Tumor volumes in T3 supraglottic cancers treated with radiotherapy in the modern era: A study of the Canadian Head & Neck Collaborative Research Initiative

PURPOSE

To evaluate the association of primary tumor volume (TV) with overall survival (OS) and disease-free survival (DFS) in T3 N0-3M0 supraglottic cancers treated with intensity-modulated radiotherapy (IMRT).

METHODS

This was a retrospective cohort study involving 239 patients diagnosed with T3 N0-3M0 supraglottic cancers between 2002 and 2018 from seven regional cancer centers in Canada. Clinical data were obtained from the patient records. Supraglottic TV was measured by neuroradiologists on diagnostic imaging. Kaplan-Meier method was used for survival probabilities, and a restricted cubic spline Cox proportional hazards regression analysis was used to analyze TV associations with OS and DFS.

RESULTS

Mean (SD) of participants was 65.2 (9.4) years; 176 (73.6%) participants were male. 90 (38%) were N0, and 151 (64%) received concurrent systemic therapy. Mean TV (SD) was 11.37 (12.11) cm3 . With mean follow up (SD) of 3.28 (2.60) years, 2-year OS was 72.7% (95% CI 66.9%-78.9%) and DFS was 53.6% (47.4%-60.6%). Increasing TV was associated (per cm3 increase) with worse OS (HR, 1.01, 95% CI 1.00-1.02, p < 0.01) and DFS (HR, 1.01, 95% CI 1.00-1.02, p = 0.02).

CONCLUSIONS

Increasing primary tumor volume is associated with worse OS and DFS in T3 supraglottic cancers treated with IMRT, with no clear threshold. The findings suggest that patients with larger tumors and poor baseline laryngeal function may benefit from upfront laryngectomy with adjuvant radiotherapy.

Association of Primary Tumor Volume With Survival in Patients With T3 Glottic Cancer Treated With Radiotherapy: A Study of the Canadian Head & Neck Collaborative Research Initiative

Importance

The association of primary tumor volume with outcomes in T3 glottic cancers treated with radiotherapy with concurrent chemotherapy remains unclear, with some evidence suggesting worse locoregional control in larger tumors.

Objective

To evaluate the association of primary tumor volume with oncologic outcomes in patients with T3 N0-N3 M0 glottic cancer treated with primary (chemo)radiotherapy in a large multi-institutional study.

Design, Setting, and Participants

This multi-institutional retrospective cohort study involved 7 Canadian cancer centers from 2002 to 2018. Tumor volume was measured by expert neuroradiologists on diagnostic imaging. Clinical and outcome data were extracted from electronic medical records. Overall survival (OS) and disease-free survival (DFS) outcomes were assessed with marginal Cox regression. Laryngectomy-free survival (LFS) was modeled as a secondary analysis. Patients diagnosed with cT3 N0-N3 M0 glottic cancers from 2002 to 2018 and treated with curative intent intensity-modulated radiotherapy (IMRT) with or without chemotherapy. Overall, 319 patients met study inclusion criteria.

Exposures

Tumor volume as measured on diagnostic imaging by expert neuroradiologists.

Main Outcomes and Measures

Primary outcomes were OS and DFS; LFS was assessed as a secondary analysis, and late toxic effects as an exploratory analysis determined before start of the study.

Results

The mean (SD) age of participants was 66 (12) years and 279 (88%) were men. Overall, 268 patients (84%) had N0 disease, and 150 (47%) received concurrent systemic therapy. The mean (SD) tumor volume was 4.04 (3.92) cm3. With a mean (SD) follow-up of 3.85 (3.04) years, there were 91 (29%) local, 35 (11%) regional, and 38 (12%) distant failures. Increasing tumor volume (per 1-cm3 increase) was associated with significantly worse adjusted OS (hazard ratio [HR], 1.07; 95% CI, 1.03-1.11) and DFS (HR, 1.04; 95% CI, 1.01-1.07). A total of 62 patients (19%) underwent laryngectomies with 54 (87%) of these within 800 days after treatment. Concurrent systemic therapy was associated with improved LFS (subdistribution HR, 0.63; 95% CI, 0.53-0.76).

Conclusions and Relevance

Increasing tumor volumes in cT3 glottic cancers was associated with worse OS and DFS, and systemic therapy was associated with improved LFS. In absence of randomized clinical trial evidence, patients with poor pretreatment laryngeal function or those ineligible for systemic therapy may be considered for primary surgical resection with postoperative radiotherapy.

