (p =  0.987). In multivariate analysis, age, T-stage, pathological grading, and anterior commissure involvement were important prognostic factors for early glottic cancer.

CONCLUSIONS

There was no significant difference in 5 year survival rate among patients treated by either radiotherapy, laser microsurgery or open surgery for early glottic cancer. We urge more attention to the age, T-stage, pathological grade, and anterior commissure involvement of the patients.

Predictors of Postoperative Radiation Following Laser Resection in Early-Stage Glottic Cancer

OBJECTIVE

Guideline recommendations for the treatment of early-stage glottic cancer are limited to single-modality therapy with surgery or radiation alone. We sought to investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) following laser excision for patients with T1-T2N0 glottic squamous cell carcinoma (SCC).

STUDY DESIGN

Retrospective observational study of the National Cancer Database.

SETTING

National Cancer Database review from 2004 to 2014.

PATIENTS AND METHODS

A total of 1338 patients with primary cT1-T2N0M0 glottic SCC undergoing primary laser excision were included. Hospitals were divided into quartiles based on yearly volume of laryngeal laser cases performed. Multivariate logistic regression was performed to identify independent predictors of PORT.

RESULTS

The overall rate of PORT was 30.0%. Predictors of PORT included treatment at lower-volume hospitals (adjusted odds ratio [aOR] for quartiles 2-4, 1.32-4.84), positive margins (aOR, 3.83 [95% CI, 2.54-5.78]), and T2 tumors (aOR, 3.58 [95% CI, 2.24-5.74]). PORT utilization demonstrated a strong inverse correlation with hospital volume. Among top-quartile hospitals, the rate of PORT was 11.2%, while rates of PORT at second-, third-, and fourth-quartile institutions were 19.2%, 32.2%, and 37.4%, respectively.

CONCLUSIONS

Predictors of PORT in multivariable analysis included treatment at lower-volume facilities, positive margins, and T2 disease. This study highlights the importance of treating early-stage glottic carcinoma at high-volume institutions. In addition, there is a need to reevaluate the use of PORT and reduce the rate of dual-modality therapy for patients with early-stage glottic SCC.

Comparison of long-term treatment outcomes of T2N0M0 laryngeal squamous cell carcinoma using different treatment methods

Early [stage I and II (T2N0M0)] laryngeal cancer types are currently recommended to be treated with a single modality, consisting of definitive radiation therapy or larynx-preserving surgery. Although the treatment outcomes of stage I are good, the frequency of successful outcomes decreases with T2N0M0. Therefore, the present study investigated the treatment outcomes of different treatment methods in T2N0M0 laryngeal cancer. In total, 83 patients with previously untreated T2N0M0 laryngeal squamous cell carcinoma were enrolled. Patients were grouped by treatment method: Radiation therapy (RT; 27 patients); chemoradiotherapy (CRT; 46 patients) with cisplatin base; and surgery-based therapy (SBT; ten patients). The recurrence rates of the RT, CRT and SBT groups were 44.4, 19.6 and 50%, respectively. Moreover, the local control rates of the RT, CRT and SBT groups were 55.6, 87.0 and 80%, respectively. The CRT group had a significantly lower recurrence rate and higher local control rate compared with the RT group (P<0.05). In the survival analysis, overall and disease-specific survival rate did not differ significantly among the treatment groups. However, 3- and 5-year disease-free survival rates (DFS) of the RT group were both 55%, those of the SBT group were both 50% and those of the CRT group were both 80%. Furthermore, the DFS was significantly higher in CRT group compared with the other groups (P=0.02). Using multivariate analysis with Cox regression, it was found that the treatment method was the most important factor for DFS and had a significant impact in the CRT group. In addition, in patients with glottic cancer with anterior commissure and subglottic invasion, the CRT group had significantly improved DFS compared with the RT group, whereas there was no significant difference between the two groups in patients without subglottic invasion. According to National Cancer Institution Common Toxicity Criteria (version 5.0), more patients had toxicity in the CRT group compared with the RT group. However, in the RT and CRT groups, no patients demonstrated mortality due to toxicity, and treatment-related toxicities were manageable. Collectively, although definitive conclusions could not be established, due to the limitations of this retrospective study, the results suggest that CRT had a positive impact on the local control and DFS rates with manageable toxicity in patients with T2N0M0 laryngeal cancer.

