Results of an organ preservation protocol with induction chemotherapy and radiotherapy in patients with locally advanced laryngeal carcinoma

An alternative treatment in patients with advanced laryngeal carcinoma who are candidates for total laryngectomy is induction chemotherapy and radical radiotherapy in an organ preservation approach. We conducted a study to evaluate results of this treatment in patients with locally advanced laryngeal carcinoma, candidates for total laryngectomy, who were treated at a single institution between 1985 and 1997. During the study period, 224 began treatment with induction chemotherapy. Induction chemotherapy consisted of three cycles of cisplatin and 5-fluoruracil in the majority of cases. Four patients died as a consequence of complications associated with chemotherapy treatment. Subsequent treatment consisted of total laryngectomy in 79 patients and radical radiotherapy in 141. After radical radiotherapy, local control for patients who achieved a complete response after induction chemotherapy was 74%, significantly better than 57% in patients with a non-complete response (P=0.04). Considering the initial group of 224 patients, the frequency of organ preservation was 39%. Considering only the patients treated with induction chemotherapy and radiotherapy, the organ preservation frequency was 62%. In a multivariate study, only the response after induction chemotherapy was significantly related to organ preservation.This paper was presented at the 38th Annual Meeting of the American Society of Clinical Oncology, Orlando, Florida, 18–21 May 2002.     

Preservación de órgano en pacientes con tumores avanzados de laringe. Resultados de la quimioterapia de inducción versus quimio-radioterapia en la práctica clínica real

Introduction and objectivesA high percentage of patients with locally advanced larynx carcinomas are candidates for inclusion in organ preservation protocols. The objective of this study is to compare the results of two schemes of preservation, induction chemotherapy versus chemoradiotherapy, in patients with locally advanced larynx carcinomas in the context of actual clinical practice.MethodsOur retrospective study included 157 patients with locally advanced tumours of the larynx (T3-T4) treated with induction chemotherapy (n = 121) or chemoradiotherapy (n = 36).ResultsFrom 121 patients who began treatment with induction chemotherapy, 6 died due to toxicity, 37 were treated with surgery, and 78 completed the preservation scheme; 36 patients received treatment with chemoradiotherapy. There were no significant differences in 5-year disease-specific survival between both treatments: 68.9% in induction chemotherapy versus 75.7% in chemoradiotherapy (p = 0.259). In 45.9% of patients the laryngeal function was preserved. Patients treated with chemoradiotherapy had a tendency to have better 5-year laryngeal dysfunction-free survival than patients treated with induction chemotherapy (55.6% versus 44.8%, p = 0.079).ConclusionPatients included in a protocol of organ preservation achieved a 5-year laryngeal dysfunction-free survival of 45.9%. There were no significant differences in disease-specific survival among patients treated with induction chemotherapy or chemoradiotherapy.     

保留喉功能的梨状窝癌的综合治疗

探讨综合治疗对保留喉功能的梨状窝癌的作用。方法：对梨状窝癌进行保留喉功能治疗的３３例进行回顾性分析。（１）３３例术前分别给予１周期或２周期诱导化疗;（２）手术治疗经化疗后的肿瘤切除;（３）术后放射治疗。结果：化疗后有效率４２．４％。３年生存率５４．８％,５年生存率３８．７％。     

Preservación de órgano tras un tratamiento con quimioterapia de inducción en pacientes con carcinomas localmente avanzados (T3-T4) de cavidad oral y orofaringe

Introduction and objectivesWith the goal of achieving functional preservation, one of the treatment strategies for patients with locally advanced squamous cell carcinomas of the head and neck is to initiate treatment with induction chemotherapy (CT) and decide the second therapeutic manoeuvre depending on the response. The objective of this study is to evaluate organ preservation capacity based on this therapeutic approach in patients with tumours of the oral cavity and oropharynx.MethodsA retrospective study of 246 patients with locally advanced carcinomas of the oral cavity or oropharynx (cT3-T4) initially treated with induction CT.ResultsAfter induction CT 28% of patients achieved a complete response of the primary location of the tumour, 43.1% a partial response greater than 50%, and 28.9% a reduction less than 50% or persistence. After the induction CT treatment 70 patients (28.5%) underwent surgical treatment, and 176 (71.5%) radiotherapy (RT) or chemoradiotherapy (CRT). Considering the patients treated non-surgically (n = 176), organ preservation for patients with a complete response (n = 66) was 65.2%, for those patients with a partial response greater than 50% (n = 75) it was 30.7%, and for patients with a partial response less than 50% or persistence (n = 35) it was 14.3%.ConclusionThe response to treatment with induction CT has prognostic value in patients with locally advanced carcinomas of the oral cavity and oropharynx. Patients who are candidates for conservative treatment with RT or CRT would be those who achieve a complete response after induction treatment.     

