Effect of tumor bulk on local control and survival of patients with T1 glottic cancer

Targeting Anterior Commissure Involvement with Hyperfractionated Radiotherapy for T1-T2 Squamous Cell Carcinoma of the Glottic Larynx

Anterior commissure is involved in about 20% of early-stage glottic squamous cell carcinomas (EGSCCs). Treatment outcomes and prognostic factors for EGSCC with anterior commissure involvement (ACI) were evaluated by focusing on hyperfractionated radiotherapy (74.4 Gy in 62 fractions). One-hundred and fifty-three patients with T1-T2 EGSCC were included in this study. The median total doses for T1a, T1b, and T2 were 66, 74.4, and 74.4 Gy, respectively. Overall, 49 (32%) patients had T1a, 38 (25%) had T1b, and 66 (43%) had T2 disease. The median treatment duration was 46 days. The median follow-up duration was 5.1 years. The 10-year overall and cause-specific survival rates were 72% and 97%, respectively. The 10-year local control rates were 94% for T1a, 88% for T1b, and 81% for T2 disease. Local control rates in patients with ACI were slightly better than those in patients without ACI with T1a and T1b diseases; however, the difference was not significant. The 10-year laryngeal preservation rate was 96%. Six patients experienced grade 3 mucositis, and four patients had grade 3 dermatitis. Hyperfractionated radiotherapy was effective for T1 disease with ACI, but insufficient for T2 disease with ACI. Our treatment strategy resulted in excellent laryngeal preservation.

Radiological Findings in Laryngeal Anterior Commissure Invasion: CT Scan Highlights

OBJECTIVES

Preoperative anterior commissure (AC) evaluation in glottic cancer is crucial for therapeutic decisions. Endoscopy is often inadequate to precisely detect the presence of cancer in the AC; thus, computed tomography (CT) scan could help. We investigated the relation between AC thickness on CT scan (in mm), AC involvement by cancer at histology, and radiologic signs of anterior paraglottic space (PGS) infiltration.

STUDY DESIGN

Retrospective observational study.

METHODS

An experienced radiologist retrospectively measured AC thickness and identified signs of anterior PGS infiltration on pretreatment contrast-enhanced CT scans of 80 patients with primary glottic cancer. The gold standard to define the presence of cancer in the AC was histology. The receiver operating characteristic (ROC) curves were used to determine the potential cut-off values of AC thickness (Youden index method) able to maximize both sensitivity and specificity in identifying the presence of cancer in the AC at histology and PGS infiltration on CT scan.

RESULTS

AC was significantly thicker in patients with cancer in the AC at histology (P < .001) and in patients with PGS infiltration on CT scan (P < .001). The cut-off values to discriminate the presence of cancer at histology and PGS infiltration on CT scan were 3.62 and 2.6 mm, respectively. We found a substantial agreement between anterior PGS infiltration on CT scan and the presence of cancer in the AC at histology (Cohen Kappa: P = .70).

CONCLUSION

AC thickness and radiologic signs of PGS infiltration on pretreatment CT scan could represent a method to predict the presence of cancer in the AC at histology.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2427-2433, 2022.

Induction chemotherapy in nonlaryngeal human papilloma virus-negative high-risk head and neck cancer: a real-world experience

The role of induction chemotherapy in the multidisciplinary treatment of locally advanced, nonlaryngeal high-risk human papilloma virus (HPV)-negative head and neck squamous cells carcinoma (HNSCC) is uncertain in terms of overall survival (OS). The primary objective of this study was to identify possible predictive factors of survival and outcome in patients with HNSCC who were treated with induction chemotherapy. Fifty-nine patients with stage IVa/b HPV-negative non-laryngeal HNSCC (mostly originating from the oral cavity) who underwent induction chemotherapy at Policlinico Umberto I were reviewed. Treatment outcomes in term of objective response rate (ORR), progression-free survival (PFS), OS and toxicities were analyzed. A significant association between nodal status, ORR, ongoing smoking use, toxicities and OS was demonstrated. ORR (obtained in 61% of patients) was associated with a reduction in mortality of 80% (P< 0.0001). Early discontinuation after just one cycle of induction chemotherapy was associated to a significantly shorter OS. In oral cavity radical surgery with negative margins was obtained in 15/16 patients. In 42% of patients G3-G4 toxicity occurred. Toxicity requiring hospitalization occurred in 42% and 21% of patients with oropharyngeal and oral cavity carcinoma, respectively. Five patients died of treatment-related causes. No treatment-related mortality occurred in oral cavity patients. G5 toxicities were different according to the sub-sites of disease (P = 0.05). Induction chemotherapy in non-laryngeal high-risk HNSCC is an active strategy, most importantly in oral cavity cancer, even though burdened with a high (G ≥ 3) toxicity and early discontinuation rate. These data will however need to be confirmed in further and larger studies.

Prognostic Factors in Early Glottic Carcinoma Implications for Treatment

Aim

In this study we aimed to determine the prognostic factors affecting local control (LC) in limited glottic carcinoma treated with definitive radiotherapy (RT).

Material and methods

Between June 1991 and December 2001, 114 patients with early squamous-cell carcinoma of the glottis were treated with definitive RT at our institution. Only four (3.5%) patients were women. The median age was 60 (27-79). Fifteen percent, 72% and 13% of the patients had Tis, T1 and T2 tumors, respectively. Forty-three (37.7%) patients had anterior commissure invasion. Prior to RT 35 (31%) patients had undergone vocal cord stripping and two (2%) cordectomy. A median dose of 66 Gy (50-70.2) was given over a median period of 46 days (20-60). Univariate and multivariate analyses were performed for LC. The prognostic parameters analyzed for LC were T classification, anterior commissure involvement, total RT dose, and overall treatment time.

Results

Five-year local and regional control rates were 84.2% and 97.7%. RTOG grade 3-4 late side effects were observed only in one (0.9%) patient. In 15 patients with local failure, salvage treatment consisted of partial laryngectomy in eight patients and total laryngectomy in five. One of the remaining two patients was medically inoperable, and the other refused salvage surgery. In one of the three patients with regional failure, salvage surgery was applied and the other two were given palliative chemotherapy because of unresectable disease. Following salvage treatments, the ultimate five-year LC rate was 96.9% and the five-year larynx preservation rate was 91.1%. Second primary cancer was diagnosed in 17 (14.9%) patients. Only one patient developed distant metastases and two patients died of laryngeal cancer. While T2 disease and anterior commissure involvement were found to be unfavorable prognostic factors significantly influencing LC in univariate analyses, only T2 disease remained independent in multivariate analysis.

Conclusion

In patients with early glottic carcinoma, T classification proved to be the only independent prognostic factor affecting LC after primary radiotherapy according to the results of this study.

