Advanced carcinoma of the larynx: results of surgery and radiotherapy without induction chemotherapy (1980-1985): a multivariate analysis

Influence of time between surgery and postoperative radiation therapy and total treatment time in locoregional control of patients with head and neck cancer: a single center experience

OBJECTIVE

This study aimed to evaluate the effect of the delay to initiate postoperative radiation therapy (RT) on locoregional control to head and neck squamous cell carcinoma patients.

METHODS

Retrospective cohort study that included patients submitted to surgery followed by adjuvant RT (with/without chemotherapy). The time interval between surgery and RT was dichotomized by the receiver operating characteristics curve method at 92 days. Other possible sources of heterogeneity with potential impact on locoregional control were explored by regressive analysis.

RESULTS

A total of 168 patients were evaluated. The median time for locoregional recurrence (LRR) was 29.7 months. The relapse-free survival rates were 66.4% and 75.4% for patients who initiated RT more than and within 92 postoperative days (p=0.377), respectively. Doses lower than 60Gy were associated with worse rates of locoregional control (HR=6.523; 95%CI:2.266-18.777, p=0.001). Patients whose total treatment time (TTT) was longer than 150 days had LRR rate of 41.8%; no patient with TTT inferior to 150 days had relapses (p=0.001).

CONCLUSIONS

The interval between surgery and RT did not show influence on locoregional control rates. However, doses <60Gy and the total treatment time >150 days were associated with lower locoregional control rates.

Survival and prognostic analysis of preoperative inflammatory markers in patients undergoing surgical resection for laryngeal squamous cell carcinoma

BACKGROUND

To estimate the prognostic value of inflammatory markers in patients with laryngeal squamous cell carcinoma (LSCC).

METHODS

A total of 361 resected LSCC patients were included. The preoperative and postoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), alkaline phosphatase (ALP) and l actate dehydrogenase (LDH) were assessed. The Kaplan-Meier survival analysis and Cox regression analysis were conducted on overall survival (OS) and progression-free survival (PFS).

RESULTS

Both Kaplan-Meier analysis and univariate analysis demonstrated significant prognostic value of preoperative and postoperative NLR, PLR and MLR. However, only preoperative ALP was predictive of OS and PFS, and LDH failed to be predictor of OS and PFS. The multivariate analysis showed that preoperative NLR (OS: HR = 1.64, 95%CI: 1.06-2.54, p = 0.026; PFS: HR = 1.52, 95%CI: 1.04-2.23, p = 0.029) and postoperative MLR (OS: HR = 2.02, 95%CI: 1.29-3.14, p = 0.002; PFS: HR = 1.57, 95%CI: 1.05-2.34, p = 0.026) were independently related with survival.

CONCLUSIONS

The elevated preoperative NLR, PLR, MLR and ALP were significantly associated with worse survival and cancer progression. The preoperative NLR and postoperative MLR might be independent prognostic markers of OS and PFS in LSCC patients undergoing surgical resection.

Clinical and histopathological prognostic factors in locoregional advanced laryngeal cancer

Objective:

To evaluate the clinical and histopathological factors affecting the prognosis of patients with squamous cell locoregional advanced laryngeal cancer.

Methods:

A retrospective chart review was conducted of 121 patients with locoregional advanced laryngeal cancer, primarily treated with surgery from 2007 to 2011. Disease-free survival and overall survival rates were analysed as oncological outcomes. Prognostic variables, namely gender, pharyngeal invasion, pathological assessment of tumour and nodal stage, adjuvant therapy, margin status, nodal extracapsular extension, tumour differentiation, lymphovascular and perineural invasion, and predominant growth pattern, were also analysed.

Results:

One-year and three-year disease-free survival rates were 81.3 per cent and 63.5 per cent, respectively. One-year and three-year overall survival rates were 88.3 per cent and 61.4 per cent, respectively. Multivariate analysis showed that nodal extracapsular extension (p < 0.05) and an infiltrative growth pattern (p < 0.05) were associated with disease progression. Nodal extracapsular extension (p < 0.05) was associated with higher mortality.

