Neoadjuvant chemotherapy combined with transoral robotic surgery for stage III and IV laryngeal and hypopharyngeal carcinomas

OBJECTIVES

To analyze the oncological and functional outcomes of patients with stage III-IV laryngo-hypopharyngeal cancer who underwent neoadjuvant chemotherapy (NAC) with subsequent transoral robotic surgery (TORS).

MATERIALS AND METHODS

A single-center retrospective cohort study included a total of 100 patients (median age of 67.0) affected by stage III-IV supraglottic or hypopharyngeal cancer. All patients underwent NAC followed by TORS and risk-adjusted adjuvant therapy. The primary outcome was recurrence-free survival (RFS).

RESULTS

The median follow-up time was 24.0 months. Estimated 2-year (95% CI) OS, DSS, and RFS were 75% (66% - 85%), 84% (76% - 92%), and 65% (56% - 76%), respectively. Among the 11 patients who relapsed on the primary site, 3 underwent salvage total laryngectomy, 3 underwent salvage CRT, and the others receive palliation or supportive care. At 6 months from surgery, 17 patients were still tracheostomized or had a stoma retainer, while 15 were gastrostomy dependent. At the Cox multivariable analysis, the clinical stage at presentation, the number of NAC cycles, and the presence of LVI were found to be independently correlated with the RFS.

CONCLUSION

This study demonstrates that NAC followed by TORS can obtain good tumor control, survival, and organ preservation rates in stage III-IV laryngo-hypopharyngeal cancer.

Prognostic Value of Lymphovascular Invasion in Patients With Pyriform Sinus Carcinoma Treated With Surgery Plus Adjuvant Chemo-/Radiotherapy

OBJECTIVE

We aimed to determine the prognostic value of lymphovascular invasion (LVI) in pyriform sinus carcinoma (PSC) after primary surgery with adjuvant radiotherapy (RT) or concurrent chemoradiotherapy (CCRT).

METHODS

Patients who underwent primary surgery at our institution between 2000 and 2018 were included in this study and retrospectively analyzed. The endpoints were locoregional recurrence (LRR), distant metastasis (DM), and disease-specific survival (DSS).

RESULTS

We reviewed 117 patients with PSC. LVI was identified in 29 patients (24.8%). The 5-year LRR rate, DM rate, and DSS rate were 29.4%, 31.7%, and 45.9%, respectively. Tumors with LVI were associated with a significantly higher LRR (P = 0.002, HR 3.678, 95% CI 1.646-8.218) and DM (P = 0.003, HR 3.666, 95% CI 1.543-8.709) and a lower DSS (P = 0.001, HR 2.814, 95% CI 1.519-5.213) in multivariate analysis.

CONCLUSION

LVI is a significant predictor of poor prognosis in patients with PSC treated with surgery plus adjuvant RT/CCRT.

Distinct Failure Patterns in Hypopharyngeal Cancer Patients Receiving Surgery-Based Versus Radiation-Based Treatment

BACKGROUND

To cure advanced hypopharyngeal squamous cell carcinoma (HPSCC), primary operation followed by adjuvant (chemo-)radiotherapy (OP-CRT) or definitive chemoradiation (CCRT) are the two primary options. This study aimed to compare the failure patterns and long-term survival outcomes of HPSCC patients treated with these two strategies. PATIENTS AND METHODS: From 2007 to 2015, 198 pathologically confirmed HPSCC patients receiving either OP-CRT or CCRT were retrospectively reviewed. Failure patterns and survival outcomes stratified by the 7th American Joint Committee on Cancer staging system and treatment modalities were compared.

RESULTS

One hundred and eighty-nine patients (95.4%) were stage III/IV and 62 patients (31.3%) received OP-CRT. Median follow-up duration was 4.9 years. Compared with CCRT, OP-CRT provided better 3-year local relapse-free survival for T3 (93 vs 48%, p < 0.0001), T4a (88 vs 37%, p = 0.0005) and better 3-year regional relapse-free survival for N2b+2c (93 vs 60%, p < 0.0001). Of note, for stage IVA subjects, OP-CRT provided better 3-year loco-regional relapse-free survival (85 vs 37%, p < 0.0001), marginal poor 3-year distant metastasis-free survival (62 vs 79%, p = 0.06), but comparable 3-year OS (52 vs 44%, p = 0.37) and 5-year OS (44 vs 31%, p = 0.15) compared with CCRT.

CONCLUSIONS

For patients with advanced HPSCC, although OP-CRT and CCRT provided similar overall survival, failure patterns were distinct. OP-CRT provided better loco-regional control but was more likely to encounter distant metastases than CCRT. The detailed analysis of failure patterns will pave the way to improve this devastating disease.

Development and validation of a nomogram to predict cancer-specific survival in patients with hypopharyngeal squamous cell carcinoma treated with primary surgery

OBJECTIVE

We aimed to develop a nomogram to predict cancer-specific survival (CSS) in patients with hypopharyngeal squamous cell carcinoma (HSCC) treated with primary surgery to provide more accurate risk stratification for patients.