Surgical Therapy of T1 and Selected Cases of T2 Glottic Carcinoma: Cordectomy, Horizontal Glottectomy and CO2 Laser Endoscopic Resection

Aims and background

Among the different laryngeal neoplasms, glottic carcinoma is known to be one of the most suitable for functional management. Nevertheless, the best treatment for T1 and T2 glottic carcinoma, whether an open neck procedure, endoscopy or radiotherapy, with reference to recurrence, survival, and functional results, has long been debated.

Study design

From February 1983 to September 1997, 83 patients with well to undifferentiated glottic carcinoma (48 pT1a, 14 pT1b, and 21 selected cases of pT2 with impairment of vocal cord mobility) were submitted to surgery at the Otorhinolaryngologic Section of the Department of Surgical Sciences and Organ Transplantations of Cagliari University. Surgical treatment included 30 laryngofissures with simple or enlarged cordectomy, 22 horizontal glottectomies and 31 endoscopic laser resections. A retrospective review of the records of the patients was performed in order to obtain a better understanding of the outcome of the three different surgical procedures in our institution.

Results

According to the Kaplan-Meier method, the probability of remaining free of local recurrence 3 years after primary surgery was 0.90 for the T1 group and 0.85 for the T2 group. The distribution of recurrences for cordectomy, glottectomy and CO2 laser at 3 years showed a cumulative probability of remaining free of disease after primary surgery of 0.86, 0.85 and 0.88. The probability of remaining free of local recurrence 3 years after salvage surgery was 0.96 for the T1 group and 0.95 for the T2 group. Analyzing the phenomena for type of surgical procedure, local control at 3 years after salvage surgery for cordectomy, glottectomy and exclusive CO2 laser was 0.93, 0.90 and 0.92, respectively. In the endoscopic group, local control rate after any type of salvage therapy modified the percentage at 3 years to 100%. Anterior commissure spread (AC1-AC2) resulted in a difference (not statistically significant) in local control between the group of patients without and with anterior commissure involvement. Laryngeal preservation was achieved in 93.7% (45/48) of patients who survived after salvage surgery following open neck procedures and in 100% of patients originally submitted to the endoscopic approach.

Conclusions

In our experience, although open laryngeal procedures can be still considered a valid option in the treatment of T1 and selected cases of T2 glottic carcinoma, endoscopic laser excision offered an oncologically adequate alternative to the traditional techniques, with minimum discomfort for the patient and satisfactory preliminary functional results.

Outcomes of Radiation Therapy for T1 Glottic Carcinoma from an Italian Regional Series with Doses Ranging from 60 to 66 Gy

Aims and background

Radiotherapy has remarkable success rates for the cure of patients affected by glottic carcinoma; local control rates are similar to surgery with lower morbidity and better functional results. Our aim was to determine local-regional control rates, overall survival, second cancer incidence, acute-late toxicity and prognostic factors in our series of T1 glottic cancer patients with radiation doses of 60 to 66 Gy. Functional results were not sufficient for statistical analysis.

Methods and study design

A retrospective study was carried out of all T1N0 glottic carcinomas treated with radiation therapy between 1996 and 2006. To be eligible, patients had to have newly diagnosed cancer and had to be treated with a curative intent by radiation therapy alone. Ninety-eight patients satisfied the eligibility requirements: 85 patients had T1a disease; 13 patients were staged as T1b. Treatment was performed for all cases with a 6 megavoltage linear accelerator. The total dose prescribed varied from 60 to 66 Gy: 2 Gy/fraction, 1 fraction/day, 5 fractions/week. During treatment, a weekly clinical evaluation was performed; endoscopic examination was performed once every two weeks. After the treatment, a clinical, endoscopic and radiological follow-up was performed every three months for the first two years, every 6 months till the fifth year, and then once a year.

Results

With a median follow-up of 41.5 months (range, 10-132; mean, 56.8), we registered 12 cases of local failures; 8 of them were successfully treated with salvage surgery (median time to relapse, 3–48 months). The local relapse rate was 12.2%, and disease-specific survival, taking into account salvage surgery, was 6%. Thirty-four deaths were registered: 2 for local progression, 2 for distant metastasis, 4 for a new primary cancer, and 26 for non-neoplastic causes. Five- and 10-year overall survival were respectively 85.8% and 69.4%. Four cases of lung cancer were detected in the upper aerodigestive tract in our series. In terms of acute-late toxicity, no grade 3-4 dermatitis, dysphagia or hoarseness occurred. Mild dermatitis and arythenoid edema were the most common causes of toxicity. Only one patient did not complete the treatment (60 Gy instead of the planned 66 Gy).

Conclusions

Our series confirmed the primary role of radiation therapy for the cure of T1N0 glottic cancer. Outcomes were good in terms of local-regional control as well as overall toxicity. Radiation therapy can be offered to T1 glottic cancer patients as a valid alternative to surgery, with high rates of functional preservation.

Clinical significance of epithelial-to-mesenchymal transition in laryngeal carcinoma: Its role in the different subsites

BACKGROUND

During epithelial-to-mesenchymal transition, cancer cells lose adhesion capacity gaining migratory properties. The role of the process on prognosis has been evaluated in 50 cases of laryngeal carcinoma.

METHODS

E-cadherin, N-cadherin, β-catenin, α-catenin, γ-catenin, caveolin-1, and vimentin immunohistochemical expression were evaluated using a double score based on staining intensity and cellular localization.

RESULTS

Cytoplasmic E-cadherin and α/γ catenin staining were associated with a decrease in survival, cytoplasmic β-catenin was associated with advanced stage, and N-cadherin and vimentin expression were associated with poor differentiation and tumor relapse. On the basis of cancer cells, epithelial or mesenchymal morphological and immunophenotypic similarity we identified 4 main subgroups correlated with a transition to a more undifferentiated phenotype, which have a different pattern of relapse and survival.

CONCLUSION

The negative prognostic role of epithelial-to-mesenchymal transition has been confirmed and a predictive role in glottic tumors has been suggested, leading us to propose epithelial-to-mesenchymal transition as an additional adverse feature in laryngeal carcinoma.

Tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers: a critical appraisal

Objective:

The tumour–node–metastasis staging system has a dynamic structure that is continuously being updated as scientific data develops. This review discusses some suggested revisions on tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers.

Methods:

The seventh edition of The American Joint Committee on Cancer Staging Manual was reviewed and important issues that could be considered for revision were identified and discussed.

Results:

According to our assessment of the oncological outcomes of previous studies, the following factors should be considered for revision: anterior commissure involvement and subglottic extension in laryngeal cancers; underlying bone involvement in hard palate and upper alveolar ridge cancers; tumour thickness in oral cancers; and extracapsular spread and carotid artery involvement in neck metastases.

Conclusion:

Sufficient data on the prognostic importance of these issues have been reported. Suggested revisions in line with current knowledge on the clinical behaviour of upper aerodigestive tract cancers would improve the relevancy of staging.

