Organ Preservation for Advanced Larynx Cancer: Issues and Outcomes

Oncological and functional outcomes in T3 and T4 laryngeal cancer patients: choice for larynx preservation or total laryngectomy based on expected laryngeal function

OBJECTIVE

To determine oncological and functional outcomes in patients with T3 and T4 laryngeal carcinoma, in which choice of treatment was based on expected laryngeal function and not T classification.

METHODS

Oncological outcomes (disease-specific survival and overall survival) as well as functional outcomes (larynx preservation and functional larynx preservation) were analysed.

RESULTS

In 130 T3 and 59 T4 patients, there was no difference in disease-specific survival or overall survival rates after radiotherapy (RT) (107 patients), chemoradiotherapy (36 patients) and total laryngectomy (46 patients). The five-year disease-specific survival rates were 83 per cent after RT, 78 per cent after chemoradiotherapy and 69 per cent after total laryngectomy, whereas overall survival rates were 62, 54 and 60 per cent, respectively. Five-year larynx preservation and functional larynx preservation rates were comparable for RT (79 and 66 per cent, respectively) and chemoradiotherapy (86 and 62 per cent, respectively).

CONCLUSION

There is no difference in oncological outcome after (chemo)radiotherapy or total laryngectomy in T3 and T4 laryngeal carcinoma patients whose choice of treatment was based on expected laryngeal function.

Swallowing after total laryngectomy surgery: where are we after 150 years?

Purpose of review

Recent findings

Dysphagia is a common sequela following total laryngectomy surgery; however, there is significant variability in its assessment and management. Manometry enables an accurate understanding of the underlying mechanism of dysphagia and precise assessment of any oesophageal dysfunction. EndoFLIP is a useful tool to better understand dysfunction of the upper oesophageal sphincter particularly to detect stricture.

Summary

Following total laryngectomy surgery, dysphagia is common; clinicians need to be alert to early indicators of dysfunction and understand the tools to comprehensively characterize swallow function. Accurate diagnosis of a stricture is important, as this aspect of dysfunction can be modified, and may alleviate surrogate problems such as a leaking voice prosthesis. Clinicians should have a low threshold to examine patients for oesophageal dysfunction due to the high prevalence of dysmotility following a laryngectomy.

Decisional Conflict in Patients with Advanced Laryngeal Carcinoma: A Multicenter Study

OBJECTIVES

Decision-making for patients with a locally advanced laryngeal carcinoma (T3 and T4) is challenging due to the treatment choice between organ preservation and laryngectomy, both with different and high impact on function and quality of life (QoL). The complexity of these treatment decisions and their possible consequences might lead to decisional conflict (DC). This study aimed to explore the level of DC in locally advanced laryngeal carcinoma patients facing curative decision-making, and to identify possible associated factors.

METHODS

In this multicenter prospective cohort study, participants completed questionnaires on DC, level of shared decision-making (SDM), and a knowledge test directly after counseling and 6 months after treatment. Descriptive statistics and Spearman correlation tests were used to analyze the data.

RESULTS

Directly after counseling, almost all participants (44/45; 98%) experienced Clinically Significant DC score (CSDC >25, scale 0-100). On average, patients scored 47% (SD 20%) correct on the knowledge test. Questions related to radiotherapy were answered best (69%, SD 29%), whilst only 35% (SD 29%) of the questions related to laryngectomy were answered correctly. Patients' perceived level of SDM (scale 0-100) was 70 (mean, SD 16.2), and for physicians this was 70 (SD 1.7).

CONCLUSION

Most patients with advanced larynx cancer experience high levels of DC. Low knowledge levels regarding treatment aspects indicate a need for better patient counseling.

LEVEL OF EVIDENCE

Level IV Laryngoscope, 2024.

The usefulness of machine-learning-based evaluation of clinical and pretreatment 18F-FDG-PET/CT radiomic features for predicting prognosis in patients with laryngeal cancer

OBJECTIVE

To examine whether machine learning (ML) analyses involving clinical and 18F-FDG-PET-based radiomic features are helpful in predicting prognosis in patients with laryngeal cancer.

METHODS

This retrospective study included 49 patients with laryngeal cancer who underwent18F-FDG-PET/CT before treatment, and these patients were divided into the training (n = 34) and testing (n = 15) cohorts.Seven clinical (age, sex, tumor size, T stage, N stage, Union for International Cancer Control stage, and treatment) and 40 18F-FDG-PET-based radiomic features were used to predict disease progression and survival. Six ML algorithms (random forest, neural network, k-nearest neighbors, naïve Bayes, logistic regression, and support vector machine) were used for predicting disease progression. Two ML algorithms (cox proportional hazard and random survival forest [RSF] model) considering for time-to-event outcomes were used to assess progression-free survival (PFS), and prediction performance was assessed by the concordance index (C-index).

RESULTS

Tumor size, T stage, N stage, GLZLM_ZLNU, and GLCM_Entropy were the five most important features for predicting disease progression.In both cohorts, the naïve Bayes model constructed by these five features was the best performing classifier (training: AUC = 0.805; testing: AUC = 0.842). The RSF model using the five features (tumor size, GLZLM_ZLNU, GLCM_Entropy, GLRLM_LRHGE and GLRLM_SRHGE) exhibited the highest performance in predicting PFS (training: C-index = 0.840; testing: C-index = 0.808).

CONCLUSION

ML analyses involving clinical and 18F-FDG-PET-based radiomic features may help predict disease progression and survival in patients with laryngeal cancer.

ADVANCES IN KNOWLEDGE

ML approach using clinical and 18F-FDG-PET-based radiomic features has the potential to predict prognosis of laryngeal cancer.

Incidence of Post Total Laryngectomy Hypothyroidism: Effects of Thyroid Gland Surgery and Post-Operative Radiotherapy

To record the incidence of hypothyroidism in patients after total laryngectomy, whether with or without postoperative radiation therapy and to analyze the effect of hemithyroidectomy for the development of hypothyroidism. A retrospective study included patients who underwent total laryngectomy (with or without hemithyroidectomy) between 2018 and 2021 for laryngeal carcinoma and/or received postoperative radiotherapy. Thirty-six (45%) of the 80 enrolled patients developed hypothyroidism after a median follow-up of 16 months. In this study, adjuvant radiation and central neck dissection were found to be significantly linked with developing post-operative hypothyroidism (p values: 0.001, 0.007, respectively). The incidence of hypothyroidism in patients treated for laryngeal carcinoma is high, especially after combination treatment of surgery and radiotherapy.

The relation between hypoxia and proliferation biomarkers with radiosensitivity in locally advanced laryngeal cancer

PURPOSE

Treatment decision-making in advanced-stage laryngeal squamous cell carcinoma (LSCC) is difficult due to the high recurrence rates and the desire to preserve laryngeal functions. New predictive markers for radiosensitivity are needed to facilitate treatment choices. In early stage glottic LSCC treated with primary radiotherapy, expression of hypoxia (HIF-1α and CA-IX) and proliferation (Ki-67) tumour markers showed prognostic value for local control. The objective of this study is to examine the prognostic value of tumour markers for hypoxia and proliferation on locoregional recurrent disease and disease-specific mortality in a well-defined cohort of patients with locally advanced LSCC treated with primary, curatively intended radiotherapy.

METHODS

In pre-treatment biopsy tissues from a homogeneous cohort of 61 patients with advanced stage (T3-T4, M0) LSCC primarily treated with radiotherapy, expression of HIF-1α, CA-IX and Ki-67 was evaluated with immunohistochemistry. Demographic data (age and sex) and clinical data (T- and N-status) were retrospectively collected from the medical records. Cox regression analysis was performed to assess the relation between marker expression, demographic and clinical data, and locoregional recurrence and disease-specific mortality.

RESULTS

Patients with high expression of HIF-1α developed significantly more often a locoregional recurrence (39%) compared to patients with a low expression (21%) (p = 0.002). The expression of CA-IX and Ki-67 showed no association with locoregional recurrent disease. HIF-1α, CA-IX and Ki-67 were not significantly related to disease-specific mortality. Clinical N-status was an independent predictor of recurrent disease (p < 0.001) and disease-specific mortality (p = 0.003). Age, sex and T-status were not related to locoregional recurrent disease or disease-specific mortality.