Conclusion:

Nodal extracapsular extension and an infiltrative growth pattern were the main prognostic factors in locoregional advanced laryngeal cancer. The presence of pharyngeal invasion, pathologically confirmed node-positive stage 2–3 disease, close or microscopic positive margins, and lymphovascular and perineural invasion have a negative impact on prognosis.

Is the Delay in Starting Postoperative Radiotherapy a Key Factor in the Outcome of Advanced (T3 and T4) Laryngeal Cancer?

OBJECTIVE: To identify factors influencing the outcome of postoperative radiotherapy in patients with advanced laryngeal cancer.

DESIGN: The files of 44 patients with advanced laryngeal cancer who were treated by surgery followed by radiotherapy (24 with pT3 and 20 with pT4) were reviewed. Median delay in starting radiotherapy was 50 days (range, 19–150 days). Treatment variables, in addition to certain patient and tumor characteristics, were analyzed in terms of locoregional control and survival.

SETTING: Major referral tertiary center in central Israel.

RESULTS: Locoregional control rates were 86% and 81% at 2 and 5 years, respectively, and corresponding survival rates were 82% for both. Only nodal involvement retained statistical significance for both locoregional control as well as survival on multivariate analysis ( P = 0.0009 and P = 0.0004, respectively).

CONCLUSIONS: This is the first study showing that delay in postoperative radiotherapy in advanced laryngeal cancer is not a significant predictor of locoregional control or survival in advanced laryngeal cancer. Only lymphatic spread was found to have a significant influence on treatment outcome.

Postoperative irradiation in patients with pT3-4N0 laryngeal cancer: results and prognostic factors

Approximately 60 % of patients with locally advanced laryngeal cancer (LALC) treated primarily with surgery require adjuvant radiotherapy. In the available literature predominate series of patients were with pathologically confirmed node-positive status. Subgroups of pN0 patients with LALC are scarce. The aim of the study is to evaluate the efficacy of postoperative radiotherapy in patients with pathological stage T3-4N0M0 and identification of prognostic factors in this group. Between 1975 and 2005, 138 patients with squamous pT3-4N0 laryngeal cancer were irradiated postoperatively. Primary surgical treatment consisted of total laryngectomy and cervical lymphadenectomy. The median time between surgery and the implementation of radiotherapy was 56 days. The median total dose was 60 Gy (range 40–70 Gy). Five-year disease-free survival (DFS5) was achieved in 76 % of patients. Cancer recurrence was observed in 34 patients. In 28 (82 %) cases it was locoregional failure. DFS5 rates for pT3 and pT4 were 92 and 69 %, for margin status R0, R1 and R2 were 82, 72 and 67 %, respectively. The pharyngeal invasion was related to a decrease in DFS5 from 80 to 59 %. Postoperative irradiation in patients with pT3-4N0 LALC is an effective treatment method. The main reason of the failure is local recurrence. The following independent prognostic factors were identified in this group of patients: pT stage, surgical margin status and pharyngeal invasion.

A panel of biomarkers for predicting response to postoperative RT for laryngeal cancer?

OBJECTIVES

Postoperative radiotherapy (PORT) improves locoregional control and survival rates for patients with advanced laryngeal carcinoma (LSCC), but reported outcomes after PORT for LSCC vary considerably. Predictive markers (including biomarkers) are needed for LSCC to orient the choice of the most appropriate adjuvant therapy for individual patients. The aim of this study was to identify a panel of LSCC tissue markers (considering EGFR, mTOR, survivin, Bcl-2, angiogenin, endoglin [CD105], nm23-H1) capable of pinpointing patients at higher risk of recurrence among 33 LSCC cases treated with PORT.