Total laryngectomy for laryngeal cancer in a nigerian tertiary health center: prognosis and outcome

Background:

Advanced laryngeal cancers presenting with upper airway obstruction are a common scenario in Sub-Saharan Africa, requiring operative intervention as a priority.

Objective:

To assess outcome of total laryngectomy as a treatment option in the surgical management of advanced laryngeal cancers in a tertiary health institution in northwestern Nigeria.

Materials and Methods:

A retrospective analysis of total laryngectomies for laryngeal cancers carried out by one surgeon from December 2000 to August 2009.

Results:

Out of 30 patients with histologically diagnosed laryngeal cancer, 18 were treated with total laryngectomy Fourteen (77.8%) were males, while 4 (22.2%) were females, with a male-to-female ratio of 3.5:1. The age range was 20-70 years with a mean age of 47years for males and 33.8 years for females. Total laryngectomy was carried out on T4 lesions (100%), with preoperative tracheostomy (100%) carried out as an emergency measure to relieve upper airway obstruction. Two female patients had safe vaginal deliveries after their surgeries. Although all patients were referred for radiotherapy, only 6 (33.3%) patients could afford postoperative radiotherapy, with a 5-year survival rate of 33.3%; while all others could not afford the cost of radiotherapy treatment, which was to be carried out at a center about 5 hours drive away from our center. Seven (38.9%) patients presented with recurrent neck nodal disease, while 3 (16.7%) had carotid blow-out hemorrhage that was fatal.

Conclusion:

Total laryngectomy remains an important surgical modality of treatment for advanced laryngeal cancers, as it affords the patient an opportunity of longer survival when combined with postoperative radiotherapy. It is superior to ‘radiotherapy only’ or ‘surgery only’ or nothing.

Impact and relationship of anterior commissure and time-dose factor on the local control of T1N0 glottic cancer treated by 6 MV photons

BACKGROUND

To evaluate prognostic factors that may influence local control (LC) of T1N0 glottic cancer treated by primary radiotherapy (RT) with 6 MV photons.

METHODS

We retrospectively reviewed the medical records of 433 consecutive patients with T1N0 glottic cancer treated between 1983 and 2005 by RT in our institution. All patients were treated with 6 MV photons. One hundred and seventy seven (41%) patients received 52.5 Gy in 23 fractions with 2.5 Gy/fraction, and 256 (59%) patients received 66 Gy in 33 fractions with 2 Gy/fraction.

RESULTS

The median follow-up time was 10.5 years. The 10-year LC rates were 91% and 87% for T1a and T1b respectively. Multivariate analysis showed LC rate was adversely affected by poorly differentiated histology (Hazard Ratio [HR]: 7.5, p = 0.035); involvement of anterior commissure (HR: 2.34, p = 0.011); fraction size of 2.0 Gy (HR: 2.17, p = 0.035) and tumor biologically effective dose (BED) < 65 Gy15 (HR: 3.38, p = 0.017).

CONCLUSIONS

The negative impact of anterior commissure involvement could be overcome by delivering a higher tumor BED through using fraction size of > 2.0 Gy. We recommend that fraction size > 2.0 Gy should be utilized, for radiation schedules with five daily fractions each week.

Multidisciplinary approach in the treatment of T1 glottic cancer. The role of patient preference in a homogenous patient population

BACKGROUND AND PURPOSE

To compare oncological outcome and voice quality among a uniform and well-defined subset of patients with T1 glottic carcinoma.

PATIENTS AND METHODS

Patients, affected by laryngeal glottic carcinoma, treated by laser CO2 surgery or radiotherapy, have been analyzed. Overall survival and disease-free survival were calculated. In order to verify differences in functional outcomes and voice quality, all patients were interviewed during their last follow-up visit during 2009 using the VHI (Voice Handicap Index) questionnaire. The data were analyzed using the MedCalc software.

RESULTS

A total of 143 patients were analyzed: 73 underwent surgery and 70 underwent radiotherapy. No statistically significant differences were found between the two groups in terms of overall survival and disease-free survival; dividing patients into stages T1a and T1b also made no difference. In order to evaluate the differences in outcomes for surgery and radiotherapy, patients were interviewed using the VHI questionnaire. Better scores for each category in the VHI were found for patients receiving radiotherapy compared to surgery (physical: p = 0.0023; functional: p < 0.0001; environmental: p < 0.001). The median VHI score for radiotherapy patients was 4, while for surgical patients it was 18 (p < 0.0001).

CONCLUSION

This study confirms the well-known knowledge that results from radiotherapy and surgery in early glottic cancer treatment are equivalent. Furthermore, the role of patient preference in the treatment modality choice and the value of a multidisciplinary approach for a detailed and multi-oriented discussion with the patient are outlined.

Outcome of transoral laser microsurgery for T2-T3 tumors growing in the laryngeal anterior commissure

BACKGROUND

To evaluate the outcomes of transoral laser microsurgery (TLM) in the treatment of T2 to T3 laryngeal carcinomas growing in the laryngeal anterior commissure.

METHODS

This study was a retrospective analysis of 107 patients. Overall survival, disease-specific survival, and laryngectomy-free survival were analyzed. Technical difficulties, postoperative complications, influence of the learning curve, and the number of surgeries were evaluated.

RESULTS

Five-year overall survival, disease-specific survival, and laryngectomy-free survival were 71%, 79.5%, and 71.4%, respectively. The probability of tumor relapse was related to the status of the margins (p = .01) and to surgical experience (p = .02), but not to tumor exposure (p = .78) or pT category (p = .36). Disease-specific survival differed significantly between the group of patients treated in the early period of surgical experience and those treated in the advanced period of surgical experience (71% vs 94%; p = .02)

CONCLUSION

TLM is a useful treatment for T2 to T3 laryngeal carcinomas growing in the laryngeal anterior commissure when it is performed under an advanced learning curve.

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.

Definitive radiation therapy for moderately advanced laryngeal cancer: effects of accelerated hyperfractionation

OBJECTIVE

The purpose of this retrospective study was to analyze the results of accelerated hyperfractionation for patients with moderately advanced (T2 and T3) laryngeal cancer.

METHODS

Between 1998 and 2007, 9 supraglottic carcinomas (6 T2N0M0, 2 T2N2M0, 1 T3N0M0), 30 glottic carcinomas (25 T2N0M0, 5 T3N0M0), and 1 T2N0M0 subglottic carcinoma were treated with definitive radiotherapy using accelerated hyperfractionation without concurrent chemotherapy. The dose-fractionation for 35 patients was 72.8 Gy/56 fractions/5.6 weeks, and that for four patients treated between 1998 and 2001 was 72 Gy/60 fractions/6 weeks. One patient who had been treated with steroid therapy for systemic lupus erythematosus was treated by 67.8 Gy/44 fractions/4.4 weeks.

