Prognostic significance of vascular and perineural invasion in cancer of the larynx

Clinicopathological Characteristics, Treatment Patterns, and Outcomes in Patients with Laryngeal Cancer

BACKGROUND

Various factors can affect the survival of patients with laryngeal cancer (LC). In this retrospective study, we assessed clinicopathological features, their prognostic value, and treatment modalities for patients with confirmed squamous cell LC.

METHODS

We collected patient data on demographics, clinicopathological characteristics, treatment patterns, and outcomes. The primary endpoints were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and locoregional control (LRC). We assessed survival using the Kaplan-Meier method and Cox regression model analyses of potential prognostic parameters.

RESULTS

After a median follow-up of 76 months, 28 (33.3%) patients had a recurrence. The median OS was 78 months, with an event recorded in 50% of patients. The DSS median was not reached (NR) with a survival rate of 72.6%, the DFS survival rate was 66.7% with median NR, and the LRC survival rate was 72.6% with median NR. After conducting a multivariate analysis of significant variables, we found that only recurrence and lymphatic invasion had an independent effect on OS and recurrence in DSS, while subsite impacted DFS and LRC.

CONCLUSIONS

Survival trends were consistent with other studies, except for OS. Recurrence, lymphatic invasion, and subsite location were significant factors that impacted patient survival.

Perineural Invasion Predicts Local Recurrence and Poor Survival in Laryngeal Cancer

(1) Background: Perineural invasion (PNI) in head and neck cancer is associated with a poor prognosis; however, the effect of PNI on the prognosis of laryngeal cancer remains under debate. This retrospective study aimed to investigate the effect of PNI in fresh or salvaged larynges on survival in patients who had undergone laryngectomy for squamous cell carcinoma. (2) Methods: This study enrolled 240 patients diagnosed with laryngeal cancer who had undergone open surgery at Seoul St. Mary's Hospital, Korea. The effects of PNI, other histopathologic factors, and treatment history on survival and recurrence patterns were assessed. (3) Results: PNI was observed in 30 of 240 patients (12.5%). PNI (HR: 3.05; 95% CI: 1.90-4.88; p = 0.01) was a significant predictor of poor 5-year disease-free survival. In fresh cases, preepiglottic invasion (HR: 2.37; 95% CI: 1.45-3.88; p = 0.01) and PNI (HR: 2.96; 95% CI: 1.62-2.96; p = 0.01) were negative prognostic factors for 5-year disease-free survival. In the salvage group, however, only PNI (HR: 2.74; 95% CI: 1.26-5.92; p = 0.01) was a significant predictor of disease-free survival. Further, PNI significantly influenced high local recurrence (HR: 5.02, 95% CI: 1.28-9.66; p = 0.02). (4) Conclusions: Independent of treatment history, PNI is a prognostic factor for poor survival and local recurrence in laryngeal cancer.

The complementary role of lymphovascular invasion and perineural invasion in the TNM staging process of rectal cancer

The aim of this study is to clarify the association between lymphovascular invasion (LVI) and/or perineural invasion (PNI) and the clinical characteristics and prognostic importance of rectal cancer, to provide a basis for early adjuvant treatment of rectal cancer. We retrospectively analyzed patients diagnosed with rectal cancer. This study involved rectal cancer tissue samples were obtained by surgical methods. Data on histological form, tumor classification, tumor size, gross growth pattern, blood and lymphatic vessel invasion, and PNI of the slice by HE staining were obtained from pathological examination. Immunohistochemical analysis of tissue samples was performed to determine p53 and EGFR expressions. There were 330 rectal cancer patients included in the study. LVI and/or PNI can be used as a high-risk factor for the prognosis of rectal cancer, predict prognostic survival, and guide adjuvant therapy. The detection rates of LVI and PNI were 32.1% and 16.1%. Differentiation grade, Union for International Cancer Control staging, tumor-lymph node-metastasis staging are significantly related to LVI or PNI. Multivariate logistic regression analysis shows that poor differentiation and N ≥ 1 can be used as independent risk factors and predictive factors for LVI. At the same time, poor differentiation and T > 3 is an independent risk factor for PNI. Only poor differentiation is the risk factor for poor prognosis in Cox risk regression analysis. In addition, the simultaneous occurrence of LVI and PNI is an independent prognostic factor.

Identification of Core Genes and Prognostic Models of Laryngeal Cancer by Autophagy Related Biomarkers

Background: The aims of our article were to identify the core genes of the autophagy-related genes (ARGs) which abnormally expressed in laryngeal cancer (LC) and constructed a risk prognostic models with these genes. Methods: In this study, we identified genes with abnormally expressed in LC, and they were mainly involved in some cancer-related gene ontology (GO) terms and Kyoto Encyclopedia of Genes and Genomes pathways (KEGG). Statistical analysis were conducted to identify the powerful independent prognostic factors associated with clinical factors and survival. Results: A total of 35 DEGs were identified in our research. The risk prediction model was constructed with three potential prognostic genes (VEGFA, SPNS1 and CCL2) of autophagy by lasso regression analysis that can successfully predict the prognosis in LC. We applied ROC curve to evaluate the effectiveness of the risk prognostic model, and found that AUC was 0.693 below the curve. Risk prediction model was only related to survival status (P < 0.01), and was not related to clinicopathological factors. Furthermore, the genes (VEGFA and CCL2) were considered as core genes not only because they were the highly connected genes but also they were the composed genes of risk prognostic model. Conclusions: Taken together, ARGs were considered as important roles in the progression of LC and the prognostic model can help to identification of new targets to guide the diagnosis and therapy.

Elective Neck Dissection during Salvage Total Laryngectomy: Personal Experience

The role of elective neck dissection during salvage surgery in patients with a clinically negative neck (cN0) is still discussed. The main objective of this work was to estimate the prevalence and predictive factors of occult neck nodes metastasis; we therefore aimed to evaluate the survival rate and the main oncologic outcomes of cN0 patients who underwent salvage total laryngectomy and elective bilateral neck dissection. In this retrospective observational study, we enrolled 80 cN0 patients affected by recurrent laryngeal cancer and who underwent salvage total laryngectomy and bilateral selective elective neck dissection. Several parameters were collected in order to find prognostic factors; finally, postoperative complications were reviewed and survival analysis was performed. Occult lymph node metastases were reported in 18 out of 80 patients (22.5%). Significant statistical correlation between lymphovascular invasion (p = 0.007), perineural invasion (p = 0.025) and occult nodal metastasis was found. Other variables (glottic subsite of recurrence, clinical T, pathological T, previous chemotherapy) were not significantly predictive of occult nodal metastasis. The 5-year OS, DSS, and RFS were 50.4%, 64.7%, and 63.4%, respectively. In conclusion, our single-institution data on a large cohort of patients, suggest performing routinely elective selective bilateral neck dissection during salvage total laryngectomy in cN0 patients due to the biological attitude of the tumor to spread to cervical nodes, considering an acceptable complications rate.