METHODS/RESULTS

Univariate analysis found 4 biomarkers (mTOR, nuclear survivin, CD105, non-nuclear nm23-H1) significantly associated with LSCC recurrence. A collinearity emerged between mTOR and CD105 expressions. The predictive role of two different panels (panel 1: mTOR, nuclear survivin, non-nuclear nm23-H1; panel 2: CD105, nuclear survivin, non-nuclear nm23-H1) was considered. According to the Hosmer and Lemeshow scale, panel 1 demonstrated an outstanding discriminatory power (AUC 0.903) in predicting LSCC recurrence after PORT. Panel 2 had an excellent discriminatory power too (AUC 0.899).

CONCLUSIONS

Both panels of biomarkers showed an important discriminatory power in pinpointing patients at higher risk of recurrence after PORT for LSCC who could reasonably benefit from adjuvant postoperative chemo-RT.

Combined modality treatment of laryngeal squamous cell carcinoma

Squamous cell carcinoma of the larynx is a major public health concern; it causes substantial morbidity and mortality, and arises chiefly as a result of tobacco and alcohol consumption. Early stage disease is best treated with radiation or surgery alone, but for patients with more locally advanced squamous cell carcinoma of the larynx, combined modality treatment has been shown to benefit selected patients, particularly when cisplatin-based chemotherapy and concurrent radiation therapy are employed, with or without altered fractionated radiation therapy. Substantial laryngectomy-associated quality-of-life decrements can be avoided in selected, potentially resectable patients with organ-sparing approaches, without sacrificing survival. Recently, trials have addressed the role of targeted systemic agents to the epidermal growth factor receptor, and other targets are under investigation. The addition of induction chemotherapy to concurrent chemoradiotherapy is a promising treatment strategy that warrants further evaluation, but has not yet emerged as a standard of care; the toxicity of such regimens must be balanced with the potential benefits on a case-by-case basis, and functional outcomes are often quite variable. Treatment planning, management and follow-up are complex, and thus should ideally be performed in a comprehensive, multidisciplinary fashion, in a center accustomed to a high volume of such cases. Future research directions are described herein.

Treatment results and prognostic factors of patients undergoing postoperative radiotherapy for laryngeal squamous cell carcinoma

Postoperative radiotherapy (PRT) is widely advocated for patients with squamous cell carcinomas of the head and neck that are considered to be at high risk of recurrence after surgical resection. The aims of this study were to evaluate the treatment outcomes of PRT for patients with laryngeal carcinoma and to identify the value of several prognostic factors. We reviewed the records of 256 patients treated for laryngeal squamous cell carcinoma between January 1993 and December 2005. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Log-rank test was employed to identify significant prognostic factors for DFS and OS. The Cox proportional hazards model was applied to identify covariates significantly associated with the aforementioned endpoints. Our results showed the 3-, 5-, and 10-year DFS for all patients were 69.9%, 59.5%, and 34.9%, respectively. The 3-, 5-, and 10-year OS rates were 80.8%, 68.6%, and 38.8%, respectively. Significant prognostic factors for both DFS and OS on univariate analysis were grade, primary site, T stage, N stage, overall stage, lymph node metastasis, overall treatment times of radiation, the interval between surgery and radiotherapy, and radiotherapy equipment. Favorable prognostic factors for both DFS and OS on multivariate analysis were lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment. In conclusion, our data suggest that lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment are favorable prognostic factors for DFS and OS and that reducing the overall treatment times of radiation to 6 weeks or less and the interval between surgery and radiotherapy to less than 3 weeks are simple measures to remarkably improve treatment outcome.

Expression TGM2 and BNIP3 have prognostic significance in laryngeal cancer patients receiving surgery and postoperative radiotherapy: a retrospective study

Background

This study was designed to determine the pattern and correlation between expression of the HIF-1α transcriptional targets TGM2 and BNIP3 in laryngeal cancer, and investigate the association of BNIP3 and TGM2 with clinical outcome in laryngeal squamous cell carcinoma (SCC) patients receiving postoperative radiotherapy.