RESULTS

The local control and overall survival probabilities at 5 years for supraglottic carcinomas were 75% and 86%, respectively. Those for glottic carcinomas were 80% and 92%, respectively. The 5-year local control probabilities for T2 and T3 tumors were 85% and 56%, respectively. This excellent local control rate especially for T2 laryngeal carcinomas may be attributable to the effect of accelerated hyperfractionation. No late toxicities of grade 2 or more was noted among the 39 patients treated with 72.8 Gy/56 fractions or 72 Gy/60 fractions.

CONCLUSION

Accelerated hyperfractionation of 72.8 Gy/56 fractions/5.6 weeks using 1.3 Gy/fraction seems a safe and effective dose-fractionation for patients with moderately advanced laryngeal carcinomas.

Utility of sonography for evaluation of clinical T1 and T2 glottic carcinoma

OBJECTIVE

The aim of this study was to evaluate the prognostic impact of sonographically determined tumor features in relation to local control of clinical T1 and T2 glottic carcinoma treated by definitive radiation therapy.

METHODS

Between 1999 and 2005, 72 patients with T1 and T2 glottic carcinoma were evaluated by percutaneous sonography in terms of tumor detectability, maximum tumor dimension, involvement of the anterior commissure, presence of supraglottic, subglottic, or paraglottic spread, and thyroid cartilage invasion. Factor analyses for local control included clinical features, sonographic findings, and treatment factors.

RESULTS

Forty-one lesions (57%) were detected as hypoechoic masses on sonography. For detectable T2 tumors, sonographic and laryngoscopic findings were in agreement in all cases with respect to spread to anatomic subsites. The 3-year local control rate with radiation therapy alone was 82%. Univariate analysis of the sonographic characteristics revealed that the maximum tumor dimension and thyroid cartilage invasion predicted a loss of local control, whereas none of the clinical or treatment characteristics was significant. Multivariate analysis showed that thyroid cartilage invasion was an independent negative prognostic factor for local control.

CONCLUSIONS

Sonography provides information about the likely outcome of radiation therapy for patients with clinical T2 glottic carcinoma, although its utility for T1 lesions is not proven. Thyroid cartilage invasion may be an independent negative predictor of the outcome.

Anterior Vocal Commissure Invasion in Laryngeal Carcinoma Diagnosis

BACKGROUND

Laryngeal carcinoma involving anterior vocal commissure (AVC) represents a great challenge for staging and treatment.

OBJECTIVES

To compare laryngoscopy and computed tomography (CT) scan efficiency in staging tumors extending to the AVC. We also analyzed the helicoidal axial CT scan accuracy in recognizing this larynx subregion invasion.

MATERIAL AND METHODS

Fifty-two glottic and supraglottic laryngeal squamous cell carcinoma patients with tumoral extension to the AVC were prospectively studied from August 2001 to August 2003 at the National Cancer Institute (Rio de Janeiro, Brazil). All patients underwent videolaryngoscopic examination and direct laryngoscopy for lesion extension analysis and biopsy. After AVC helicoidal axial CT scan with sagittal and coronal 1.0 mm thick reconstruction, patients were submitted to surgical treatment. The same pathologist analyzed all surgical specimens.

RESULTS

When compared with pathologic stage, clinical endoscopic classification was correct in 40.38% of cases (40% for T1, 29.41% for T2, 46.43% for T3, and 50% in T4). Helicoidal axial CT scan accuracy for AVC tumors was 75% (P = .0001), being more important for T2 (62.50%), T3 (73.91%), and T4 (88.24%) lesions. Identification of radiologic signs described as gross radiologic anterior commissure involvement (GRACI) increased radiologic image staging accuracy to over 96%.

CONCLUSIONS

Endoscopic evaluation understaged tumors in all clinical stages but really T1. Helicoidal axial CT scan reformatted to 1.0 mm thick played an important role in correctly staging more advanced AVC laryngeal tumors. Radiologic signs, here identified as GRACI, may be very helpful for tomographic staging and patient treatment.

Clinical outcome of T1 glottic carcinoma since the introduction of endoscopic CO2 laser surgery as treatment option

BACKGROUND

Since the introduction of endoscopic laser surgery at our institution in 1996, 189 patients have been treated for T1 glottic carcinoma.

METHODS

Treatment allocation (radiotherapy vs laser surgery) and outcome were evaluated.

RESULTS

Fifty-one percent of T1a lesions were considered suitable for laser surgery. Sixteen percent of T1a patients treated with laser surgery needed additional treatment because of positive resection margins. Overall local control and larynx preservation were 89% and 96%. Both were poorer in T1a patients with larger lesions treated with radiotherapy (local control 75% versus 89%, p = .05, larynx preservation 83% vs 100%, p = .001).

CONCLUSION

Outcome for T1a patients selected for laser surgery is excellent. In patients with larger lesions treated with radiotherapy, outcome is inferior to patients selected for laser surgery, but also to that reported for (unselected) T1a carcinomas treated with radiotherapy in literature. Strategies to improve treatment results in patients deemed unsuitable for laser surgery should be designed.

Outcome of radiotherapy in T1 glottic carcinoma: a population-based study

We evaluated the radiation outcome and prognostic factors in a population-based study of early (T1N0M0) glottic carcinoma. Survival parameters and prognostic factors were evaluated by uni- and multivariate analysis in 316 consecutive irradiated patients with T1 glottic carcinoma in the Comprehensive Cancer Center West region of the western Netherlands. Median follow-up was 70 months (range 1-190 months). Five and ten-year local control was 86 and 84%. Disease specific survival was 97% at 5 and 10 years. In multivariate analysis, pre-existent laryngeal hypertrophic laryngitis was the only predictive factor for local control (relative risk = 3.0, P = 0.02). Comorbidity was prognostic for overall survival. No factor was predictive for disease specific survival. Pre-existent laryngeal hypertrophic laryngitis is a new risk factor associated with reduced local control in T1 glottic carcinoma treated with radiotherapy.

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.

Second malignant neoplasia in early (TIS-T1) glottic carcinoma

BACKGROUND

We performed a population-based study to determine the incidence and patterns of second malignant neoplasia (SMN) in early glottic carcinoma.

METHODS

All patients diagnosed with Tis-T1 glottic carcinoma in the southwest of the Netherlands between 1982 and 1993 (359) were included. Sources of the data were patient charts and the regional cancer registry.

RESULTS

SMN incidence was 27.7% (median follow-up, 89 months). Observed-to-expected ratios were increased for lung, bladder, urinary tract, pancreatic, colorectal, and head and neck cancers. The incidence of head and neck and esophageal cancer was surprisingly low.

CONCLUSIONS

Patients with early glottic carcinoma are at a reliably increased risk of the development of tumors not only in the areas of the upper aerodigestive tract, but also in the bladder, pancreas, and colorectum. The low incidence of head and neck and esophageal tumors does not appear to support routine panendoscopy in this patient population.

