Twice-a-day radiotherapy for T3 squamous cell carcinoma of the glottic larynx

Radiotherapy for T3N0 glottic carcinoma without cord fixation: elective nodal irradiation or not?

Background

Although the T3 category has been changed in the sixth edition of the TNM staging system proposed by the Union for International Cancer Control (UICC), the appropriate clinical target volume (CTV) of elective nodal irradiation (ENI) for T3N0 glottic carcinoma without cord fixation, which was formerly treated as a T1-2N0 disease, is not fully discussed.

Materials and Methods

We retrospectively analyzed 64 patients staged or restaged as T3N0 disease without cord fixation. All patients received irradiation to the primary lesion alone using opposed lateral fields. Surgery was performed in 10 patients without tumor regression after the delivery of 40 Gy. The other 54 patients received a median total dose of 66 Gy. Concurrent chemoradiotherapy (CRT) with low-dose cisplatin and UFT (low-dose CRT) and docetaxel, cisplatin, and 5-fluorouracil (TPF-CRT) were performed in 23 and 19 patients, respectively.

Results

Eighteen (28.1%) patients suffered treatment failure; all were recorded as local failure alone. The 5-year local control rates for RT alone, low-dose CRT, and TPF-CRT groups were 51.7%, 61.6%, and 93.8%, respectively (p = 0.027). The 5-year laryngeal preservation rates for RT alone, low-dose CRT, and TPF-CRT groups were 57.4%, 81.6%, and 89.5%, respectively (p = 0.048).

Conclusions

The rate of regional failure was zero when irradiating the primary lesion alone using opposed lateral fields. This treatment technique covers the most level III regions; hence, CTV for ENI should include level III alone.

Results of 226 patients with T3 laryngeal carcinoma after treatment with transoral laser microsurgery

BACKGROUND

The purpose of this study was to assess the feasibility of transoral laser microsurgery (TLM) in treatment of pT3 laryngeal cancer.

METHODS

We conducted a retrospective case series study of 226 patients with pT3 glottic (n = 122; 54%) or supraglottic laryngeal carcinoma (n = 104; 46%). All patients were treated by TLM in combination with neck dissection (63%) and with postoperative radiotherapy (18%). Our main outcome measures were local control, organ preservation, functional outcome, overall survival, recurrence-free survival, and disease-specific survival.

RESULTS

Median follow-up period was 57.8 months. The 5-year organ-preservation and local control rates for all patients were 87% and 71.4%, respectively. The 5-year overall, recurrence-free, and disease-specific survival were 64.4%, 63.0%, and 83.3%, respectively.

CONCLUSION

Results are comparable to partial or total laryngectomy, while being superior to primary chemo(radio)therapy. TLM results in low morbidity, rapid recovery, and good function and can be a valid option for organ-preserving surgery of pT3 glottic and supraglottic cancer.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Induction chemotherapy with paclitaxel and cisplatin and CT-based 3D radiotherapy in patients with advanced laryngeal and hypopharyngeal carcinomas--a possibility for organ preservation

BACKGROUND

To evaluate the effect of paclitaxel/cisplatin induction chemotherapy (ICHT) and CT-based radiotherapy (RT) on larynx preservation, tumor control, and survival in patients with larynx/hypopharynx carcinoma eligible for total laryngectomy (TL) or TL plus partial pharyngectomy (TLPP).

PATIENTS AND METHODS

Fifty patients eligible for TL or TLPP were enrolled onto a prospective study and treated with ICHT (200 mg/m(2) paclitaxel, 100 mg/m(2) cisplatin; day 1, 22). In patients with complete or partial tumor response RT (69.9 Gy in 5.5 weeks at the gross tumor, 50.4 Gy in the lymphatic drainage; single dose: 1.8 Gy, concomitant boost: 1.5 Gy) was applied. Non-responders had TL/TLPP and RT with total doses adapted to the radicality of tumor resection (56-70 Gy).

RESULTS

The response rate to ICHT was 88% (10% complete, 78% partial response). At a median follow-up period of 25 months the larynx preservation rate was 84%. The 2-year local-regional control rate was 91% and the 2-year overall survival rate was 72.3%. The 3-year estimate to survive with functional larynx is 60%.

CONCLUSION

In a large portion of patients eligible for TL or TLPP the larynx was preserved by paclitaxel/cisplatin ICHT and 3D RT.

Multivariate Analysis of Prognostic Factors in T3 N0 Laryngeal Carcinoma Treated With Total Laryngectomy

OBJECTIVE: The aim of our study was to clarify the real importance of 16 possible prognostic factors analyzed retrospectively for the disease-free interval and survival of a total of 327 patients with T3 N0 M0 laryngeal carcinoma treated with total laryngectomy.

