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

Primary surgical treatment of T3 glottic carcinoma: long-term results and decision-making aspects

OBJECTIVES/HYPOTHESIS

The aim of this study was to assess the efficacy of primary surgical treatment in the management of T3 glottic carcinomas.

STUDY DESIGN

Retrospective clinical study.

METHODS

A retrospective evaluation of the records for all patients treated with primary surgery for T3 glottic carcinomas at a tertiary referral center between 1980 and 2005 was carried out. Data for the 5-year disease-specific survival (DSS) were assessed, as well as local control rates in relation to vocal cord immobility, N classification, choice of surgical modality, and adjuvant therapy. Patients who underwent partial laryngectomy were also evaluated in relation to organ preservation and the rate of permanent tracheotomies.

RESULTS

The 5-year DSS in the 120 patients was 78.3%. Positive neck disease was shown to be a significant negative prognostic factor. Organ preservation was achieved in 90.1% of the patients who underwent partial laryngectomy and in 50% of the overall patient group. The occult metastasis rate was 14%.

CONCLUSIONS

Primary surgical treatment is an effective modality against T3 glottic carcinomas. Partial laryngectomy is a reliable method in carefully selected cases. Low complication rates can be expected.

Treatment-induced changes in vocal cord mobility and subsequent local recurrence after organ preservation therapy for laryngeal carcinoma

BACKGROUND

As multidisciplinary cancer treatment evolves, strategies to identify patients needing early resection/salvage are necessary. Some have suggested that vocal cord function after organ-preservation treatment may be an indicator.

METHODS

A retrospective review was performed of patients presenting with fixed or impaired vocal cord function at a tertiary center. Local recurrence rates were examined in patients with and without improved/normal mobilization after treatment.

RESULTS

Sixty-nine patients met the inclusion criteria, with 35 patients having vocal cord fixation and 34 patients with impaired mobility. After treatment, 44 patients had normalization of vocal cord function, while 25 patients did not, with 2-year local control rates of 70% and 77%, p = .23, respectively. No difference in local control was found between patients with normalized/improved cord function (n = 53) and those who remained the same/worsened (n = 16; p = .81).

CONCLUSION

Therapy-induced changes in vocal cord mobility did not correlate with local recurrence. Other criteria are needed to identify patients most likely to benefit from early surgical resection/salvage after organ preservation.

Larynx preservation clinical trial design: summary of key recommendations of a consensus panel

An international consensus panel was convened to develop guidelines for the conduct of phase III clinical trials of larynx preservation in patients with locally advanced laryngeal and hypopharyngeal cancer. According to their recommendations, future trial populations should include patients with T2 or T3 laryngeal or hypopharyngeal squamous cell carcinoma not considered for partial laryngectomy and should exclude those with laryngeal dysfunction or aged >70 years. Baseline and post-treatment functional assessments should include speech and swallowing evaluations. Furthermore, voice should be routinely assessed with a simple, validated instrument. Regarding endpoints, the primary endpoint should capture survival and function. As a result, the panel created a new endpoint of laryngoesophageal dysfunction (LED)-free survival, which includes the events of death, local relapse, total or partial laryngectomy, tracheotomy at ≥2 years, or feeding tube at ≥2 years. Recommended secondary endpoints are freedom from LED, overall survival, progression-free survival, locoregional control, time to tracheotomy, time to laryngectomy, time to discontinuation of feeding tube, and quality of life/patient-reported outcomes. Future exploratory correlative biomarker studies should include epidermal growth factor receptor, excision repair cross-complementation group 1 gene, E-cadherin and β-catenin, epiregulin and amphiregulin, and TP53 mutation. Revised trial designs in several key areas are needed to advance the study of larynx preservation. With consistent methodologies, clinical trials can more effectively evaluate and quantify the therapeutic benefit of novel treatment options for patients with locally advanced laryngeal and hypopharyngeal cancer.

Organ preservation surgery for advanced unilateral glottic and subglottic cancer

OBJECTIVES

Functional surgery of unilateral T(2b) to T3 glottic cancer and cricoid chondrosarcoma is possible using the technique of tracheal autotransplantation. The objective of this paper is to report the functional and oncologic outcome of 24 consecutive patients treated with this technique between 2001 and 2007.

METHODS

Seventeen patients, of whom nine were previously irradiated, had unilateral glottic cancer with impaired mobility of the vocal fold. Clinical staging was T(2b) to (3)N(0). Seven patients had a chondrosarcoma of the cricoid cartilage. In a first operation, an extended hemilaryngectomy was performed, and a radial forearm flap, comprising a distal fascial and a proximal skin component, was transferred to the neck. The fascial paddle was wrapped around the upper 4-cm segment of cervical trachea, and the skin paddle was used for temporary closure of the extended hemilaryngectomy defect. The definitive reconstruction was performed after 2 to 3 months and consisted of removal of the skin paddle from the laryngeal defect and a transplantation of a patch of revascularized cervical trachea to reconstruct the laryngeal defect.

RESULTS

Swallowing and speech were restored after the first operation. The glottic and subglottic airway lumen was restored during the second operation. The tracheostomy could be closed in 20 patients. After a median follow-up period of 33 (range, 1-66) months or almost 3 years, 23 patients remained free of tumor recurrence.

CONCLUSIONS

Tracheal autotransplantation can be recommended as a functional treatment for selected T(2b) to T(3) glottic cancers and for unilateral chondrosarcomas of the cricoid cartilage. The technique is oncologically robust while resulting in good postoperative function.

T3 and T4 true vocal cord squamous carcinomas treated with external beam irradiation: a single institution's 35-year experience

PURPOSE

The purpose of this study was to report the outcomes after external-beam radiotherapy (RT) for selected T3 and T4 vocal cord squamous cell carcinomas.