METHODS

We retrospectively collected data of 1144 eligible patients with HSCC from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. Patients were randomly divided into training and validation groups (ratio 6:4) and we used univariate and multivariate Cox analysis. We developed and validated a nomogram using calibration plots and time-dependent receiver operating characteristic, Kaplan-Meier, and decision curves.

RESULTS

Age; marital status; T, N, and M stage; and postoperative adjuvant therapy were independent factors associated with CSS, which were included in the nomogram. The nomogram's C-index was 0.705 to 0.723 in the training group and 0.681 to 0.736 in the validation group, which were significantly higher than conventional American Joint Committee on Cancer (AJCC) staging. Calibration curves showed good agreement between prediction and observation in both groups. Kaplan-Meier and decision curves suggested the nomogram had better risk stratification and net benefit than conventional AJCC staging.

CONCLUSIONS

We established a nomogram that was superior to conventional AJCC staging in predicting CSS for HSCC.

Delta-volume radiomics of induction chemotherapy to predict outcome of subsequent chemoradiotherapy for locally advanced hypopharyngeal cancer

INTRODUCTION

Induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CCRT) is recommended for larynx-preserving treatment of locally advanced hypopharyngeal cancer (LAHC). However, the conventional evaluation of response is not robust enough to predict the outcome of subsequent treatments. This study aimed to develop an imaging biomarker using changes in radiomic features in invasive tumor front (ITF) by IC to predict treatment outcome of subsequent CCRT in LAHC.

METHODS

From 2006 to 2018, 59 computed tomography (CT) scan images before and after IC in patients with LAHC were used to contour the gross tumor volumes (GTVs). A total of 48 delta-volume radiomics features were acquired from the absolute spatial difference of GTVs (delta-GTV) before and after IC, conceptually representing a consistent portion of ITF. Least absolute shrinkage and selection operator regression (LASSO) was used to select features for establishing the model generating radiomic score (R score).

RESULTS

A model including 5 radiomic features from delta-GTV to predict better progression-free survival (PFS) of patients receiving subsequent CCRT was established. The R score was validated with all datasets (area under the curve 0.77). Low R score (<-0.16) was associated with improved PFS (p < 0.05).

CONCLUSIONS

The established radiomic model for ITF from radiomic features of delta-GTV after IC might be a potential imaging biomarker for predicting clinical outcome of subsequent CCRT in LAHC.

Functional outcomes of soft palate free flap reconstruction following oropharyngeal cancer surgery

INTRODUCTION

The objective of this study was to assess the impact of surgical resection and free flap reconstruction of soft palate cancer on speech, swallowing and quality of life, and to identify the factors influencing functional outcomes and quality of life.

MATERIAL AND METHODS

Patients treated with surgical resection of squamous cell carcinoma and free-flap reconstruction of the soft palate were reviewed at least 12 months after surgery. Speech was assessed using the Hirose intelligibility scoring system, nasalance scoring, GRBAS scoring and the Voice Handicap Index 30 (VHI30) questionnaire. Swallowing was assessed by fiberoptic endoscopy and the Deglutition Handicap Index (DHI). Quality of life was assessed using EORTC QLQ-C30 and QLQ-H&N35 questionnaires.

RESULTS

29 patients were included. Speech outcomes were satisfactory, demonstrating normal or slightly below normal speech intelligibility in 75.9% of the patients, moderate or no rhinolalia in 72.4% of the patients and mean overall VHI30 scores indicative of slight or no handicap in 86.2% of the patients. Swallowing outcomes were satisfactory, with mean overall DHI scores indicative of slight or no handicap in 82.8% of the patients. Patient quality of life was preserved as demonstrated by mean quality of life and functioning scales scores all superior to 80%.

CONCLUSION

The sequelae arising from surgical resection and free-flap reconstruction of soft palate cancer are tolerable, involving slight handicap in terms of speech and swallowing and relatively little impact on quality of life.

Survival and complications with a surgical approach in advanced hypopharyngeal cancer

BACKGROUND AND OBJECTIVES

The treatment paradigm for advanced hypopharyngeal cancer has shifted from surgical approaches to organ preservation. However, recent studies indicated that surgical approaches may be associated with better survival rates. This study aimed to conduct a head-to-head comparison of survival outcomes and complications with surgical versus nonsurgical approaches using a nationwide database.

METHODS

Using a nationwide data set, we gathered 2196 propensity score-matched patients with stage III/IVa hypopharyngeal cancer. We compared survival rates and complications among patients with surgical and nonsurgical cancer treatment.

RESULTS

Patients with stage III and IVa hypopharyngeal cancer who underwent initial surgery had significantly better 5-year overall survival and disease-free survival rates compared to their nonsurgical counterparts. There were no significant differences in long-term complications with regard to swallowing.

CONCLUSIONS

These results suggest that patients who underwent initial surgery for advanced hypopharyngeal cancers had better survival rates and equivalent long-term function.

