Stage T3 squamous cell carcinoma of the glottic larynx treated with surgery and/or radiation therapy

Long-term results of intensity-modulated radiotherapy concomitant with chemotherapy for hypopharyngeal carcinoma aimed at laryngeal preservation

BACKGROUND

The objective of this retrospective study is to investigate laryngeal preservation and long-term treatment results in hypopharyngeal carcinoma treated with intensity-modulated radiotherapy (IMRT) combined with chemotherapy.

METHODS

Twenty-seven patients with hypopharyngeal carcinoma (stage II-IV) were enrolled and underwent concurrent chemoradiotherapy. The chemotherapy regimens were monthly cisplatin and 5-fluorouracil for six patients and weekly cisplatin for 19 patients. All patients were treated with IMRT with simultaneous integrated boost technique. Acute and late toxicities were recorded based on CTCAE 3.0 (Common Terminology Criteria for Adverse Events).

RESULTS

The median follow-up time for survivors was 53.0 months (range 36-82 months). The initial complete response rate was 85.2%, with a laryngeal preservation rate of 63.0%. The 5-year functional laryngeal, local-regional control, disease-free and overall survival rates were 59.7%, 63.3%, 51.0% and 34.8%, respectively. The most common greater than or equal to grade 3 acute and late effects were dysphagia (63.0%, 17 of 27 patients) and laryngeal stricture (18.5%, 5 of 27 patients), respectively. Patients belonging to the high risk group showed significantly higher risk of tracheostomy compared to the low risk group (p = 0.014).

CONCLUSIONS

After long-term follow-up, our results confirmed that patients with hypopharyngeal carcinoma treated with IMRT concurrent with platinum-based chemotherapy attain high functional laryngeal and local-regional control survival rates. However, the late effect of laryngeal stricture remains a problem, particularly for high risk group patients.

Improved Exact Confidence Intervals for the Odds Ratio in Two Independent Binomial Samples

For two independent binomial samples, the usual exact confidence interval for the odds ratio based on the conditional approach can be very conservative. Recently, Agresti and Min (2002) showed that the unconditional intervals are preferable to conditional intervals with small sample sizes. We use the unconditional approach to obtain a modified interval, which has shorter length, and its coverage probability is closer to and at least the nominal confidence coefficient.

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.

Organ preservation surgery for laryngeal cancer

The open organ preservation surgical procedures are an important part of the head and neck surgeon's armamentarium for treating laryngeal cancer. The principles of organ preservation surgery as they apply to laryngeal cancer must be thoroughly appreciated and strictly applied for oncologic and functional success. The selection of eligible patients for these procedures is an art and requires a keen clinical acumen. The vertical partial laryngectomy and supraglottic laryngectomy have defined clinical applications that are relatively well accepted. The supracricoid laryngectomy continues gaining acceptance as a means of treating more extensive glottic and transglottic lesions while maintaining physiologic speech and swallowing without the need for a permanent tracheostoma. The inability to include and use the open surgical organ preservation approaches in the organ preservation paradigm for larynx cancer severely limits the patient's treatment options. Total laryngectomy and medical organ preservation protocols may not be acceptable to the patient from a quality-of-life standpoint. Therefore, it is incumbent upon the head and neck surgeon to have a thorough understanding of all the options available for treatment in the organ preservation paradigm for laryngeal cancer. These options must be skillfully evaluated as they relate to the patient's disease process and confidently used to provide the best oncologic and functional outcome.

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.

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.

Analysis of recurrence after surgical treatment of advanced laryngeal carcinoma

The pattern of recurrences after surgical treatment of 276 patients with stage T3 and T4 laryngeal carcinoma was reviewed. Nodal recurrence was the commonest site and occurred mainly in patients with supraglottic and transglottic carcinoma. Distant metastasis was the second commonest site of recurrence, and the most distant metastases developed without locoregional recurrence. Local recurrence alone was uncommon in patients treated with primary surgery.