Emerging Concepts and Novel Strategies in Radiation Therapy for Laryngeal Cancer Management

Laryngeal squamous cell carcinoma is the second most common head and neck cancer. Its pathogenesis is strongly associated with smoking. The management of this disease is challenging and mandates multidisciplinary care. Currently, accepted treatment modalities include surgery, radiation therapy, and chemotherapy—all focused on improving survival while preserving organ function. Despite changes in smoking patterns resulting in a declining incidence of laryngeal cancer, the overall outcomes for this disease have not improved in the recent past, likely due to changes in treatment patterns and treatment-related toxicities. Here, we review emerging concepts and novel strategies in the use of radiation therapy in the management of laryngeal squamous cell carcinoma that could improve the relationship between tumor control and normal tissue damage (therapeutic ratio).

Early glottic tumours with anterior commissure involvement. Literature review and consensus document. Head and Neck and Skull Base Commission, SEORL-CCC

The choice of the most appropriate treatment in early-stage glottic cancer with anterior commissure involvement remains controversial. Its therapeutic management is complex because it is a significant prognostic indicator of local control with 37% recurrence, due to the difficulty in establishing tumour extension with understaging of up to 40%, and due to the comparison of results in series on tumours that behave variably as they progress, such as T1a, T1b and T2a with commissure involvement. Furthermore, the complexity of the surgical approach using transoral CO2 laser microsurgery requires surgical skill, appropriate equipment and experience. Aspects to be reviewed in this document are: an updated anatomical definition of the anterior commissure, tumour progression based on histopathological studies, usefulness of videostroboscopy and NBI in diagnostic accuracy, validity of imaging tests, oncological results published in series reviews, systematic reviews and meta-analyses, tumour margin treatment and voice evaluation.Finally, by way of a summary, the document includes a series of recommendations for the treatment of these tumours.

The nonsurgical management of early stage (T1/2 N0 M0) laryngeal cancer: A population analysis

BACKGROUND

The purpose of this study was to evaluate the patterns of care and survival in the nonsurgical management of early-stage (T1/2 N0 M0) laryngeal cancer.

STUDY DESIGN

This was a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) database during the period 2004 to 2015. Patients diagnosed with T1/2 N0 M0 laryngeal SCC definitively treated without surgery were included. Study predictors were age, gender, race, marital status, histologic grade, stage, and management strategy defined as radiotherapy (RT), chemotherapy, chemoradiotherapy (CRT), or no treatment. Study outcomes were overall survival (OS) and disease-specific survival (DSS).

RESULTS

In total, 3221 patients comprised the final sample. Over half of the lesions were stage I (63.8%); 74.0%, 24.8%, and 1.2% were located in the glottis, supraglottis, and subglottis, respectively. RT (77.6%) was the preferred nonsurgical treatment modality, followed by CRT (12.7%). A greater proportion of patients with stage II disease (25.1%) received CRT compared with those with stage I (5.6%). Similarly, patients receiving CRT were significantly younger and more likely to present with higher-grade lesions located in the supraglottis and subglottis. In the multivariate model, the risks of both disease-specific and overall death were increased by age, male gender, supraglottic and subglottic location, stage II disease, CRT, and no treatment.

CONCLUSIONS

Definitive RT was the preferred treatment modality regardless of tumor characteristics. CRT was more often selectively reserved for younger patients with higher grade, stage II tumors located in the supraglottis and subglottis. This approach may be driven by the poorer rates of survival associated with these particular characteristics. CRT did not appear to improve survival in comparison with RT after controlling for subsite and disease severity; however, future clinical studies are required to validate this finding.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

2C (Outcomes Research).