Outcome of Pyriform Sinus Cancer

Pyriform sinus cancer remains one of the most lethal of human diseases. Regardless of approach attempted significant enhancement of survival has not been realized. In this study a retrospective single institutional review of all patients diagnosed with pyriform sinus cancer during the 1980s was conducted. The results in 93 patients show an overall determinant 5-year survival of 14.3%. Of patients undergoing surgery, median determinant survival was 37 months and 5-year survival was 34.6%. In resectable patients treated with radiation with or without chemotherapy, median determinant survival was 13 months with 5-year survival of 7.1% (P<.01). Surgical salvage was attempted in 8 patients without success. In conclusion, due to the apparent survival advantage for surgical patients, the low rate of surgical salvage, and the relatively low rate of organ preservation in prospective trials, pyriform sinus cancer is a poor site for organ preservation. Surgery followed by radiation therapy should remain the standard of care for pyriform sinus cancer.     

Induction chemotherapy and laryngeal preservation in pharyngolaryngeal carcinomas. Study of a 124 serie's patients and patient's follow up with laryngeal preservation

OBJECTIVE: To try and determine the value of chemotherapy and its subsequent effect on laryngeal preservation in patients presenting with laryngeal and pharyngeal carcinomas. One group was initially treated with surgery and radiotherapy. The second group was treated with chemotherapy and subsequent salvage surgery and/or radiotherapy. Their survival rates and laryngeal preservation rates were compared. PATIENTS AND METHODS: From 251 patients the authors have retrospectively studied 124 patients with induction chemotherapy. The survival rate has been compared with a control group of 127 patients who was treated by initial surgery and radiotherapy. RESULTS: The survival rate at 5 years for the patients initially treated by surgery and radiotherapy was 64.1%. The survival for patients with a total clinical response following chemotherapy was 49.8% at 5 years. Survival with no total clinical response following chemotherapy treated by secondary radiotherapy was 25.7% at 3 years. The initial rate of laryngeal preservation is 32.2% but this rate fell to 22% after local recurrencies. CONCLUSION: The group with total clinical response after induction chemotherapy with laryngeal preservation have a non significantly difference in their survival compared with the group initially treated by surgery and radiotherapy. In contrary patients with non complete clinical response have a survival of 25.7% at 3 years. The rate of local recurrency of patients with laryngeal preservation is 32.5% and gives a finally rate of laryngeal preservation of 21%. These recurrencies decrease the survival rate.     

Effectiveness of salvage neck dissection for advanced regional metastases when induction chemotherapy and radiation are used for organ preservation.

The recently completed VA Cooperative Study (CSP #268) of induction chemotherapy (cisplatin/5-FU) and definitive radiation (6600 to 7600 cGy) for organ preservation in advanced (stage III or IV) laryngeal cancer demonstrated that, although larynx preservation could be achieved in 64% of randomized preservation could be achieved in 64% of randomized patients, overall survival rates were not improved over conventional treatment (surgery/postoperative radiation). Of 166 patients randomized to induction chemotherapy, 46 had N2 or N3 disease and were analyzed to determine the effectiveness of the organ preservation treatment strategy on control of neck disease and survival. The clinical response of neck metastases to induction chemotherapy was significantly associated with subsequent salvage neck dissection (P = .008). The overall death rate was increased (P = .014) and survival time decreased in patients with less than a complete response in the neck after chemotherapy (P = .15). This was related primarily to failure to control the disease in the neck. The overall survival of patients achieving a complete response in the neck was improved over the randomized group of N2 or N3 patients treated with primary surgery. The findings suggest that response of neck nodes should be assessed independently of primary tumor response in trials of organ preservation strategies using induction chemotherapy, and that failure to achieve a clinical complete response in the neck warrants planned early salvage neck dissection in order to achieve improved overall survival.     