Prognostic impact of perineural invasion in oral cancer: a systematic review

Introduction

Numerous studies have evaluated the prognostic significance of perineural invasion (PNI) in oral cancer; however, the results are inconclusive.

Purpose

To identify the prognostic value of PNI in oral cancer through a metanalysis.

Methods

A literature review was carried out, searching the MedLine databases via Pubmed, Scielo, Lilacs, Cochrane and Websco.

Results

A total of 56 studies were included. The results indicate that PNI in oral cancer has an incidence of 28% (95% confidence interval (CI) 24-31%); 5-year survival with relative risk (RR) 0.67 (0.59-0.75); 5-year disease-free survival RR 0.71 (0.68-0.75); locoregional recurrence with RR 2.09 (1.86-2.35).

Conclusions

PNI is a negative prognostic factor in oral cancer.

Upfront surgical organ-preservation strategy in advanced-stage laryngeal cancer

PURPOSE

Advanced-stage laryngeal cancer is a challenging disease that needs multimodal treatment. Medical and surgical organ-preservation strategies have been developing in the last decades to spare these functions while granting cancer cure. The current work presents the experience of a tertiary-care center in conservative surgery for advanced-stage laryngeal cancer.

MATERIALS AND METHODS

We collected clinical data of patients submitted to open partial horizontal laryngectomies (OPHLs) and any possible adjuvant treatment from 2005 to 2018. Outcomes were also compared to the most recent studies reporting on both medical and surgical organ-preservation strategies.

RESULTS

One hundred ten patients were included in the analysis. Adjuvant therapy was employed in 51% of cases. The local control rate was 96.4%, while overall survival (OS) was 67%, and laryngo-esophageal dysfunction free survival (LEDFS) was 66%. Stage IV and vascular invasion were associated with a statistically-significant worse survival.

CONCLUSIONS

OPHLs are valid as upfront treatment in fit patients affected by advanced-stage laryngeal cancer. Disease control and function preservation are granted in a significant percentage of cases, even when followed by adjuvant therapy.

Perineural Invasion as a Prognostic Factor in Laryngeal Squamous Cell Cancer: A Matched-Pair Survival Analysis

BACKGROUND

The purpose of this study was to compare survival outcomes in patients with perineural invasion (PNI)-positive laryngeal squamous cell carcinoma (LSCC) and patients with PNI-negative LSCC.

METHODS

A total of 1,272 patients with LSCC, diagnosed between 2008 and 2017, were included in this study. LSCC Patients with and without PNI were matched based on possible confounding factors. Survival analysis was performed using Kaplan-Meier estimates and the Cox proportional hazards model.

RESULTS

Of the 1,272 LSCC patients, 118 (9.28%) were positive for PNI. Compared to PNI-negative patients, PNI-positive LSCC patients had significantly worse overall survival (OS) (p = 0.017), disease-specific survival (DSS) (p = 0.034) and recurrence-free survival (RFS) (p = 0.002). After pair matching, cohorts consisted of 118 patients in the PNI-positive group and 118 in the PNI-negative group. Significantly increased risk of OS (HR, 2.17; 95% confidence interval [CI], 1.29-3.61, p = 0.003), DSS (HR, 2.07; 95% CI, 1.32-3.24, p = 0.004) and RFS (HR, 2.65; 95% CI, 1.59-4.40, p < 0.001) was observed after adjustment for prognostic variables.

CONCLUSIONS

Patients with PNI-positive LSCC have significantly worse survival outcomes compared to patients with PNI-negative LSCC.

Survival Outcomes and Predictors for Patients who Failed Chemoradiotherapy/Radiotherapy and Underwent Salvage Total Laryngectomy

Background: To assess the presence of adverse pathological features at the time of salvage total laryngectomy (TL) associated with oncologic outcome. Methods: Ninety patients with persistent/locally recurrent disease and who subsequently underwent salvage TL after definitive treatment by radiation alone (RTO) or concurrent chemo-radiation (CCRT) from 2009 to 2018 were retrospectively enrolled. Kaplan–Meier methods were used to estimate overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Results: Lymphovascular invasion (LVI), perineural invasion, positive margin, and stage IV disease were associated with worse survival in the univariate analysis. In the multivariate analysis, the presence of LVI and positive margin were both independent negative predictors in OS (LVI: adjusted hazard ratio (aHR) = 2.537, 95% CI: 1.163–5.532, p = 0.019; positive margin: aHR = 5.68, 95% CI: 1.996–16.166, p = 0.001), DSS (LVI: aHR = 2.975, 95% CI: 1.228–7.206, p = 0.016); positive margin: aHR = 11.338, 95% CI: 2.438–52.733, p = 0.002), and DFS (LVI: aHR 2.705, 95% CI: 1.257–5.821, p = 0.011; positive margin (aHR = 6.632, 95% CI: 2.047–21.487, p = 0.002). Conclusions: The presence of LVI and positive margin were both associated with poor OS, DSS, and DFS among patients who underwent salvage TL after failure of RTO/CCRT. The role of adjuvant therapy for high-risk patients after salvage TL to improve the chance of survival requires more investigation in the future.

Postoperative Concurrent Chemoradiotherapy versus Postoperative Radiotherapy Alone for Larynx Squamous Cell Carcinoma Patients with Lymphovascular Invasion: A Propensity Score Matching Study

Purpose

To date, no guidelines have been proposed for the ideal treatment of postoperative larynx squamous cell carcinoma (LSCC) patients with lymphovascular invasion due to a lack of similar studies. The present study was conducted to compare the survival and toxicity in LSCC patients with lymphovascular invasion receiving either postoperative radiotherapy (PORT) or postoperative chemoradiotherapy (POCRT). The results can be applied for more appropriate treatment of these patients.

Patients and Methods

Three hundred eighty-eight eligible LSCC patients with lymphovascular invasion were enrolled in this retrospective study. Survival and treatment-related toxicities were compared in the POCRT and PORT group using propensity score matching (PSM) methodology (1:1).