Effect of tumor bulk on local control and survival of patients with T1 glottic cancer: a 30-year experience

PURPOSE

To evaluate the effect of tumor bulk on local control and survival of patients with T1 glottic cancer.

METHODS AND MATERIALS

Effects of tumor bulk, T-stage, anterior-commissure involvement, treatment duration, and fraction size were analyzed in 208 patients; 136 had small tumors and 72 had bulky tumors. Anterior-commissure was involved in 54 patients. Treatment duration ranged from 39 to 64 days and fraction size ranged from 1.8 to 2.0 Gy. Median follow-up was 5.1 years.

RESULTS

Five-year actuarial local control rates were 86.1% and 91.4% after radiotherapy and salvage laryngectomy. On univariate analysis, local control rates were 92.6% and 73.6% for small and bulky tumors (p = 0.03), 89.6% and 75.9% for patients without and with anterior-commissure involvement (p = 0.01), 92.6% and 75.6% when treatment duration was <or=50 days and >50 days (p = 0.04), and 90.2% and 76.4% with 2 Gy and 1.8 Gy (p = 0.02) per fraction. On multivariate analysis, tumor bulk was the only significant factor that affected local control (p = 0.007). Ultimate local control rates after salvage were 97.1% and 80.5% for patients with small and bulky tumors. Disease-free survival rates at 5 years for small and bulky tumors were 96.3% and 84.7% (p = 0.001). Median duration to recurrence for small tumors was 30 months as compared with 11 months for bulky tumors.

CONCLUSION

Tumor bulk is a highly significant prognostic factor for radiation control of T1 glottic cancer. Patients with bulky tumors had lower local control and disease-free survival rates and shorter duration to recurrence than those with small tumors.

The role of laser microsurgery in the treatment of laryngeal cancer

PURPOSE OF REVIEW

Transoral laser microsurgery has developed in recent years into a surgical method that combines a minimally invasive approach with the surgical precision of laser and microscope. The outcomes of laser microsurgical treatment of laryngeal carcinomas are reviewed and compared with the results of competitive standard procedures.

RECENT FINDINGS

Laser microsurgery is widely acknowledged to have advantages in the treatment of early glottic carcinoma. In the treatment of glottic carcinoma causing impaired mobility or fixation of the vocal cord the role of laser surgery has not yet been definitively assessed. Based on published results, primary laser therapy can achieve local tumor control with a functional residual larynx in approximately 70-80% of cases. In patients with early or moderately advanced supraglottic carcinoma, laser microsurgery is comparable to open supraglottic laryngectomy in terms of local control and survival. With regard to organ preservation, laser microsurgery is comparable to open supraglottic laryngectomy but superior to radiotherapy. Microsurgery can preserve functionally important structures, allowing for early swallowing rehabilitation while avoiding tracheotomy.

SUMMARY

This review elucidates the role of laser microsurgical partial resections of the larynx in comparison with other treatment modalities.

Impact of tumor control and presence of visible necrosis in head and neck cancer patients treated with radiotherapy or radiochemotherapy

PURPOSE

Tumor volume after the lymph node involvement is one of the most important single prognostic factor in patients of head and neck cancers treated with radiotherapy. We have recently demonstrated that the hypoxic subvolume is more important than the total tumor volume. We therefore propose the hypothesis that the presence of visible necrosis might be an important factor for cure by radiotherapy in squamous cell cancers of the head and neck.

METHODS

A total of 51 patients with locally advanced inoperable (T3-4 or N2-3) squamous cell cancers of the head and neck (mean age 57 years, range 41-75 years) were prospectively investigated with regard to a possible impact of tumor volume. All patients received CT examination of the head and neck according to a standardized protocol (spiral CT, contrast enhancement after automatic injection), and the total tumor volume was calculated as the sum of volumes of all visible macroscopic tumor sites. Poorly perfused and necrotic areas (no contrast enhancement) within macroscopic tumor sites were also calculated. Patients were then treated with accelerated-hyperfractionated radiotherapy in about 6 weeks. Seventeen patients were treated with only radiation. Patients without contraindications to cisplatin chemotherapy received cisplatin chemotherapy or a combination of cisplatin and paclitaxel (N=34). The allocation of patients to certain treatment regimens was based on individual decisions in each case and not randomized.

RESULTS

In patients treated with radiation alone, 12/17 (71%) got recurrence whereas in patients treated with radiation plus cisplatin, only 14/34 (41%) recurred (P=0.05). The 2-year overall survival was for radiation alone versus radiation plus cisplatin 0% vs. 62% (P<0.0008). Tumors with smaller amount of necrosis (necrosis volume<4 cm3) had a good prognosis irrespective of type of treatment (radiation alone or radiation plus cisplatin). However, patients with tumors with a larger amount of necrosis (necrosis volume> or =4 cm3) had a significantly better outcome if they were treated with radiation plus cisplatin as compared to patients treated with radiation alone. In a multi-variate analysis using a Cox-regression model the type of treatment (radiotherapy plus versus without cisplatin) was the only independent prognostic factor for event-free survival (P<0.03) in the whole group.

CONCLUSIONS

In this non-randomized retrospective investigation with limited sample size, radiation plus cisplatin was superior to radiation alone. This resulted mainly from a higher efficacy of the radiochemotherapy regimen in patients with large and especially necrotic tumors. The prognostic and predictive impact of visible necrosis should be further evaluated.

Molecular markers in laryngeal squamous cell carcinoma: towards an integrated clinicobiological approach

Of the most frequent malignancies in the United States, cancers of the larynx and of the uterine corpus are the only ones not to show an increase in 5-year survival rates over the last 30 years. The increasing use of chemo- and radiotherapy and conservative surgery to preserve organs and their functions has probably led to a better quality of life in patients with laryngeal cancer, but has definitely failed to improve survival, which remains the primary aim. In our opinion, to reduce laryngeal cancer-related mortality, a change in clinical approach is required. We have reviewed the literature on the potential role of molecular markers in the clinical management of laryngeal cancer. We believe that some of the most significant biological markers might be integrated with the evaluation of behavioural risk factors, clinical TNM staging and histopathological grading for a novel clinicomolecular approach to laryngeal cancer. We foresee the use of the most promising biological markers in the phases of prevention, diagnosis, prognostic assessment and drug design.

A hystopathological study of thyroarytenoid muscle invasion in early (T1) glottic carcinoma

PATIENTS AND METHODS

Surgical specimens belonging to 16 patients who underwent partial laryngectomy for T1 glottic cancer were subjected to detailed histopathologic examination; 11 of the patients were staged as T1a while 5 were staged as T1b.

RESULTS

It was detected that in 11 patients the tumor was confined to the mucosal or submucosal connective layer, and in 5 (31.2%) cases, the tumor invaded the thyroarytenoid (TA) muscle. In cases involving the one-third anterior part of the vocal cords and the anterior commissure, a 50% (4/8) TA muscle invasion was detected.