Treatment of neck nodes after induction chemotherapy in patients with primary advanced tumours

Responsiveness of neck nodes to induction chemotherapy often differs from that of the primary tumour. We have conducted a retrospective study to evaluate the results of treating the neck in a cohort of 350 patients with locally advanced (T3–4) head and neck carcinomas treated with radiation therapy at the primary location of the tumour after induction chemotherapy. One hundred and thirty-nine patients (40%) did not have neck nodes on diagnosis (N0). The treatment of the neck included surgery in 65 patients. Neck dissections were carried out before radiotherapy in 37 patients and after radiotherapy in 28 patients. The frequency of neck treatment failure was 24%. There was a tendency to better neck control when treatment included neck dissection, independently of the neck stage or response to chemotherapy. This tendency was statistically significant in patients with an advanced regional tumour (N2–3) who did not achieve a complete regional response after chemotherapy. In a multivariate analysis the variables that were related to the regional failure were the relapse of the tumour at the primary site, the neck stage (N), the type of treatment used in the neck, and the grade of regional response after induction chemotherapy. Our results lead us to suggest that after induction chemotherapy neck surgery is advisable in all cases with advanced regional disease (N2–3), independently of the grade of response achieved after induction chemotherapy, and is also advisable in N1 patients in whom induction chemotherapy does not achieve a complete response. Received: 27 December 1999 / Accepted: 6 June 2000     

T3和T4期梨状窝癌的综合治疗

目的评价不同治疗方式治疗梨状窝癌T3、T4病变的治疗效果。方法回顾性分析了1974年1月-1999年12月中国医学科学院肿瘤医院头颈外科初治的287例T3、T4梨状窝癌患者。根据治疗方式，分为4组：单纯放疗组（Ra组）134例，平均放疗剂量68．8Gy；术前放疗加手术组（R＋S组）125例，平均术前放疗剂量45．5Gy，其中32例行喉功能保留手术；单纯手术组（Sa组）13例，全部为非喉功能保留手术；手术加术后放疗组（S＋R组）15例，全部为非喉功能保留手术，平均术后放疗剂量56．3Gy。结果Kaplan-Meier方法计算Ra组、R＋S组、Sa组和S＋R组的5年生存率分别为23．13％、46．51％、18．33％和44．44％。综合治疗（R＋S组和S＋R组）与单纯治疗（Ra组和Sa组）的5年生存率分别为46．22％和22．60％，两组间差异有统计学意义（P=0．000）。Cox模型对生存时间的多因素分析显示，对生存时间有影响的是治疗模式（P=0．000）和放疗效果（P=0．0070）Ra组、R＋S组、Sa组和S＋R组的喉功能保存率分别为14．08％、13．61％、0和0。Ra组、R＋S组、Sa组和S＋R组的并发症的发生率分别为14．93％、37．60％、53．84％、33．33％。结论术前放疗有助于T3、T4梨状窝癌患者喉功能的保留。     

Induction chemotherapy with cisplatinum, 5-fluorouracil, bleomycin, mitomycin C and hydroxyurea for previously untreated locally advanced squamous cell carcinomas of the head and neck

Fifty-three patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with a combined modality treatment consisting of three cycles of induction chemotherapy before definitive surgery and/or radiotherapy. Two additional cycles of the same chemotherapy were given after local-regional therapy. The chemotherapeutic regimen included cisplatinum 100 mg/m2 on day 1, 5-fluorouracil 1000 mg/m2 as a continuous infusion on days 2-6, bleomycin 15 units i.m. on days 15 and 29, mitomycin C 4 mg/m2 i.v. on day 22 and hydroxyurea 1000 mg/m2 p.o. on days 23-27. Each cycle was repeated every 42 days. Forty-nine patients are evaluable for response. There were 37 men and 12 women, with a median age of 58 years (range 18-75 years) and performance status of 80 (range 40-90). Sixteen patients (33%) demonstrated a complete response, 20 (41%) a partial response, yielding a 74% response rate to induction chemotherapy; 12 (24%) patients had stable disease and 1 (2%) progressive disease. The actuarial survival of those patients who completed the whole treatment program was 65% at 2 years and 47% at 3 years. Toxicities included nausea and vomiting (66%). anemia (34%), leukocytopenia (54%), thrombocytopenia (22%), stomatitis (36%), diarrhea (10%), alopecia (78%), hear impairment (4%) and transient creatinine elevation (2%). The results of the present study showed that induction chemotherapy with the above regimen produced a high rate of complete responses and can be safely combined with local-regional therapy to improve local tumor control and increase disease-free survival in patients with locally advanced SCCHN.     