Results

Five-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) of all patients were 48.7%, 58.2%, and 56.0%, respectively. Significantly, higher RFS rates (P=0.040) were found in the POCRT group than the PORT group in the PSM cohort. In the multivariate analysis, higher OS, DSS, and RFS rates were observed in the POCRT group than the PORT group (P=0.049, 0.024, and 0.011 respectively). Patients in the POCRT group presented more acute toxicities than those in the PORT group such as hematological toxicities (25.0% vs 0.9%, P<0.001) and mucositis (35.0% vs 19.1%, P=0.002).

Conclusion

In the context of no ideal treatment for LSCC patients with lymphovascular invasion, the present study proposes POCRT as a preferable modality compared with PORT, as POCRT was associated with higher RFS rates. Higher RFS, DFS, and OS rates were also observed in the POCRT group in the multivariate analysis.

A key genomic signature associated with lymphovascular invasion in head and neck squamous cell carcinoma

Background

Lymphovascular invasion (LOI), a key pathological feature of head and neck squamous cell carcinoma (HNSCC), is predictive of poor survival; however, the associated clinical characteristics and underlying molecular mechanisms remain largely unknown.

Methods

We performed weighted gene co-expression network analysis to construct gene co-expression networks and investigate the relationship between key modules and the LOI clinical phenotype. Functional enrichment and KEGG pathway analyses were performed with differentially expressed genes. A protein–protein interaction network was constructed using Cytoscape, and module analysis was performed using MCODE. Prognostic value, expression analysis, and survival analysis were conducted using hub genes; GEPIA and the Human Protein Atlas database were used to determine the mRNA and protein expression levels of hub genes, respectively. Multivariable Cox regression analysis was used to establish a prognostic risk formula and the areas under the receiver operating characteristic curve (AUCs) were used to evaluate prediction efficiency. Finally, potential small molecular agents that could target LOI were identified with DrugBank.

Results

Ten co-expression modules in two key modules (turquoise and pink) associated with LOI were identified. Functional enrichment and KEGG pathway analysis revealed that turquoise and pink modules played significant roles in HNSCC progression. Seven hub genes (CNFN, KIF18B, KIF23, PRC1, CCNA2, DEPDC1, and TTK) in the two modules were identified and validated by survival and expression analyses, and the following prognostic risk formula was established: [risk score = EXP_DEPDC1 * 0.32636 + EXP_CNFN * (− 0.07544)]. The low-risk group showed better overall survival than the high-risk group (P < 0.0001), and the AUCs for 1-, 3-, and 5-year overall survival were 0.582, 0.634, and 0.636, respectively. Eight small molecular agents, namely XL844, AT7519, AT9283, alvocidib, nelarabine, benzamidine, L-glutamine, and zinc, were identified as novel candidates for controlling LOI in HNSCC (P < 0.05).

Conclusions

The two-mRNA signature (CNFN and DEPDC1) could serve as an independent biomarker to predict LOI risk and provide new insights into the mechanisms underlying LOI in HNSCC. In addition, the small molecular agents appear promising for LOI treatment.

Schwann Cell-Derived CCL2 Promotes the Perineural Invasion of Cervical Cancer

Perineural invasion (PNI) has guiding significances for nerve preservation in cervical cancer, but there is no definite marker indicating PNI. Two cervical cancer cell lines (HeLa and ME-180) showed significant abilities to migrate along neurites in vitro and in vivo. Morphological observation revealed that Schwann cells (SC) arrived at the sites of cervical cancer cells before the onset of cancer metastasis. We used high-throughput antibody array to screen the signals mediating the interaction of nerve cells and cancer cells and found the high expression of CCL2 in dorsal root ganglion (DRG). Meanwhile, serum CCL2 showed a notable raise especially in cervical adenocarcinoma. SC-derived CCL2 bound to its receptor CCR2 and promoted the proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT) of cervical cancer cells. In turn, cancer cell-derived signals triggered the expression of metalloproteinases (MMPs) including MMP2, MMP9, and MMP12 in SCs, promoting SCs to dissolve matrix. These data demonstrated that the cancer-nerve crosstalk formed a tumor microenvironment (TME) that facilitated to PNI. We identified the CCL2/CCR2 axis as a potential marker to predict the PNI and affect the nerve preservation for cervical cancer.

Prognostic significance of venous invasion in node-negative head and neck squamous cell carcinoma

BACKGROUND

Venous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node-negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain.

METHODS

A total of 105 consecutive lymph node-negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow-up data were recorded.

RESULTS

Of 37 patients with venous invasion, 19% had loco-regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence-free survival in the presence of venous invasion (log-rank [Mantel-Cox] test P-value .025).

CONCLUSION

Identification of VI is greatly aided by elastic stain. In patients with node-negative HNSCC, presence of VI resulted in decreased recurrence-free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.

Prognostic significance of soft tissue deposits in laryngeal carcinoma

Introduction

Soft tissue deposits is tumorous islands apart from lymph nodes and occasionally diagnosed in neck dissection specimens. Their importance has begun to be recognized, however, their value has not been investigated in laryngeal cancer as a single tumor site.

Objective

To investigate the prognostic value of soft tissue deposits in patients with laryngeal carcinoma.

Methods

Medical records of 194 patients with laryngeal carcinoma who were treated primarily by surgery and neck dissection were reviewed. Prognostic significance of soft tissue deposits was assessed along with other clinical and pathological findings. Recurrence rates, overall and disease-specific survival rates were examined.

Results

The incidence of soft tissue deposits was found to be 7.2% in laryngeal carcinoma. N stage was more advanced in patients who had soft tissue deposits. Regional recurrence rate was higher and disease specific and overall survivals rates were significantly lower in patients with soft tissue deposits in univariate analysis. However, in multivariate analysis, soft tissue deposits were not found as an independent risk factor.

Conclusion

In laryngeal carcinoma, soft tissue deposits was diagnosed in patients with more advanced neck disease and their significance was lesser than other factors including extranodal extension.

Laryngeal Dysplasia, Squamous Cell Carcinoma, and Variants

Squamous cell carcinoma (SCC) is a malignant epithelial tumor showing evidence of squamous differentiation. It is the most common malignancy of the larynx, with several variants (verrucous, exophytic or papillary, spindle-cell, basaloid, acantholytic, adenosquamous) recognized, with well-established precursor lesions. Dysplasia is now separated into only low-grade and high-grade categories. Each SCC variant has unique cytomorphologic features and histologic differential diagnoses that are important to consider, as management and outcomes are different.