METHODS AND MATERIALS

One hundred nine patients with previously untreated T3 and T4 squamous cell carcinomas of the glottic larynx were treated with curative intent in this Institutional Review Board-approved outcome study using continuous-course RT alone (106 patients) or followed by a planned neck dissection (3 patients) between September 1966 and June 2002. Patients selected for such treatment had relatively low-volume, unilateral disease. Patients were staged according to the recommendations of the American Joint Committee on Cancer (AJCC) as follows: T3N0, 68 patients (62%); T3N1, 14 patients (13%); T3N2B, 5 patients (5%); T4N0, 17 patients (16%); T4N1, 4 patients (4%); and T4N2B, 1 patient.

RESULTS

The 5-year outcomes after treatment were: local control for stage T3 and T4, 78% and 81%; locoregional control for AJCC stage III and IVa, 62% and 78%; distant metastasis-free survival for AJCC stage III and IVa, 97% and 100%; cause-specific survival for AJCC stage III and IVa, 84% and 87%; and overall survival for AJCC stage III and IVa, 52% and 67%, respectively. Severe complications occurred in 13 patients (12%).

CONCLUSIONS

The results of this retrospective study compare favorably with those published elsewhere in the literature for T3 and T4 vocal cord carcinomas. Local control and ultimate cure probabilities will hopefully improve further with the addition of concomitant chemotherapy to RT for larger tumors.

Therapeutic Options in Advanced Laryngeal Cancer: An Overview

Historically, patients with advanced laryngeal cancer have been treated with radical surgery and adjuvant radiation therapy. Intensive surgical research has allowed surgeons to deal with almost any local extension and to propose an appropriate surgical procedure for each case. Several function-sparing surgical options are available to treat moderately advanced/advanced laryngeal cancer. Better understanding of the anatomy and biology of cancer in this anatomical site has enabled us to devise effective oncological strategies associated with a great effort to preserve laryngeal function. Numerous efforts have been made to augment the therapeutic armamentarium with the addition of chemotherapeutic agents combined with radiation therapy. For advanced laryngeal cancer, the debate is still open between partial/subtotal surgical procedures, which are more efficient but sacrifice parts of the larynx, and radiotherapy/chemoradiation protocols which can preserve the larynx and its function even though it requires radical surgery for salvage. Efforts should be made to select patients properly, in an individual basis, based on tumor characteristics, clinical aspects, patient's expectations, and the expertise of the head and neck oncologic team for the various therapeutic strategies in order to get better oncological results in association with the preservation of the laryngeal form and function, when possible.

Supracricoid laryngectomy with cricohyoidoepiglottopexy for advanced glottic cancer

BACKGROUND

Supracricoid laryngectomy with cri-cohyoidoepiglottopexy (CHEP) is a conservative surgical procedure indicated in selected cases of advanced glottic carcinoma.

METHODS

This study is a review of our experience with 43 patients with T3/T4 glottic squamous cell carcinoma who underwent CHEP in our institution. All but two patients underwent selective neck dissections. All patients were staged on the basis of the 2002 TNM classification. Rates of recurrence and death were estimated by the Kaplan-Meier method.

RESULTS

The 5-year disease-specific survival and 5-year relapse-free survival rates were 78% and 83%, respectively. Neck metastases were found in three patients. Cartilage invasion occurred in 11 cases. The average length of hospital stay was 5.7 days. The mean time of enteral feeding tube was 33.8 days, and the mean time for tracheotomy was 29.6 days. Overall, normal swallowing was achieved in 74.4% of patients. Eleven patients had mild and major complications. Laryngeal stenosis emerged as the most frequent major complication. Three patients (6.9%) had local recurrences. Two patients (4.6%) had neck metastases.

CONCLUSIONS

On the basis of this study, over a 7-year period with 43 patients with advanced glottic cancer, a successful on-cologic outcome is confirmed.

Management of T3N0M0 glottic carcinoma: therapeutic outcomes

BACKGROUND

The best therapeutic approach for the treatment of T3N0M0 (stage III) glottic carcinoma is controversial.

METHOD

A retrospective study of Tumor Research Project data were performed using patients with T3N0M0 glottic squamous cell carcinoma treated with curative intent by seven different treatment modalities from January 1950 to December 1996 at Washington University School of Medicine/Barnes-Jewish Hospital.

RESULTS

Two hundred patients with T3N0M0 glottic carcinoma were treated using seven modalities: total laryngectomy (TL, n = 30), TL with neck dissection (TL/ND, n = 40), conservation surgery alone (CS, n = 22), radiation therapy alone (RT, n = 29), TL combined with RT (TL/RT, n = 31), TL and ND combined with RT (TL/ND/RT, n = 36), and CS combined with RT (CS/RT, n = 12). The overall 5-year observed survival rate (OS) was 54% and the 5-year disease-specific survival rate (DSS) was 67%. The 5-year DSS for the individual treatment modalities included TL, 65.4%; TL/ND, 76.5%; CS, 71.4%; RT, 56.5%, TL/RT, 51.9%; TL/ND/RT, 71.4%; and CS/RT, 80%. There was no significant difference in DSS for any individual treatment modality (P =.375). The overall local and regional control rate was 74% (148 of 200). The overall recurrence rate was 37.5% with recurrence at the primary site and in the neck of 19.5% and 11%, respectively. Recurrence was not related to treatment modality. The 5-year DSS after treatment of recurrent cancer (salvage rate) was 35.8%. The incidence of distant metastasis was 11% and for second primary cancers it was 19.5%. There was no statistically significant difference in survival between necks initially treated (72%, 5-y DSS) versus necks observed and later treated if necessary (70%, 5-y DSS) (P =.797).