Resultados de un protocolo de preservación de órgano en pacientes con tumores localmente avanzados de la laringe

Introduction and objectivesAdvanced laryngeal carcinoma patients, candidates for total laryngectomy, nowadays have different treatment options. One of them is induction chemotherapy, which allows modulation of the second manoeuvre according to the degree of response achieved. This study presents the results of a large series of patients treated according to this protocol.MethodsRetrospective study of 370 patients with T3-T4 carcinomas of the larynx considered as candidates for total laryngectomy. All patients were treated with the protocol mentioned above.ResultsSeven patients died as a consequence of the treatment with chemotherapy. Among 363 patients finishing chemotherapy, 154 (43 %) achieved complete response and proceeded with radiotherapy. Total laryngectomy was performed in 135 (37 %) non-responders and 74 (20 %) patients were treated with radiotherapy in spite of an incomplete response to chemotherapy. Overall actuarial survival was 73 % at five years. Survival for patients with complete response and treated with radiotherapy was 77 % and for non-responders subjected to total laryngectomy it was 76 %. Non-responders treated with radiotherapy had a 5-year survival rate of 64 %, significantly different to both other groups (p = 0.01). Larynx preservation was achieved in 42 % of the patients, rising to 72 % for complete responders to chemotherapy and to 62 % in non-responders receiving radiotherapy.ConclusionsOur larynx preservation protocol including induction chemotherapy for patients with advanced carcinomas who are candidates for total laryngectomy achieved a total survival rate of 73 % with a 42 % larynx preservation rate. The response to the induction chemotherapy was the factor contributing most to larynx preservation.     

Supracricoid hemilaryngopharyngectomy in patients with invasive squamous cell carcinoma of the pyriform sinus. Part II: Incidence and consequences of local recurrence

Supracricoid hemilaryngopharyngectomy (SCHLP) was performed in 147 patients over a 19-year period for previously untreated invasive squamous cell carcinoma of the pyriform sinus. With a minimum of 3 years' follow-up, the current retrospective series was designed to document the incidence, risk factors, and consequences of local recurrence following SCHLP. Before operation, 97.4% of patients had an induction chemotherapy regimen. A complete clinical response and a complete histologic regression were noted in 21.7% and 16.8% of patients, respectively. A significant statistical relationship (p = .0001) was noted between complete clinical response and complete histologic regression. Postoperative radiotherapy was used in 49.8% of patients. The overall local recurrence rate was 8.2%. The 5-year actuarial (Kaplan-Meier life-table method) local control estimate was 90.4%. As a function of T stage, the 5-year actuarial local control estimates were 96.2%, 91.1%, 92.9%, and 62.6% in patients with tumors classified as T1, T2, T3, and T4a, respectively. On univariate analysis, the overall local recurrence rate varied significantly, from 5.3% to 55.6% if the apex of the pyriform sinus was invaded (p = .02), 6.9% to 18.7% if the posterior pharyngeal wall was invaded (p = .03), and 6.3% to 60% if the margins of resection were positive (p = .02). In a stepwise regression model, positive margins of resection (odds ratio, 8.4; 95% confidence interval, 2.2 to 32.2; p = .002) and invasion of the apex of the pyriform sinus (odds ratio, 6.1; 95% confidence interval, 1.1 to 33.3; p = .04) were the variables statistically associated with an increased risk of local recurrence. Local recurrence resulted in a statistically significant increased risk of nodal recurrence (p = .005) and death (p < .004). The overall laryngeal preservation rate was 91.2%. From an oncological perspective, these results suggest that SCHLP should become a major tool in the armamentarium of the head and neck surgeon and should be integrated into future trials aimed at organ preservation in patients with invasive squamous cell carcinoma of the pyriform sinus.     

Outcome of locally advanced stage III and IV head and neck cancer treated by surgery and postoperative external beam radiotherapy

An uncontrolled retrospective analysis of 76 patients with locally advanced Stage III and Stage IV squamous cell carcinoma of the oral cavity, oropharynx, pyriform sinus, supraglottic larynx, glottic larynx, and hypopharynx, who were treated in a uniform manner by surgical resection and 6,600 rad postoperative external beam radiotherapy, revealed relatively high 2-year and 4-year adjusted survival rates of 76% and 68%, respectively. Complication rates were acceptable (8%). The advantages of this treatment approach for locally advanced head and neck cancers compared to treatment by surgery alone are discussed.     

