Curative radiotherapy for stage II-III squamous cell carcinoma of the glottic larynx

Hyperfractionated Radiotherapy for T2N0 Glottic Carcinoma: A Retrospective Analysis at 10 Years Follow-up in a Series of 60 Consecutive Patients

Aims and background

To report results of hyperfractionated radiotherapy for T2N0 glottic carcinoma at a single institution after extended follow-up.

Methods

Between 1980 and 1988 at Varese University Hospital, 60 consecutive patients with T2N0 glottic carcinoma received exclusive radiotherapy consisting of 1.5 Gy/fraction twice a day. Treatment gaps during the radiotherapy course were allowed according to individual tolerance. This policy resulted in a wide range of elapsed treatment time: median, 5.7 weeks; range, 3.7-8.9. Median follow-up is 9.8 years.

Results

As a result of dose/time distribution, 16, 20 and 24 patients received an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week or >10 Gy/week, respectively. Mean total dose for each group was 62.8 Gy, 63.7 Gy and 63.8 Gy, respectively. Five-year local-regional control was 69 ± 6% (95% Cl); ultimate local-regional control, including salvage surgery, was 78 ± 5%. All failures were at the primary site, and no patient developed neck recurrence as first site of failure. The actuarial incidence of grade 2-3 late reactions at 5 years was 42 ± 6%. Most late toxicity events were grade 2: only 2 patients developed grade 3 reactions and none grade 4. None of the several clinical and treatment-related variables showed any statistically significant impact on local-regional control or late toxicity at univariate and multivariate analysis. In particular, 3-year local-regional control rates were 73 ± 11%, 84 ± 8% and 69 ± 10% for an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week and >10 Gy/week, respectively (not significantly different).

Conclusions

At a very long follow-up, the hyperfractionated regimen tested in the study was shown to be effective and devoid of major complications, provided individual patient acute tolerance is carefully taken into account. Also, time factor did not affect outcome in this series.

Transoral laser microsurgery versus radiotherapy for T2 glottic squamous cell carcinoma: a systematic review of local control outcomes

BACKGROUND

Systematic reviews comparing treatment of early glottic cancer with transoral surgery or radiotherapy demonstrate similar oncological outcomes. Most studies of 'early-stage' laryngeal cancer include Tis, T1a, T1b and T2 cases. The data are dominated by patients with T1 and Tis tumours, although extrapolating these results and applying them for T2 cases may be inappropriate. No previous systematic reviews have focused on T2 cancers as a separate group.

OBJECTIVE OF REVIEW

This review compares local control outcomes for T2 glottic squamous cell carcinoma, treated with transoral microsurgery or external beam radiotherapy.

TYPE OF REVIEW

This is a systematic review of case series and comparison studies, focusing on oncological outcomes.

SEARCH STRATEGY

Independent searches of MEDLINE, EMBASE and the Cochrane Database were conducted by two authors, using the search terms: laryngeal/glottic/vocal cord combined with carcinoma/cancer/tumour and laser/microsurgery or radiotherapy. Studies of adult patients treated for primary T2N0 glottic squamous cell carcinoma (SCC) with laser surgery or curative radiotherapy were included.

EVALUATION METHOD

Full text of studies satisfying the inclusion criteria were reviewed with extraction of local control and survival data and laryngeal preservation rates. The primary endpoint is local control at 5 years.

RESULTS

Initial searches identified 3252 studies. Following full-text review of 183 papers, 59 studies met the inclusion criteria, all level IV evidence. A total of 48 studies specified 5-year local control for 1156 patients treated with transoral laser surgery and 3191 patients treated with radiotherapy. Weighted averages of local control at 5 years demonstrated similar results: 75.81% for radiotherapy versus 77.26% for transoral laser surgery.

CONCLUSIONS

The results of this review indicate no difference in 5-year local control between radiotherapy and transoral surgery for T2 glottic SCC. The data demonstrated higher rates of local failure for T2b compared with T2a cases, although outcomes were similar between laser excision and radiotherapy for each substage. Further research focusing upon functional outcomes for T2 glottic tumours is imperative to guide decision-making, ideally with subgroup analysis of T2a and T2b cases.

Endoscopic Treatment of cT2 Glottic Carcinoma: Prognostic Impact of Different pT Subcategories

Objectives:

The cT2 glottic squamous cell carcinomas are a heterogeneous group of lesions in terms of superficial and deep extension. As a consequence, they differ greatly in treatment indications and prognosis. The aim of the present study was to divide cT2 glottic tumors into subcategories according to radiologic and postoperative histopathologic information, in order to identify risk factors connected with determinate survival, local-regional control, and laryngeal preservation rates.

Methods:

We retrospectively analyzed 55 cT2 glottic lesions treated at a single institution by carbon dioxide laser with at least 2 years of follow-up. Clinical, radiologic, surgical, and histopathologic data were reviewed, and the tumors were accordingly divided into 5 subcategories: I, or pT2 with lateral supraglottic extension (19 patients); II, or pT2 with lateral subglottic extension (6 patients); III, or pT2 with supracommissural and/or subcommissural extension (10 patients); IV, or pT2 with deep vocal muscle infiltration (14 patients); and V, or pT3, for superior and/or inferior paraglottic space invasion lateral to the thyroarytenoid muscle not detected before operation by computed tomographic scan (6 patients).