Addition of S-1 to radiotherapy for treatment of T2N0 glottic cancer: Results of the multiple-center retrospective cohort study in Japan with a propensity score analysis

OBJECTIVES

This multicenter retrospective cohort study aimed to evaluate the significance of adding S-1 to radiotherapy (RT) for the treatment of T2N0 glottic cancer using a propensity score matched analysis in Japan.

MATERIALS AND METHODS

This study was conducted on 287 patients with T2N0 glottic cancer who were treated with definitive RT or chemoradiotherapy with S-1 (S-1 RT) between April 2007 and March 2017. Propensity score matched analysis was performed to ensure the well-balanced characteristics of the groups of patients who received RT alone and S-1 RT. Overall, progression-free and laryngectomy-free survivals and local control and laryngeal preservation rates were compared.

RESULTS

Fifty-four pairs of patients were selected after performing propensity score matched analysis. Clinical characteristics were well-balanced between the two groups. The overall survival of patients in the S-1 RT group was significantly better than those in the RT alone group (P = 0.008). The progression-free and laryngectomy-free survivals of patients in the S-1 RT group were also better than those in the RT alone group; however, the differences were not significant. In contrast, patients in the S-1 RT group had slightly lower local control and laryngeal preservation rates compared with those in the RT alone group. The incidence of dermatitis in the S-1 RT group was significantly higher than that in the RT alone group in the matched population (P = 0.013).

CONCLUSIONS

The addition of S-1 to RT for the treatment of T2N0 glottic cancer was not associated with better local control and laryngeal preservation rates in this study.

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

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

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.

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

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

Long-Term Outcomes of Patients with Squamous Cell Carcinoma of the Temporal Bone after Concomitant Chemoradiotherapy

Objectives  This article aims to clarify the long-term outcomes of patients with squamous cell carcinoma of the temporal bone who underwent concomitant chemoradiotherapy (CCRT). Design and Setting  The study design was a retrospective chart review. Patients and Methods  From December 2001 to June 2014, 23 patients with cancer of the temporal bone who were treated by CCRT at the Tohoku University Hospital and the Iwate Medical University Hospital were enrolled in this study. For advanced cancer of the temporal bone, a modified docetaxel, cisplatin, and 5-fluorouracil (TPF) regimen was used for CCRT. The long-term outcomes, including prognoses and late complications, were analyzed after CCRT of patients with cancers of the temporal bone. Results  The main long-term complications were stenosis of the external auditory canal and conductive hearing loss. No harmful late complications were observed in these patients. Disease-specific survival rates were 84.9% for all patients, 100% for patients of stage I, II, and III ( n  = 10), and 75.5% for patients of stage IV ( n  = 13) at 5 years. Conclusions  Our study showed that CCRT is an effective treatment choice for squamous cell carcinoma of the temporal bone. Furthermore, CCRT using the TPF regimen is a safe and effective initial treatment for patients with advanced cancers of the temporal bone.

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 .

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

Background

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

Methods

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

Results

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

Conclusion

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

WRAP53β, survivin and p16INK4a expression as potential predictors of radiotherapy/chemoradiotherapy response in T2N0-T3N0 glottic laryngeal cancer

The current treatment recommendation for T2-3N0M0 glottic squamous cell carcinoma (SCC) in the Nordic countries comprises of radiotherapy (RT) and chemoradiotherapy (CRT). Tumor radiosensitivity varies and another option is primary surgical treatment, which underlines the need for predictive markers in this patient population. The aim of the present study was to investigate the relation of the proteins WRAP53β, survivin and p16^INK4a to RT/CRT response and ultimate outcome of patients with T2-T3N0 glottic SCC. Protein expression was determined using immunohistochemistry on tumors from 149 patients consecutively treated with RT or CRT at Helsinki University Hospital, Karolinska University Hospital, and Linköping University Hospital during 1999–2010. Our results demonstrate a significantly better 5-year relapse-free survival, disease-free survival (DFS), disease-specific survival and overall survival of patients with T3N0 tumors treated with CRT compared with RT alone. Patients with tumors showing a cytoplasmic staining of WRAP53β revealed significantly worse DFS compared with those with nuclear staining. For survivin, we observed a trend towards better 5-year DFS in patients with strong nuclear survivin expression compared with those with weak nuclear survivin expression (P=0.091). Eleven (7%) tumors showed p16 positivity, with predilection to younger patients, and this age group of patients with p16-positive SCC had a significantly better DFS compared with patients with p16-negative SCC. Taken together, our results highlight WRAP53β as a potential biomarker for predicting RT/CRT response in T2-T3N0 glottic SCC. p16 may identify a small but distinct group of glottic SCC with favorable outcome. Furthermore, for T3N0 patients better outcome was observed following CRT compared to RT alone.