Association of tumor volume and outcomes in T3 larynx cancer with organ preservation approach

e18044

Background: Organ preservation approaches to treatment of locally advanced larynx cancers are widely used and consist of radiotherapy (RT) with or without concurrent systemic therapy (CRT). Analyses of the National Cancer Database point to decreasing survival as CRT became widely adopted in place of total laryngectomy (TL). Tumor volume in T3 laryngeal tumors has been postulated as one variable to explain this finding, with higher volume associated with lower local control based on small sample size studies largely in pre-intensity modulated radiotherapy (IMRT) era, and low volume T3 tumors being associated with improved local control with CRT. We sought to validate these findings in a contemporary cohort of T3 larynx patients treated with IMRT. Methods: This was a national, multicentre retrospective cohort study of patients diagnosed with American Joint Committee on Cancer (AJCC) T3 N0-3 M0 glottic and supraglottic cancers who underwent curative intent IMRT with or without systemic treatment from 2002-2018. Tumor volumes were calculated using a validated standardized approach by a Neuroradiologist. Primary predictor was tumor volume, primary outcome was local control (LC), and secondary outcomes included overall survival (OS), as well as late grade 3+ toxicities. Kaplan Meier estimates and log-rank tests were used for survival analyses, with Cox proportional hazards used for univariable analyses. Results: 246 patients met inclusion criteria, 147 glottic and 99 supraglottic cancers. At baseline, glottic patients were more likely to be male (p < 0.01), have a fixed vocal cord (p < 0.01), not have pre-epiglottic space invasion ( < 0.01), be cN0 (p < 0.01), and have lower grade tumors (p < 0.01). Mean tumor volumes for glottic and supraglottic tumors were 5.0 (4.2-5.8) cc and 13.0 (10.3–15.6) cc respectively. Univariable analysis showed systemic therapy was associated with improved local failure (HR 0.49, 95%CI 0.24 – 0.99, p = 0.05). Within the glottic cohort, tumor volume was not associated with local failure (HR 1.09, 95%CI 0.71 – 1.67, p = 0.38), however having a local failure event was associated with increased feeding tube dependence (HR 2.52, 95%CI 1.05 – 6.02, p = 0.04). Median local failure free survival in the overall cohort was 28.5 months, with median OS 23.2 months. There was a trend towards improved local control in the supraglottic cohort compared to glottic patients (log-rank p = 0.08), but the supraglottic cohort had significantly worse overall survival (log-rank p = 0.02). Conclusions: In this retrospective cohort study, there were baseline and outcome differences between patients with T3 glottic and supraglottic larynx cancer, with worse overall survival in supraglottic patients. Tumor volume was not associated with local control in the glottic cohort. These findings are pending further validation in a larger cohort and will be analyzed separately for supraglottic tumors.

The ankle-brachial index in normal neonates and infants is significantly lower than in older children and adults

Vascular trauma from accidental or iatrogenic causes is becoming more common in children. In early infancy, the most common arterial injuries are caused by diagnostic or interventional cardiac catheterizations. Doppler arterial pressure measurements and the computed ankle-brachial pressure index (ABI) are the most helpful diagnostic modalities in the assessment and follow-up of the ischemic extremity. Because normative ABI data in small children are not available, an ABI of 0.9 or less (based on data obtained from an adult population), is used to indicate limb ischemia in young infants. The purpose of this study was to define the normal values of ABI in newborns and infants.

MATERIALS AND METHODS

Three hundred and fifty patients were divided into two groups: group 1 (n = 200; male-to-female ratio, 1:1) were full-term (gestational age 40 +/- 1.3 weeks, surface area 0.22 +/- 0.02 m2) healthy newborns following uneventful pregnancy and delivery. Group 2 (n = 150) were healthy patients aged 2 weeks to 2.5 years admitted for elective hernia repair. All the patients underwent a complete physical examination, which excluded any cardiovascular pathology. The systolic blood pressure (BP) was measured bilaterally over the brachial, tibialis posterior, and dorsalis pedis arteries. All BP data were obtained in the supine position, using an ultrasonic Doppler flow detector, an appropriately-sized pneumatic cuff and a sphygmomanometer. The chosen cuff size was long enough to completely encircle the circumference and wide enough to cover 75% of the length of the upper arm. The same cuff was applied around the ankle above the malleoli. BP values were expressed as mean +/- SD in mm Hg. If there was a difference between the BP in the two arms, the higher pressure was used for calculation of the ABI.

RESULTS

The BP measurements in newborns (group 1) were left brachial, 98 +/- 11; right brachial, 90 +/- 10 (P < .001), left and right tibialis posterior and left and right dorsalis pedis were 83, 81, 84, and 82 mm Hg, respectively. The mean computed ABI was 0.88 +/- 0.11. Fifty eight percent of the newborns had an ABI less than 0.9 (lower limit of normal in adults). The ABI values in patients belonging to group 2 increased with age and surface area. The mean ABI was 1.0, 1.1, and more than 1.1 in patients aged, 1, 1.5, and 2 years with surface areas of 0.4, 0.5 and 0.6 m2, respectively (P < .001 compared with group 1).

CONCLUSION

The normative ABI in newborns and infants is significantly lower than in older children and reaches normal (adult) values during the second year of life. These data may be used as a reference when assessing lower extremity ischemia caused by trauma in young patients.