CONCLUSION

HIF-1α overexpression and the presence of regional lymph node metastases at diagnosis were independent predictors of locoregional recurrent disease after primary treatment with curatively intended radiotherapy in patients with locally advanced LSCC.

Survival Outcomes in T3 Laryngeal Cancers: Primary Total Laryngectomy vs. Concurrent Chemoradiation or Radiation Therapy-A Meta-Analysis

BACKGROUND

The management of cT3 laryngeal cancers remains controversial, with studies recommending surgical or non-surgical approaches. Despite the many papers that have been published on the subject, there is a lack of studies showing which treatment has better results in terms of survival.

OBJECTIVE

To determine the difference in survival outcomes following total laryngectomy (TL), concurrent chemoradiation (CRT) or radiation therapy (RT) alone in T3 laryngeal cancers.

METHODS

Search of PubMed, Scopus, and Google Scholar databases from 1995 to 2023 employing specific keywords and Boolean operators to retrieve relevant articles. Statistical analysis was conducted using a random-effects model, and heterogeneity was evaluated using the Q-test and I2 statistic. Funnel plot asymmetry was assessed using rank correlation and regression tests.

RESULTS

The qualitative data synthesis comprised 10,940 patients from 16 included studies. TL was performed in 2149 (19.4%), CRT in 6723 (61.5%), RT in 295 (2.7%), while non-surgical treatment was not specified in 1773 (16.2%) patients. The pooled 2-year overall survival (OS) rates were TL = 73%, CRT = 74.7%, RT = 57.9%, 3-year OS rates were TL = 64.3%, CRT = 62.9%, RT = 52.4%, and 5-year OS rates were TL = 54.2%, CRT = 52.7%, RT = 40.8%. There was a significant heterogeneity in the included studies. There was no statistically significant difference in 2-year OS (logOR= -0.88 (95% confidence interval (CI): -1.99 to 0.23), p = 0.12), 3-year OS (logOR = -0.6 (95% CI: -1.34 to 0.15), p = 0.11), and 5-year OS (logOR = -0.54 (95% CI: -1.29 to 0.21), p = 0.16) between TL and CRT. Instead, there was significant difference in 2-year OS (logOR= -1.2383 (95% CI: -2.1679 to -0.3087), p = 0.009), 3-year OS (-1.1262 (95% CI: -1.6166 to -0.6358), p < 0.001), and 5-year OS (-0.99 (95% CI: -1.44 to -0.53)), p < 0.001) between TL and RT alone.

CONCLUSIONS AND SIGNIFICANCE

TL followed with adjuvant (chemo)radiation on indication and CRT with salvage surgery in reserve appear to have similar OS outcomes. Both resulted in better OS outcomes compared to RT alone in the treatment of T3 laryngeal cancers. If patients are unfit for chemotherapy, making CRT impossible, surgery may become the choice of treatment.

Partial Laryngectomy for pT4a Laryngeal Cancer: Outcomes and Limits in Selected Cases

A large multi-institutional case series of laryngeal cancer (LC) T4a was carried out, including 134 cases treated with open partial horizontal laryngectomies (OPHL) +/- post-operative radiation therapy (PORT). The goal was to understand better whether OPHL can be included among the viable options in selected pT4a LC patients who refuse a standard approach, represented by total laryngectomy (TL) + PORT. All 134 patients underwent OPHL type I (supraglottic), II (supracricoid), or III (supratracheal), according to the European Laryngological Society Classification. Comparing clinical and pathological stages showed pT up-staging in 105 cases (78.4%) and pN up-staging in 19 patients (11.4%). Five-year data on overall survival, disease-specific survival, disease-free survival, freedom from laryngectomy, and laryngo-esophageal dysfunction-free survival (rate of patients surviving without a local recurrence or requiring total laryngectomy and without a feeding tube or a tracheostomy) were, respectively, 82.1%, 89.8%, 75.7%, 89.7%, and 78.3%. Overall, complications were observed in 22 cases (16.4%). Sequelae were observed in 28 patients (20.9%). No patients died during the postoperative period. This large series highlights the good onco-functional results of low-volume pT4a laryngeal tumors, with minimal or absent cartilage destruction, treated with OPHLs. The level of standardization of the indication for OPHL should allow consideration of OPHL as a valid therapeutic option in cases where the patient refuses total laryngectomy or non-surgical protocols with concomitant chemo-radiotherapy.

Swallowing Function After Treatment of Laryngeal Cancer

Dysphagia is a common functional outcome following treatment of laryngeal cancer. Despite curative advances in both nonsurgical and surgical approaches, preserving and optimizing swallowing function is critical. Understanding the nature and severity of dysphagia depending on initial tumor staging and treatment modality and intensity is crucial. This chapter explores current evidence on the acute and chronic impacts of treatments for laryngeal cancer on swallow function, as well as the medical and nonmedical management of dysphagia in this population.

Treating Head and Neck Cancer in the Age of Immunotherapy: A 2023 Update

Most patients diagnosed with head and neck squamous cell carcinoma (HNSCC) will present with locally advanced disease, requiring multimodality therapy. While this approach has a curative intent, a significant subset of these patients will develop locoregional failure and/or distant metastases. The prognosis of these patients is poor, and therapeutic options other than palliative chemotherapy are urgently needed. Epidermal growth factor receptor (EGFR) overexpression is an important factor in the pathogenesis of HNSCC, and a decade ago, the EGFR targeting monoclonal antibody cetuximab was approved for the treatment of late-stage HNSCC in different settings. In 2016, the anti-programmed death-1 (PD-1) immune checkpoint inhibitors nivolumab and pembrolizumab were both approved for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy, and in 2019, pembrolizumab was approved for first-line treatment (either as monotherapy in PD-L1 expressing tumors, or in combination with chemotherapy). Currently, trials are ongoing to include immune checkpoint inhibition in the (neo)adjuvant treatment of HNSCC as well as in novel combinations with other drugs in the recurrent/metastatic setting to improve response rates and survival and help overcome resistance mechanisms to immune checkpoint blockade. This article provides a comprehensive review of the management of head and neck cancers in the current era of immunotherapy.

Long-term Survivorship and Non-cancer Competing Mortality in Head and Neck Cancer: A Nationwide Population-Based Study in South Korea

PURPOSE

As the survival of head and neck cancer (HNC) improves, survivors increasingly confront non-cancer-related deaths. This nationwide population-based study aimed to investigate non-cancer-related deaths in HNC survivors.

MATERIALS AND METHODS

Data from the Korean Central Cancer Registry were obtained to characterize causes of death, mortality patterns, and survival in patients with HNC between 2006 and 2016 (n=40,890). Non-cancer-related mortality relative to the general population was evaluated using standardized mortality ratios (SMRs). The 5- and 10-year cause-specific competing risks probabilities of death (cumulative incidence function, CIF) and subdistribution hazards ratios (sHR) from the Fine-Gray models were estimated.

RESULTS

Comorbidity-related mortality was frequent in older patients, whereas suicide was predominant in younger patients. The risk of suicide was greater in patients with HNC than in the general population (SMR, 3.1; 95% confidence interval [CI], 2.7 to 3.5). The probability of HNC deaths reached a plateau at 5 years (5-year CIF, 33.9%; 10-year CIF, 39.5%), whereas the probability of non-HNC deaths showed a long-term linear increase (5-year, CIF 5.6%; 10-year CIF, 11.9%). Patients who were male (sHR, 1.56; 95% CI, 1.41 to 1.72), diagnosed with early-stage HNC (localized vs. distant: sHR, 1.86; 95% CI, 1.58 to 2.21) and older age (65-74 vs. 0-44: sHR, 6.20; 95% CI, 4.92 to 7.82; ≥ 75 vs. 0-44: sHR, 9.81; 95% CI, 7.76 to 12.39) had an increased risk of non-cancer mortality.

CONCLUSION

Non-HNC-related deaths continue increasing. HNC survivors are at increased risk of suicide in the younger and comorbidity-related death in the older. Better population-specific surveillance awareness and survivorship plans for HNC survivors are warranted.