Correlation of neural cell adhesion molecules with perineural spread of squamous cell carcinoma of the head and neck

Perineural spread (PNS) is a poor prognostic factor associated with increased risk of local recurrence and nodal metastasis and reduced survival of patients with squamous cell carcinoma of the head and neck (SCCHN). There is some evidence to indicate that neural cell adhesion molecules (NCAMs) may play a role in PNS of a variety of tumor types. We performed this study to investigate whether NCAM expression can be used as a predictor of PNS in SCCHN. The surgical specimens of 66 patients with SCCHN were evaluated with monoclonal IgG antibody immunoperoxidase staining for NCAM. Of the 41 specimens with PNS, 38 (93%) showed evidence of NCAM expression. In contrast, only 9 specimens (36%) without PNS expressed NCAMs. The difference in NCAM expression between the study and control groups was statistically significant ( P < 0.01).

Evaluation of the inferior and superior laryngeal nerve stumps for perineural spread in laryngeal cancer

Objective

Perineural spread (PNS) is an important risk factor for locoregional failure and is correlated with reduced survival rates in squamous cell carcinoma of the larynx. PNS may extend proximally and/or distally in the nerve sheath by leaving unin-volved nerve segments. This method of extension may preclude obtaining tumor-free surgical margins, which may be responsible for recurrent disease. The purpose of this study is to investigate the presence or absence of PNS in extralaryngeal superior and inferior laryngeal nerves in patients who underwent total laryngectomy for squamous cell carcinoma of the larynx.

METHODS

Extralaryngeal segments of superior and inferior laryngeal nerves were resected bilaterally during 15 consecutive laryngectomies. Laryngectomy specimens and the harvested proximal nerve segments were histopathologically examined for the presence or absence of PNS.

RESULTS

Ten of 15 laryngectomy specimens showed PNS; however, none of the extralaryngeal superior or inferior laryngeal nerve segments revealed perineural involvement.

CONCLUSION

Extralaryngeal extension of PNS is highly unlikely in squamous cell carcinoma of the larynx.

Prognostic significance of stromal eosinophilic infiltration in cancer of the larynx

OBJECTIVE: To investigate prevalence and possible role of tumor-associated tissue eosinophilia (TATE) as a prognostic factor in laryngeal squamous cell cancer.

STUDY DESIGN: Prospective case series.

METHODS: Seventy-eight consecutive patients with diagnosis of squamous cell carcinoma of the larynx and who were treated surgically in our center were evaluated. The possible role of TATE as a prognostic factor in laryngeal squamous cell cancer was investigated with respect to tumor differentiation, depth of invasion, perineural and vascular invasion (histopathological parameters), and neck metastasis (clinical parameter). The relation between presence of TATE and age was also examined.

RESULTS: TATE was positive in the tumors of 32% of the patients, including low grade, 20 (26%); medium grade, 4 (5%); and high grade, 1 (1%). The relationships between TATE and tumor differentiation, perineural invasion, vascular invasion, pathologic N stage, and depth of invasion were not statistically significant ( P >0.05). According to Spearman correlation analysis ( r = −0.383, P = 0.001), there is a negative correlation between TATE and age. Ages of TATE-positive patients tend to be clustered in the 5th and 6th decades of life, whereas the TATE-negative patients’ ages tend to be clustered in the 6th and 7th decades.

CONCLUSIONS: TATE has no correlation with prognostic parameters in laryngeal squamous cell cancer. Presence of TATE is highly correlated with age. Incidence of TATE is very low over the age of 60 years, and this may suggest that age influences the tissue inflammatory response to tumor. Further investigation is needed to explain the associations of TATE and age and also the host response to malignancy.

Role of perineural invasion as a prognostic factor in laryngeal cancer

The diffusion of laryngeal cancer cells in the perineural space is a parameter associated with a negative prognosis, high loco-regional recurrence and low disease-free survival rates. The spread of tumor cells on the perineural sheath highlights the histopathological and clinically aggressive behavior of this type of tumor, which may extend proximally or distally in the nerve for >10 cm. Therefore, the surgical resection margin is generally insufficient to treat patients with laryngeal cancer presenting with perineural invasion (PNI) with surgery alone. In PNI, the minor laryngeal nerves are frequently involved, rather than the superior and inferior laryngeal nerves. The aim of the present study was: i) To evaluate the prognostic importance of PNI; ii) to correlate the rate of infiltration with factors associated with the tumor, including histotype, site and tumor-node-metastasis stage, and with the type of surgery (total or partial laryngectomy); and iii) to evaluate the rate of disease-free survival according to the outcome of combined surgery and radiotherapy (RT) treatment, by means of retrospective analysis. The results of the present study highlighted the importance of performing a closer clinical and instrumental follow-up in patients with laryngeal cancer whose histopathological examination is positive for PNI. In such cases, it is important to complement the surgical therapeutic treatment with adjuvant RT.

The 100 Most Cited Turkish Papers in the Otorhinolaryngology Journals of Web of Science

Objective

The aim of the study was to analyze the 100 most cited publications with Turkish origin in the Web of Science Otorhinolaryngology (ORL) journals.

Methods

The Web of Science database was searched in terms of citations for publications originating from Turkey in ORL journals since 1983. After the identification of the 100 most cited articles, analysis was performed for the first author, institution, city, publication type, subject related to subspecialty, and journals having the most cited articles. Moreover, the number of ORL publications and citations of countries was determined in descending order using the same database.

Results

A total of 3948 ORL articles with Turkish origin was identified. The number of citations was 181 for the first and 28 for the last in the 100 most cited articles. As there was more than one article with 28 citations, 101 articles were analyzed. The number of the articles was 76, 22, and 3 for the university, education/research, and state hospitals, respectively. Hacettepe University, Ankara Numune Hospital, and Gazi University were the three leading institutions having the most cited articles, and Ankara was the first city. While 98 of 101 articles were original research, the number of case reports and review articles were 2 and 1, respectively. Thirty-five articles were related to otology, 23 to pediatric ORL, 20 to rhinology and head and neck surgery, and 3 to facial plastic surgery. Laryngoscope, Otolaryngology-Head and Neck Surgery, and International Journal of Pediatric Otorhinolaryngology were the leading 3 journals with the most cited articles coming from Turkey. The evaluation of countries revealed that Turkey was among the first 10 countries in terms of number of ORL articles but fell behind for the number of citations.