Results:

The disease-free survival, ultimate local control with laser alone, and laryngeal preservation rates were compared for each subcategory. Statistically significant differences were found only for the pT3 subgroup (2-year rates of 16.7%, 16.7%, and 16.7% for pT3 versus 5-year rates of 80.5%, 84.7%, and 93.3% for the entire pT2 group).

Conclusions:

Endoscopic treatment of cT2 glottic tumors can be considered effective when the pT2 stage has been confirmed. In cT2/pT3 patients, after the first endoscopic resection that allows the correct pT staging, additional treatment should always be considered.

FDG PET with contrast-enhanced CT: a critical imaging tool for laryngeal carcinoma

Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has evolved to be an essential imaging modality in the evaluation of laryngeal carcinoma. Although the modality has limited utility in assessing the extent of the primary tumor, FDG PET has proved to be superior to anatomic modalities in the detection of lymph node and distant metastases. The role of FDG PET in the evaluation of patients with laryngeal tumors that are clinically classified as N0 has not shown consistent usefulness because of the innate resolution limitations of the camera. In the posttherapy setting, however, FDG PET has consistently demonstrated a high negative predictive value in the identification of recurrent disease, both during the course of therapy and during long-term follow-up. In addition, contrast material-enhanced computed tomography (CT) in conjunction with FDG PET has demonstrated a complementary role by allowing for superior anatomic coregistration and therefore more definitive diagnosis. There is sufficient evidence that with further advances in PET technology, this modality will likely become more useful in the detection of small lesions and occult nodal disease, as well as in guiding the management of laryngeal carcinoma.

Hyperfractionated radiotherapy for T2 glottic cancer for preservation of the larynx

To evaluate the effectiveness of hyperfractionation for T2 glottic cancer from a viewpoint of laryngeal preservation, we analyzed 21 patients (twice-a-day group) who were treated with hyperfractionation between 1992 and 1998 and compared the results with those of 27 patients (once-a-day group) treated with conventional once-a-day radiation between 1987 and 1992. In the twice-a-day group, radiation was performed with two fractions of 1.2 Gy/day up to a total dose of 72-74.4 Gy. In the once-a-day group, radiation was performed with a fraction of 2 Gy/day up to a total dose of 66 Gy. If radiation was ineffective at 40 Gy, it was stopped, and surgical treatment was carried out. Kaplan-Meier estimates were used for the analysis of the survival rate and laryngeal preservation rate, and the results were compared. In the once-a-day group, the 5-year survival rate was 92.3%. The 5-year laryngeal preservation rate was 51.8%, and it was 60.3% in 20 patients who had undergone full-dose radiation (once-a-day full-dose group). In the twice-a-day group, no major complication, such as laryngeal necrosis, was seen in any case, and the 5-year survival rate was 95.3%. The 5-year laryngeal preservation rate was 95.3%, and it was significantly better than that of both the once-a-day group and the once-a-day full-dose group. Hyperfractionation is considered to be useful for preserving the larynx for the treatment of T2 glottic cancer.

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.

Local recurrences following transoral laser surgery for early glottic carcinoma: frequency, management, and outcome

Although transoral laser surgery (TLS) for the treatment of early stage glottic carcinoma is now widely used, the patterns of local recurrences, related re-treatment methods, and results have not been documented comprehensively. Two hundred fifty-two patients with glottic carcinoma stage I or II were treated for cure with TLS alone and followed up for 24 to 139 months (mean, 62 months). Their charts were retrospectively reviewed to identify local recurrence patterns. Thirty-five patients (13.9%) presented with local recurrences or second laryngeal primaries 4 to 84 months (mean, 23 months) after initial treatment. Of the 161 patients classified T1N0M0, 21 (13.0%) suffered local recurrences, and in the 91 classified T2N0M0, 14 (15.4%) tumors recurred. If tumors recurring more than 60 months after initial treatment are considered second primary tumors rather than recurrences, then only 18 (11.2%) of 161 patients classified T1N0M0 would have had a recurrence. However, the difference in local control between patients with stage I versus stage II disease would still not be significant (p = .41). Of the 35 patients with local recurrences, 16 (45%) were managed with total laryngectomy, 10 (28.6%) with further TLS, 4 (11.4%) with partial laryngectomy, and 2 (5.7%) with radiotherapy, and 3 (8.6%) had no curative treatment. Accordingly, 16 patients (45.7%) with local treatment failure could be treated with further organ-sparing treatment methods. The actuarial overall survival, disease-specific survival, and organ preservation rates 5 years after the diagnosis of recurrent disease were 43.6%, 74.6%, and 33.7%. Transoral laser surgery leads to local control rates that are comparable to those found after radiotherapy for lesions classified T1 and leads to slightly better control rates for lesions classified T2, but the results are inferior to those achieved with conventional partial laryngectomy. However, if local recurrence occurs, then more re-treatment options are available after TLS as compared to initial radiotherapy or open surgery.