A preliminary analysis of prognostic genes in advanced laryngeal squamous cell carcinoma patients with postoperative radiotherapy

Advanced laryngeal squamous cell carcinoma (LSCC) has a high mortality rate, and the prognosis is poor. However, the underlying molecular biological mechanisms bringing about the development and progression of advanced LSCC are not entirely clarified. This study aimed to find out the potential biomarkers to predict the prognosis in advanced LSCC patients who had undergone postoperative radiotherapy alone. The next-generation sequencing of RNA was performed to detect the mRNAs expression profiling in 10 advanced LSCC samples, comprised of 5 samples from LSCC patients with favorable outcome and 5 samples from paired patients with poor outcome. Then bioinformatics analysis including Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway were used to find out functional core genes that were significantly different between the two groups. 1630 differentially expressed genes (DEGs) were confirmed to have significant differences between the two groups. 53 GO terms and 19 pathways which were closely related to the DEGs were identified. Finally, 52 intersection DEGs which were both related to the top three GO terms and pathways were identified. The expression of several core genes was confirmed with RT-qPCR in tissues from another 75 patients. RT-qPCR confirmed that the genes of c-JUN, LYN, PIK3R2, and TNFAIP3 were significantly differentially expressed between the two groups, which was in accordance with the RNA sequencing data. The DEGs identified above may be potential prognostic markers for advanced LSCC patients with postoperative radiotherapy, and may provide essential guidance for following-up.

The efficacy and safety of radiotherapy combined chemotherapy for laryngeal preservation in advanced laryngeal cancer: A protocol for systematic review and meta-analysis

BACKGROUND

The appropriate use of surgery or chemoradiotherapy-based approaches for organ preservation has been the subject of much debate. Unfortunately, there has been a lack of improvement in overall survival for patients with laryngeal carcinoma. In this study, we performed a protocol for systematic review and meta-analysis to evaluate the efficacy and safety radiotherapy combined chemotherapy for laryngeal preservation in advanced laryngeal cancer.

METHODS

This protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. We will search the PubMed, Cochrane Library, EMBASE, and Web of Science databases from the inception dates to October, 2022, using the keywords "laryngeal cancer," "radiotherapy", and "chemotherapy." Cochrane "bias risk" tool is used to assess the bias risk of the quality of the included literature. All calculations were carried out with RevMan V.5.3 software.

RESULTS

The results of this study will provide evidence for judging whether radiotherapy combined chemotherapy is superior to surgery for treatment of advanced laryngeal cancer.

CONCLUSION

This review will provide directions and recommendations for future research and clinical practices of radiotherapy combined chemotherapy for laryngeal preservation in advanced laryngeal cancer.

Clinicopathology and Treatment Patterns of Head and Neck Cancers in Ethiopia

Head and neck cancers are the third most common cancers treated with radiation in Ethiopia. There is, however, a lack of published data on clinical and pathological characteristics and treatment patterns of head and neck cancers in the country. The objective of the study was to assess clinical and pathological characteristics and treatment patterns of head and neck cancers at Tikur Anbessa Specialized Hospital, which housed the only radiotherapy facility in Ethiopia during the study period.

Curative radiation dosing for #headandneck #cancer in #Ethiopia is challenged by the limitations of 2D radiation and long wait times. @JCOGO_ASCO

Primary Total Laryngectomy versus Organ Preservation for Locally Advanced T3/T4a Laryngeal Cancer

OBJECTIVE

Organ preservation (OP) treatment for advanced laryngeal cancer has increased compared to primary total laryngectomy. Our study compares oncologic and functional outcomes between these approaches.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary care institution.

METHODS

Retrospective review of patients receiving primary total laryngectomy or OP for laryngeal cancer between 1/1/2000 and 12/31/2018.

RESULTS

A total of 118 patients received primary total laryngectomy and 119 received OP. Overall survival was similar between total laryngectomy and OP. When stratified by T stage, disease-free survival was worse among T3 patients receiving OP versus total laryngectomy. In T3 patients, 28 OP patients experienced local recurrence (28.9%) compared to 3 total laryngectomy patients (7.1%; p < 0.01). In total, 20 OP patients with local recurrence received salvage surgery. These patients had similar overall survival to patients who underwent initial total laryngectomy (TL). About 14 OP patients with local recurrence did not receive salvage surgery. About 89 (75.4%) TL patients achieved normal diet as compared to 64 (53.8%) OP patients (p < 0.001). In TL patients, 106 (89.8%) received primary or secondary tracheoesophageal-prosthesis, 82 (77.4%) of whom achieved completely understandable speech.

CONCLUSIONS

There was no difference in survival by treatment in T4 patients, possibly because of strict patient selection. However, disease-free survival was worse in T3 patients receiving OP, likely due to a high local recurrence rate. Approximately 40% of patients with local recurrence were not eligible for salvage laryngectomy. TL patients had comparable swallowing and speech outcomes with OP patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Factors Associated with Outcomes Following Salvage Surgery for Recurrent Laryngeal Cancer: A Retrospective Study of 50 Cases from a Single Center in Poland

BACKGROUND This retrospective study from a single center in Poland aimed to identify factors associated with outcomes following salvage surgery in 50 patients with recurrent laryngeal cancer. MATERIAL AND METHODS The study group consisted of 50 patients with recurrent laryngeal cancer after primary organ preservation treatment (12 patients after partial surgery, 30 patients after radiation therapy, and 8 patients after prior treatment using both methods). None of the patients received chemotherapy before salvage surgery. All patients with recurrence of laryngeal cancer underwent total laryngectomy with elective bilateral nodal surgery. Local and/or nodal recurrence was considered the failure of primary organ preservation treatment. Efficacy of treatment was assessed in relation to overall survival (OS), disease-free survival (DFS), local control (LC), and locoregional control (LRC). RESULTS Treatment results showed a poor prognosis in patients with local and/or nodal recurrence of laryngeal cancer. In the study group, the updated 5-year rates were as follows: OS rate of 26%; DFS rate of 25%; LC rate of 44%; and LRC rate of 39%. Univariate analysis showed that the stage before primary treatment was a predictive factor of OS (P=0.012). CONCLUSIONS The findings from this retrospective study of 50 patients with recurrent laryngeal carcinoma showed that salvage surgery following organ preservation treatment resulted in a 5-year OS rate of 26%.

Statistical harmonization can improve the development of a multicenter CT-based radiomic model predictive of nonresponse to induction chemotherapy in laryngeal cancers

PURPOSE

To develop a radiomic model predicting nonresponse to induction chemotherapy in laryngeal cancers, from multicenter pretherapeutic contrast-enhanced computed tomography (CE-CT) and evaluate the benefit of feature harmonization in such a context.

METHODS

Patients (n = 104) eligible for laryngeal preservation chemotherapy were included in five centers. Primary tumor was manually delineated on the CE-CT images. The following radiomic features were extracted with an in-house software (MIRAS v1.1, LaTIM UMR 1101): intensity, shape, and textural features derived from Gray-Level Co-occurrence Matrix (GLCM), Neighborhood Gray Tone Difference Matrix (NGTDM), Gray-Level Run Length Matrix (GLRLM), and Gray-Level Size Zone Matrix (GLSZM). Harmonization was performed using ComBat after unsupervised hierarchical clustering, used to determine labels automatically, given the high heterogeneity of imaging characteristics across and within centers. Patients with similar feature distributions were grouped with unsupervised clustering into an optimal number of clusters (2) determined with "silhouette scoring." Statistical harmonization was then carried out with ComBat on these 2 identified clusters. The cohort was split into training/validation (n = 66) and testing (n = 32) sets. Area under the receiver operating characteristics curves (AUC) were used to evaluate the ability of radiomic features (before and after harmonization) to predict nonresponse to chemotherapy, and specificity (Sp) and sensitivity (Se) were used to quantify their performance in the testing set.

RESULTS

Without harmonization, none of the features identified as predictive in the training set remained significant in the testing set. After ComBat, one textural feature identified in the training set keeps a predictive trend in the testing set-Zone Percentage, derived from the GLSZM, was predictive of nonresponse in the training set (AUC = 0.62, Se = 70%, Sp = 64%, P = 0.04) and obtained a satisfactory performance in the testing set (Se = 80%, Sp = 67%, P = 0.03), although significance was limited by the size of the testing set. These results are consistent with previously published findings in head and neck cancers.