Conclusion

This bibliometric study is the first one regarding the contribution of Turkish authors and institutions to ORL literature. Similar studies might be periodically repeated to determine national development in the field of ORL and place of Turkey in the world.

Association of the Cylin D1 G870A polymorphism with laryngeal cancer: are they really related?

BACKGROUND

Cylin D1(CCDN1) is an important regulator of the cell cycle whose alterations are thought to be involved in cancer development. There have been many studies indicating CCDN1 amplification or over- expression in a variety of cancer types. In addition to gene amplification, the G870A polymorphism may be related with altered CCDN1 activity, and therefore with cancer development. This hypothesis has been tested in different cancer types but results have been contradictory. We therefore aimed to investigate any relationship between CCDN1 A870G genotypes and laryngeal squamous cell cancer development and progression.

MATERIALS AND METHODS

A total of 68 Turkish patients with primary laryngeal squamous cell cancer and 133 healthy controls were enrolled. Polymerase chain reaction-restriction fragment length polymorphism analysis was used to determine the CCDN1 genotypes.

RESULTS

No significant association was detected between CCDN1 genotypes and laryngeal squamous cell cancer (LxSCCa) development. Similarly CCDN1 genotypes were not related to clinical parameters of Lx SCCa. However, there was a very significant association between CCDN1 G allele and presence of perineural invasion (p= 0.003; OR: 1.464; CI% 1.073-1.999). CCDN1 G allele frequency was significantly higher in the individuals with perineural invasion (85.7%) when compared to those without (58.5%). The 2 patients who died of disease were both found to possess the GG genotype.

CONCLUSIONS

These results pose a controversy in suggesting a protective role of the G allele against LxSCCa development and support the association of CCDN1 gene GG genotype with mortality in patients with LxSCCa.

Oral carcinoma with perineural invasion has higher nerve growth factor expression and worse prognosis

BACKGROUND

This study elucidated the association between histopathological factors and the prognosis of oral carcinoma. As the histopathological factors were determined from the surgical specimen and this can only be used for the choices of postoperative regimens, this study also investigated the linkage between prognostic factors and the expression of key molecules to examine the feasibility of markers as predictors.

METHODS

Clinicopathological factors of 101 oral carcinomas were cross-analyzed with disease-free survival. The expression of nerve growth factor (NGF) and its receptor, tyrosine kinase A receptor, was assayed with immunohistochemistry.

RESULTS

Nodal metastasis was the most crucial clinical predictor for disease-free survival. Perineural invasion (PNI) was an independent histopathological predictor for both nodal metastasis (P = 0.004) and disease-free survival (P = 0.019). Patients with advanced tumor and PNI exhibited the high hazard for tumor progression and poor disease-free survival. NGF immunoreactivity in tumors was correlated with PNI (P = 0.005) and neck lymph node metastasis (P = 0.036).

CONCLUSION

Perineural invasion is the indicator of worst prognosis. As NGF immunoreactivity was found to be associated with PNI and nodal metastasis, the NGF immunoreactivity of oral carcinoma revealed by diagnostic biopsy suggests that alternative therapeutic approaches might be appropriate.

Direct skin involvement of cervical lymph node metastasis from mucosal squamous cell carcinoma of the head and neck

INTRODUCTION

Direct skin involvement of nodal metastasis from mucosal head and neck squamous cell carcinoma has traditionally been considered a poor prognostic indicator.

METHODS

This retrospective review identified eight patients (five with mucosal upper aerodigestive and three with occult primary squamous cell carcinoma) who presented between 2000 and 2007 with direct skin involvement of nodal metastasis.

RESULTS

Five patients were treated with extended radical and three with extended modified radical neck dissection. Closure was achieved directly (four cases), with local (two) or pedicled (two) flaps. Surgery was always followed by radiotherapy (pan-mucosal or to the primary site). The five-year recurrence-free and disease-specific survival rates were 100 per cent.

CONCLUSION

It is exceptionally rare to encounter direct skin involvement of metastatic lymph nodes from mucosal head and neck squamous cell carcinoma without evidence of involvement of other anatomical structures. Surgical intervention is possible and combined modality treatment with curative intent is essential, as most patients can have a favourable outcome.

Potential therapeutic target and independent prognostic marker of TROP2 in laryngeal squamous cell carcinoma

BACKGROUND

The human trophoblastic cell surface antigen 2 (TROP2) gene is associated with the development of malignancies, but its expression in laryngeal squamous cell carcinoma (SCC) and its relationship with clinical characteristics of the disease remain undetermined.

METHODS

Expression of TROP2 protein was detected by immunohistochemistry with a self-made anti-TROP2 antibody in laryngeal SCC tissue microarrays.

RESULTS

Elevated expression of TROP2 was detected in laryngeal SCC tissues compared with adjacent noncancerous tissues. TROP2 expression in laryngeal SCC was related to tumor differentiation (p = .0001) and lymph node metastasis (p = .0352). Cox regression analyses confirmed that TROP2 expression (p = .015), lymph node metastasis (p = .001), degree of differentiation (p = .002), tumor site (p = .021), and T classification (p = .003) were independent prognostic factors.

CONCLUSIONS

TROP2 can be used as an independent prognostic indicator for laryngeal SCC.

Identification and validation of gene expression models that predict clinical outcome in patients with early-stage laryngeal cancer

BACKGROUND

Despite improvement in therapeutic techniques, patients with early-stage laryngeal cancer still recur after treatment. Gene expression prognostic models could suggest which of these patients would be more appropriate for testing adjuvant strategies.

MATERIALS AND METHODS

Expression profiling using whole-genome DASL arrays was carried out on 56 formalin-fixed paraffin-embedded tumor samples of patients with early-stage laryngeal cancer. We split the samples into a training and a validation set. Using the supervised principal components survival analysis in the first cohort, we identified gene expression profiles that predict the risk of recurrence. These profiles were then validated in an independent cohort.

RESULTS

Gene models comprising different number of genes identified a subgroup of patients who were at high risk of recurrence. Of these, the best prognostic model distinguished between a high- and a low-risk group (log-rank P<0.005). The prognostic value of this model was reproduced in the validation cohort (median disease-free survival: 38 versus 161 months, log-rank P=0.018), hazard ratio=5.19 (95% confidence interval 1.14-23.57, P<0.05).