Methods

Immunostaining with antibodies specific to BNIP3 and TGM2 was performed in formalin-fixed, paraffin-embedded specimens from 148 laryngeal SCC patients. BNIP3 and TGM2 expression was scored as high or low, based on the number of tumor cells stained and the staining intensity. All patients received postoperative radiotherapy. Patient follow up and clinicopathological data were compared using the Chi-squared test, univariate and multivariate analyses, and survival curves were generated using the Kaplan-Meier method and log-rank test.

Results

The 3, 5 and 10-year overall survival rates (OS) for all patients were 77.7%, 71.6%, 56.4%, respectively. Primary tumor site, T stage, overall stage, lymph-node metastasis, BNIP3 expression and TGM2 expression were significant prognostic factors for OS in univariate analysis. Negative cervical lymph nodes, high BNIP3 expression and low TGM2 expression were independent prognostic factors of improved OS in multivariate analysis. BNIP3 expression correlates with TGM2 expression in laryngeal SCC (P = 0.012).

Conclusions

This study indicates that lymph-node metastasis, BNIP3 expression and TGM2 expression are independent prognostic factors in laryngeal SCC patients receiving postoperative radiotherapy. Further studies are required to investigate how BNIP3 and/or TGM2 influence the prognosis of laryngeal SCC patients treated with postoperative radiotherapy, and to determine how TGM2 and BNIP3 expression are regulated.

Larynx squamous cell carcinoma: concepts and future directions

The larynx is one of the most important structures in the upper aerodigestive tract. Functional impairment of the larynx is a bur-den to patients who suffer from laryngeal carcinoma, the second most common cancer of the head and neck region after the oral cavity.

Glottic carcinoma--patterns of failure and salvage treatment after curative radiotherapy in 861 consecutive patients

BACKGROUND AND PURPOSE

The aim of this study was to evaluate the patterns of failure and the treatment of recurrences, in a series of primary irradiated patients with squamous cell carcinoma of the glottic larynx.

MATERIALS AND METHODS

Eight hundred and sixty-one consecutive patients were included in this study from 1963 to 1991, out of which 74 were females and 787 males. The stages were: I 56, II 26, III 15, and IV 3%. In 847 of 861 cases (98%) the primary treatment was delivered with curative intent, and out of these 834 patients received primary radical radiotherapy.

RESULTS

With a minimum follow up of 5 years, 274/861(32%) patients had persistent or recurrent disease; in 91% of these the persistent or recurrent disease was in the T-position, 15% in the N-position, and 5% developed distant metastases. Curative salvage attempt was possible in 207 patients, and 145 were subsequently controlled. A total of 718 (83%) patients obtained ultimate tumour control, 584 (68%) without a laryngectomy (134 of the controlled had a laryngectomy, 109 had a total laryngectomy and 25 had a partial laryngectomy). In the patients treated with curative intent, the overall 5-year local tumour control, loco-regional tumour control, disease specific survival rate and overall survival rate was 72, 70, 86 and 66%, respectively. For patients with small tumours the disease specific survival for T1a, T1b and T2 was 95, 93 and 83%, respectively. In the 718 patients cured for their glottic carcinoma, 204 new primary malignant tumours were detected.

CONCLUSIONS

The study shows that laryngeal glottic carcinoma can be effectively managed by primary radiotherapy and surgery salvage. The control is obtained with a high proportion of laryngeal preservation (68%). Recurrences treated with surgical salvage have a success rate of 70%. New primaries are a major problem.

Time-dose-response relationships in postoperatively irradiated patients with head and neck squamous cell carcinomas

BACKGROUND AND PURPOSE

To define the influence of the dose and time on the response to treatment in postoperatively irradiated head and neck cancer patients and to establish a good prediction of failure.