Impact of combined modality treatment with radiotherapy and S-1 on T2N0 laryngeal cancer: Possible improvement in survival through the prevention of second primary cancer and distant metastasis

BACKGROUND

In patients with head and neck cancer, the management of second primary cancer (SPC) is particularly important for improving survival because of its high incidence and associated mortality. We evaluated the impact of combination chemotherapy on survival and SPC.

METHOD

We retrospectively analyzed data from 49 patients treated with definitive radiation therapy (RT) for T2N0M0 laryngeal squamous cell carcinoma between 2003 and 2011. Among them, 22 patients received combined modality treatment with radiotherapy and S-1 (RT+CT group).

RESULTS

The median follow-up period was 71months (32-111months). A significant difference in overall survival (OS, P<0.01) was observed between the RT+CT group (n=22) and the RT alone group (n=27) though no significant differences were observed in local control and disease specific survival. Univariate analyses showed that an older age (P<0.05) and a higher grade (P<0.05) were associated with OS. Multivariate analysis identified chemotherapy as the most significant predictor of survival (OR, 0.056; 95% CI, 0.008-0.353, P<0.01). A significantly lower incidence of distant metastasis (DM)+SPC (5-year incidence: 5% vs. 19%, P<0.05) and fewer deaths from these causes (1 vs. 8: P<0.05) were observed in the RT+CT group. Multivariate analysis showed that chemotherapy was the most significant factor for the incidence of DM+SPC (OR, 0.074; 95% CI, 0.0065-0.84; P<0.05).

CONCLUSION

The findings of this study suggest the possibility that combined modality treatment with radiotherapy and S-1 improve survival by preventing distant metastasis and second primary cancer.

Concurrent chemoradiotherapy with conventional fractionated radiotherapy and low-dose daily cisplatin plus weekly docetaxel for T2N0 glottic cancer

Background

To assess the efficacy of concurrent chemoradiotherapy (CCRT) with daily low-dose cisplatin (CDDP) plus weekly docetaxel (DTX) for patients with T2N0 glottic cancer.

Methods

Between January 2004 and December 2013, 62 treatment-naive patients with histologically proven T2N0 glottic cancer were treated with concurrent chemoradiotherapy. Radiation therapy (RT; 2 Gy daily fractions up to a total dose of 66 Gy) was administered in combination with daily low-dose CDDP (6 mg/m², five times a week), plus weekly DTX (10 mg/m²) for up to 4 weeks from the commencement of RT.

Results

Median duration of follow-up was 70 months. The actuarial 3-year and 5-year overall survival rates were 95% and 93%. The 3-year and 5-year cause-specific survival rates were both 100%. The actuarial 3-year and 5-year local control rates were 94% and 94%, respectively. Hematologic toxicity (neutoropenia of severity ≥ Grade 3) was observed in 8% of the patients, and non-hematologic toxicity (radiation mucositis of severity ≥ Grade 3) developed in one patient (2%). Radiation dermatitis of severity ≥ Grade 3 and laryngeal necrosis developed in one patient.

Conclusion

CCRT with weekly DTX and low-dose CDDP appears to be a practical and safe modality and is expected to improve local control.

Trial registration

UMIN000025046. Registered 1 October 2015, retrospectively registered.