CONCLUSIONS

We have identified gene expression prognostic models that can refine the estimation of a patient's risk of recurrence. These findings, if further validated, should aid in patient stratification for testing adjuvant treatment strategies.

The oncologic radicality of supracricoid partial laryngectomy with cricohyoidopexy in the treatment of advanced N0-N1 laryngeal squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

The aim of the study was to evaluate the oncologic outcome of our series of advanced laryngeal squamous cell carcinomas, primarily treated by supracricoid laryngectomy with cricohyoidopexy or total laryngectomy, to compare the two therapeutic modalities.

STUDY DESIGN

Retrospective controlled study.

METHODS

We retrospectively reviewed the medical files, operative charts, and pathology reports of 83 patients who underwent total laryngectomy or supracricoid laryngectomy with cricohyoidopexy between February 1999 and March 2009. We only included cases in which both surgical treatments were feasible. Endpoints included local control, locoregional control, overall survival, and disease-specific survival.

RESULTS

When we stratified the patients according to T stage, no statistically significant differences emerged in terms of overall and disease-specific survival. When we compared total laryngectomy to cricohyoidopexy in N1 patients, 3-year overall survival and disease-specific survival differences were statistically relevant (P = .022 and P = .030, respectively).

CONCLUSIONS

Total laryngectomy warranted better results in term of overall and disease-specific survival, although the differences were not statistically significant. Local and locoregional control in the two treatment groups were overlapping, showing that cricohyoidopexy (when technically feasible) could be a valid surgical option in selected advanced laryngeal squamous cell carcinoma.

Perineural invasion of the major and minor nerves in laryngeal and hypopharyngeal cancer

OBJECTIVE: To investigate the perineural invasion in patients with squamous cell carcinoma of the larynx and hypopharynx.

STUDY DESIGN: A prospective study of patients with laryngeal and hypopharyngeal squamous cell carcinoma who underwent total or partial laryngectomy.

METHODS: Patients with squamous cell carcinoma of the larynx and pyriform sinus who underwent laryngectomy between 2002 and 2006 in the ENT Clinic of Cluj-Napoca were investigated for histopathological identification of perineural invasion.

RESULTS: The present study included 256 patients. Perineural invasion was present in 86 cases out of the 256. Perineural invasion was detected in the major nerves of only one case out of 219 patients who had undergone total laryngectomy. The difference between the mean disease-free survival of patients with or without perineural invasion of the minor nerves was statistically significant (Mann-Whitney U test, P = 0.000102). The local recurrence rates in the cases with or without perineural invasion were significantly different (log-rank test, P = 0.00001).

CONCLUSION: Major nerves do not constitute a way of spreading in the squamous cell carcinoma of the larynx and hypopharynx, whereas minor nerves remain a potential one.

Clinical relevance of ceramide metabolism in the pathogenesis of human head and neck squamous cell carcinoma (HNSCC): attenuation of C(18)-ceramide in HNSCC tumors correlates with lymphovascular invasion and nodal metastasis

It has been documented previously that defects in the generation of C(18)-ceramide, a product of ceramide synthase 1 (CerS1), also known as longevity assurance gene 1 (hLASS1), play important roles in the pathogenesis and/or progression of HNSCC. However, whether altered levels of ceramide generation in HNSCC tumors have any clinical relevance remains unknown. In this study, the levels of endogenous ceramides were measured in tumor tissues of 45 HNSCC patients as compared to their normal tissues using high-pressure liquid chromatography/mass spectrometry (LC/MS), and then possible link between ceramide levels and the clinical parameters of HNSCC were examined. The data showed that the levels of C(16)-, C(24)-, C(24:1)-ceramides were significantly elevated in the majority of tumor tissues compared to their normal tissues, while the levels of only C(18)-ceramide were significantly decreased in HNSCC tumors, especially in tumor tissues of male patients. Importantly, it was also shown here that decreased C(18)-ceramide levels in HNSCC tumor tissues were significantly associated with the higher incidences of lymphovascular invasion, and pathologic nodal metastasis. Importantly, attenuation of C(18)-ceramide was also positively linked to the higher overall stages of the primary HNSCC tumors. Therefore, these data suggest, for the first time, that the defects in the generation/accumulation of C(18)-ceramide might have important clinical roles in HNSCC, especially in lymphovascular invasion and nodal disease.

Perineural and vascular invasion in oral cavity squamous carcinoma: increased incidence on re-review of slides and by using immunohistochemical enhancement

CONTEXT

Perineural invasion and vascular invasion may be adverse prognostic factors in patients with oral cavity squamous cell carcinoma. However, the incidence of perineural and vascular invasion varies in the literature, and the use of immunohistochemistry to enhance their detection has not been evaluated in oral cavity squamous cell carcinomas.

OBJECTIVE

To determine if the previously assessed incidence of perineural and vascular invasion in cases of oral cavity squamous cell carcinoma would be increased by re-review of the original routinely hematoxylin-eosin-stained sections as well as review of slides stained immunohistochemically with S100 and CD31 to enhance visualization of nerves and vessels.

DESIGN

Forty cases of oral cavity squamous cell carcinoma in which the status of perineural and vascular invasion had been part of the original pathology report were reviewed. All original routinely stained slides were reviewed as well as S100- and CD31-stained sections of each case's tissue blocks that contained tumor.

RESULTS

Perineural invasion was identified in 30% (12/ 40) of tumors in the original reports, 62% (25/40) of the authors' re-review of the same slides, and 82% (33/40) when cases were stained with S100. Vascular invasion was identified in 30% (12/40) of tumors in the original reports, 35% (14/40) of the authors' re-review of the same slides, and 42% (17/40) when cases were stained with CD31. False-positive and false-negative results were common in the original reports. The number of foci of both types of invasion was related to its discovery in the original reports. Vascular invasion, but not perineural invasion, was significantly associated with death at 5-year follow-up.

CONCLUSIONS

Although careful re-review of routinely stained slides will detect a significant number of cases of perineural and vascular invasion, immunohistochemical enhancement further improves the accuracy of the determination.

Total Pharyngolaryngectomy for Squamous Cell Carcinoma of the Hypopharynx: A Review

OBJECTIVES

To evaluate our experience with total pharyngolaryngectomy in the treatment of hypopharyngeal squamous cell carcinoma.

STUDY DESIGN

Retrospective analysis of consecutively treated patients in an academic otolaryngology, head and neck department.

METHODS

One hundred eighty patients who had total pharyngolaryngectomy performed for hypopharyngeal carcinoma were included in this study. Patients with a history of previous head and neck cancer were excluded. Clinicopathologic parameters were recorded and survival calculated using the Kaplan-Meier method.