Results of Surgical Salvage for Radiation Failures of Laryngeal Carcinoma

The results of surgical salvage of radiation failures of laryngeal carcinoma were reviewed. There were 167 stage T3 and T4 patients. The operative mortality was 7%. The complication rates were 8% wound infection, 13% chest complication, and 25% anastomotic leakage. After the first salvage operation, pharyngeal recurrence developed in 28 (48%) patients. Seven (25%| patients were feasible for second salvage operation, and none of them had further local recurrence. There were 9 (5%) tracheostomal recurrences. Of the 126 NO patients, 23(18%) had nodal recurrence, and only 5 of the nodal recurrences were feasible for salvage by radical neck dissection. All 41 node-positive patients underwent radical neck dissection, and 9 (23%) had nodal recurrence. Of the 126 node-negative patients, 19 (15%) had distant metastasis. Of the 41 node-positive patients, 18 (44%) had distant metastasis. The node-positive patients had a significantly high distant failure rate despite locoregional control of tumor. The adjusted 5-year survival rate of T3–4NOMO was 45%, and that of T3–4N + MO was 22%.

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.

A clinical audit of glottic cancer in Nova Scotia: a paradigm for effectiveness research

We conducted a clinical audit of the recurrence-free rates and absolute survival of 146 patients who presented with T1-T3 glottic cancer and received primary radiotherapy treatment at the Nova Scotia Cancer Centre between 1984 and 1990. The outcomes are compared with a review of published results from other centres. We used stage T3 glottic cancer as an example to illustrate concepts of effectiveness research which are used to determine at what level interventions operate in the day to day practice of medicine. The actuarial recurrence-free rates at 5 years are: T1 91%, T2 73%, and T3 44%. The actuarial absolute survival rates are: T1 84%, T2 68%, and T3 52%. Effectiveness research may utilize efficacy research, clinical audit, quality of life assessment and decision making theory. Its objective is to aid the implementation of appropriate clinical management for specific individuals and defined communities. Expert computer systems may be necessary to synthesize the data and to enhance communication and decision making.

T3N0 glottic carcinoma: DNA S-phase as a predictor of the outcome after radiotherapy

In consecutive series of 326 laryngeal cancer patients, of 29 (9%) with stage T3N0 glottic carcinomas, 23 achieved complete local remission after curative radiotherapy and form the basis of the present investigation. Flow cytometry determinations of DNA-ploidy status and the S-phase fraction, and a "histopathological malignancy grading system" were evaluated as possible patient- and/or tumor-related predictors of local recurrence. Twelve patients (52%) were continuously disease-free after radiotherapy, whereas 10 (43%) manifested local recurrence, and one distant metastasis. The radiotherapy delivered to patients who later suffered from a local recurrence did not differ from those being continuously disease-free. The frequency of local recurrence was significantly correlated to patients whose primary tumours manifested a low S-phase fraction (p < 0.05). A low S-phase fraction may indicate slowly proliferating tumour-cells, which become more radioresistant on exposure to a series of fractionated doses, as their reassortment into sensitive phases will be proportionately slower.

Twice-a-day radiotherapy for squamous cell carcinoma of the head and neck: the University of Florida experience

Between March 1978 and March 1989, 419 patients with 439 moderately advanced or advanced primary squamous cell carcinomas of the head and neck received treatment with curative intent with twice-a-day radiotherapy (120 cGy per fraction with a 4- to 6-hour interfraction interval). Seventy-nine percent of the patients had AJCC stage III or stage IV cancers. The primary site in most patients was the oropharynx, hypopharynx, or larynx. All patients received radiotherapy alone to the primary site, with or without planned neck dissection after radiotherapy. Surgery at the primary site was reserved for salvage of radiotherapy failures. No patient received chemotherapy as part of the initial treatment plan. Total doses were 7440 cGy to 7920 cGy in the majority of patients. In 54 patients with oropharyngeal lesions, an interstitial implant was used to add a 1,000- to 1,500-cGy boost after the basic dose. Local control results were compared on a site-by-site and stage-by-stage basis with the results of continuous-course, once-a-day radiotherapy at the University of Florida; the control results were the same as or better than after once-a-day radiotherapy for each site and stage (T2 to T4). Severe complications of radiotherapy occurred in 4% of patients and correlated with tumor dose, T stage, and disease site (oropharynx or larynx/hypopharynx). The addition of a neck dissection 4 to 6 weeks after radiotherapy of patients with advanced-stage neck disease was accomplished with an acceptable rate of morbidity and significantly improved the rate of control of neck metastases compared with radiotherapy alone.