CONCLUSIONS

The seven treatment modalities had statistically similar recurrence, complication, and survival rates. Patients with clear surgical margins have a significant survival advantage compared with patients with close and involved margins. Because postoperative radiation therapy in patients with positive margins did not improve survival, formal re-resection of the site of the positive margin should be considered. In patients whose N0 neck was not treated electively, close follow-up observation with meticulous examinations combined with appropriate treatment for subsequent neck disease resulted in a similar survival rate compared with those patients whose N0 necks were treated initially. Six-year minimum follow-up is recommended for early identification of primary and neck recurrence and for discovering expected second primary cancers. Patients treated with RT and CS had statistically similar rates of survival, maintenance of voice, and acquired permanent tracheal stoma. CS is a valid alternative to RT in treating highly selected patients with T3N0 glottic carcinoma.

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.

Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection

PURPOSE

To present the results of radiotherapy with or without neck dissection for squamous cell carcinoma of the supraglottic larynx treated at the University of Florida and to compare these data with those obtained after conservation surgery.

METHODS AND MATERIALS

Continuous-course radiotherapy alone or combined with a planned neck dissection was used to treat 274 patients with squamous cell carcinoma of the supraglottic larynx between 1964 and 1998. All patients had follow-up for a minimum of 2 years, and 250 (91%) had follow-up for 5 years or more.

RESULTS

At 5 years, the actuarial probability of local control after radiotherapy according to T stage was as follows: T1, 100%; T2, 86%; T3, 62%; and T4, 62%. The probability of cause-specific survival at 5 years by AJCC stage was as follows: stage I, 100%; II, 93%; III, 81% IVA, 50%; and IVB, 13%. The risk of severe late complications was 4%. Of 57 patients undergoing planned postradiotherapy neck dissection, 7% experienced a severe complication.

CONCLUSIONS

On the basis of our data and the literature, early or moderately advanced supraglottic carcinomas may be treated successfully with either supraglottic laryngectomy or radiotherapy. Supraglottic laryngectomy probably produces a higher initial local control rate but, based on anatomic and coexisting medical constraints, is suitable for a smaller subset of patients and has a higher risk of complications compared with radiotherapy.

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.

Treatment results and prognostic factors of advanced T3--4 laryngeal carcinoma: the University of California, San Francisco (UCSF) and Stanford University Hospital (SUH) experience

PURPOSE

To review the UCSF-SUH experience in the treatment of advanced T3--4 laryngeal carcinoma and to evaluate the different factors affecting locoregional control and survival.

METHODS AND MATERIALS

We reviewed the records of 223 patients treated for T3--4 squamous cell carcinoma of the larynx between October 1, 1957, and December 1, 1999. There were 187 men and 36 women, with a median age of 60 years (range, 28--85 years). The primary site was glottic in 122 and supraglottic in 101 patients. We retrospectively staged the patients according to the 1997 AJCC staging system. One hundred and twenty-seven patients had T3 lesions, and 96 had T4 lesions; 132 had N0, 29 had N1, 45 had N2, and 17 had N3 disease. The overall stage was III in 93 and IV in 130 patients. Seventy-nine patients had cartilage involvement, and 144 did not. Surgery was the primary treatment modality in 161 patients, of which 134 had postoperative radiotherapy (RT), 11 had preoperative RT, 7 had surgery followed by RT and chemotherapy (CT), and 9 had surgery alone. Forty-one patients had RT alone, and 21 had CT with RT. Locoregional control (LRC) and overall survival (OS) were estimated using the Kaplan--Meier method. Log-rank statistics were employed to identify significant prognostic factors for OS and LRC.

RESULTS

The median follow-up was 41 months (range, 2--367 months) for all patients and 78 months (range, 6--332 months) for alive patients. The LRC rate was 69% at 5 years and 68% at 10 years. Eighty-four patients relapsed, of which 53 were locoregional failures. Significant prognostic factors for LRC on univariate analysis were primary site, N stage, overall stage, the lowest hemoglobin (Hgb) level during RT, and treatment modality. Favorable prognostic factors for LRC on multivariate analysis were lower N stage and primary surgery. The overall survival rate was 48% at 5 years and 34% at 10 years. Significant prognostic factors for OS on univariate analysis were: primary site, age, overall stage, T stage, N stage, lowest Hgb level during RT, and treatment modality. Favorable prognostic factors for OS on multivariate analysis were lower N stage and higher Hgb level during RT.

CONCLUSION

Lower N-stage was a favorable prognostic factor for LRC and OS. Hgb levels > or = 12.5 g/dL during RT was a favorable prognostic factor for OS. Surgery was a favorable prognostic factor for LRC but did not impact on OS. Correcting the Hbg level before and during treatment should be investigated in future clinical trials as a way of improving therapeutic outcome in patients with advanced laryngeal carcinomas.

T3 glottic cancer: oncologic results and prognostic factors

OBJECTIVES

To analyze oncologic results, prognostic factors, and consideration of transglottic tumors as a separate entity in 73 patients with T3 glottic carcinoma treated by surgery +/- radiation therapy at La Paz University Hospital from 1984 to 1994.

METHODS

Sixty-four patients underwent a total laryngectomy; neck dissection was performed in 50 patients; 29 patients received postoperative radiotherapy.

RESULTS

The 5-year overall survival, cause-specific survival, and relapse-free survival rates were 58.1%, 66.8%, and 63.7%. Univariate analysis revealed prognostic significance for age, dyspnea, initial tracheostomy, and pathologic lymph node status. No difference was found when comparing survival and relapse rates between transglottic and glottic tumors.

CONCLUSION

Surgery provides acceptable rates of cancer control and survival for patients with T3 glottic carcinoma. Older patients, patients with positive neck nodes, and those presenting with dyspnea have worse prognosis. The term transglottic is merely descriptive and has little impact on prognosis.