RESULTS

One hundred sixty-two (90%) of the patients were male, and the patients had a mean age of 62 years. The majority (91%) of patients had advanced overall clinical stage disease (stage 3,4). Thirty-one (17.8%) and 43 (24%) patients developed locoregional and metastatic disease recurrence, respectively. The 2- and 5-year disease-specific survival rates were 72% and 52%, respectively. Advanced nodal stage, perineural invasion, lymphovascular invasion, and positive margins were predictors of poor survival on univariate analysis, and lymphovascular invasion was an independent prognostic factor on multivariate analysis.

CONCLUSION

Surgery and postoperative radiotherapy remains the treatment against which other modalities should be compared for advanced stage hypopharyngeal squamous cell carcinoma.

Prognostic significance of Langerhans cell infiltration in cancer of the larynx

OBJECTIVE

Determine the effect on prognosis of Langerhans cell infiltration in cancer of the larynx.

STUDY DESIGN AND SETTING

Retrospective review of 72 surgically treated patients with T1-3 lesions. The streptavidin-biotin method to determine Langerhans cell infiltration, which was graded as 1+, 2+, and 3+.

RESULTS

A higher degree of Langerhans cell infiltration was significantly associated with less cervical lymph node metastasis, longer disease-free survival, less locoregional recurrence, and less clinical N-positivity ( P < 0.05). According to multivariant analysis, Langerhans cell infiltration was independently related to disease-free survival and recurrence ( P < 0.05).

CONCLUSIONS

Langerhans cell infiltration is prognostically important in cancer of the larynx. More intense infiltration is significantly related to prolonged disease-free survival, less locoregional recurrence, less cervical lymph node metastasis, and less clinical N-positivity.

SIGNIFICANCE

Langerhans cell infiltration may be determined on a biopsy specimen and this information may be useful in deciding about elective neck dissection. Patients with mild infiltration may have a higher risk of locoregional recurrence, shorter disease-free survival, and therefore they suggest a poor prognosis.

Clinical and molecular prognostic factors in operable laryngeal cancer

Many factors affect the prognosis in operable laryngeal squamous cell carcinoma (LSCC). Many clinical factors have been implicated in tumor recurrence and poor survival of the patients. The aim of the present study is to investigate the demographic, clinical and histological characteristics as prognostic factors. Moreover, our aim is to analyze the role of modern molecular biomarkers in the prognosis of patients with LSCC. One hundred patients with operable laryngeal carcinoma underwent surgery as primary treatment between April 1999 and April 2002. Ninety-four of them were men and 6 women, with a median age of 62 years (39-77). All demographic data of the patients were recorded. Staging of the tumor revealed 20 cases with T2 cancer, 46 cases with T3 and 34 cases with T4, while N classification included 91 patients with N0 tumor, 3 with N1 and 6 with N2. Among the 100 cases, 47 were located in the glottis, 46 in the supraglottic region and 7 were transglottic. Histology grading revealed 35 cases of grade G1, 50 cases of G2 and 15 cases of G3. Postoperatively, all patients were followed regularly for the possibility of tumor relapse, with a median follow-up period of 40.2 months (4.8-58.4). During the operation, a tissue specimen was collected from the tumor. The specimens were used for RNA and DNA extraction. Isolated RNA was used to investigate the expression of wt-p53, bcl-2, VEGF and EGFR by the reverse transcriptase PCR method (RT-PCR) using specific primers, while genomic DNA was used for the detection of EBV and HPV (16/18 subtypes) by the consensus primer-mediated polymerase chain reaction method (PCR). All data such as tumor recurrence and survival were recorded. Statistical analysis was performed using the SPSS and STATA statistical packages in order to investigate the role of all clinical and molecular factors and their combinations as significant prognostic markers. The tumor recurrence rate was 31%, while the tumor associated death rate was 27% and total death rate 30%. Univariate analysis for overall survival showed significance for the T stage, TNM stage and site of the tumor. Univariate analysis for the time to progression showed significance for the T stage, N stage, TNM stage, site of the tumor and tumors simultaneously positive for EGFR and VEGF, while EGFR expression was borderline insignificant. Multivariate analysis revealed TNM stage as the only significant factor for overall survival, and TNM stage, site of the tumor and EGFR expression as significant factors for time to progression. The molecular biomarkers EGFR and VEGF have a prognostic significance in laryngeal cancer in addition to the established clinical prognostic factors such as the stage and site of the tumor. These markers, apart from their role in carcinogenesis, seem to play an important role in tumor relapse.

c-met overexpression in supraglottic laryngeal squamous cell carcinoma and its relation to lymph node metastases

BACKGROUND

The c-met oncogene encodes the receptor for the hepatocyte growth factor/scatter factor (HGF/SF), which is known to have the effects of stimulation of cell motility, dissociation of epithelial sheets, invasion of cellular matrix, and induction of angiogenesis. Many studies in solid tumors have indicated a role for c-met and HGF/SF in the progression of the disease.

METHODS

The expression of c-met in tissue specimens was studied by immunohistochemical examination in 60 patients with supraglottic laryngeal squamous cell carcinoma. Patients were chosen such that there were 30 with lymph node metastases in the neck and 30 without metastases. TNM staging, differentiation, lymphovascular and perineural invasion, and growth pattern for tumors were also recorded, and their relation to lymph node metastases was analyzed.

RESULTS

Overexpression of c-met was observed in 90% of the cases at the primary site and in 83% of the cases with lymph node metastases in the neck. Lymphovascular invasion (P = 0.005) and the N stage (P = 0.001) were found to be related to lymph node metastases, but other variables-c-met overexpression, the T stage, perineural invasion, and growth pattern-were found to have no relation to lymph node metastases in multivariate analysis of the data with linear regression.

CONCLUSIONS

c-met overexpression is observed in both the primary site and the neck in supraglottic laryngeal squamous cell carcinoma. We believe that it may have a role in the progression of malignancy, but we were unable to find a definite relation between c-met expression and lymph node metastases.

Prognostic significance of perineural invasion in oral and oropharyngeal carcinoma

OBJECTIVE

To evaluate the occurrence and prognostic significance of perineural invasion (PNI) in squamous cell carcinomas (SCC) of the oral cavity and oropharynx.