Radiation therapy of glottic carcinoma: Peter MacCallum Cancer Institute experience

The medical records of patients with T1N0, T2N0 and T3N0 squamous cell carcinomas of the glottis treated at the Peter MacCallum Cancer Institute between January 1983 and October 1988 were retrospectively reviewed. One hundred and twenty-seven patients were identified. There were 93 T1, 26 T2 and eight T3 tumours. These patients were treated with curative radiotherapy (60-70 Gy). The survival from glottic cancer of patients with T1, T2 and T3 tumours at 5 years was estimated to be 97, 62 and 100% respectively. The local disease free survival for T1 and T2 disease at 5 years was estimated to be 82 and 65% respectively. The local disease free survival for T3 tumours at 2 years was estimated to be 63% with 5 year survival not yet reached. The surgical salvage rates for 24 radiotherapy failures were 77, 25 and 66% for T1, T2 and T3 tumours respectively. Radiotherapy remains the treatment of choice for T1 tumours and a viable alternative to primary laryngectomy in more advanced glottic tumours, with salvage surgery in reserve.

Vertical partial laryngectomy: our results after treating 81 cases of T2 and T3 laryngeal carcinomas

From 1976 to 1989, 81 patients with T2 and T3 laryngeal carcinomas were treated with vertical patrial laryngectomy at the University ENT Department of Thessaloniki, Greece. All patients were male with a median age of 56 years (33-71 years). Four patients had N1 lymph nodes. Ten patients received post-operative radiotherapy. Seventeen patients developed local recurrences or distant metastases. Mean follow-up was more than seven years. Absolute three-year survival was 94.6 per cent for 74 patients and absolute five-year survival was 89.6 per cent for 58 patients. Actuarial five-year survival of the whole group of 81 patients was 91 per cent calculated with the Kaplan-Meier method. Recurrence rate and survival of stage II and III patients are also discussed and compared using the log-rank test. We conclude that vertical partial laryngectomy is a very successful treatment selection for T2 glottic and false vocal cord carcinomas and for some selected T3 glottic lesions.

The prognostic value of hemoglobin and a decrease in hemoglobin during radiotherapy in laryngeal carcinoma

An association between a low Hb-content and a poor response on radiation therapy has been established in previous years, especially in patients with squamous cell carcinomas. Whether this is linked with hypoxic conditions of the tumour or associated with tumour volume, blood loss or other conditions, is not yet known for certain. Patients with small head and neck tumours seem to form an interesting group to study this issue because several factors can be ruled out. Therefore, a retrospective analysis of 306 patients with glottic or supraglottic carcinoma was performed, to identify whether the Hb-value was of prognostic importance and whether this was linked to other patient characteristics. All patients were treated with primary radiotherapy with doses ranging from 60 to 70 Gy in 6-7 weeks. It appeared that in glottic carcinoma, the disease-free survival was significantly worse in patients with a Hb-value below normal at the start or/and at the end of therapy (p = 0.09, p = 0.0012, respectively). In patients with supraglottic carcinoma, the above mentioned difference approved only for a Hb-value below normal at the end of treatment (p = 0.05). A decrease in Hb-level of greater than or equal to 0.5 mmol/l during therapy, regardless whether the Hb-values were within or beyond normal range, reduced the disease-free survival in patients with glottic carcinoma (p = 0.0125). In a multivariate analysis, the Hb-value at the end of treatment proved to be an independent prognostic factor after T- and N-classification. There was no relationship with nutritional condition of the patient, nor with the Karnofsky Performance scale.(ABSTRACT TRUNCATED AT 250 WORDS)