DISCUSSION AND CONCLUSION

Our finding TA muscle invasion at the rate of 31.2% in our 16 case series clinically staged as T1 revealed that deep invasion did not always impair the vocal cord mobility. Observing TA muscle invasion at the rate of 50% in cases involving the one-third anterior part of the vocal cord and the anterior commissure suggested that TA muscle invasion in the anterior part did not significantly impair mobility.

Can I treat this small larynx lesion with radiation alone? Update on the radiation management of early (T1 and T2) glottic cancer

This article endeavors to explain the advantages and disadvantages of radiotherapy (RT) versus transoral laser excision (TLE)and to suggest when each modality may be employed for optimal treatment of patients with this heterogeneous group of tumors. It compares RT and TLE using the criteria of cure and local control rates, posttreatment voice quality, side effects and morbidity, cost,convenience, and salvage potential.

Radiotherapy for patients with early-stage glottic carcinoma: univariate and multivariate analyses in a group of consecutive, unselected patients

BACKGROUND

Radiotherapy (RT) has a remarkable success rate in the treatment of patients with glottic carcinoma. The objectives of the current study were to assess the results in a group of consecutive patients with comparable characteristics who were treated with RT (6-megavolt photon linear accelerator) and to determine the prognostic factors that may influence local control in patients with early-stage glottic carcinoma. The impact on local control of tobacco smoking and second primary malignancies also was investigated.

METHODS

Four hundred ten patients with T1-T2 squamous cell carcinoma of the glottis who were treated between 1986 and 2001 were analyzed retrospectively with regard to local control and overall survival. Potential prognostic factors for local control were evaluated with univariate and multivariate models. The impact of technologic advances also was evaluated.

RESULTS

The 5-year and 10-year overall survival rates were 83% and 63.5%, respectively. The overall 10-year local control rate for patients with T1-T2 glottic carcinoma was 89%. The median time to recurrence was 7 months. Univariate analysis showed that tumor category, tumor size, macroscopic appearance of the lesion, RT fraction size, persistent edema, year of RT treatment, unchanged dysphonia, and surgical option all had a significant influence on local control; whereas multivariate analysis showed that only persistent dysphonia and year of RT treatment were significantly associated with increased local control. A 22.2% rate of second primary malignancies was reported: second primary tumors were the major cause of death in the patients studied. Only 2 patients died of laryngeal carcinoma; 304 patients were alive with their disease in complete remission, 1 patient was alive with recurrent laryngeal carcinoma after undergoing salvage surgery, and 103 patients died of either intercurrent disease or a second primary tumor.

CONCLUSIONS

The use of a 6-megavolt photon linear accelerator achieved a high rate of local control in patients with T1-T2 glottic carcinoma. Dysphonia and the year of RT treatment were the most important prognostically significant factors for patient outcome. The occurrence of a second primary tumor was the most frequent cause of death, especially among patients who did not stop smoking after a diagnosis of glottic carcinoma.

Three weeks radiotherapy for T1 glottic cancer: the Christie and Royal Marsden Hospital Experience

BACKGROUND AND PURPOSE

Radiotherapy for laryngeal carcinoma is conventionally given over a 6-7-week period. However, in a number of UK centres early lesions are treated over 3 weeks. We review recent results of this policy and discuss the reasons why short treatment times may be advantageous.

MATERIALS AND METHODS

Two hundred patients (100 from each centre) with T1 glottic invasive squamous cell carcinoma treated with definitive radiotherapy between 1989 and 1997 were analysed. The median age was 68 years. All patients received once daily fractionation, 5 days a week to a total tumour dose of 50.0-52.5 Gy in 16 fractions over 21 days; the fraction size ranged from 3.12 to 3.28 Gy. The median follow-up period was 5 years and 10 months.

RESULTS

The 5-year local control rates with radiotherapy for the whole group was 93%; there were 14 recurrences of which seven were salvaged by laryngectomy giving an ultimate local control of 96%. The 5-year overall survival was 80% and cause specific survival at 5 years was 97%. Univariate analysis revealed that T1 substaging (P=0.82) and anterior commissure involvement (P=0.47) did not significantly influence local control. A severe late radiation complication was seen in only one patient who continued to smoke heavily after treatment. There were no severe acute complications.

CONCLUSIONS

Once daily radiotherapy over 3 weeks gives excellent local control in patients with T1 glottic squamous-cell carcinoma and has a low rate of severe complications. The short overall treatment time and large fraction size may be advantageous in radiotherapy of these well-differentiated tumours.

Transoral laser microresection for cancer of the larynx involving the anterior commissure

OBJECTIVE

To share the authors' experience of transoral laser microresection in the treatment of squamous cell carcinoma of the anterior commissure of the larynx.

STUDY DESIGN

Retrospective review of 39 patients with squamous carcinoma involving the anterior commissure of the larynx, all managed with transoral laser microresection between September 1996 and December 2001. Twenty-three patients had pT1 or pT2 cancers. Sixteen patients had pT3 or pT4 disease, two with N2b neck metastases. Twenty patients had cancers exhibiting spread to the subglottis. Twenty-five patients had received prior treatment(s).

METHODS

Specific data points entered into a portable database were retrospectively verified against the patient's electronic medical record. Sorting and analysis were completed in a desktop spreadsheet. We evaluated tumor recurrence, cause of death, tracheostomy, hospital length of stay, and voice quality.

RESULTS

None of the 17 patients with early cancers (pT1 or pT2a) had local recurrence, and none received postoperative radiotherapy. Five of the 22 patients with intermediate or advanced disease (pT2b/pT3 or pT4 cancer) required second treatments for persistent or recurrent disease. Of these, two had small residual foci amenable to second-stage resection by laser. One patient developed a prelaryngeal soft tissue recurrence and retained his larynx after wide local excision and radiotherapy. Two patients (both previously irradiated) developed delayed recurrences requiring total laryngectomy. Four retreated patients remained alive without disease. One patient died of other causes. Voice remained no worse after transoral laser microresection in 19 patients. It was one level worse (on a scale of 0 to 5) for 16 patients. Eleven patients received temporary tracheotomies, some for airway, some for exposure. Twelve patients left the hospital on a same-day basis. The average hospital stay was 3.3 days.

CONCLUSION

Transoral laser microsurgery is one of the options to be considered for the treatment of squamous cell cancer involving the anterior commissure of the larynx.

[Treatment of T1N0 glottis carcinoma with radiotherapy. Results at our center and review of the literature]

OBJECTIVE

To evaluate the results of radiotherapy in the treatment of patients with T1N0 glottic squamous cell carcinoma.

MATERIAL AND METHODS

Retrospective study of a cohort of 338 patients with T1N0 glottic carcinoma treated with radiotherapy at our institution between 1985-1997. A review of the literature published during the last ten years was carried out.