ORGAN PRESERVATION FOR CARCINOMA OF THE LARYNX AND HYPOPHARYNX

Treatment of laryngeal and hypopharyngeal cancers often necessitates total laryngectomy. This article reviews approaches of curing patients with these diseases while preserving their larynx. Strategies include radiation alone, neoadjuvant chemotherapy with radiation for responders, or concurrent chemotherapy and radiation. Both retrospective experiences and randomized trials evaluating differing therapies in an effort to achieve voice preservation are reported and analyzed.

Glottic cancer in Ontario, Canada and the SEER areas of the United States. Do different management philosophies produce different outcome profiles?

We compared the management and outcome of glottic cancer in Ontario, Canada to that in the Surveillance, Epidemiology and End Results (SEER) Program areas in the United States to determine whether the greater use of primary radiotherapy with surgery reserved for salvage in Ontario was associated with similar survival and better larynx retention rates than the U.S. approach where primary surgery is used more often. Electronic, clinical and hospital data were linked to cancer registry data and supplemented by chart review where necessary. Initial treatment and survival in patients diagnosed in the SEER areas from 1988 through 1994 were compared to patients from Ontario diagnosed from 1982 through 1995. Actuarial laryngectomy rates were compared for patients over 65 at diagnosis in the two regions. Analyses were conducted over all cases and stratified by disease stage. In localized disease (T1 or T2), conservative treatment was the most common initial treatment in both regions, although total laryngectomy was used more often in SEER than Ontario (6.2% vs. 0.2%, respectively, P <.001). In advanced disease (T3 or T4), total laryngectomy was more commonly used as initial treatment in SEER (62.9% vs. 21.0% in Ontario, P < or =.001). Over all cases, the relative survival rate was 80% in Ontario at 5 years compared to 78% in SEER (P =.33). In localized disease, the relative survival rates were 4 to 5% higher in Ontario from the second year on, while in advanced disease 2 to 3% higher rates in SEER did not approach statistical significance. Actuarial laryngectomy rates at 3 years differed between the two regions, with a 4% higher rate in SEER (P =.01). In localized disease, 12.6% of Ontario patients had a laryngectomy by 3 years postdiagnosis compared to 17.9% in SEER (P =.05). In advanced disease, the rates were 63.3% and 79.2%, respectively (P =.07). There are large differences in the management of glottic cancer between the SEER areas of the U.S. and Ontario and no evidence that a policy emphasizing radiotherapy with surgery reserved for salvage is associated with worse survival. Ultimate laryngectomy rates are lower in Ontario for localized disease and may be lower for advanced disease. Conservation treatment should be used for localized disease while the treatment decision in advanced disease may be especially sensitive to patient values for voice retention versus initial cure.

Sequential induction chemotherapy and concomitant chemoradiotherapy in the management of locoregionally advanced laryngeal cancer

PURPOSE

To determine overall survival, progression-free survival, rate of voice preservation, and patterns of failure in locoregionally advanced laryngeal cancer treated with induction chemotherapy with or without surgery followed by concomitant chemoradiation.

BACKGROUND

Locoregionally advanced laryngeal cancer has been conventionally treated with either surgery and adjuvant radiotherapy or radiotherapy alone, and clinical and functional outcomes have been poor. Chemoradiotherapy has been demonstrated to improve functional outcome and disease control over conventional treatment in recent randomized head and neck trials.

PATIENTS AND METHODS

Advanced head and neck cancer patients were enrolled onto two consecutive phase II studies. Induction treatment consisted of three cycles of cisplatin, 5-fluorouracil (5-FU), leucovorin, and interferon-alpha 2b (PFL-IFN) followed by surgery for residual disease. Surgical intent was to spare the larynx when possible. All patients then proceeded to concomitant chemoradiation consisting of seven or eight cycles of 5-FU, hydroxyurea, and a planned total radiotherapy dose of 7000 cGy (FHX).

RESULTS

A subset of thirty-two laryngeal cancer patients with predominantly stage IV disease comprises the study group for this report. Clinical CR was observed in 59% of patients following induction therapy. The median follow-up was 63.0 months for surviving patients and 44.5 months for all patients. At five years, overall survival is 47%, progression-free survival is 78%, and locoregional control is 78%. No distant failures were observed. Voice preservation with disease control was 75% at five years. Only two total laryngectomies were performed during the course of treatment and follow-up. Treatment-related toxicity accounted for two deaths.

CONCLUSIONS

The addition of concomitant chemoradiotherapy to induction chemotherapy for locoregionally advanced laryngeal cancer appears to increase locoregional control and survival rates. PFL-IFN-FHX resulted in high rates of disease cure and voice preservation in a group of patients that has traditionally fared poorly in both clinical and functional outcome.

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.

Pre- and post-radiotherapy computed tomography in laryngeal cancer: imaging-based prediction of local failure

PURPOSE

To determine if pre-radiotherapy (RT) and/or post-radiotherapy computed tomography (CT) can predict local failure in patients with laryngeal carcinoma treated with definitive RT.

METHODS AND MATERIALS

The pre- and post-RT CT examinations of 59 patients (T3 glottic carcinoma [n = 30] and T1-T4 supraglottic carcinoma [n = 29]) were reviewed. For each patient, the first post-RT CT study between 1 and 6 months after irradiation was used. All patients were treated with definitive hyperfractionated twice-daily continuous-course irradiation to a total dose of 6,720-7,920 cGy, and followed-up clinically for at least 2 years after completion of RT. Local control was defined as absence of primary tumor recurrence and a functioning larynx. On the pre-treatment CT study, each tumor was assigned a high-or low-risk profile for local failure after RT. The post-RT CT examinations were evaluated for post-treatment changes using a three-point post-RT CT-score: 1 = expected post-RT changes; 2 = focal mass with a maximal diameter of < 1 cm and/or asymmetric obliteration of laryngeal tissue planes; 3 = focal mass with a maximal diameter of > 1 cm, or < 50% estimated tumor volume reduction.