Dose, time, and fraction size issues for late effects in head and neck cancers

This paper contains a statistical analysis of the dose-time factors influencing late complications in 784 patients with squamous cell carcinomas of the pharynx or larynx treated with external beam irradiation only at the University of Florida. The patients include 560 who received continuous course once-a-day therapy, 116 who received twice-a-day treatment, and 108 who received a once-a-day split course regimen. Both 2+ and 3+ complications were considered. Fifty-six patients developed either of these complications. The factors included in the analysis were site and size of the primary, total dose, fraction size, and treatment time. The linear-quadratic model was used to incorporate fraction size into the analysis. Proportional hazards analysis, which models the time to occurrence of the late complication, was used to quantify the joint influence of the above patient and fractionation variables on the incidence of late effects. The occurrence of the late effects was heterogeneous, with only a weak relationship to the patient and fractionation variables. The influence of the size of the primary was significant, with larger primaries associated with higher complication rates independent of fractionation variables. For oropharynx primary sites there was no significant effect of the fractionation variables. For larynx and hypopharynx, excluding T1-T2 true vocal cord, there was a significant effect of total dose and fraction size. The alpha/beta ratio was estimated to be 7.8 Gy (95% confidence interval, 3.0, infinity). There was no significant effect of overall treatment time. The estimated 2+ complication rate at 1 year from 68 Gy given in 2 Gy fractions in 50 days is 0.1% for T 1-2 vocal cord, 4.1% for T1-T2 supraglottic larynx, 3.8% for T3 supraglottic larynx and vocal cord, 14.9% for T4 supraglottic larynx, 6.7% for T1-T2 tonsil and soft palate, 7.6% for T3-T4 tonsil and soft palate, 7.0% for T1-T2 pyriform sinus and pharyngeal wall, and 13.0% for T3-T4 pyriform sinus and pharyngeal wall.

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.

Advances in radiation therapy for head and neck cancer

Radiation therapy either as a single modality or as part of multimodality plans remains an integral part of curative treatment for cancers of the head and neck. This paper traces the modernization of radiation therapy regarding tumors of the head and neck using examples of sites of malignancy where radiation therapy is the sole modality or where radiation therapy can be combined with surgery and chemotherapy for optimal results. As local-regional control rates have improved with the use of combined radiation therapy and surgery and aggressive hyperfractionation schemes for advanced primary tumors, distant metastases and second primary neoplasms are now accounting for a larger proportion of treatment failures. Until such time as more effective systemic therapy and cancer control mechanisms are developed to address these problems, radiation therapy will continue to play a major role in the overall management of patients with cancers of the head and neck.

Dose-time considerations of head and neck squamous cell carcinomas treated with irradiation

The dose-time factors in the external beam treatment of 473 patients with squamous cell carcinoma of the pharyngeal wall, vocal cord, pyriform sinus or supraglottic larynx were considered. The effect of overall treatment time on the tumor response was quantified by estimating the increment in dose per day needed to achieve a constant rate of local control, that is, the dose required to counterbalance the effect of growth of the tumor during irradiation. The estimated increment in isoeffect dose per day varies between sites, however, the increments, although estimated with considerable uncertainty, are in general larger than 1 Gy per day. These estimates are consistent with accelerated tumor clonogen repopulation during irradiation.

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

Between March 1978 and April 1986, 21 previously untreated patients with T3 squamous cell carcinoma of the true vocal cord received radical courses of twice-a-day radiotherapy (120 cGy twice daily) to total doses of 7,440-7,680 cGy. The rate of local control at the primary site was 67% after radiotherapy. The ultimate control rate after salvage surgery was 83%. Five-year absolute and cause-specific survival rates were 59% and 81%, respectively. It is concluded that radiotherapy is a rational approach for many patients with T3 glottic cancer.

Glottic and supraglottic carcinoma: a retrospective comparison of radiotherapy alone with sandwich therapy in 366 patients

From 1971 through 1982, 442 patients with laryngeal carcinoma were seen at the Leiden University Hospital. They were treated either with radiotherapy alone, sandwich therapy (pre- and postoperative radiotherapy) or by surgery followed by postoperative irradiation. Three hundred and sixty-six patients with glottic or supraglottic tumours could be analysed with respect to two different treatments, complications of treatment and some prognostic factors. Two endpoints of analysis were used: disease-free interval and survival to cancer death. In patients with glottic or supraglottic carcinoma, the survival of patients with advanced disease, treated with radiotherapy only, was worse as compared to the survival of the same category of patients who were treated with sandwich therapy (p less than 0.005). In patients with small glottic tumours, radiotherapy alone was mostly used. In small supraglottic tumours, the survival with both therapy policies was equal. Persistent hoarseness in patients with small glottic tumours, treated with radiotherapy only, is of predictive value for the development of a recurrence (p less than 0.001). There was no influence on prognosis of histological differentiation of the tumour. It appeared that interruption of radiotherapy for more than two days had an adverse effect on survival in patients with glottic carcinoma (p = 0.0001). Finally, the occurrence of second malignancies was analysed. It was found that 19% had a second malignancy. Almost 60% of them were lung cancers.