RESULTS

Local control with radiotherapy in our patients was 82%, reaching 97% when salvage surgery was included. The local control with radiotherapy in most of the published series ranges between 81.90%.

CONCLUSIONS

Treatment with radiotherapy achieves local control in early glottic carcinomas (T1N0) in 80-90% of cases. In our centre such treatment achieved local control in 82% of cases.

Gross tumor volume, critical prognostic factor in patients treated with three-dimensional conformal radiation therapy for non-small-cell lung carcinoma

PURPOSE

Three-dimensional conformal radiation therapy (3D-CRT) has recently become widely available with applications for patients with non-small-cell lung cancer (NSCLC). These techniques represent a significant advance in the delivery of radiotherapy, including improved ability to delineate target contours, choose beam angles, and determine dose distributions more accurately than were previously available. The purpose of this study is to identify prognostic factors in a population of NSCLC patients treated with definitive 3D-CRT.

METHODS AND MATERIALS

Between March 1991 and December 1998, 207 patients with inoperable NSCLC were treated with definitive 3D-CRT. Tumor targets were contoured in multiple sections from a treatment planning computed tomography (CT) scan. Three-dimensional treatment volumes and normal structures were reconstructed. Doses to the International Commission on Radiation Units and Measurements (ICRU) reference point ranged from 60 to 83.85 Gy with a median dose of 70 Gy. The median dose inhomogeneity was +/- 5% across planning target volume. Outcome was analyzed by prognostic factors for NSCLC including pretreatment patient and tumor-related factors (age, gender, race, histology, clinical stage, tumor [T] stage, and node [N] stage), parameters from our 3D-CRT system (gross tumor volume [GTV] in cm3), irradiation dose prescribed to isocenter, volume of normal lung exceeding 20 Gy (V20), and treatment with or without chemotherapy. The median follow-up time was 24 months (range, 7.5 months to 7.5 years).

RESULTS

One and two-year overall survival rates for the entire group were 59% and 41%, respectively. Overall survival, cause-specific survival, and local tumor control were most highly correlated with the GTV in cm3. On multivariate analysis the independent variable most predictive of survival was the GTV. Traditional staging such as T, N, and overall clinical staging were not independent prognostic factors. Patients receiving ICRU reference doses > or =70 Gy had better local control and cause-specific survivals than those treated with lower doses (p = 0.05). Increased irradiation dose did not improve overall survival.

CONCLUSIONS

GTV as determined by CT and 3D-CRT planning is highly prognostic for overall and cause-specific survival and local tumor control and may be important in stratification of patients in prospective therapy trials. T, N, and overall stage were not independent prognostic factors in this population of patients treated nonsurgically. The value of dose escalation beyond 70 Gy should be tested prospectively by clinical trial.

Stomal recurrence in patients with T1 glottic cancer after salvage laryngectomy for radiotherapy failures: role of p53 overexpression and subglottic extension

The role of p53 overexpression in the development of stomal recurrence was studied in patients with T1 glottic cancer who had undergone salvage laryngectomy after primary radiotherapy failure (first recurrence). The role of subglottic extension of the recurrent tumor in the development of stomal recurrence was also studied. One hundred fourteen patients with T1 squamous cell carcinoma of the glottic larynx were irradiated with curative intent. A local recurrence (first recurrence) developed in 23 patients (20%), and salvage laryngectomy was performed for 20 of these patients. No postlaryngectomy radiation therapy was included in the treatment of recurrences. Several risk factors thought to be significant in the development of stomal recurrence were analyzed in these 20 patients. Prognostic factors analyzed include: p53 overexpression in the preradiation biopsy specimen, subglottic extension of the first recurrence, thyroid cartilage and lymph node involvement at the time of first recurrence, emergency tracheostomy performed before salvage laryngectomy, and the laryngectomy procedure performed for first recurrence. Presence of p53 protein in the preradiation biopsy specimen of laryngeal cancer did not show any adverse effect on the development of stomal recurrence. Stomal recurrence developed in 27% of patients with positive biopsies and in 20% of patients with negative biopsies (p = 1.00). Subglottic extension of the first recurrence was associated with an increased incidence of stomal recurrence. Rates of stomal recurrence were 6% in patients without subglottic extension and 100% in patients with subglottic extension (p = 0.001). All other risk factors studied showed no effect on stomal recurrence. In this study, p53 overexpression showed no effect on the development of stomal recurrence after salvage laryngectomy in patients with T1 glottic cancer. Conversely, subglottic extension of the recurrence was found to be strongly associated with stomal recurrence. All other factors analyzed showed no effect on stomal recurrence.

Short-time ultrasound of head and neck squamous cell carcinoma under radiotherapy

To evaluate the efficacy of ultrasonography for patients with head and neck squamous cell carcinoma before and during radiotherapy (RT), consecutive patients with macroscopic lesions were examined before and during RT. Each scan was performed percutaneously in a short time (less than 5 min). The demonstration rate of primary tumors and the largest node of previously known metastatic cervical nodes were measured. Of all 190 patients, 91 primary tumors were detected (47.9%). Primary tumors in oral cavity, oropharynx, hypopharynx and cervical esophagus were determined in over 70% and, for those of nasopharynx and larynx, the demonstration rates were 30% or less. Nodal metastases were visualized in 78 of 80 patients with regional metastases (97.5%). Using the above information, 73 patients (38.4%) received the benefit of radiation therapy. Short-time sonography is a valuable modality for patients with selected sites of head and neck cancers.

Local recurrences following transoral laser surgery for early glottic carcinoma: frequency, management, and outcome

Although transoral laser surgery (TLS) for the treatment of early stage glottic carcinoma is now widely used, the patterns of local recurrences, related re-treatment methods, and results have not been documented comprehensively. Two hundred fifty-two patients with glottic carcinoma stage I or II were treated for cure with TLS alone and followed up for 24 to 139 months (mean, 62 months). Their charts were retrospectively reviewed to identify local recurrence patterns. Thirty-five patients (13.9%) presented with local recurrences or second laryngeal primaries 4 to 84 months (mean, 23 months) after initial treatment. Of the 161 patients classified T1N0M0, 21 (13.0%) suffered local recurrences, and in the 91 classified T2N0M0, 14 (15.4%) tumors recurred. If tumors recurring more than 60 months after initial treatment are considered second primary tumors rather than recurrences, then only 18 (11.2%) of 161 patients classified T1N0M0 would have had a recurrence. However, the difference in local control between patients with stage I versus stage II disease would still not be significant (p = .41). Of the 35 patients with local recurrences, 16 (45%) were managed with total laryngectomy, 10 (28.6%) with further TLS, 4 (11.4%) with partial laryngectomy, and 2 (5.7%) with radiotherapy, and 3 (8.6%) had no curative treatment. Accordingly, 16 patients (45.7%) with local treatment failure could be treated with further organ-sparing treatment methods. The actuarial overall survival, disease-specific survival, and organ preservation rates 5 years after the diagnosis of recurrent disease were 43.6%, 74.6%, and 33.7%. Transoral laser surgery leads to local control rates that are comparable to those found after radiotherapy for lesions classified T1 and leads to slightly better control rates for lesions classified T2, but the results are inferior to those achieved with conventional partial laryngectomy. However, if local recurrence occurs, then more re-treatment options are available after TLS as compared to initial radiotherapy or open surgery.