[Sequential Chemoradiotherapy for Advanced Head and Neck Cancer: A Clinical Study with 33 Cases]

A total of 33 patients with advanced head and neck cancer (AHNC) treated with sequential chemoradiotherapy (SCRT) were retrospectively evaluated at Gunma University Hospital between 2009 and 2011. The regimen of SCRT was docetaxel, cisplatin, and fluorouracil (TPF)-based induction chemotherapy (ICT), accompanied by docetaxel and cisplatin-based concurrent chemoradiotherapy (CCRT), and oral administration of TS-1 after that. The response rate was 61%, the 3-year overall survival rate was 42%, the non-tumor-bearing survival rate was 27%, and the tumor-bearing survival rate was 15%. Fourteen of 33 patients were tumor-free, and their 3-year overall survival rate was surprisingly 86%. On the other hand, 3-year overall survival rate in the remaining 19 patients was significantly low. To select good response cases for ICT was important. In such cases, TPF should be applied repeatedly, which achieved a 61% response rate even in AHNC. A long-term TS-1 oral medication suppressed cancer regrowth and contributed to long-term survival.

Phase II study of concurrent chemoradiotherapy with S-1 in patients with stage II (T2N0M0) squamous cell carcinoma of the Pharynx or Larynx

OBJECTIVE

The goals of treatment for head and neck cancer are cure and organ-function preservation. For organ preservation, primary treatment via radiotherapy alone is thought to be insufficient for Stage II squamous cell carcinoma of the larynx, oropharynx or hypopharynx. The objective of the present study was to investigate the efficacy and safety of concurrent chemoradiotherapy with S-1 for patients with Stage II squamous cell carcinoma of the pharynx or larynx for primary organ preservation.

METHODS

Previously untreated patients with Stage II squamous cell carcinoma of the larynx, oropharynx or hypopharynx received three courses of S-1 (40 or 50 mg twice a day; 2 weeks of administration followed by 1 week of rest every 3 weeks) during conventional radiotherapy (a single daily fraction of 1.8 Gy) to a total dose of 70.2 Gy. The primary endpoint was the local control rate at 3 years.

RESULTS

From August 2009 to October 2012, 37 patients were evaluated for the study. The overall response rate was 100%. The 3-year local control rate was 89.0% (95% confidence interval, 78.9-99.2%), and the 3-year overall survival rate was 97.2% (95% confidence interval, 91.8-100%). Mucositis and dermatitis in the radiation field were the most common acute adverse events observed. The rates of Grade 3 mucositis and dermatitis were 27 and 35%, respectively. No patients experienced Grade 4 acute adverse events. The treatment completion rate was 89.2%.

CONCLUSION

Concurrent chemoradiotherapy with S-1 was safe and effective in improving local control for Stage II squamous cell carcinoma of the pharynx or larynx.

Definitive radiotherapy for early (T1-T2) glottic squamous cell carcinoma: a 20 year Cleveland Clinic experience

Purpose

To report our 20 yr experience of definitive radiotherapy for early glottic squamous cell carcinoma (SCC).

Methods and materials

Radiation records of 141 patients were retrospectively evaluated for patient, tumor, and treatment characteristics. Cox proportional hazard models were used to perform univariate (UVA) and multivariate analyses (MVA). Cause specific survival (CSS) and overall survival (OS) were plotted using cumulative incidence and Kaplan-Meir curves, respectively.

Results

Of the 91% patients that presented with impaired voice, 73% noted significant improvement. Chronic laryngeal edema and dysphagia were noted in 18% and 7%, respectively. The five year LC was 94% (T1a), 83% (T1b), 87% (T2a), 65% (T2b); the ten year LC was 89% (T1a), 83% (T1b), 87% (T2a), and 53% (T2b). The cumulative incidence of death due to larynx cancer at 10 yrs was 5.5%, respectively. On MVA, T-stage, heavy alcohol consumption during treatment, and used of weighted fields were predictive for poor outcome (p < 0.05). The five year CSS and OS was 95.9% and 76.8%, respectively.

Conclusions

Definitive radiotherapy provides excellent LC and CSS for early glottis carcinoma, with excellent voice preservation and minimal long term toxicity. Alternative management strategies should be pursued for T2b glottis carcinomas.