RESULTS

The local control rates at 2 years post-RT based on pre-treatment CT evaluation were 88% for low pre-treatment risk profile patients (95% CI: 66-96%) and 34% (95% CI: 19-50%) for high pre-treatment risk profile patients (risk ratio 6.583; 95% CI: 2.265-9.129;p = 0.0001). Based on post-treatment CT, the local control rates at 2 years post-RT were 94% for score 1, 67% for score 2, and 10% for score 3 (risk ratio 4.760; 95% CI: 2.278-9.950 p = 0.0001). Post-RT CT scores added significant information to the pre-treatment risk profiles on prognosis.

CONCLUSIONS

Pre-treatment CT risk profiles, as well as post-RT CT evaluation can identify patients, irradiated for laryngeal carcinomas, at high risk for developing local failure. When the post-RT CT score is available, it proves to be an even better prognosticator than the pre-treatment CT-risk profile.

Carcinoma of the larynx treated with hypofractionated radiation and hyperbaric oxygen: long-term tumor control and complications

PURPOSE

To evaluate the long-term outcome with respect to local control, survival, and complications in a cohort of patients with locally advanced laryngeal carcinoma treated with hypofractionated radiation and hyperbaric oxygen at 4 atmospheres of pressure (HBO-4).

METHODS AND MATERIALS

Between January 1970 and August 1982, 45 patients with locally advanced carcinoma of the larynx were treated with primary radiation using a unique hypofractionated schedule of 2 fractions of 11 Gy separated by 21 days, with concomitant HBO-4 during each radiotherapy session. To avoid seizures, discomfort and other complications of HBO-4, each session was performed under general anesthesia. All patients had pathologically confirmed squamous cell carcinoma of the glottic (23) or supraglottic larynx (22) and were staged as follows: T2-5, T3-24, T-4-16; N0-26, N1-4, N2-13, N3-1. Patients were treated with opposed lateral wedged fields of 4-6 MV photons, with a median field size of 5.5 x 9.75 to a total median dose of 22.5 Gy.

RESULTS

As of February 1998, follow-up was complete on all but one patient, who relocated to another country after 8 years. Complete clinical responses were observed in 39 (87%) of the cases. The 10-year local control rate for all 45 patients was 58%, and local control for the complete responders was 69%. Three patients underwent laryngectomy for complications and were found to have no pathological evidence of disease in the laryngectomy specimen. The 10-year survival of the overall population was 27%. The 10-year voice preservation rate for the the 39 complete responders was 55%. Acute mucosal and skin reactions were modest and acceptable. Significant late complications occurred in 14 patients consisting of severe fibrosis, necrosis, pharyngeal fistula, with 3 patients requiring laryngectomy for complications. The actuarial rate of severe complications at 5 years was 42%.

CONCLUSIONS

The response rate and long-term tumor control rate obtained with this treatment program were comparable to more protracted radiation schedules with or without systemic chemotherapy. The complication rate was high resulting in an adverse therapeutic ratio. The radiobiologic interpretation of this clinical data, and implications for hypoxia directed therapy, are discussed.

Predicting the local outcome of glottic squamous cell carcinoma after definitive radiation therapy: value of computed tomography-determined tumour parameters

BACKGROUND AND PURPOSE

The T-classification has shortcomings in the prediction of local outcome of glottic squamous cell carcinoma (SCC) treated by definitive radiation therapy. In this regard, the value of several CT-derived tumour parameters as predictors of local outcome was investigated.

MATERIALS AND METHODS

The pretreatment CT studies of 119 patients with glottic SCC (T1, n=61; T2, n=40; T3, n=14; T4, n=4) treated with curative intent by radiation therapy were reviewed for tumoral involvement of specific laryngeal anatomic subsites (including laryngeal cartilages). Tumour volume was calculated with the summation-of-areas technique. Actuarial (life-table) statistical analysis was done for each of the covariates; multivariate analysis was performed using the Cox proportional hazards model.

RESULTS

In the actuarial analysis tumour volume was significantly correlated with local recurrence rate (P=0.0062). Involvement of the cricoid cartilage (P=0.0052), anterior commissure (P=0.0203), subglottis (P=0.0481) and preepiglottic space (P=0.0134) and degree of involvement of the true vocal cord (P=0.0441) and paraglottic space at the level of the true vocal cord (P=0.0002) were also significantly correlated with local recurrence rate. In the multivariate analysis, only degree of involvement of the paraglottic space (at the level of the true vocal cord) (P=0.0001) and preepiglottic space (P=0.02) were found to be independent predictors of local recurrence. The T-category was significantly correlated with local outcome in the actuarial analysis (P=0.0001), but not in the multivariate analysis (P=0.5915).

CONCLUSIONS

Several CT-derived parameters are powerful predictors of local outcome in glottic cancer treated with radiation therapy; some of these parameters are stronger linked to the local control rate than the T-classification.

Management of the N0 neck during salvage laryngectomy

BACKGROUND

Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated.

OBJECTIVE

Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy.

STUDY DESIGN

Prospective study (1991-1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection.

METHODS

Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y).

RESULTS

The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottic, and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries).

CONCLUSIONS

Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most.

Radical radiotherapy for squamous cell carcinoma of the larynx, oropharynx and hypopharynx: patterns of recurrence, treatment and survival

The present study investigates 1085 previously untreated patients with squamous cell carcinoma of the head and neck for factors that influence recurrence following treatment with definitive radiotherapy. In the second part of this study, those diagnosed with recurrence were studied with regard to treatment and were further analysed with regard to identification of prognostic factors which may affect outcome in the patient who actually develops a recurrence.

Audit in the management of T3 fixed-cord laryngeal cancer

PURPOSE

To determine results of various treatments for T3 fixed-cord lesions and the subset T3 glottic cancer in Auckland from 1979 to 1995.