METHODS AND MATERIALS

From January 1985 to December 1995, 214 patients with histologically proven head and neck squamous cell carcinomas were irradiated after radical surgery or single tumour resection according to surgical and histopathological findings. The total doses given ranged between 50 and 75 Gy to the primary bed tumour and between 42 and 56 Gy to the neck with fraction sizes of 1.7-2 Gy/day. The median length of the time interval between surgery and radiotherapy, time of irradiation and total treatment time were 81, 59 and 139 days, respectively. The end-point analyzed was the local-regional tumour control rate at the primary tumour bed and neck for 5 years from the beginning of radiotherapy. Univariate and multivariate analyses were used to determine predictors of failure from among the following studied variables: (i), clinical stage (T/N) of the patients; (ii), tumour grade; (iii), neck surgery; (iv), tumour margins; (v), histological tumour nodal extension; (vi), chemotherapy; (vii), normalized total dose; (viii), time interval between surgery and radiotherapy; (ix), time of irradiation; and (x), total treatment time.

RESULTS

The actuarial 5-year tumour control rate for the entire group was 72%, and 92% of the patients who achieved local control are currently alive without disease. Tumour control was inversely related to T stage (83% for T2 vs. 57% for T4) and the probability of local control within each stage was dependent on the N status (> or =71% for T3-T4/N0 vs. 31-44% for T3-T4/N1-N3). Histological N status and tumour margins, but not tumour grade, impacted significantly on tumour control. When local control was analyzed as a function of the dose to the primary, a non-significant negative dose-response relationship was found. The total treatment time was a significant prognostic factor, and the time interval between surgery and irradiation proved to be an independent predictor of failure.

CONCLUSIONS

Despite the absence of a statistically significant dose-response relationship, the present results suggest that postoperative irradiation treatment given to patients with head and neck squamous cell carcinomas should not be unduly prolonged, in order to minimize the amount of tumour cell proliferation. In these patients, nodal involvement, positive margins of the resected specimens and time interval between surgery and irradiation were the most important prognostic factors.

Potential molecular prognostic markers in head and neck squamous cell carcinomas

BACKGROUND

Current management strategies for squamous cell carcinoma of the head and neck (HNSCC) rely on an understanding of the natural history of the disease, along with the use of prognostic factors to guide selection of appropriate treatment. However, it is recognized that tumor heterogeneity limits the reliable use of currently available prognostic markers. With the evolving understanding of the genetic and molecular basis of human malignancies, there has been much interest in determining whether specific molecular changes in HNSCC might guide treatment decisions.

METHODS

A literature review of potential molecular markers relevant to HNSCC was undertaken and evaluated. It is evident that the published information is promising but, oftentimes, limited by a scarcity of large, uniformly staged and treated patients, from which the value of novel molecular markers can be assessed.

RESULTS

On the basis of the review of more than 100 articles, some of the emerging molecular markers that might provide independent prognostic information include epidermal growth factor receptor (EGFR), transforming growth factor-alpha (TGF-alpha), cyclin D1, and p53. This review will discuss the current status of these molecular factors and consequent implications for novel therapeutic approaches for patients with HNSCC.

CONCLUSION

With the evolving understanding that human malignancies have developed and progressed on the basis of accumulated molecular abnormalities, there is an existing body of work trying to determine whether such abnormalities can predict clinical behavior of HNSCC. Such studies have to be conducted rigorously to derive useful information. Nevertheless, the role of such molecular markers, and the possibility to exploit them for therapeutic gain, is already at the horizon.