STUDY DESIGN

A retrospective study of 101 patients with previously untreated SCC of the oral cavity and oropharynx was undertaken to evaluate the occurrence and prognostic significance of PNI in relation to local recurrence, regional recurrence, distant metastasis and survival. The logistic regression test was used for univariate and multivariate analyses. Actuarial survival curves were determined using the Kaplan-Meier method.

RESULTS

PNI was present in 26 (25.7%) of 101 patients and was significantly associated with tumor differentiation, lymph node metastasis, and depth of invasion. Univariate analyses showed PNI was associated with local recurrence (P=.005), regional recurrence (P=.007), and distant metastasis (P=.013). In multivariate analysis, PNI was significantly associated with regional recurrence (P=.033) and distant metastasis (P=.021), but not with local recurrence (P=.109). The 5-year disease-specific survival for patients with and without PNI was 56.6% and 94.6%, respectively (P<.0001).

CONCLUSION

PNI is an important predictor for outcome of patients with SCC of the oral cavity and oropharynx.

The relationship between tumor thickness and clinical and histopathologic parameters in cancer of the larynx

OBJECTIVES

We sought to determine the relationship of tumor thickness to clinical and histopathologic parameters in laryngeal cancer. Study design and setting We conducted a retrospective review of laryngectomy specimens of 111 surgically treated T1-3 laryngeal cancer patients for tumor thickness and various histopathologic parameters.

RESULTS

Tumor thickness was significantly related to T, N, and clinical stage; pathologic cervical lymph node metastasis; cartilage invasion; microscopic appearance; mode of invasion to surrounding tissues; perineural invasion; and lymphocytic infiltration (P < 0.05). Tumor thickness had significant correlation with T, N, and clinical stage; cervical lymph node metastasis; cartilage invasion; mode of invasion to surrounding tissues; perineural invasion; and lymphocytic infiltration (P < 0.05). Multifactorial statistical analysis showed that cartilage invasion and lymphocytic infiltration significantly determined tumor thickness independently (P < 0.05).

CONCLUSION

Tumor thickness is well correlated to most of the reliable clinical and histopathologic parameters, and it is an objective and easy-to-obtain measure.

SIGNIFICANCE

Tumor thickness can be used as a reliable histopathological factor and should be measured in every laryngectomy specimen.

Cervical node metastases in squamous cell carcinoma of the upper aerodigestive tract: the significance of extracapsular spread and soft tissue deposits

BACKGROUND

Literature regarding the prognostic significance of extracapsular spread and soft tissue deposits in cervical lymph node metastases of squamous cell carcinoma of the upper aerodigestive tract shows variable results.

METHODS

We analyzed 215 prospectively collected neck dissections from 155 patients with upper aerodigestive tract squamous cell carcinoma to assess the prevalence of extracapsular spread and soft tissue deposits and to assess their effect on survival.

RESULTS

Both extracapsular spread and soft tissue deposits significantly reduced survival (actuarial and recurrence free) compared with pN0 necks (p <.001) and pN+ve necks without extracapsular spread (p <.0025). There was no statistically significant difference between pN+ve necks without soft tissue deposits or extracapsular spread compared with those with pN0 necks (p =.24). Multivariate analysis revealed comparable results.

CONCLUSIONS

Microscopic and macroscopic extracapsular spread and soft tissue deposits are of prognostic significance for survival and recurrence-free survival in patients with upper aerodigestive tract squamous cell carcinoma.

Correlation of neural cell adhesion molecules with perineural spread of squamous cell carcinoma of the head and neck

Perineural spread (PNS) is a poor prognostic factor associated with increased risk of local recurrence and nodal metastasis and reduced survival of patients with squamous cell carcinoma of the head and neck (SCCHN). There is some evidence to indicate that neural cell adhesion molecules (NCAMs) may play a role in PNS of a variety of tumor types. We performed this study to investigate whether NCAM expression can be used as a predictor of PNS in SCCHN. The surgical specimens of 66 patients with SCCHN were evaluated with monoclonal IgG antibody immunoperoxidase staining for NCAM. Of the 41 specimens with PNS, 38 (93%) showed evidence of NCAM expression. In contrast, only 9 specimens (36%) without PNS expressed NCAMs. The difference in NCAM expression between the study and control groups was statistically significant (P < 0.01).

Laryngeal long-term morbidity after supraglottic laryngectomy and postoperative radiation therapy

PURPOSE

This study was performed to investigate factors associated with laryngeal morbidity when postoperative radiation therapy (RT) is added to supraglottic laryngectomy.

MATERIALS AND METHODS

From 1980 to 1994, 56 patients affected with T1 to 4 N0 to 2c supraglottic squamous cell carcinoma selected for standard (59%) or extended (41%) supraglottic laryngectomy at 2 different institutions were retrospectively analyzed. Most of the patients (91%) also underwent neck dissection. Approximately 80% of the patients had stage T4 primary lesions or N2 neck disease. Postoperative RT was added for presumed microscopic disease at the primary site (13 patients), regional nodes (23 patients), or both (20 patients). Median delivered doses to the larynx and to the neck were 50 Gy (range, 40 to 64 Gy) and 46 Gy (range, 40 to 64 Gy), respectively. Median follow-up for living patients is 11 years (range, 2.8 to 16.9 years). Laryngeal complication was defined as the appearance of grade 2 or higher toxicity according to the European Organization for Research and Treatment of Cancer (EORTC) and the Radiation Therapy Oncology Group (RTOG) scoring systems.

RESULTS

Two- and 5-year actuarial locoregional control rates were 85+/-5% and 83+/-5%, respectively. Thirty patients (54%) developed laryngeal complications. However, just one patient experienced grade 4 laryngeal oedema requiring permanent tracheostomy. Estimated actuarial survival without laryngeal complications were 50+/-7%, 43+/-7%, and 39+/-7% at 2, 5, and 10 years, respectively. At univariate analysis, treated volumes (P = .03) and total dose to the larynx (P = .03) were significantly associated with local toxicity. A trend was observed also for the maximum dose to the neck (P = .06) and dose per fraction (P = .09). A multivariate Cox proportional hazards model showed total dose to the larynx to be the only independent predictor of toxicity (P = .03). The hazard ratio of laryngeal toxicity was 2.2 (95% confidence interval: 1.1/4.6), for a total dose to the larynx greater than 50 Gy.

CONCLUSION

After supraglottic laryngectomy, postoperative RT to the neck does not affect local morbidity, but careful RT treatment planning is necessary to avoid delivering a total dose to the larynx greater than 50 Gy.