METHODS: The role of each possible prognostic factor and their joint effect was explored by Cox proportional hazard survival analysis.

RESULTS and CONCLUSIONS: In a Cox univariate analysis for the whole group, tumor site, pattern of growth, tumor size, histologic grading, lymph node status, and the occurrence of postoperative complications were predictive of the risk of tumor recurrence. In univariate analysis, all these factors except for pattern of tumor growth, neck treatment and postoperative complications maintained their prognostic value when analyzed as predictors of survival; however, the loco-regional control of disease was the most significant one. In a Cox multivariate analysis tumor size, histologic grading and postoperative complications had a significant impact on disease-free survival, whereas only histologic grading and loco-regional failure apeared to be prognostic with a significant decrease in overall survival.

Advanced larynx cancer

Despite advances in diagnosis and treatment, the prognosis for patients with stage III-IV laryngeal cancer is not significantly different than it was four decades ago [1]. This failure to improve survival is multifactorial and is likely linked to controversy surrounding optimal treatment regimens for a heterogeneous patient and tumor population. At the root of this controversy is a lack of randomized controlled trials that compare different therapeutic options, personal and institutional treatment philosophies, and a paucity of standardized functional and quality-of-life outcome measures for specific treatment modalities. Therapeutic decision making is further complicated by the potential use of organ preservation approaches in some patients [2**, 3*, 4**]. Clearly, quality-of-life considerations are an integral part of treatment planning and a well-informed patient is necessary to achieve an optimal result. Philosophically, it is the physician's responsibility to recommend the best treatment option and to explain the other viable treatment strategies. It is our opinion that conservation laryngeal surgery represents the mainstay of treatment for patients with advanced laryngeal carcinomas, whose tumors have characteristics amenable to these approaches and who functionally can tolerate such procedures. For those patients who would likely require a total laryngectomy or who are not suitable for surgical conservation, organ preservation should be used as a primary option in a controlled setting.

Definitive radiotherapy for 114 cases of T3N0 glottic carcinoma: influence of dose-volume parameters on outcome

BACKGROUND AND PURPOSE

Assuming that the dose-response curve for T3N0M0 glottic carcinoma is steep and that the rate of occult lymph node metastases is low, it should be possible to employ high biological tumour doses to modest target volumes and thereby maximise laryngeal control without compromising final neck control. Within the constraints of a retrospective study we aim to examine this policy with respect to local control, incidence of nodal relapse and late complications.

MATERIALS AND METHODS

One hundred and fourteen patients with T3N0M0 glottic carcinoma who received a 3-week schedule of radical radiotherapy between 1986 and 1994 were analysed. The median age was 67 years (range, 34-85 years) and the median follow-up for living patients was 4.8 years (1.9-8.9 years). There were no strict selection criteria for those patients treated with radiotherapy.

RESULTS

The 5-year overall survival was 54%. The 5-year local control with radiotherapy and the ultimate loco-regional control following salvage laryngectomy were 68 and 80%, respectively. Nine patients (8%) suffered a regional nodal relapse but only three of these (3% overall) occurred in the absence of local failure. Four patients (3.5%) developed serious late complications requiring surgical intervention (three received 55 Gy and one 52.5 Gy).

CONCLUSIONS

It is possible to employ maximum tolerable doses to specific target volumes and thereby exploit the dose response demonstrated and minimise major late effects. The use of modest target volumes resulted in only 3% of patients requiring surgery that might have been avoided had prophylactic neck irradiation been employed.

T3-4 squamous cell carcinoma of the larynx treated with radiation therapy alone

This article reviews the results of radiation therapy alone for T3-4 squamous cell carcinoma of the larynx. Local control after radiation therapy is approximately 65% for patients with T3 glottic and supraglottic carcinoma. The likelihood of local control is inversely related to tumor volume and, for those with glottic cancers, is adversely influenced by cartilage sclerosis on pretreatment computed tomography of the larynx. Local control after radiotherapy is approximately 60% for T4 glottic cancers and 50% for T4 supraglottic carcinomas. The probability of severe complications is related to primary site and T-stage.