Concomitant chemoradiotherapy as a standard treatment for squamous cell carcinoma of the temporal bone

We sought to characterize the effectiveness of concomitant chemoradiotherapy (CCRT) for patients with squamous cell carcinoma of the temporal bone. We performed a retrospective chart review of 14 patients with cancer of the temporal bone who were provided initial treatment in our hospital from December 2001 to November 2008. Four patients with stage I tumors were treated by radiation therapy alone or with oral administration of S1. One patient with a stage II tumor was treated by radiation therapy concomitant with low dose docetaxel. Nine patients with stage IV tumors were treated by CCRT using the TPF regimen (docetaxel, cisplatin, and 5-fluorouracil). As an initial treatment, all patients but one were treated by radiation therapy with or without chemotherapy. Grade 4 adverse events of patients who received CCRT using the TPF regimen involved the leukopenia in one patient and the neutropenia in two patients. Local recurrences were observed in three patients including two patients with T4 tumors. Five-year disease-specific survival rates for all patients and for patients with T4 tumors were 78% and 67%, respectively. CCRT using the TPF regimen is safe and effective as the first treatment for patients with cancer of the temporal bone.

Multi-institutional analysis of early glottic cancer from 2000 to 2005

BACKGROUND

The purpose of this study is to analyze the outcome of patients with early glottic cancer (GC) treated with radiotherapy (RT) with or without chemotherapy at 10 institutions in the Tokai District, Japan.

METHODS

Ten institutions combined data from 279 patients with T1-T2 GC treated with RT with or without chemotherapy between 2000 and 2005. The overall survival rate, disease-specific survival rate, and local control rate were evaluated in 270 patients, except for incomplete cases due to issues such as discontinuation, using the method of Kaplan-Meier and compared using the log-rank test. Results were considered statistically significant at the level of p < 0.05.

RESULTS

For 122 patients, the tumors were classified as T1a, while 64 patients had T1b tumors, and 84 patients had T2 tumors. In three cases of T1 tumors, the subtype was unknown. Combined chemoradiotherapy (CRT) was administered during each stage, and various chemotherapy drugs and regimens were used. The median follow-up period was 55.4 months. The 5-year LC rates for T1a, Tb, and T2 tumors in all patients were 87.9%, 82.7%, and 74.1%, respectively. The difference between T1a and T2 was statistically significant (p = 0.016). The 5-year LC rates for T1a, Tb, and T2 with CRT were 92.7%, 78.6%, and 80.7%, respectively, while the rates with radiation alone were 86.5%, 83.8%, and 64.4%, respectively. The difference between CRT and RT alone was not statistically significant in each stage.

CONCLUSIONS

In this survey, CRT was performed for early GC at most institutions in clinical practice. Our data showed no statistical difference in the LC rates between CRT and RT alone in each stage. However, there was a tendency for the LCRs of the CRT group to be more favorable than those of the RT group in the T2-stage.

Definitive radiation therapy for early glottic cancer: experience of two fractionation schedules

OBJECTIVES

The authors would report the results of definitive radiation therapy (RT) for early glottic cancer by two different radiation dose schedules.

METHODS

From February of 1995 till June of 2008, 157 patients with T1-2N0 glottic cancer were treated with curative RT at Samsung Medical Center. All patients had squamous cell carcinoma, and there were 89 patients (56.7%) with T1a, 36 (22.9%) with T1b, and 32 (20.4%) with T2. Two different radiation dose schedules were used: 70 Gy in 35 fractions to 64 patients (40.8%, group A); and 67.5 Gy in 30 fractions to 93 patients (59.2%, group B). The median treatment durations were 50 days (range, 44 to 59 days) and 44 days (range, 40 to 67 days) in the groups A and B, respectively.

RESULTS

The median follow-up durations were 85 and 45 months for the groups A and B. No severe late complication of RTOG grade 3 or higher was observed, and there was no difference in acute or chronic complication between the groups. Twenty-four patients experienced treatment failure: local recurrence only in 19 patients; regional recurrence only in one; combined local and regional recurrence in four; and systemic metastasis in none. The overall 5-year disease-free survival and disease-specific survival rates were 84.7% and 94.8%. The disease-free survival rate in the group B was better (78.3% vs. 90.8%, P=0.031). This difference was significant only in T1 stage (83.4% vs. 94.6%, P=0.025), but not in T2 (62.7% vs. 60.6%, P=0.965). Univariate analysis showed that the tumor extent, cord mobility, T-stage, and the dose schedule had significant influence on the disease-free survival, and multivariate analysis showed that only the tumor extent and the dose schedule were associated with the disease-free survival.