Deep spread patterns in CT staging of T2-4 squamous cell laryngeal carcinoma

In addition to clinical examination and less sophisticated radiographic techniques, high-resolution computerized tomography (CT) can help to stage squamous cell carcinoma of the larynx. This study was undertaken to identify findings on CT scans that might predict the likelihood of radiation therapy (RT) alone, controlling the primary site disease without significant irradiation-related complications. Of 30 patients with T2-4 cancers of the larynx, 13 were classified as favorable and 17 were classified as unfavorable candidates for RT based on the CT criteria of transglottic spread, more than 25% pre-epiglottic space involvement, extensive paralaryngeal space spread, or cartilage involvement. Seven of 17 (41%) unfavorable patients had local recurrences, two are alive with cancer, three patients are dead of disease (DOD), and five had significant complication, but there was no evidence of recurrent cancer. In the favorable group, there were two local recurrences (15%), one distant metastasis, one patient is DOD, and one had a significant complication, but no recurrent cancer. These data may be used to more adequately select and inform patients with T2-4 squamous cell carcinoma of the larynx before RT.

Regression after 50 Gy as a selection for therapy in advanced laryngeal cancer

Radiation alone for advanced laryngeal cancer will result in an initial local control rate of 50%. When a local recurrence is diagnosed, only 50% will be successfully salvaged by surgery. To identify patients with a high chance of local control with radiation alone in advanced laryngeal cancer, the clinical response following radiotherapy was assessed a few days after 50 Gy/5 weeks. In patients with T-stage reduction or greater than 50% tumor regression radiotherapy was continued, if not, laryngectomy was performed after 4-6 weeks. According to this protocol 30 patients (out of 50) with T3/T4 laryngeal cancer were treated. Initial local control was assessed 6 weeks after radiotherapy, the ultimate local control included successful salvage surgery. Initial local control in patients, treated with a full course of radiotherapy after T-stage reduction or greater than 50% tumor regression, was 69% for T3 and 43% for T4 while the ultimate local control rate was 85% and 71% respectively. Although the percentage of voice preservation in our study was slightly lower (40%) than data from literature with radiation alone, the ultimate local control was high and comparable with those of combined therapy (in which laryngectomy is a part). The corrected actuarial 5-year survival in all T3 and T4 patients treated with radiation alone and salvage surgery was 73% and 31% respectively and was not different compared to surgery with pre- or post-operative radiotherapy, 74% and 53% respectively. We believe that this protocol may select a favorable group of patients for high dose radiation alone in T3 and probably in T4 laryngeal cancer.

Postoperative radiation as adjuvant treatment for carcinoma of the oral cavity, larynx, and pharynx: preliminary report of a prospective randomized trial

A prospective randomized trial was performed in patients with advanced squamous cell carcinomas (SCC) of the oral cavity, larynx, and pharynx to examine the effect of adjuvant postoperative radiation therapy on locoregional recurrence and survival following "curative" resection. Fifty-one patients with stage III or IV SCC treated from 1981 through 1984 were randomized to receive either surgery alone (n = 27) or surgery with postoperative radiation (n = 24). Five patients were excluded from the study after randomization because of ineligibility or protocol violations. Overall recurrence rates of 55.6% and 36.8% were noted in the surgery and surgery with adjuvant radiotherapy arms, respectively (p = NS). This trend towards a higher recurrence rate in the surgery only arm was in part due to the development of lymph node metastases in the contralateral, nonoperated neck. Thus far, no significant differences in either locoregional or overall survival have been noted between the two treatment arms. In this preliminary analysis, adjuvant postoperative radiotherapy does not appear to improve disease-free or overall survival.