CONCLUSIONS

Radiomic features from CE-CT could help in the selection of patients for induction chemotherapy in laryngeal cancers, with relatively good sensitivity and specificity in predicting lack of response. Statistical harmonization with ComBat and unsupervised clustering seems to improve the predictive value of features extracted in such a heterogeneous multicenter setting.

Risk groups of laryngeal cancer treated with chemoradiation according to nomogram scores - A pooled analysis of RTOG 0129 and 0522

OBJECTIVES

To develop nomograms predicting overall survival (OS), freedom from locoregional recurrence (FFLR), and freedom from distant metastasis (FFDM) for patients receiving chemoradiation for laryngeal squamous cell carcinoma (LSCC).

MATERIAL AND METHODS

Clinical and treatment data for patients with LSCC enrolled on NRG Oncology/RTOG 0129 and 0522 were extracted from the RTOG database. The dataset was partitioned into 70% training and 30% independent validation datasets. Significant predictors of OS, FFLR, and FFDM were obtained using univariate analysis on the training dataset. Nomograms were built using multivariate analysis with four a priori variables (age, gender, T-stage, and N-stage) and significant predictors from the univariate analyses. These nomograms were internally and externally validated using c-statistics (c) on the training and validation datasets, respectively.

RESULTS

The OS nomogram included age, gender, T stage, N stage, and number of cisplatin cycles. The FFLR nomogram included age, gender, T-stage, N-stage, and time-equivalent biologically effective dose. The FFDM nomogram included age, gender, N-stage, and number of cisplatin cycles. Internal validation of the OS nomogram, FFLR nomogram, and FFDM nomogram yielded c = 0.66, c = 0.66 and c = 0.73, respectively. External validation of these nomograms yielded c = 0.59, c = 0.70, and c = 0.73, respectively. Using nomogram score cutoffs, three risk groups were separated for each outcome.

CONCLUSIONS

We have developed and validated easy-to-use nomograms for LSCC outcomes using prospective cooperative group trial data.

A 10-Year Study on Larynx Preservation Compared With Surgical Resection in Patients With Locally Advanced Laryngeal and Hypopharyngeal Cancers

Background

Few reports from China provide confirmed evidence of the effectiveness of the larynx preservation strategy compared with surgery on the treatment of laryngeal and hypopharyngeal cancers. This study assessed the clinical outcomes of patients with locally advanced laryngeal and hypopharyngeal cancers treated with larynx preservation and determined the optimal larynx preservation procedure.

Methods

Data of 1,494 patients treated with total laryngectomy or larynx preservation between 2006 and 2014 were retrieved from the database of Sun-Yat Sen University Cancer Center in Guangzhou, China, and 366 eligible patients were selected for final analysis. The clinical outcomes of 228 patients received total laryngectomy and 138 patients received larynx preservation treatments, which comprises induction followed by radiotherapy and concurrent radio-chemotherapy, were compared.

Results

There was no statistical difference in the 3-, 5-, and 10-year PFS and OS in patients received larynx preservation compared with patients treated with laryngectomy. With respect to T stage, a better overall OS in T2-stage disease (P = 0.036) but poorer PFS (P = 0.005) in T3-stage disease was observed in the larynx preservation group compared with the surgery group in Univariate analysis. T3-stage disease had poorer PFS in multivariable analysis (P = 0.022). With larynx preservation intent, induction chemotherapy followed by radiotherapy showed no advantage in the control of disease progression and survival compared with concurrent chemoradiotherapy. The patient subpopulations who received efficacy assessment after induction chemotherapy exhibited significantly longer PFS and OS compared with those without efficacy assessment.

Conclusions

This is the largest sample size study on larynx preservation treatment for laryngeal and hypopharyngeal cancers in China. Our results indicated that larynx preservation treatments did not jeopardize the survival of patients with advanced resectable laryngeal or hypopharyngeal cancers. Efficacy assessment should be emphasized in induction chemotherapy.

Machine learning-based FDG PET-CT radiomics for outcome prediction in larynx and hypopharynx squamous cell carcinoma

AIM

To determine whether machine learning-based radiomic feature analysis of baseline integrated 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET) computed tomography (CT) predicts disease progression in patients with locally advanced larynx and hypopharynx squamous cell carcinoma (SCC) receiving (chemo)radiotherapy.

MATERIALS AND METHODS

Patients with larynx and hypopharynx SCC treated with definitive (chemo)radiotherapy at a specialist cancer centre undergoing pre-treatment PET-CT between 2008 and 2017 were included. Tumour segmentation and radiomic analysis was performed using LIFEx software (University of Paris-Saclay, France). Data were assigned into training (80%) and validation (20%) cohorts adhering to TRIPOD guidelines. A random forest classifier was created for four predictive models using features determined by recursive feature elimination: (A) PET, (B) CT, (C) clinical, and (D) combined PET-CT parameters. Model performance was assessed using area under the curve (AUC) receiver operating characteristic (ROC) analysis.

RESULTS

Seventy-two patients (40 hypopharynx 32 larynx tumours) were included, mean age 61 (range 41-77) years, 50 (69%) were men. Forty-five (62.5%) had chemoradiotherapy, 27 (37.5%) had radiotherapy alone. Median follow-up 26 months (range 12-105 months). Twenty-seven (37.5%) patients progressed within 12 months. ROC AUC for models A, B, C, and D were 0.91, 0.94, 0.88, and 0.93 in training and 0.82, 0.72, 0.70, and 0.94 in validation cohorts. Parameters in model D were metabolic tumour volume (MTV), maximum CT value, minimum standardized uptake value (SUVmin), grey-level zone length matrix (GLZLM) small-zone low grey-level emphasis (SZLGE) and histogram kurtosis.

CONCLUSION

FDG PET-CT derived radiomic features are potential predictors of early disease progression in patients with locally advanced larynx and hypopharynx SCC.

Clinical significance of neuropilin-2 expression in laryngeal squamous cell carcinoma

PURPOSE

The purpose of the study is to evaluate the expression of NRP-2 and explore its role in Laryngeal squamous cell carcinoma (LSCC).

MATERIALS AND METHODS

NRP-2 expression in 70 primary LSCC tissue specimens were analyzed by immunohistochemistry and correlated with clinicopathological parameters and patients´ survival rate. Additionally, 9 paired LSCC tissues were evaluated for NRP-2 expression by Western blotting.

RESULTS

The Western blotting indicated that NRP-2 expression levels in LSCC were significantly higher than those in the paraneoplastic tissues (P < 0.05). Immunohistochemistry staining revealed that NRP-2 was detected in all primary tumor samples, moreover, high expression of NRP-2 was significantly correlated with TNM stage (P < 0.05), clinical stage (P < 0.05), histological classification (P < 0.05), lymph node metastasis (P < 0.05) and recurrence (P = 0.001). Survival curves determined by the Kaplan-Meier method showed that high expression of NRP-2 can reduce overall survival (both group P < 0.05). Then we combined the NRP-2 expression and lymph node status, and Kaplan-Meier survival showed patients with high expression of NRP-2 or lymph node metastasis (+) had both shorter disease-free and overall survival than others (both P < 0.05). Multivariate Cox proportional hazards model analysis confirmed that histological grade (P = 0.045), lymph node metastasis (P = 0.020) and high expression of NRP-2 (P = 0.033) were statistically significant, independent predictor of prognosis.

CONCLUSIONS

NRP-2 may contribute to LSCC progression and represents as a novel prognostic indicator as well as a potential therapeutic target for LSCC.