CONCLUSION

Superior disease-free survival could be achieved by 2.25 Gy per fraction without increased toxicity over shorter RT duration, when compared with 2.0 Gy per fraction.

Definitive radiotherapy for early stage glottic cancer by 6 MV photons

Purpose

To evaluate the clinical outcome of early glottic cancer (GC) treated by primary radiotherapy (RT) with 6 MV photons.

Methods and materials

We retrospectively reviewed the medical records of 695 consecutive patients with T1N0 and T2N0 GC treated between 1983 and 2005 by RT in our institution. Clinical outcome in terms of local control (LC), overall survival (OS) and cause- specific survival (CSS) rate were evaluated.

Results

The median follow-up time was 10.5 years. The 10-year actuarial LC rates were as follows: T1A, 91%; T1B, 87%; T2, 77%. The 10-year OS were as follows: T1, 74.2%; T2, 70.7%. The 10-year CSS were as follows: T1, 97.7%; T2, 97.1%.

Poorly differentiated histology and tumor biologically effective dose < 65 Gy₁₅ were adverse factors in both LC of T1 and T2 disease. Involvement of anterior commissure was an adverse factor in both LC and CSS of T1 disease. Subglottic extension was associated with poor LC in T2 disease whereas hemoglobin <13.0 was associated with poor LC and CSS of T2 disease.

Conclusion

Primary RT remains an option among the various standard treatments for early GC. Clinical treatment outcome by 6MV photons is similar and comparable to historic data of Cobalt-60 and 2 MV photons.

Quality of voice after radiotherapy in early vocal cord cancer

Early glottic cancer (T1, T2N0M0), a disease of the voice box, mainly affects the voice. It can be effectively treated with both surgery and radiotherapy. Preservation of the voice while treating vocal cord cancer is not simply retaining the ability to vocalize. It is the determinant of choice of treatment and quality of life following curative management. Radiotherapy has resulted in excellent control rates with voice preservation and has been the standard of care for many decades. Several patient- (e.g., smoking, age, amount of talking during treatment), disease- (e.g., extent and site of lesion) and treatment- (e.g., radiation field size and dose, voice therapy) related factors adversely affect the quality of voice after radiotherapy. Several studies have evaluated voice quality either subjectively or objectively. Still, little is known about it. Voice quality after radiotherapy improves but does not reach the standard of the normal controls.

Profiling of the care processes for laryngeal cancer with the Japanese administrative database

At present, there is a shortage of detailed data on head and neck cancer treatment in acute care hospitals in Japan. We conducted an analysis of the care process for laryngeal cancer inpatients in Japan using a national administrative database based on the case-mix system known as the Diagnosis Procedure Combination to evaluate the recent clinical situation of a relatively high incidence of head and neck cancers. We obtained discharge data relating to 2790 cases (one case = one hospitalization) involving 2319 laryngeal cancer patients from 346 acute care hospitals that participated in the Japanese national case-mix project between July and December of 2008. The details of their treatment procedures were analyzed according to the Japanese procedure codes managed by the Ministry of Health, Labour, and Welfare of Japan. There were 2156 male and 163 female patients. The median age was 69 years (range: 22-96 years). The most frequent surgical procedure was endoscopic resection which was performed for 781 cases. Chemotherapy was given in 31.6% of cases in the < 60 age group, 28.2% in the 60-79, and 14.1% in the ≥ 80. The most frequently used chemotherapy regimen was a single drug, S-1 (compound of tegafur, gimeracil and oteracil potassium), which was more frequently used in the ≥ 70 age group than in the younger age group. The Diagnosis Procedure Combination database, which collects a large volume of data from all over the country, is useful for analysis of the care process for head and neck cancers in Japan.