Cricohyoidoepiglottopexy for glottic carcinoma with fixation or impaired motion of the true vocal cord: 5-year oncologic results with 112 patients

The medical charts and operative files of 112 patients (combined inception cohort) with well to moderately differentiated invasive glottic squamous cell carcinoma presenting fixation (22) or impaired motion (90) of the true vocal cord (TVC) consecutively treated with cricohyoidoepiglottopexy (CHEP) at our institutions from 1972 to 1989 were retrospectively reviewed. A minimum 5-year follow-up was always achieved. The Kaplan-Meier 5-year actuarial survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate for the entire group of patients were 84.7%, 5.4%, 6.4%, 1.2%, and 10.8%, respectively. The 5-year absolute and cause-specific survival rates were 85.5% and 94.1% for patients with fixation of the TVC and 81.3% and 96% for patients with impaired motion of the TVC. The 5-year actuarial local control rates for patients with fixation or impaired motion of the TVC were 95.4% and 94.4%, respectively. Local recurrence was statistically more likely in patients with positive margins (p = .007). Nodal recurrence was statistically more likely in patients with local recurrence (p = .005). Permanent tracheostomy related to postoperative laryngeal stenosis was requested in 2 patients. Aspiration-related completion total laryngectomy and/or permanent gastrostomy were never requested. Overall, local control and laryngeal preservation were achieved in 97.3%, and 95.5% of patients, respectively. At our institutions, the change from the conservative treatment modalities of radiotherapy and vertical partial laryngectomy to CHEP has brought about an increase in long-term survival, local control, and laryngeal preservation rates when compared to historical controls using vertical partial laryngectomy or radiotherapy.

Advanced laryngeal cancer T3-T4 in Sweden: a retrospective study 1986-1990. Survival and locoregional control related to treatment

Different treatment modalities for advanced laryngeal cancer are much discussed in the literature. One-hundred-and-sixty patients with T3-4, N0-3, M0-1 laryngeal cancer diagnosed in Sweden between 1986 and 1990 were retrospectively analysed. One hundred (65 T3: 35 T4) received radical radiotherapy with salvage surgery (RRSS) in case of residual or recurrent disease. Thirty-eight (11T3: 27 T4) patients received surgery with or without radiotherapy (S +/- RT). Twenty-two patients received no treatment. After a median follow up of 4.4 years, the estimated 5-year actuarial corrected survival and 3-year locoregional control were 59% and 44% for T3 RRSS and 47% and 54% for T3 S +/- RT. No significant difference between the different treatment modalities was found. The 5-year corrected survival rate and the locoregional control at 3 years between T4-RRSS (32%; 26%) and T4-S + RT (58%; 68%) groups were significantly different (p < 0.05 and p < 0.01). This might suggest that surgery with or without radiotherapy still has its place as a treatment modality for patients with advanced T4 laryngeal carcinoma.

Glottic Carcinoma with a Fixed True Vocal Cord: Outcomes after Neoadjuvant Chemotherapy and Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

Twenty patients with glottic squamous cell carcinoma and a fixed true vocal cord underwent neoadjuvant chemotherapy followed by supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Phonation, respiration, and deglutition were preserved. Local control was better than has been previously reported for either extended vertical partial laryngectomy or radiation therapy. All patients were monitored for at least 3 years or until death. The Kaplan-Meier 3-year survival, local recurrence, nodal recurrence, distant metastasis, and second primary rates were 75%, 10.8%, 5%, 10.8%, and 10.8%, respectively. Overall local control was achieved in all cases, and laryngeal preservation in 90%. Our experience suggested that neoadjuvant chemotherapy with supracricoid partial laryngectomy with cricohyoidoepiglottopexy deserves further consideration in the treatment of glottic tumors with a fixed true vocal cord.

Head and neck cancer

This synthesis of the literature on radiotherapy for head and neck cancer is based on 424 scientific articles, including 3 meta-analyses, 38 randomized studies, 45 prospective studies, and 246 retrospective studies. These studies involve 79174 patients. The literature review shows that radiotherapy, either alone or in combination with surgery, plays an essential role in treating head and neck cancers. When tumors are localized, many tumor patients can be cured by radiotherapy alone and thereby maintain full organ function (1, 2). Current technical advancements in radiotherapy offer the potential for better local tumor control with lower morbidity (3). This, however, will require more sophisticated dose planning resources. To further improve treatment results for advanced tumors, other fractionation schedules, mainly hyperfractionation, should be introduced (5). This mainly increases the demands on staff resources for radiotherapy. The combination of radiotherapy and chemotherapy should be subjected to further controlled studies involving a sufficiently large number of patients (4, 5). Interstitial treatment (in the hands of experienced radiotherapists) yields good results for selected cancers. The method should be more generally accessible in Sweden. Intraoperative radiotherapy should be targeted for further study and development.

Treatment decisions in T3N0M0 glottic carcinoma

PURPOSE

To analyze the results of T3N0M0 glottic carcinoma treated with radiotherapy, surgery, or both.