Organ Preservation for Advanced Laryngeal Cancer: Experience with Concurrent Chemoradiation Therapy

Introduction The larynx is a part of the upper respiratory tract that performs many essential functions including breathing, speaking, and swallowing. For this reason, the quality of life is significantly affected by laryngeal cancer and its treatment. Therefore, the focus of management for the last few decades has been on preserving the function of a larynx without compromising survival. This study was done with the purpose of reviewing our experience of organ preservation approach with concurrent chemoradiation therapy (CCRT) for locally advanced cancers of larynx. Methods A retrospective chart review was carried out for the data of pathology reports and clinical notes of the patients who were diagnosed with laryngeal squamous cell carcinoma and primarily treated with CCRT at our tertiary care institute from November 2010 to June 2015. Results Of 25 patients included in the study, there were 19 males and six females. The mean age was 56 years. On comparison of post-treatment CT scan following eight weeks of completion of therapy, 21 patients showed complete resolution of the disease and four patients had persistent disease who were later treated with salvage laryngectomy. The speech was understandable in 18 patients and poor or not understandable in seven patients. Three patients had chronic aspiration and breathing difficulties necessitating permanent tracheostomy. Three patients required permanent gastrostomy due to chronic dysphagia, one of them belonged to those who were also tracheostomized. Conclusions Our experience with CCRT as an organ preservation approach for advanced laryngeal cancers was promising. When considering the functional organ preservation, the proportion of success is remarkably less; however, the overall impression is worthy enough to uphold the sentiment in favor of non-surgical organ preservation. The debate is ongoing in the quest of finding a balanced approach with acceptable toxicity and decent functional outcome with adequate speech, breathing, and swallowing.

Tumor radiomic features complement clinico-radiological factors in predicting long-term local control and laryngectomy free survival in locally advanced laryngo-pharyngeal cancers

OBJECTIVE

To study if pre-treatment CT texture features in locally advanced squamous cell carcinoma of laryngo-pharynx can predict long-term local control and laryngectomy free survival (LFS).

METHODS

Image texture features of 60 patients treated with chemoradiation (CTRT) within an ethically approved study were studied on contrast-enhanced images using a texture analysis research software (TexRad, UK). A filtration-histogram technique was used where the filtration step extracted and enhanced features of different sizes and intensity variations corresponding to a particular spatial scale filter (SSF): SSF = 0 (without filtration), SSF = 2 mm (fine texture), SSF = 3-5 mm (medium texture) and SSF = 6 mm (coarse texture). Quantification by statistical and histogram technique comprised mean intensity, standard-deviation, entropy, mean positive pixels, skewness and kurtosis. The ability of texture analysis to predict LFS or local control was determined using Kaplan-Meier analysis and multivariate cox model.

RESULTS

Median follow-up of patients was 24 months (95% CI:20-28). 39 (65%) patients were locally controlled at last follow-up. 10 (16%) had undergone salvage laryngectomy after CTRT. For both local control & LFS, threshold optimal cut-off values of texture features were analyzed. Medium filtered-texture feature that were associated with poorer laryngectomy free survival were entropy ≥4.54, (p = 0.006), kurtosis ≥4.18; p = 0.019, skewness ≤-0.59, p = 0.001, and standard deviation ≥43.18; p = 0.009). Inferior local control was associated with medium filtered features entropy ≥4.54; p 0.01 and skewness ≤ - 0.12; p = 0.02. Using fine filters, entropy ≥4.29 and kurtosis ≥-0.27 were also associated with inferior local control (p = 0.01 for both parameters). Multivariate analysis showed medium filter entropy as an independent predictor for LFS and local control (p < 0.001 & p = 0.001).

CONCLUSION

Medium texture entropy is a predictor for inferior local control and laryngectomy free survival in locally advanced laryngo-pharyngeal cancer and this can complement clinico-radiological factors in predicting prognosticating these tumors.

ADVANCES IN KNOWLEDGE

Texture features play an important role as a surrogate imaging biomarker for predicting local control and laryngectomy free survival in locally advanced laryngo-pharyngeal tumors treated with definitive chemoradiation.

Overexpression of circRNA_100290 promotes the progression of laryngeal squamous cell carcinoma through the miR-136-5p/RAP2C axis

Circular RNAs (circRNAs) exert critical functions in tumorigenesis and tumor development, but whether and how circRNAs contribute to laryngeal squamous cell carcinoma (LSCC) is unclear. In this study, we explored the function and mechanisms of circRNA_100290 in LSCC. Tissue samples were obtained from 40 patients with LSCC. The expression of circRNA_100290 and other targets was measured through quantitative reverse transcription-polymerase chain reaction and western blot analysis. Cell proliferation, colony-forming ability, and apoptosis were tested using CCK-8 assay and EdU assay, colony formation assay, and flow cytometry, respectively. Cell migration and invasion were detected by Transwell assay. Moreover, the interactions between circRNA_100290, miR-136-5p, and RAP2C were analyzed by bioinformatics, and verified by dual-luciferase reporter assays. Here, we found that circRNA_100290 expression was significantly upregulated in LSCC tissues and cell lines compared with the normal controls. Expression of circRNA_100290 positively correlated with advanced TNM stage and lymph node metastasis in LSCC patients. In cell culture, upregulation of circRNA_100290 promoted LSCC cell proliferation, migration, and invasion, while it inhibited cell apoptosis; downregulating circRNA_100290 exerted the opposite effects. In vivo, circRNA_100290 overexpression dramatically promoted tumor growth. Mechanistically, circRNA_100290 may act as a sponge of miR-136-5p, and inhibiting miR-136-5p in LSCC cells indeed reversed the effects of circRNA_100290 downregulation. The RAS oncogene RAP2C was predicted to be a target of miR-136-5p, and downregulating RAP2C in LSCC cells partially reversed the oncogenic effects of circRNA_100290 overexpression or miR-136-5p decrease. Our findings suggest that circRNA_100290 promotes LSCC progression by targeting the miR-136-5p/RAP2C axis, which may lead to the identification of potential therapeutic targets.

Causes of death in patients with locally advanced head and neck cancer treated with radiotherapy and systemic therapy

BACKGROUND

To investigate the incidence of non-cancer mortalities and prognostic factors associated with competitive causes of death in a homogeneous cohort of patients with locally advanced head and neck cancer treated with radiotherapy and systemic treatment.

METHODS

This study included 284 patients with locally advanced head and neck cancer treated with radiotherapy and systemic treatment between 2005 and 2017. The cumulative incidence of death associated with tumour, second tumours, treatment, side effects and comorbidity was calculated. A Fine and Gray regression model was used to investigate factors associated with cancer and competitive mortality.

RESULTS

The cumulative incidence of tumoral death at 5 and 10 years were 35 and 47% respectively, whereas the cumulative incidence of competitive mortality were 10 and 12% respectively. In the multivariate analysis, age and comorbidity were independent factors for non-cancer mortality. Patients with a high risk of non-cancer mortality presented a cumulative incidence of 17.3% at 5 years and 18.4% at 10 years.

CONCLUSIONS

This study demonstrated a high incidence of competing mortality in older patients with comorbidities. Non-cancer deaths should be considered when selecting patients for combination therapies and in the study design ofclinical trials.

Onset of hypothyroidism after total laryngectomy: Effects of thyroid gland surgery and preoperative and postoperative radiotherapy

Background

To determine time of onset and risk of hypothyroidism after total laryngectomy (TL) with and without (hemi)thyroidectomy in relation to treatment regimen, that is, preoperative radiotherapy (RT‐TL), postoperative radiotherapy (TL‐RT), and postoperative re‐irradiation (RT‐TL‐RT).

Methods

Retrospective review of 128 patients treated by RT‐TL (51 patients), TL‐RT (55 patients), and RT‐TL‐RT (22 patients). Risk of hypothyroidism was determined by multivariable Cox regression analysis and euthyroid survival was calculated using Kaplan‐Meier method.

Results

Hypothyroidism developed in 69 (54%) patients. The median onset of hypothyroidism was later (P < .01) and the risk of hypothyroidism was lower (hazard ratio 0.49; P = .014) in the TL‐RT group compared to both other treatment regimens. Euthyroid survival did not differ between the treatment regimens. Two years euthyroid survival was 24% with and 61% without (hemi)thyroidectomy (P < .001).

Conclusions

Patients treated with TL‐RT have later onset of hypothyroidism. Higher risk for hypothyroidism is associated with salvage TL after radiotherapy and (hemi)thyroidectomy.

The molecular landscape of the University of Michigan laryngeal squamous cell carcinoma cell line panel

BACKGROUND

Laryngeal squamous cell carcinomas (LSCCs) have a high risk of recurrence and poor prognosis. Patient-derived cancer cell lines remain important preclinical models for advancement of new therapeutic strategies, and comprehensive characterization of these models is vital in the precision medicine era.