Radiotherapy with or without chemotherapy for patients with T1-T2 glottic carcinoma: retrospective analysis

BACKGROUND

To assess the results for local control (LC) and survival in patients with early-stage glottic cancer (GC) who were treated by radiotherapy (RT) with or without chemotherapy.

METHODS

Fifty-eight patients with T1-T2 squamous cell carcinoma of the glottis who were treated between 2001 and 2006 were analyzed retrospectively. Potential prognostic factors for LC were evaluated by univariate analysis.

RESULTS

The 5-year LC rate in all patients was 84.3%. The overall 5-year LC rates for patients with T1a, Tb, and T2 GC were 85.9%, 83%, and 85%, respectively. Of the 58 patients, eight developed recurrent disease at the primary site, and one had lymph node recurrences on the neck. In the final analysis, the total laryngectomy-free survival rate was 93% at five years, and the ultimate LC rates for T1a, Tb, and T2 were 100%, 90.9%, and 95.2%, respectively. In a univariate analysis of 55 patients, there was no statistical significance between the LC rate for RT alone and that for chemoradiation. Only two patients died of laryngeal carcinoma, and one died of intercurrent disease. Fifty-five patients were living disease-free at the end of the study period. The 5-year overall survival (OS) rate for all patients was 88.1%, and the 5-year OS rates for T1a, Tb, and T2 were 91.6%, 77.8%, and 89.9%, respectively.

CONCLUSIONS

The retrospective analysis showed a high rate of LC and larynx preservation in patients with T1-T2 GC by means of RT with or without chemotherapy. There was, however, no statistical difference in LC rates for the two types of therapy.

Concurrent chemoradiotherapy with S-1 for T2N0 glottic squamous cell carcinoma

In this study, we evaluated the feasibility, efficacy and toxicity of concurrent chemoradiotherapy with S-1 (tegafur-gimeracil-oteracil potassium) for T2N0 glottic carcinoma. A total of 23 patients with T2N0 glottic carcinoma received chemoradiotherapy with S-1. Radiotherapy consisted of five daily fractions of 2 Gy per week, to a total median dose of 70 Gy. S-1 was administered 65 mg/m(2) per day for 4 weeks, beginning on the day therapy was started, followed by 2 weeks off the drug and twice a day until the end of radiotherapy. Initial local control rate of the primary tumor was achieved in all patients. The median follow-up period for all patients was 38 months. The 3-year local control rate was 95.4%. Regarding adverse reactions, grade 3 mucositis upon clinical examination, mucositis upon functional/symptomatic examination, dysphagia, hepatic toxicity and anemia were observed in 13, 2, 2, 1 and 1 patients, respectively. This chemoradiotherapy did not result in grade 4 acute toxicity or severe late toxicity. Chemoradiotherapy with S-1 was feasible, well tolerated and effective. This therapy is suggested as a possible regimen for improving local control of T2N0 glottic carcinoma.

Concurrent hyperfractionated radiotherapy and carboplatin with transoral debulking microsurgery for T2N0 glottic cancer

BACKGROUND

Our aim was to evaluate the efficacy and toxicity of chemoradiotherapy (CRT) with transoral debulking microsurgery for T2N0 glottic cancer.

METHODS

Thirty patients with T2N0 glottic cancer treated with concurrent hyperfractionated radiotherapy (RT) and carboplatin were retrospectively analyzed. Median total dose of RT was 72 Gy. Nineteen of 30 patients also received transoral debulking microsurgery during or before CRT. The remaining 11 patients who demonstrated complete response or good partial response at 36 to 45.6 Gy were not treated with transoral debulking microsurgery.

RESULTS

Local recurrence developed in 5 patients; 4 of these patients did not undergo transoral debulking microsurgery. The 3-year local control rate was significantly better for CRT with transoral debulking microsurgery (95%) than for CRT alone (61%) (p = .02).

CONCLUSION

CRT with transoral debulking microsurgery may have a positive impact on the local control of T2N0 glottic cancer, which justifies further evaluation to confirm its definite benefit.

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.