PATIENTS AND METHODS

Data were collected retrospectively from a departmental database, and the notes were reviewed. Because of the difficulty in determining the subsite of some fixed-cord lesions, the entire group of T3 fixed-cord lesions was examined, and those tumors that were considered to be definitely arising from the glottis were then analyzed as a specific subset.

RESULTS

Fixed-cord lesions were diagnosed in 75 patients (21 supraglottic, 54 glottic). Primary surgery (total laryngectomy) was performed on 46 patients, primary radical dose radiotherapy was undertaken on 25 patients, and four patients were treated palliatively. For T3 fixed-cord lesions, disease-specific survival for radiotherapy and surgery was 36% and 66%, respectively, and 32% and 67%, respectively, for T3 glottic lesions. For both T3 fixed-cord and T3 glottic lesions, surgery produced significantly better survival than did radiotherapy (<60 Gy; P = .0157). With radiotherapy greater than 60 Gy, cancer of the larynx has been controlled in seven of 13 patients, although only five patients are alive, with a median follow-up of 24 months (range, 12-49 months).

CONCLUSION

Radiotherapy less than 60 Gy produced markedly inferior results to surgery for T3 fixed-cord lesions and T3 glottis in Auckland. Radiotherapy at more than 60 Gy shows promise, but an ongoing audit is essential to ensure that survival is similar to surgery and to that reported by those promoting organ-preservation protocols.

Quality of life and voice in patients with laryngeal carcinoma: a posttreatment comparison of laryngectomy (salvage surgery) versus radiotherapy

OBJECTIVES

This study was designed to compare the voice and the quality of life (QOL) of laryngeal cancer patients receiving treatment with radical radiotherapy with or without laryngectomy as salvage surgery. We also compared the patients' own perceptual ratings of their voice to the perceptual ratings of a group of listeners.

STUDY DESIGN

Two groups of laryngeal cancer patients were studied.

METHODS

Fourteen irradiated laryngeal speakers with preserved larynx were matched with 14 salvage surgery laryngectomized patients speaking with tracheoesophageal prosthesis (TEP). To measure patients' QOL, we used the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck module (EORTC QLQ-H&N35), the Hospital Anxiety and Depression scale (HAD) and a study-specific questionnaire. For the perceptual speech evaluation we used visual analog scales.

RESULTS

The perceptual ratings of speech intelligibility, voice quality, and speech acceptability showed a significant difference between the treatment groups. Both the patients who received treatment with radiotherapy and the listeners rated the irradiated laryngeal voices higher than the tracheoesophageal speech. The laryngectomized patients scored significantly better than the patients treated with radical radiotherapy on the question about hoarseness. No other significant difference was found for the QOL functions and symptoms.

CONCLUSION

When patients treated with radiotherapy were compared with patients treated with laryngectomy as salvage surgery, QOL was similar, only small differences being found in the perceptual speech evaluation.

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.

The prognostic significance of tracheostomy in carcinoma of the larynx treated with radiotherapy and surgery for salvage

PURPOSE

To determine retrospectively the prognostic significance of airway compromise necessitating tracheostomy in carcinoma of the larynx managed with radical radiotherapy and surgery for salvage (RRSS).

METHODS AND MATERIALS

The charts of 270 patients managed with RRSS at the Toronto-Sunnybrook Regional Cancer Centre between June 1980 and December 1990 were reviewed. Airway compromise necessitating tracheostomy was documented in 26 patients prior to radiotherapy and 3 patients during radiotherapy. Of 29, 27 had T3T4 primaries. Patients have been followed for a median of 5 years.

RESULTS

Patients managed without tracheostomy had a 2-year disease-free survival of 74% compared to 41% for those managed with tracheostomy. The adverse impact of airway compromise was more marked in patients with glottic primaries (78% vs. 32%, p = 0.0001) than those with supraglottic primaries (64% vs. 47%, p = 0.18). Tracheostomy was identified in univariate analysis, but not in multivariate analysis, as having a statistically significant impact on local control and local-regional control. Radiotherapy controlled disease above the clavicles in 185 of 267 (69%) evaluable patients. 83% of isolated local-regional failures underwent salvage surgery. Among those managed without tracheostomy, ultimate local-regional control (LRC) was achieved in 161 (94%) of 172 glottic primaries and 54 (81%) of 67 supraglottic primaries. Among those managed with tracheostomy, ultimate LRC was achieved in 9 (69%) of 13 glottic primaries and 12 (80%) of 15 supraglottic primaries. In a subset analysis of 76 patients with T3T4 primaries, there was no statistically significant difference in larynx preservation, disease-free survival, or cause-specific survival between those managed with and without tracheostomy.

CONCLUSION

Airway compromise necessitating tracheostomy is an adverse prognostic factor in patients with carcinoma of the larynx. However, larynx preservation is possible in over 40% of those undergoing tracheostomy and radiotherapy with no compromise of cause-specific survival. The need for pretreatment tracheostomy should not rule out the possibility of RRSS.

The "gregorio marañon" hospital experience in the treatment of laryngeal carcinoma

A retrospective analysis has been carried out of 4100 patients with pharyngolaryngeal carcinoma who were seen at the Hospital Gregorio Marañon between 1962 and 1993. 1287 patients were excluded from this study, leaving 2813 patients available for analysis. The great majority of the 2813 pharyngolaryngeal carcinomas were primary laryngeal tumours (2519). These are the subject of our study.We present our theoretic protocol for treatment of laryngeal carcinoma, both glottic and supraglottic, with special attention to the partial surgery. Our oncological and functional results are presented and discussed.

Can pretreatment computed tomography predict local control in T3 squamous cell carcinoma of the glottic larynx treated with definitive radiotherapy?

PURPOSE

To determine if pretreatment computed tomography (CT) can predict local control in T3 squamous cell carcinoma of the glottic larynx treated with definitive radiotherapy (RT).