METHODS

We performed exome and transcriptome sequencing as well as copy number analysis of a panel of LSCC-derived cell lines that were established at the University of Michigan and are used in laboratories worldwide.

RESULTS

We observed a complex array of alterations consistent with those reported in The Cancer Genome Atlas head and neck squamous cell carcinoma project, including aberrations in PIK3CA, EGFR, CDKN2A, TP53, and NOTCH family and FAT1 genes. A detailed analysis of FAT family genes and associated pathways showed disruptions to these genes in most cell lines.

CONCLUSIONS

The molecular profiles we have generated indicate that as a whole, this panel recapitulates the molecular diversity observed in patients and will serve as useful guides in selecting cell lines for preclinical modeling.

Cancer of the head and neck: a set of indicators based on register and administrative data

SUMMARY

Head and neck (H&N) tumours are a heterogeneous group of neoplasms with 5-year relative survival ranging from about 25% for the hypopharynx to 60% for the larynx in Europe. To improve survival rates, along with therapeutic improvements, it is important to standardise and optimise care received by patients with H&N tumours across different healthcare providers. To reach this goal, it is necessary to evaluate adherence to standards of received care at a population level. Published guidelines can serve as the basis to develop indicators, which can be computed from administrative health databases, measuring the adherence to specific recommendations at the individual level in unselected H&N cancer patients, identified from a population cancer register. We developed a set of indicators and calculated them in a cohort of 2007-2012 incident cases of H&N tumours in the cancer register of the Milan province (n = 1441 cases). The study cohort was mainly composed of men (77%) and patients older than 50 years (89%). Surgery was the most frequently employed treatment (66%). Ten percent of patients had no recorded treatment. Timing between cyto-histological assessment and first therapy for those having a recorded microscopic verification procedure was ≤ 60 days for 90.4% of patients undergoing surgery, 86.3% of those undergoing radiotherapy, and 90.7% of patients receiving chemotherapy. Eighty-three percent of patients underwent cyto-histological assessment in the 180 days before the first treatment. Evaluation by a pain therapist, opioid therapy or hospitalisation for palliative therapy in the 90 days before death was performed in 51% of patients who eventually died of cancer. This is the first Italian study defining and calculating quality indicators to monitor adherence to standards of care received by H&N cancer patients at a population level.

Analysis of tumor-infiltrating CD103 resident memory T-cell content in recurrent laryngeal squamous cell carcinoma

BACKGROUND

Recurrent laryngeal squamous cell carcinomas (LSCCs) are associated with poor outcomes, without reliable biomarkers to identify patients who may benefit from adjuvant therapies. Given the emergence of tumor-infiltrating lymphocytes (TIL) as a biomarker in head and neck squamous cell carcinoma, we generated predictive models to understand the utility of CD4+, CD8+ and/or CD103+ TIL status in patients with advanced LSCC.

METHODS

Tissue microarrays were constructed from salvage laryngectomy specimens of 183 patients with recurrent/persistent LSCC and independently stained for CD4+, CD8+, and CD103+ TIL content. Cox proportional hazards regression analysis was employed to assess combinations of CD4+, CD8+, and CD103+ TIL levels for prediction of overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) in patients with recurrent/persistent LSCC.

RESULTS

High tumor CD103+ TIL content was associated with significantly improved OS, DSS, and DFS and was a stronger predictor of survival in recurrent/persistent LSCC than either high CD8+ or CD4+ TIL content. On multivariate analysis, an "immune-rich" phenotype, in which tumors were enriched for both CD103+ and CD4+ TILs, conferred a survival benefit (OS hazard ratio: 0.28, p = 0.0014; DSS hazard ratio: 0.09, p = 0.0015; DFS hazard ratio: 0.18, p = 0.0018) in recurrent/persistent LSCC.

CONCLUSIONS

An immune profile driven by CD103+ TIL content, alone and in combination with CD4+ TIL content, is a prognostic biomarker of survival in patients with recurrent/persistent LSCC. Predictive models described herein may thus prove valuable in prognostic stratification and lead to personalized treatment paradigms for this patient population.

Computed tomography evaluation after induction chemotherapy for T3 laryngeal cancer: Does response correlate with vocal cord mobility?

OBJECTIVES

After induction chemotherapy (IC) for laryngeal cancer, Computed Tomography (CT) is used to assess tumor response but lacks rationalized methods for measurement of this response. In T3 laryngeal cancer, remobilization of an initially fixed vocal cord (VC) is a major sign of tumor response. We compared the performances of RECIST1.1, WHO and volumetric methods of evaluating response with laryngeal remobilization to determine if these measurements could objectively assess tumor response.

MATERIAL AND METHODS

This monocentric retrospective cohort study included patients treated with T3 laryngeal cancer with initial VC fixation treated with an organ preservation protocol with IC between 1999 and 2012. Tumors were measured with CT using RECIST1.1, WHO and volumetric methods by two radiologists blinded to VC remobilization (VCR), before and after induction chemotherapy and VC mobility was clinically assessed. Radiologic tumor shrinkage was compared to VCR. AUCs of ROC curves were compared. Inter-reader reliability, sensitivity and specificity of optimal cutoffs were determined.

RESULTS

Seven females and thirty-six males with a mean age of 59 years were included. AUCs were 0.759, [95%CI 0.614; 0.904] for RECIST1.1, 0.763, [95%CI 0.617; 0.909] for WHO and 0.752, [95%CI 0.608; 0.896] for volumetric evaluations with no significant difference among the three techniques. Inter-reader reader reliabilities were good (RECIST1.1) to excellent (WHO and volumetric methods).

CONCLUSION

RECIST1.1, WHO and volumetric measures match with VCR after IC in patient with T3 laryngeal cancer. WHO criteria combine accuracy, reproducibility and practical use; they may be best adapted for response assessment and protocol design.

Origin of Locoregional Recurrences After Definitive Intensity-modulated Radiation Therapy (IMRT) for Laryngeal Cancer Determined Based on Follow-up PET/CT Imaging

Purpose: The aim of our study was to report on patterns of failure using detailed information from follow-up positron emission tomography-computed tomography (PET/CT) scans for patients with laryngeal squamous cell carcinoma (SCCA) treated with definitive radiation therapy using intensity-modulated radiation therapy (IMRT).

Methods: One hundred and sixty-eight patients with laryngeal SCCA treated with definitive IMRT using a simultaneous integrated boost were included. The point of recurrence origin on follow-up PET/CT was determined using two separate data-driven methods. The first method, the mathematical epicenter point of origin (PO_Epi), calculated the mathematical focal epicenter point for which the maximum distance to the surface of the surrounding volume was smaller than for any other point. The second method, maximum standardized uptake value point of origin (PO_Max), calculated the voxel with maximum standardized uptake value (SUV) uptake within the recurrence volume. The failure pattern was then determined by whether the point of recurrence origin fell within the low, intermediate, or high-risk target volumes in the original treatment planning CT.

Results: Thirty-five primary/nodal recurrences in 33 patients were included in the analysis. In the PO_Epi method, 94% (33/35) of all recurrences originated either within the high-risk gross tumor volume (GTV_High-risk) or within an average of 0.9 ± 1.3 mm from it. In the PO_Max method, 91% (32/35) of all recurrences originated either within the GTV_High-risk or within an average of 1.8 ± 1.7 mm from it. There were no recurrences outside the low-risk planning target volume (PTV_Low-risk) for the PO_Epi method but there was one for the PO_Max method, which was 19.8 mm away from the edge of the gross tumor volume receiving 70 Gy (GTV₇₀). Increasing distance between the two different origin points was strongly correlated with the size of the recurrence volume.

Conclusion: The majority of recurrences for laryngeal cancer patients treated with definitive IMRT originated from within the high-dose treatment region. This can have implications for reducing clinical target volumes while using a risk-adaptive treatment approach to both constrain dose to critical areas and further escalate the dose to the gross tumor to improve locoregional control rates.