Role of multimodal treatment in oropharynx, larynx, and hypopharynx cancer

Due to recent advances in radiation fractionation, radiochemotherapy, and conservative surgical techniques, the concept of multimodal therapy in head and neck cancer is currently changing. The recently published RTOG Phase III trial 9003, with 1,113 patients accrued, showed that hyperfractionation and accelerated fractionation with concomitant boost are more efficacious than standard fractionation for locally-advanced head and neck cancer. Acute, but not late, toxicity was also increased. Three meta-analyses have suggested that the impact of chemotherapy in head and neck cancer is small but is highly associated with the timing of therapy. Concomitant administration of radiation therapy and chemotherapy led to an absolute benefit in 5-year survival of about 10%. This finding has been further supported by recently published randomized prospective trials comparing concomitant radiochemotherapy with radiotherapy alone in advanced head and neck cancer. There is now clear evidence that radiochemotherapy provides a substantial and statistically significant improvement in survival and local-regional control, as compared to radiotherapy alone. Radiochemotherapy should be considered an accepted standard of care in cancers of the oropharynx, particularly for patients with locally-advanced disease who have a good performance status. Two randomized studies conducted by the Department of Veterans' Affairs and the EORTC, with a total of 534 patients accrued, showed that induction chemotherapy followed by radiotherapy of responders yields survival rates equal to those of total laryngectomy with postoperative radiotherapy. After 4 years, one-half to two-thirds of survivors of the chemotherapy arm retained a functional larynx. Larynx preservation using induction chemotherapy can now be regarded as feasible but still investigational. Current phase II studies show excellent larynx preservation rates using a primary concomitant radiochemotherapy with an altered fractionation regimen. More clinical and laboratory research is required to further evaluate the different treatment options of the multimodality concept, and to develop prognostic models that will allow individualization of the therapy.

Larynx preservation in head and neck cancers. A discussion of the National Comprehensive Cancer Network Practice Guidelines

The management of advanced cancers of the larynx and hypopharynx has become increasingly complex as different treatment modalities, including surgery, radiation, and chemotherapy, have been combined with the goal of improving local disease control and disease-specific survival. A union of 17 comprehensive cancer centers in the United States, the National Comprehensive Care Network (NCCN), was formed in 1995 to promote state-of-the-art cancer care. To achieve this goal, multidisciplinary panels of experts from member institutions have created disease-specific practice guidelines for the evaluation and treatment of cancer patients, including those with head and neck cancers. Although detailed analysis of surgical methods and radiation techniques are beyond the scope of this article, the evolving laryngeal preservation strategies for patients with advanced, resectable hypopharyngeal or laryngeal (including supraglottic and glottic) cancers are reviewed using relevant sections of the NCCN practice guidelines as a framework for discussion.

Accelerated radiotherapy with carbogen and nicotinamide (ARCON) for laryngeal cancer

BACKGROUND AND PURPOSE

Tumor hypoxia and tumor cell repopulation are known factors determining radiation response. Accelerated radiotherapy as a method to counteract cellular repopulation was combined with carbogen (95% O2 + 5% CO2) breathing and oral administration of nicotinamide as a means to improve tumor perfusion and oxygenation. The feasibility, toxicity and clinical effectiveness of this approach as a voice-preserving treatment for carcinoma of the larynx was assessed in a prospective study.

PATIENTS AND METHODS

Sixty-two patients with stage III-IV laryngeal carcinoma were treated with a schedule of accelerated radiotherapy. The total radiation dose to the primary tumor was 64 Gy and that to the metastatic nodes was 68 Gy delivered in fractions of 2 Gy over 35-37 days. Radiotherapy was combined with carbogen breathing in the initial 11 patients and with both carbogen and nicotinamide administration in the subsequent 51 patients.

RESULTS

After a median follow-up of 24 months, the actuarial local control rate at 2 years was 92%. This is higher than any previous report in the literature for this category of patients. Five patients had a local tumor recurrence and underwent laryngectomy. There was one regional recurrence. Including salvage surgery the loco-regional control rate was 100%. Four patients developed distant metastases and died. The actuarial overall survival rate at 2 years was 85%. Toxicity was increased relative to conventional radiotherapy but was considered as acceptable. One patient underwent laryngectomy for radiation-induced cartilage necrosis.

CONCLUSION

These preliminary results indicate that advanced laryngeal cancer can be controlled in a high proportion of patients when treated with accelerated radiotherapy combined with carbogen and nicotinamide. This approach offers excellent possibilities for larynx preservation.