METHODS AND MATERIALS

Forty-two patients with previously untreated T3 squamous cell carcinoma of the glottic larynx were treated for cure with RT alone; all had a minimum 2-year follow-up. Tumor volumes and extent were determined by consensus of two head and neck radiologists on pretreatment CT studies. A tumor score was calculated and assigned to each primary lesion depending on the extent of laryngeal spread. Sclerosis of any laryngeal cartilage was recorded. The specific CT parameters assessed were correlated with local control.

RESULTS

Tumor volume was a significant predictor of local control. For tumors measuring < 3.5 cm3, local control was achieved in 22 of 26 patients (85%), whereas for tumors > or = 3.5 cm3, local control was achieved in 4 of 16 patients (25%) (p = 0.0002). Sensitivity and specificity using this cutpoint were 85% and 75%, respectively. Tumor score as a measure of anatomic extent was also found to be a significant predictor of local control. The local control rate for tumors assigned a low tumor score (< or = 5) was 78% (21 of 27) compared to 33% (5 of 15) for tumors assigned a high tumor score (6, 7, or 8) (p = 0.008). A significant decrease in the local control rate was observed for cancers involving the paraglottic space at the false vocal cord level (14 of 16 [88%] vs. 12/26 [46%]) (p = 0.010), cancers involving the face of the arytenoid (15 of 18 [83%] vs. 11 of 24 [46%]) (p = 0.024), and tumors involving the interarytenoid region (25 of 36 [69%] vs. 1 of 6 [17%]; p = 0.020). There were 12 patients with sclerosis of both the ipsilateral arytenoid and the adjacent cricoid cartilage. These patients showed a significant decrease in local control (4 of 12 [33%]).

CONCLUSION

Pretreatment CT can stratify patients with T3 glottic carcinoma into groups more or less likely to be locally controlled with definitive RT. The local control rate for these tumors can be improved using a CT-based tumor profile; the ideal CT profile for a radiocurable T3 glottic larynx carcinoma is volume < 3.5 cm3 and no or single laryngeal cartilage sclerosis.

[Primary radiotherapy of laryngeal carcinoma. An analysis of the therapeutic results and of the the relapse behavior in 283 patients]

PURPOSE

In the treatment of laryngeal carcinoma definitive radiotherapy results in a similar outcome as surgical treatment in the early stages with a lower morbidity rate and good functional results. In fact no randomized studies exist, so far, and the optimal treatment concept for the different stages is not well defined. The following study analyses retrospectively the treatment results and the recurrence data in patients with a squamous cell carcinoma of the larynx treated with definitive radiotherapy.

PATIENTS AND METHOD

Two hundreds and eighty-three patients with carcinoma of the larynx were treated with radiation therapy in the department of radiology of the LMU München between September 1971 and June 1986. Twenty-six patients (9.2%) were female and 257 (73.1%) male. The median age was 68.5 years, respectively 70 years. All patients had a histologically confirmed squamous cell carcinoma of the larynx. No true subglottic cases were observed. Forty-one (14.5%) tumors were localized supraglottically, 207 (73.1%) glottically. Thirty-five patients had a T4 tumor with glottic and supraglottic involvement. In 147 patients the histopathological grading was evaluable: 32 tumors were classified as G1, 95 as G2, 15 as G3 and 5 as G4. According to the UICC classification of 1979 25 patients had a carcinoma in situ (Tis), 93 patients had a stage T1, 90 stage T2, 40 stage T3 and 35 stage T4. Two hundreds and thirty-three of 283 (82.3%) had no lymph node involvement. In 50 patients clinically a lymph node involvement was observed. 22 patients had a stage N1, 5 patients stage N2 and 23 patients stage N3. An external beam radiation mostly with cobalt-60 was performed with a mean dose of 61.9 Gy.

RESULTS

The 5-years relapse-free survival for the whole group was 61.7%. The probability for "no evidence of disease" (NED) depended on tumor stage and localisation (glottic tumors: Tis/T1 90.5%: T2 59.4%: T3 39.6%: [5-year NED]; supraglottic tumors T1 64.2%: T2/3 28.6%: T4/N3 24.7% [3-year NED]). Other significant prognostic factors besides T-stage were N-stage (NO vs. N1-3: 3-year recurrence-free survival 68% vs. 37.2%, p < 0.001) and histopathologic grading (G1 vs. G3/4: 3-year recurrence-free survival 74% vs. 37.1%, p < 0.01). One hundred and twenty-two (43.1%) patients had a recurrence, which occurred in 75.4% local, in 12.3% loco regional, in 8.2%, with distant metastases and 4.1% combined. In 50 patients with a recurrent disease a salvage therapy was carried out. Thereby 17 patients achieved a complete response.

CONCLUSION

Even for the here described negatively selected patient group with a high median age and multimorbidity, good local control rates could be achieved especially in early stages with definitive radiation therapy. In more advanced stages even in elderly patients a combined surgical-radiotherapeutic treatment should be performed.

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.

Cell kinetics and tumor regression during radiotherapy in head and neck squamous-cell carcinomas

Head and neck squamous-cell carcinoma (HN-SCC) patient management is mainly based on TNM classification and needs be improved by considering other potentially useful prognostic factors. We examined the pre-radiotherapy tumor potential doubling time (Tpot) evaluated after in vivo infusion of bromodeoxyuridine and flow-cytometric analysis and the early clinical tumor regression after 40 Gy (40 Gy-TR). Tpot values and clinical 40 Gy-TR classes (minor and major) were available for 82 HN-SCC patients. Radiation therapy completion was done either with 1 dose per day (conventional regimen) or 2 doses per day (accelerated regimen). Local control was also available for follow-up times above 4 years. We found that major 40 Gy-TR was strongly correlated with fast tumor growth, characterized by Tpot values below 5 days, and that patients with major 40 Gy-TR showed better local control than those with minor 40 Gy-TR, independently from the radiotherapy regimen type. We also found that treatment completion with accelerated radiotherapy gave better local control for patients with major 40 Gy-TR and fast tumor growth than conventional radiotherapy. Multivariate analysis, performed on all patients, assigned an independent prognostic value to Tpot, tumor classification and 40 Gy-TR.