Reinke edema

The effect on quality of life (QOL) of laryngectomy and organ preservation protocols is important in decision making. The aim of this cross-sectional study was to evaluate QOL outcomes of patients with advanced laryngeal tumors who were treated with laryngectomy or organ preservation protocols in Latin America. A total of 35 patients from three oncology units were enrolled. Patients with stage III/IV laryngeal cancer who were treated using organ preservation protocols or laryngectomy were assessed with the University of Washington QOL Questionnaire. The most important domains that affected QOL for both groups were speech and activity. In the laryngectomy group, the next most important domains were appearance, taste, pain, and recreation, whereas in the organ preservation group, they were saliva, recreation, mood, and swallowing. There were no statistically or clinically significant differences in the global score or the 7 days of QOL assessments before patients were interviewed. Global QOL assessments were similar when comparing laryngectomy and organ preservation protocols.

Mutational profiles of persistent/recurrent laryngeal squamous cell carcinoma

BACKGROUND

We sought to describe targeted DNA sequencing data of persistent/recurrent laryngeal squamous cell carcinoma (LSCC) and to compare gene-specific alteration frequencies with that of primary, untreated LSCC specimens from The Cancer Genome Atlas (TCGA).

METHODS

The tumors of 21 patients with persistent/recurrent LSCC were subjected to targeted DNA sequencing using the Ion AmpliSeq Comprehensive Cancer Panel. Gene-specific alteration frequencies were compared (Chi-Square test) to primary, untreated LSCC sequencing data from TCGA using the cBioPortal platform.

RESULTS

Persistent/recurrent LSCC was characterized by a high rate of inactivating alterations in TP53 (38.1%) and CDKN2A (33%), amplification events of CCND1 (19.1%), and ERBB2 (14.3%), and NOTCH1 (19.1%) mutations. Comparison of primary vs persistent/recurrent LSCC revealed significant differences in alteration frequencies of eight critical genes: BAP1, CDKN2A, DCUN1D1, MSH2, MTOR, PIK3CA, TET2, and TP53.

CONCLUSIONS

Our results provide preliminary support for a distinct mutational profile of persistent/recurrent LSCC that requires validation in larger cohorts.

Surgery vs. radiotherapy for locally advanced hypopharyngeal cancer in the contemporary era: A population-based study

Objectives

To compare overall survival (OS) in locally advanced hypopharyngeal cancer treated with surgery or definitive chemoradiotherapy in the contemporary era.

Methods

From 2010 to 2015, data for patients diagnosed with hypopharyngeal cancer (T2‐T4aM0) and treated with total pharyngectomy with lymph node dissection (surgery group) or definitive radiotherapy and chemotherapy (chemoradiotherapy group) was retrieved from the SEER database. Multivariate analyses were performed in each subgroup divided according to T category (T2‐3 or T4a).

Results

The number of patients in the surgery and chemoradiotherapy groups was 209 and 648, respectively. Among them, the number of T4a patients was 111 and 126 in each group. Three‐year OS rate in the surgery and chemoradiotherapy groups was 37.9% and 44.1%, respectively (P = 0.178). The 3‐year OS rate for the T2‐3 patients was 46.5% and 48.7% (P = 0.598), and the 3‐year OS rate for the T4a patients was 29.9% and 26.1% in the surgery and chemoradiotherapy groups, respectively (P = 0.439). On multivariate analysis, the chemoradiotherapy group was not inferior to the surgery group in T2‐T4a patients (Hazard ratio [HR] for the chemoradiotherapy group 0.889, 95% confidence interval [CI] 0.699‐1.129, P = 0.334), in T2‐3 patients (HR 0.932, 95% CI 0.699‐1.297, P = 0.675), and in T4a patients (HR 0.880, 95% CI 0.617‐1.256, P = 0.481).

Conclusions

Chemoradiotherapy for locally advanced hypophagyngeal cancer showed a comparable OS rate to surgery. For patients with T4a category cancer with high possibility of preserving the laryngopharyngeal function, chemoradiotherapy may be a promising alternative treatment.

Outcome of salvage procedures for recurrent oral and oropharyngeal cancer

Despite advances in the primary treatment of oral and oropharyngeal cancer, many patients develop local or regional recurrence, or both, and when radiotherapy has already been used, operation provides the best chance of salvage for these patients. We have looked at the outcomes of salvage procedures in a single unit, including improved survival, morbidity, and treatment-related quality of life. Patients treated with salvage procedures were identified from a prospectively-completed database. Overall and disease-free survival were analysed using Kaplan-Meier curves and logrank tests. Functional, social, and emotional outcomes were assessed using the University of Washington Quality of Life Questionnaires. Twenty-nine patients were identified, of whom 24 had free flap reconstructions, and their estimated mean overall survival was 25 months (95% CI 20.4 to 29.2). Disease-free survival was significantly worse in patients with stage IV recurrences or in whom resection margins were close or invaded. Permanent gastrostomy was required in 15/29 patients, and four/29 needed a permanent tracheostomy. Answers to questionnaires showed that a large proportion of patients had considerable problems with speech, chewing, swallowing, and appearance. The decision on whether to treat recurrent head and neck cancer is a balance between improving survival and poor functional outcomes. The extent of disease and whether clear surgical margins can be achieved should be considered when treatment is recommended.

Decision making in advanced larynx cancer: An evidenced based review

Organ preservation versus total laryngectomy for advanced laryngeal cancer continues to be hotly debated. This review presents evidence-based decision making points for these patents.

Quality of life in patients with larynx cancer in Latin America: Comparison between laryngectomy and organ preservation protocols

The effect on quality of life (QOL) of laryngectomy and organ preservation protocols is important in decision making. The aim of this cross-sectional study was to evaluate QOL outcomes of patients with advanced laryngeal tumors who were treated with laryngectomy or organ preservation protocols in Latin America. A total of 35 patients from three oncology units were enrolled. Patients with stage III/IV laryngeal cancer who were treated using organ preservation protocols or laryngectomy were assessed with the University of Washington QOL Questionnaire. The most important domains that affected QOL for both groups were speech and activity. In the laryngectomy group, the next most important domains were appearance, taste, pain, and recreation, whereas in the organ preservation group, they were saliva, recreation, mood, and swallowing. There were no statistically or clinically significant differences in the global score or the 7 days of QOL assessments before patients were interviewed. Global QOL assessments were similar when comparing laryngectomy and organ preservation protocols.

Robotics in otorhinolaryngology - head and neck surgery

A look at the past, present and future.

Induction chemotherapy in patients with resectable laryngeal cancer: A meta-analysis

Head and neck squamous cell carcinoma (SCC) ranks 6th among the most frequently diagnosed carcinomas globally. Laryngeal carcinoma is quite common, and 95% of the cases are SCCs. Since the introduction of larynx-preserving surgery, induction chemotherapy (IC) has played a substantial role. The aim of IC is to shrink or downstage primary laryngeal carcinomas, increasing the chances of complete surgical removal, particularly in cases with advanced but potentially resectable lesions. The aim of the present study was to investigate the value of IC in patients with resectable laryngeal cancer. A meta-analysis was performed of randomized controlled trials (1985-2017) investigating the effect of IC on survival, disease control, larynx-preserving surgery and disease-free survival. Engauge-Digitizer software was used to construct Kaplan-Meier curves and RevMan software was used for the analysis of the data. A total of 12 trials (4,320 patients) were included. There was no significant difference in local recurrence or locoregional control between patients receiving and those not receiving IC (P>0.05). However, the experimental group (IC) exhibited a lower propensity for distant metastasis by 11.7% (95% confidence interval: 10.3-13.3%, P=0.02) compared with the control group (no IC). Among patients with laryngeal cancer, larynx preservation was possible in those who responded well to IC, without a significant decrease in survival compared with radical surgery (P<0.05). Taking into consideration these findings, IC confers an advantage in terms of lowering the risk of distant metastasis in patients with resectable laryngeal carcinoma, and enables laryngeal preservation in responders. Moreover, IC increases the overall survival rate in patients with locally advanced but resectable LC.