METHODS AND MATERIALS

The records were retrospectively reviewed of 97 patients with this tumor subsite and stage seen for treatment at the Queensland Radium Institute over a 29-year period. The results for radiotherapy with surgical salvage of failure (XRT/SS) were compared to those with surgery with or without radiotherapy (SURG/SURG+XRT). For those treated initially with radiotherapy alone, the results for different ranges of biologically equivalent doses were compared. These results were compared to those of other published studies.

RESULTS

The 5-year disease-specific survival rats for the XRT/SS and SURG/SURG+XRT groups were 50% and 58%, respectively; this difference is not significant. For the XRT/SS group, there was a trend towards improved 5-year recurrence-free survival (73%) and 5-year disease-specific survival (86%) in those treated to a dose equivalent to 60-64 Gy in 2 Gy fractions, when compared with higher or lower dose equivalents.

CONCLUSION

A group of patients with T3N0M0 glottic carcinoma is specified for which the option of radiotherapy offers a similar chance of survival to those treated surgically. More than 50% of the XRT/SS survivors will retain their larynx.

Laryngectomy alone for T3 glottic cancer

BACKGROUND

The long-term survival of 81 patients with T3 squamous cell carcinoma of the glottic larynx treated with laryngectomy alone is presented and pathologic predictors for cancer recurrence above the clavicles and cancer death are identified.

METHODS

Clinical records, operative notes, and pathologic slides were reviewed. The major end points were failure above the clavicles, cause-specific survival, and overall survival. All patients were followed until death or a minimum of 10.8 years.

RESULTS

The main pattern of treatment failure was within an undissected ipsilateral or contralateral neck. Subglottic extension and nodal metastases predicted failure above the clavicles and delayed metastasis within an undissected neck. The 5-year rate of control of disease above the clavicles, cause-specific survival, and overall survival were 74.1%, 73.7%, and 54.3%, respectively.

CONCLUSIONS

Patients treated with laryngectomy for T3 glottic cancer who have pathologic evidence of subglottic extension or nodal metastasis are at higher risk for recurrence above the clavicles, particularly within an undissected neck.

Prognostic factors for survival in patients with T3 laryngeal carcinoma

In a total of 511 patients with T3,N0-3,M0 laryngeal carcinoma, 24 possible prognostic factors were analyzed retrospectively. The factors were age, sex, mode of treatment, duration of several clinical symptoms, the presence of sore throat, otalgia, dyspnea, and dysphagia, previous tracheotomy, tumor extension, lymph node status (five items), histologic grading, smoking habits, and alcohol intake. For 300 patients in whom surgery was part of the primary treatment, pathologic staging of the primary tumor and of lymph nodes in neck dissection specimens, cartilage invasion, radicality of the operation, differentiation grade, and subglottic extension ware also evaluated. In a univariate analysis for the whole group, tumor extension (limited to the glottic region), lymph node status (clinically palpable lymph nodes, cytologically confirmed positive lymph nodes), level of lymph node metastasis (high and midjugular site), histologic grading (poor differentiation grade), and treatment modality (planned combined therapy) were considered to be prognostic factors of corrected actuarial survival. In the group that underwent surgery, all factors derived from specimens of the larynx and neck dissections had prognostic significance. Multivariate analysis revealed that the glottic site of the tumor, the presence of cyto- and histopathologically proven metastatic lymph nodes, pretreatment tracheotomy, positive resection margins, and planned combined treatment had a significant influence on corrected actuarial survival.

T3 laryngeal cancer: a retrospective study of the Dutch Head and Neck Oncology Cooperative Group: study design and general results

511 Patients with T3 N0-3 M0 squamous cell carcinoma of the larynx, treated in the Netherlands from 1975 until 1984, were retrospectively analysed. Four different treatment policies were followed: primary surgery, planned combination of radiotherapy and surgery, primary radical radiotherapy, and selective radiotherapy. General results are presented. Local control rate was 72%. Regional control rate was 90% for clinically N0 patients and 78% for clinically N+ patients. Salvage therapy was overall successful in 38%. Surgical salvage for local radiation failures (with regional relapse) was successful in 69%, and for regional failures (without local relapse) in 46%. Ultimate locoregional control was 78% and, due to 8% distant metastases, 5-year actuarial corrected survival was 70%. Prognosis did not improve over the years. Corrected survival was independently correlated with tumour extension, involvement of neck nodes and treatment strategy. Corrected survival was similar for primary radiotherapy and primary surgery, but significantly better for planned combined therapy. Multiple primary tumours occurred significantly more often in male (19.5%) than in female patients (7.3%) (P = 0.05), the bronchus being most commonly affected. Cumulative actuarial risk for metachronous tumour was 15% after 5 years and 30% after 10 years so prevention and early detection of these second tumours may play the most important role in improving overall survival rates in the future.