Supracricoid partial laryngectomy with cricohyoidoepiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas

OBJECTIVES

To review the patients operated in our department with supracricoid partial laryngectomy with either cricohyoidoepiglottopexy (CHEP) (59 cases) or cricohyoidopexy (CHP) (10 cases) technique, for primary or recurrent glottosupraglottic squamous cell carcinoma and compare the technique with other surgical or conservative approaches for treatment of laryngeal carcinoma.

METHODS

From hospital charts, we retrospectively reviewed 69 patients who had undergone supracricoid partial laryngectomy with the CHEP or CHP technique between 1983 and 1996 for primary or recurrent glottosupraglottic squamous cell carcinoma in our department. Statistical evaluation of oncological and functional results were conducted. Results were compared with other surgical and conservative treatment for glottosupraglottic carcinoma of the larynx that were published previously in the literature.

RESULTS

Sixty-nine patients had CHEP or CHP for glottosupraglottic carcinoma of the larynx. Thirteen percent of the patients received adjuvant radiotherapy. Minimum follow-up was 2 years or until death. Five-year actuarial survival (Kaplan-Meier method) was 68%. Global local control was achieved in 84% of cases. Among previously untreated patients (n = 54), local control rate was 94.5%. After 1 year, 92.7% of patients achieved normal swallowing and respiration. Salvage total laryngectomy had to be performed in four patients (5.7%) for persistent aspiration and in five patients (7.2%), who were previously treated with radiotherapy, for local recurrence. No permanent tracheostomy or gastrostomy was required.

CONCLUSIONS

Our experience with supracricoid partial laryngectomy with either CHP or CHEP suggests that this technique is a valuable alternative to radiotherapy for T2-T4 glottosupraglottic carcinomas, particularly those with extension and invasion of the anterior commissure. It allows for preservation of a good laryngeal function without altering the long-term survival, keeping total laryngectomy as a salvage procedure.

Curative radiotherapy for anterior commissure laryngeal carcinoma

There is continuing controversy surrounding the most effective treatment of glottic carcinoma involving the anterior commissure (AC). Surgery has been the preferred method of treatment, since studies previously indicated early tumor invasion of the thyroid cartilage at the AC, thereby assuming less curability by radiotherapy (RT). Subsequent laryngeal anatomic studies and refinement of RT techniques have brought into question the ineffectiveness of curative irradiation. A retrospective review of 174 patients with early-stage glottic carcinoma treated with standard fractionation curative RT revealed 34 patients with T1 and T2 lesions involving the AC. Allowing for a follow-up of at least 3 years, we observed only a 12% (4 of 34 patients) local recurrence rate after RT alone, with excellent voice quality and no major complications related to the irradiation. The 4 local recurrences were controlled by total laryngectomy, although 2 patients developed distant metastatic disease. Radiotherapy represents an effective method of treating T1 squamous cell carcinoma of the glottis with AC involvement. The small number of T2 glottic carcinomas in this study prevents a meaningful conclusion concerning treatment of these lesions.

Prognostic impact of total tumor volume and hemoglobin concentration on the outcome of patients with advanced head and neck cancer after concomitant boost radiochemotherapy

PURPOSE

To identify prognostic clinical and treatment related factors for local control, distant metastasis-free survival, and survival by means of a multivariate analysis in patients with advanced squamous cell carcinoma of the head and neck after concomitant boost radiochemotherapy.

PATIENTS AND METHODS

From 1992 to 1995, 68 patients with squamous cell cancer of the head and neck (93% stage IV disease) were treated with a simultaneous radiochemotherapy with Carboplatin using a concomitant boost technique. The total tumor volume (TTV) was quantitatively determined based on computed tomography scans in 56 patients. A Cox proportional hazards regression analysis was performed for each of the above endpoints and statistical significance of the Cox models was verified using the likelihood ratio test and Bonferroni correction for multiple testing.

RESULTS

The survival and locoregional control rates at three years were 35 and 32%. The multivariate analysis revealed a significant association between the TTV and survival (P = 0.0008) and between the pretreatment serum hemoglobin concentration and locoregional control (P = 0.01) and survival (P = 0.05). The locoregional control was significantly associated with the N-stage (P = 0.007) and there was a good correlation between the N-stage and TTV in this study population.

CONCLUSION

Our data corroborate the prognostic relevance of the tumor volume and hemoglobin concentration. In studies comparing the survival of patients with advanced cancer of the head and neck, the use of the TTV as a covariable may improve the statistical power.

Second primary tumors in laryngeal cancer: results of long-term follow-up

PURPOSE

The development of second primary tumors (SPTs) is the most important factor determining the survival in early-stage head and neck cancer patients, whose first tumor has been successfully treated. New methods of examining genetic changes have raised doubts about the validity of the widely held field cancerization hypothesis as the cause of SPTs, and an alternative hypothesis of monoclonal origin has been proposed. The objectives of this study were to look at the pattern of development of SPTs and the possible factors influencing the incidence of SPTs and the survival in early-stage laryngeal cancer with long-term follow-up.

METHODS AND MATERIALS

One hundred forty-four consecutive patients of T1N0M0 squamous cell carcinoma of the true vocal cord treated with definitive radiotherapy between 1976 and 1992 were analyzed. The incidence, time to development, and survival of aerodigestive and other SPTs were noted. p53 overexpression indicating a mutated p53 gene was analyzed by immunohistochemistry.

RESULTS

With a median follow-up of 6 years (range 2-20 years), 42 patients developed a SPT, 24 in upper aerodigestive tract and lung and 18 at other sites. The actuarial incidence of developing a SPT at 5, 10, and 15 years was 23%, 44%, and 48.7% respectively. The median time interval for development of SPT in an upper aerodigestive tract was 21 months as opposed to 50 months for other sites (p = 0.02). The most common sites of SPTs included lung for upper aerodigestive tract; and prostate, followed by colon, for other sites. The actuarial risk of developing a nonaerodigestive SPT at 5 and 10 years was 35% and 55% respectively. p53 status affected neither the incidence of SPT nor the survival. SPTs were the leading cause of death in these early-stage laryngeal cancer patients.

CONCLUSION

The origin of SPTs seems to be multifactorial, involving both the field cancerization effect and an increased baseline genetic predisposition. Until more reliable genetic markers are developed, chemoprevention remains the best treatment option at preventing SPTs in these early-stage patients.