Discovery and Validation of a CT-Based Radiomic Signature for Preoperative Prediction of Early Recurrence in Hypopharyngeal Carcinoma

Purpose

In the clinical management of hypopharyngeal squamous cell carcinoma (HSCC), preoperative identification of early recurrence (≤2 years) after curative resection is essential. Thus, we aimed to develop a CT-based radiomic signature to predict early recurrence in HSCC patients preoperatively.

Methods

In total, 167 HSCC patients who underwent partial surgery were enrolled in this retrospective study and divided into two groups, i.e., the training cohort (n = 133) and the validation cohort (n = 34). Each individual was followed up for at least for 2 years. Radiomic features were extracted from CT images, and the radiomic signature was built with the least absolute shrinkage and selection operator (LASSO) logistic regression (LR) model. The associations of preoperative clinical factors with early recurrence were evaluated. A radiomic signature-combined model was built, and the area under the curve (AUC) was used to explore their performance in discriminating early recurrence.

Results

Among the 1415 features, 335 of them were selected using the variance threshold method. Then, the SelectKBest method was further used for the selection of 31 candidate features. Finally, 11 out of 31 optimal features were identified with the LASSO algorithm. In the LR classifier, the AUCs of the training and validation sets in discriminating early recurrence were 0.83 (95% CI: 0.76-0.90) (sensitivity 0.8 and specificity 0.83) and 0.83 (95% CI: 0.67-0.99) (sensitivity 0.69 and specificity 0.71), respectively.

Conclusions

Using the radiomic signature, we developed a radiomic signature to preoperatively predict early recurrence in patients with HSCC, which may serve as a potential noninvasive tool to guide personalized treatment.

Safety of esophagogastroduodenoscopy-guided forceps biopsy and the feasibility of esophagogastroduodenoscopy for evaluation of hypopharyngeal cancer

Background

There is currently no established standard tissue sampling method for hypopharyngeal cancer. The present study aimed to evaluate the feasibility of esophagogastroduodenoscopy (EGD) for the pretreatment evaluation of hypopharyngeal cancer and the safety of EGD-guided forceps biopsy.

Methods

We reviewed nine patients with hypopharyngeal cancer who underwent EGD for the evaluation of tumor extent and tissue biopsy from March 2014 to March 2017 at International St. Mary’s Hospital. One experienced endoscopist performed all the EGD procedures in the presence of a head and neck surgeon. The procedure included determining tumor location, extent (presence of pyriform sinus apex involvement), and size, and passing the endoscope through the upper esophageal sphincter. The success rate of tissue sampling was assessed, and procedure-related complications were recorded.

Results

All patients were male, with a mean age of 69.9 ± 10.9 years (range 61–69 years). Tissue sampling using biopsy forceps was performed in 6/9 patients (66.7%). No complications related to moderate sedation or biopsy, including post-biopsy bleeding or respiratory distress, were reported. Histologic confirmation was successful in 5/6 patients (83.3%). Upper gastrointestinal lesions were evaluated in 7/9 (77.8%) patients in whom the scope passed through the lesion.

Conclusions

EGD and EGD-guided forceps biopsy may be useful for the evaluation of hypopharyngeal cancer extent and tissue sampling, respectively.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0571-z) contains supplementary material, which is available to authorized users.

Surgery vs. radiotherapy for locally advanced hypopharyngeal cancer in the contemporary era: A population-based study

Objectives

To compare overall survival (OS) in locally advanced hypopharyngeal cancer treated with surgery or definitive chemoradiotherapy in the contemporary era.

Methods

From 2010 to 2015, data for patients diagnosed with hypopharyngeal cancer (T2‐T4aM0) and treated with total pharyngectomy with lymph node dissection (surgery group) or definitive radiotherapy and chemotherapy (chemoradiotherapy group) was retrieved from the SEER database. Multivariate analyses were performed in each subgroup divided according to T category (T2‐3 or T4a).

Results

The number of patients in the surgery and chemoradiotherapy groups was 209 and 648, respectively. Among them, the number of T4a patients was 111 and 126 in each group. Three‐year OS rate in the surgery and chemoradiotherapy groups was 37.9% and 44.1%, respectively (P = 0.178). The 3‐year OS rate for the T2‐3 patients was 46.5% and 48.7% (P = 0.598), and the 3‐year OS rate for the T4a patients was 29.9% and 26.1% in the surgery and chemoradiotherapy groups, respectively (P = 0.439). On multivariate analysis, the chemoradiotherapy group was not inferior to the surgery group in T2‐T4a patients (Hazard ratio [HR] for the chemoradiotherapy group 0.889, 95% confidence interval [CI] 0.699‐1.129, P = 0.334), in T2‐3 patients (HR 0.932, 95% CI 0.699‐1.297, P = 0.675), and in T4a patients (HR 0.880, 95% CI 0.617‐1.256, P = 0.481).

Conclusions

Chemoradiotherapy for locally advanced hypophagyngeal cancer showed a comparable OS rate to surgery. For patients with T4a category cancer with high possibility of preserving the laryngopharyngeal function, chemoradiotherapy may be a promising alternative treatment.