Does conventional tomography still have a place in glottic cancer evaluation?

Computed tomography (CT) can detect laryngeal cancer invading the pre-epiglottic, paraglottic spaces, laryngeal cartilages, and soft tissues, but in T1 and limited T2 tumours its main value is in evaluating subglottic extent. Conventional tomography in the coronal plane has been used with reasonable success to detect both subglottic and ventricular invasion and is less expensive than CT. Twenty-nine cases of glottic carcinoma of all stages were examined clinically, endoscopically and radiographically by both coronal conventional tomography and CT. The results of these imaging studies are compared in this investigation, stressing their relationship to clinical findings (and stage), especially vocal and cord mobility. Coronal conventional tomography was found to be as accurate as CT for sublottic spread in nine cases of T1 and T2A cancer with normal vocal cord mobility. Conventional tomography had a slight tendency to overestimate ventricular and false cord involvement (two out of seven patients) with T1 glottic cancer. When mobility was impaired (four cases) or absent (15 cases), CT added data which changed staging and/or treatment plan in six cases. In seven others it was suggestive of a more advanced stage.

Stage T3 squamous cell carcinoma of the glottic larynx: a comparison of laryngectomy and irradiation

One-hundred eighteen patients with previously untreated T3 squamous cell carcinoma of the glottic larynx were treated with curative intent between March 1965 and November 1988 at the University of Florida. All patients were observed for at least 2 years and 83% were observed for 5 or more years. Fifty-three patients were treated with irradiation alone and 65 patients were treated with surgery alone (32) or combined with irradiation (33). Thirty-two patients treated with irradiation alone had twice-daily fractionation and the remainder had once-daily fractionation. The local-regional control rates, including patients successfully salvaged after a local-regional recurrence, were 81% after irradiation alone and 81% after surgery alone or combined with adjuvant irradiation. The local control rates for patients treated with irradiation alone were 53% after once-daily fractionation and 71% after twice-daily fractionation. There was no relationship between vocal cord mobility at 5000 cGy, at the end of radiotherapy, or at 1 month after treatment and subsequent local control. The 5-year cause-specific survival rates were 74% for patients treated with irradiation alone and 63% for patients treated surgically. The incidence of severe complications, including those associated with salvage procedures, was 15% for both treatment groups. The rates of laryngeal voice preservation were 66% after irradiation alone and 2% after surgery. Irradiation alone for selected patients with T3 glottic cancer resulted in similar rates of local-regional control, survival, and severe complications, with a significantly higher likelihood of voice preservation, compared with surgery.

Primary subglottic cancer: results of radical radiation therapy

Between October 1964 and December 1985, six patients with primary squamous cell carcinoma of the subglottis were treated with radical radiation therapy at the University of Florida. The disease was staged as Tis (one patient), T2N0 (two patients), and T4N0 (three patients). Local control was achieved with irradiation in four patients (66%) who were observed for 3.5, 4, 4, and 5 years after radiation therapy. Two patients whose tumors recurred at the primary site underwent salvage laryngectomy, which was successful in one patient.

Local control in T3 laryngeal cancer treated with radical radiotherapy, time dose relationship: the concept of nominal standard dose and linear quadratic model

In a retrospective study of the Dutch cooperative head and neck group 104 evaluable patients with T3NxMO squamous cell carcinoma of the larynx were treated primarily with a full course of radiotherapy. The results of treatment are presented in terms of locoregional control. The actuarial 3-year local control rate was 53%. Regional control was 77% for node positive patients and 96% for N0 patients (p = 0.01). Surgical salvage was successful in 53% of cases with a local recurrence and in 3/8 regional recurrences, resulting in an ultimate locoregional control rate of 83% for N0 patients and 68% for N+ patients. A uni- and multivariate analysis of local control rate versus total dose, nominal standard dose, and extrapolated response dose has been done. To calculate extrapolated response dose the linear quadratic equation was used, assuming an a/b of 10 and a potential doubling time of clonogenic cells of 3, 5, and 7 days. In multivariate analysis the extrapolated response dose with a potential doubling time of 5 days was the only independent prognostic factor for local control (p = 0.069) and ultimate locoregional control (p = 0.0015). Nominal standard dose showed no dose-response relationship. Based on the S-shaped dose response curve, using the LQ model, several therapeutical options are discussed.