An Overview of Laryngeal Cancer Treatment at a Tertiary Care Oncological Center in a Developing Country

Introduction Development of laryngeal cancer is multifactorial, and management is surrounded with controversies. Recent reports suggest a decline in the survival of these patients. We conducted a study to analyze the clinicopathological parameters and compute the outcomes in terms of survival in patients with laryngeal cancer treated at our institution. Methods Electronic charts of 515 patients with Laryngeal cancer treated at our Hospital and Research Center from 2004 to 2014 were retrospectively reviewed. Results Median age was 62 years. Male: female ratio 91%: 9%. Sixty-two percent were smokers. Histologically, all were squamous cell carcinoma. Most common subsite was glottis (88%). Treatment was non-surgical in 92% and surgical in 8%. The five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional control (LRC) were 67%, 74%, 59% and 70%, respectively. OS, DSS, DFS and LRC for early stage (I-II) and advance stage (III-IV) were 81 and 54%, 86 and 63%, 75 and 45%, and 83 and 57%, respectively. Twenty-two percent recurred locally. Of these failures, 19% were inoperable, 36% were surgically salvaged and 34% refused laryngectomy. Conclusions Our survival rates are comparable with published data. The high refusal rate for salvage total laryngectomy is concerning and needs further study to evaluate the reasons.

Organ preservation surgery for patients with T4a laryngeal cancer

PURPOSE

Surgical preservation of laryngeal function is very challenging in patients with advanced SCCL, especially those of stage T4a. The purpose of this study was to assess the feasibility of organ preservation surgery for patients with T4a squamous cell carcinoma of the larynx (SCCL).

METHODS

We enrolled 32 patients with T4a SCCL and performed organ preservation surgery on them. Surgical details and perioperative morbidity were described, functional and oncologic outcomes were also evaluated.

RESULTS

All patients underwent supracricoid subtotal laryngectomy with unilateral or bilateral neck dissection, restoring laryngeal function via direct anastomosis of the cricoid cartilage and tongue base. The patients recovered well and exhibited relatively acceptable survival duration, with a 5-year overall survival rate of 62.5%. Most patients commenced oral intake within 2 weeks, and aspiration was commonly observed. Subjective functional outcomes indicated a relatively acceptable swallowing function and voice quality.

CONCLUSION

Our retrospective analysis of 32 patients with T4a SCCL showed that successful organ preservation surgery is safe and reliable, and associated with a relatively acceptable disease-free survival, normal swallowing function, and acceptable voice quality. More patients with T4a SCCL who wish to preserve the larynx should be considered for organ preservation surgery.

Pharyngeal fistulas after total laryngectomy with and without tracheostoma plasty according to Herrmann

PURPOSE

Pharyngeal fistula (PF) is one of the most common complications after total laryngectomy (TL). The tracheostoma plasty technique according to Herrmann (TPH) represents an alternative surgical technique to shape the tracheostoma. The aim of this study was to determine whether the performance of a TPH affects the incidence of PF after TL. A secondary aim was to identify potential risk factors for the development of PF with regard to TPH.

METHODS

Retrospective evaluation of records of 151 consecutive patients at two tertiary care centers with regard to the occurrence and risk factors of PF after TL with and without TPH.

RESULTS

60 patients with TPH and 91 patients without TPH contributed to the results. The overall incidence of PF was 21.2% (32 out of 151). 23.3% (14 out of 60) of patients with TPH and 19.8% (18 of 91) of patients without TPH developed a PF (p = 0.91). Binary logistic regression analysis revealed significant influence of salvage surgery on the risk to develop PF (odds ratio = 2.9; 95% CI 1.16-7.23; p = 0.026). The occurrence of PF was not significantly influenced by any other investigated factors including performance of TPH.

CONCLUSIONS

Performance of TPH after TL does not increase the incidence of PF. Thus, TPH can be considered as a safe alternative surgical technique for the shaping of the tracheostoma following TL.

Locally advanced laryngeal cancer: Total laryngectomy or primary non-surgical treatment?

Between January 1997 and December 2013, the Charles University 3rd Medical School and Royal Vinohrady Teaching Hospital Ear, Nose and Throat oncology team treated 185 patients with advanced laryngeal cancer, which, from a surgical perspective, required a total laryngectomy. Overall, ~70% of these patients (n=129) underwent conventional treatment (i.e., total laryngectomy with post-operative radiotherapy), and ~30% (n=56) were treated with larynx preservation protocols (including primary radiotherapy, neoadjuvant chemotherapy followed by radiotherapy or chemoradiotherapy, or primary chemoradiotherapy). Patients treated with laryngeal preservation protocols had a 5-year survival probability of 48%, whereas those treated with total laryngectomy and post-operative radiotherapy had a 5-year survival probability of 63%. This difference was not statistically significant. However, patients who underwent primary surgical treatment survived for a significantly longer period (P<0.010). The sex of the patient did not have a statistically significant impact on patient survival probability. More extensive local disease and more advanced disease stages conferred a lower survival probability, but were not statistically significant; however, a lower survival probability in patients >70 years was identified to be statistically significant (P<0.010). Local disease recurrence and recurrent cervical nodal metastases had a statistically significant impact on the 5-year survival probability (P<0.001). A step wise Cox regression analysis was used to compare the parameters of sex, patient age, tumor extent, disease stage, choice of primary surgery, local recurrence and cervical nodal recurrence. In the first step, local recurrence was selected as the parameter having the greatest effect on survival (P<0.001); patient age >70 years (P<0.001) was selected in the second step; cervical nodal recurrence (P<0.001) in the third step; and disease stage (P<0.010) in the fourth step. Other parameters did not significantly affect survival. The results of the present study confirmed that primary non-surgical treatment is an alternative approach to total laryngectomy, and that an informed patient should determine the treatment approach. The decreased overall survival observed in more extensive tumors suggests that surgical treatment may be a better selection in these cases. Due to increased overall survival, primary non-surgical treatment may be recommended for younger patients. If the patient chooses primary non-surgical treatment, concomitant chemoradiotherapy is recommended. If the patient cannot tolerate cytostatic chemotherapy, radiotherapy alone is recommended.

Decreased radiation doses to tongue with "stick-out" tongue position over neutral tongue position in head and neck cancer patients who refused or could not tolerate an intraoral device (bite-block, tongue blade, or mouthpiece) due to trismus, gag reflex, or discomfort during intensity-modulated radiation therapy

Purpose

To assess changes in oral cavity (OC) shapes and radiation doses to tongue with different tongue positions during intensity-modulated radiation therapy (IMRT) in patients with head and neck squamous cell carcinoma (HNSCC) but who refused or did not tolerate an intraoral device (IOD), such as bite block, tongue blade, or mouthpiece.

Results

Tongue volume outside of OC was 7.1 ± 3.8 cm³ (5.4 ± 2.6% of entire OC and 7.8 ± 3.1% of oral tongue) in IMRT-S. D_mean of OC was 34.9 ± 8.0 Gy and 31.4 ± 8.7 Gy with IMRT-N and IMRT-S, respectively (p < 0.001). OC volume receiving ≥ 36 Gy (V36) was 40.6 ± 16.9% with IMRT-N and 33.0 ± 17.0% with IMRT-S (p < 0.001). D_mean of tongue was 38.1 ± 7.9 Gy and 32.8 ± 8.8 Gy in IMRT-N and IMRT-S, respectively (p < 0.001). V15, V30, and V45 of tongue were significantly lower in IMRT-S (85.3 ± 15.0%, 50.6 ± 16.2%, 24.3 ± 16.0%, respectively) than IMRT-N (94.4 ± 10.6%, 64.7 ± 16.2%, 34.0 ± 18.6%, respectively) (all p < 0.001). Positional offsets of tongue during the course of IMRT-S was –0.1 ± 0.2 cm, 0.01 ± 0.1 cm, and –0.1 ± 0.2 cm (vertical, longitudinal, and lateral, respectively).

Materials and Methods

13 patients with HNSCC underwent CT-simulations both with a neutral tongue position and a stick-out tongue for IMRT planning (IMRT-N and IMRT-S, respectively). Planning objectives were to deliver 70 Gy, 63 Gy, and 56 Gy in 35 fractions to 95% of PTVs. Radiation Therapy Oncology Group (RTOG) recommended dose constraints were applied. Data are presented as mean ± standard deviation and compared using the student t-test.

Conclusions

IMRT-S for patients with HNSCC who refused or could not tolerate an IOD has significant decreased radiation dose to the tongue than IMRT-N, which may potentially reduce RT related toxicity in tongue in selected patients.