Tumour recurrence or treatment sequelae following radiotherapy for larynx cancer

Differentiating between recurrent carcinoma and significant sequelae of radiotherapy after treatment of laryngeal carcinoma is an uncommon but difficult clinical problem. Head and neck surgeons can be faced with deciding on the necessity for salvage laryngectomy without prior histological confirmation of recurrence. This paper reviews the literature pertaining to this topic to provide a better overall estimate of the risk of recurrence in these cases. Approximately 50% of patients with severe oedema or necrosis following radiotherapy for larynx cancer will have recurrence. Less than 10% of all larynges removed will be histologically negative when persistent or recurrent tumour is suspected clinically or indicated by biopsy following radiotherapy.

Radiotherapy for squamous cell carcinoma of the supraglottic larynx: an alternative to surgery

BACKGROUND

The purpose of this article is to present the results of radiotherapy with or without neck dissection for squamous cell carcinoma of the supraglottic larynx at the University of Florida and to compare these data with those obtained after conservation surgery.

METHODS

Continuous-course radiotherapy alone or combined with a planned neck dissection was used to treat 209 patients with 211 supraglottic carcinomas between 1964 and 1992; all patients had follow-up for > or = 2 years.

RESULTS

The 5-year rates of local control after radiotherapy were as follows: T1, 100%; T2, 83%; T3, 68%; and T4, 56%. Tumor volume, as calculated on pretreatment computed tomography (CT) scan, and vocal cord mobility influenced the likelihood of local control.

CONCLUSIONS

Based on our data and the literature, early or moderately advanced supraglottic carcinomas may be treated successfully with either supraglottic laryngectomy or radiotherapy. Supraglottic laryngectomy probably produces a higher initial local control rate but, based on anatomic and coexisting medical constraints, is suitable for a smaller subset of patients and has a higher risk of complications compared with radiotherapy.

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.

Function preservation in stage III squamous laryngeal carcinoma: results with an induction chemotherapy protocol

Until recently, standard treatment for stage III laryngeal carcinoma (LC) was total laryngectomy and radiotherapy. Recent data suggest that induction chemotherapy (ICH) plays a role in preserving function in advanced head and neck cancer. No reports to date prospectively evaluate ICH exclusively in stage III LC. The authors designed a sequential phase II trial to assess if ICH allowed a conservative treatment in this disease. The objective of the first part of the study was to rule out a complete response rate with ICH below 30% with P < .05. ICH protocol consisted of three courses of cisplatin 100 mg/M2 on day 1 and 5-fluorouracil 5000 mg/M2 continuous infusion over 120 hours. Radiotherapy was administered to patients who attained a complete response (CR). Functional surgery (FS) was planned for patients with partial response. A total laryngectomy followed by radiotherapy was performed when FS was not feasible. Fifty-two previously untreated patients (all males) with squamous stage III LC were diagnosed in our institution, and 46 were entered in the ICH trial. After 9 patients were included, data showed 7 (78%) CR, ruling out a CR rate of less than 30%. After ICH, a CR was achieved in 29 (63%) of 46 patients. At the end of treatment, 35 patients (76%) had a functioning larynx. With a median follow-up of 3 years, larynx function was preserved in 26 (57%) of 46 patients and in 64% of survivors. Four-year actuarial larynx function preservation, overall survival, and disease-free survival were 55%, 77%, and 67%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Advances in radiotherapy for head and neck cancer

Selected advances in radiotherapy for treatment of head and neck cancer are reviewed. These include the role of postoperative radiotherapy, planned postirradiation neck dissection, altered fractionation, neoadjuvant chemotherapy and radiotherapy for laryngeal preservation, three-dimensional conformal treatment planning, charged particle irradiation for skull base tumors, and stereotactic radiosurgery.

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.

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.

Can pretreatment computed tomography findings predict local control in T3 squamous cell carcinoma of the glottic larynx treated with radiotherapy alone?

PURPOSE

To determine if pretreatment computed tomography findings can predict local control in T3 squamous cell carcinoma of the glottic larynx treated with radiotherapy alone.

METHODS AND MATERIALS

Twenty-nine patients with previously untreated T3 squamous cell carcinoma of the glottic larynx were treated for cure with radiotherapy alone; all had a minimum 2-year follow-up. High-quality pretreatment computed tomography scans were retrospectively reviewed by a single head and neck radiologist for tumor involvement of various anatomic subsites within the larynx, and total tumor volumes were calculated for 18 of the most recent patients using a computer digitizer. A tumor score was calculated and assigned to each primary lesion depending on the extent of laryngeal spread.

RESULTS

A significant decrease in the local control rate was observed for cancers involving the face of the arytenoid (11 of 20 [55%] vs. 9 of 9 [100%]; p = .02), or the paraglottic space at the false vocal cord level (7 of 16 [44%] vs. 13 of 13 [100%]; p not equal to < .01). Tumors assigned a high tumor score (6, 7, or 8) had a significantly decreased rate of local control with radiation therapy when compared with tumors assigned a low tumor score (< or = 5): 1 of 7 (14%) vs. 19 of 22 (86%) (p = .01). Total tumor volume also significantly correlated with the rate of tumor control. For tumors measuring 3.5 cm3 or less, local control was achieved in 11 of 12 patients (92%), whereas for tumors greater than 3.5 cm3, local control was achieved in 2 of 6 patients (33%) (p = .02).

CONCLUSION

Pretreatment computed tomography scans can contribute significantly to the treatment decision for patients with T3 glottic carcinoma and can define a subset of patients with an excellent chance of being cured with preservation of a functional larynx after treatment with radiotherapy alone.