Hyperfractionation for head and neck cancer

Between March 1978 and April 1984, 144 patients with 148 moderately advanced to advanced primary squamous cell carcinomas of the head and neck received treatment with curative intent with twice-a-day irradiation (120 cGy/fraction, 4-6 hour interfraction interval). Eighty-eight percent of the patients had AJCC Stage III-IV cancers. One hundred and thirty-two patients received irradiation alone to the primary site with or without radical neck dissection, with surgery reserved for salvage. The total doses administered were 7440-7920 cGy in the majority of instances. In 19 patients with oropharyngeal lesions, a 1000-1500 cGy radium needle boost was added after the basic dose. Twelve patients received preoperative irradiation (5040-6000 cGy) followed by primary resection and radical neck dissection. Local control results following irradiation alone to total doses of greater than 7000 cGy with minimum 2-year follow-up were 25/31 (81%), 38/50 (76%), and 5/25 (20%) for T2, T3, and T4 cancers, respectively. Local control rates did not correlate well with total dose. Local control following preoperative irradiation plus primary resection was obtained in 4 of 5 T3 and 2 of 3 T4 primary lesions. The 5-year actuarial rates of neck control were 100% for N0 (45 patients), 90% for N1 (25 patients), 77% for N2 (23 patients), 50% for N3A (9 patients), and 70% for N3B (42 patients). The 5-year actuarial rates of continuous disease control above the clavicles were 73% for Stage III, 64% for Stage IVA, and 32% for Stage IVB. The actuarial 4-year rate of continuous disease control above the clavicles was 78% for Stage II. For patients whose disease was controlled above the clavicles, distant metastases developed in 4% of patients with Stage II-III disease and in 18% of patients with Stage IV disease. Radiation complications following irradiation alone to the primary site correlated with total dose. Complications of planned neck dissection(s) were acceptable. Complications of salvage surgery at the primary site were similar to those seen in patients treated once a day. The actuarial 5-year survival rates, according to modified AJCC stage, were 59% for Stage III, 37% for Stage IVA, and 23% for Stage IVB. The actuarial 4-year survival rate for Stage II was 69%. Compared to historical control groups treated with once-a-day, continuous-course irradiation at our institution, twice-a-day treatment has produced local control results that are higher by 10-15 percentage points.

Radiation therapy for advanced (T3T4N0-N3M0) laryngeal carcinoma: the need for a change of strategy: a radiotherapeutic viewpoint

Since 1974 through 1984, 137 selected patients with loco-regionally advanced carcinoma of the larynx (T3T4 N0-N3) were treated primarily with quality controlled high dose megavoltage radiation therapy with salvage surgery in reserve. This policy of treatment has yielded 67% loco-regional control probability with primary radiotherapy and 85% with salvage surgery at 3 years. Fourteen patients (14/38) had moderate to severe complications after salvage surgery. The quality of life of the patients successfully treated by radiation therapy is obviously and unquestionably better. Primary radiotherapy with salvage surgery in reserve should be accepted as the strategy of choice in at least a selected group of patients with advanced laryngeal carcinoma.

Advanced laryngeal cancer: a management perspective

A retrospective study of 197 T3 and T4 squamous cell carcinomas of the larynx presenting between 1969 and 1978 has been undertaken. These patients have in the main been treated by primary radiotherapy with back-up salvage surgery. The aim of the study was to examine survival, and to try to identify reasons for failure of control. Various prognostic factors have been analysed and are discussed. Overall 5-year survival was 53 per cent but patients with nodal disease responded poorly. Subglottic tumours have a better survival than usually reported. Failure to pick up recurrence was the main problem, and in particular a persistently fixed cord carried a very poor prognosis if laryngectomy was delayed.

Carcinoma of the larynx

Six hundred sixty-eight patients with tumours of the larynx were treated by radiotherapy. The patients had stage T1 N0 M0 to T4 N3 M0 disease. Patients with T1 N0 M0 disease (273) had an excellent long-term survival (90%) as did those with T2 N0 M0 disease (142), whose 5-year survival was 70%. Patients with more advanced disease but no nodal spread did not respond as readily to radiotherapy; the 5-year survival was 40%. All patients were treated using a parallel pair set-up 6 X 6 cm lateral neck fields. A more aggressive radiotherapy regime to a larger tissue volume to include microscopic spread to lymph nodes may improve survival of locally advanced disease.