Five hundred cancers of the larynx and pyriform sinus: Results of treatment by radiation and surgery

Three hundred eighty cancers of the larynx and 120 of the pyriform sinus were treated in the 15 years from 1958-1973 at Yale-New Haven Hospital. They were studied for response to treatment by surgery, radiation or a combination of the two. Overall control rates in the entire group of 500 were 51% for radiotherapy, 51% for surgery. Further analysis showed significant differences in the results obtained by stage and by location for surgery and radiotherapy. The total number of cases treated by combined therapy was relatively small, except for pyriform sinus. Radiotherapy success showed a steep gradient from 82% in Tl lesions to 5% in T4. The gradient for surgery was less steep with 64% success for Tl and 40% for T4. Both radiotherapy and surgery were most successful in glottic cancer and least successful in the pyriform sinus. However, the success range varied more with radiation than with surgery (83% success in glottic cancer, 5% in pyriform sinus cancer for radiotherapy; 81% in glottic cancer and 24% in pyriform sinus for surgery). Late primary recurrences (3 years or more after radiation therapy) developed only in the glottic group. Recurrent cancer at the primary site in non-glottic lesions appeared within 2 years after radiotherapy in 65 of the 66 local recurrences. Similarly, 77 of the 82 local recurrences of non-glottic cancer after surgery appeared within 2 years. With only 1 exception in 34 cases, surgical salvage of radiation failures succeeded only in glottic cancer. Of the 136 T1 glottic lesions there were no discernible regional metas-tases. In the remaining 73 glottic T2 and T3 lesions, cervical node me-tastases developed in 8 lesions. Supraglottic cancer was the most likely to produce cervical node metastasis from an early primary lesion (5 Tl lesions among 10 supraglottic lesions with unrecognized positive nodes). Eight of the 65 patients with fixed cervical node metastasis were controlled with no evidence of disease after 3 years. Among the treatment failures, most of those in the radiotherapy group were due to uncontrolled primary disease (72%). The failures among the surgical group were due mainly to metastasis (72%). Final controls obtained by surgery, radiotherapy, combined treatment and secondary salvage of radiation or surgical failures were as follows: glottic 82%; supraglottic 58%; transglottic 58%; subglottic 60%; pyriform sinus 17%.     

Induction chemotherapy with cisplatinum, 5-fluorouracil,bleomycin, mitomycin C and hydroxyurea for previously untreated locally advanced squamous cell carcinomas of the head and neck

Summary Fifty-three patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with a combined modality treatment consisting of three cycles of induction chemotherapy before definitive surgery and/or radiotherapy. Two additional cycles of the same chemotherapy were given after local-regional therapy. The chemotherapeutic regimen included cisplatinum 100 mg/m² on day 1, 5-fluorouracil 1000 mg/m² as a continuous infusion on days 2–6, bleomycin 15 units i.m. on days 15 and 29, mitomycin C 4 mg/m² i.v. on day 22 and hydroxyurea 1000 mg/m² p.o. on days 23–27. Each cycle was repeated every 42 days.Forty-nine patients are evaluable for response. There were 37 men and 12 women, with a median age of 58 years (range 18–75 years) and performance status of 80 (range 40–90). Sixteen patients (33%) demonstrated a complete response, 20 (41%) a partial response, yielding a 74% response rate to induction chemotherapy; 12 (24%) patients had stable disease and 1 (2%) progressive disease. The actuarial survival of those patients who completed the whole treatment program was 65% at 2 years and 47% at 3 years. Toxicities included nausea and vomiting (66%), anemia (34%), leukocytopenia (54%), thrombocytopenia (22%), stomatitis (36%), diarrhea (10%), alopecia (78%), hear impairment (4%) and transient creatinine elevation (2%). The results of the present study showed that induction chemotherapy with the above regimen produced a high rate of complete responses and can be safely combined with local-regional therapy to improve local tumor control and increase disease-free survival in patients with locally advanced SCCHN.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29 September 1988     

Conservative Surgery in T3–T4 Pharyngolaryngeal Squamous Cell Carcinoma: An Alternative to Radiation Therapy and to Total Laryngectomy for Good Responders to Induction Chemotherapy

Objective To evaluate the possibility of preservation of the larynx after neoadjuvant chemotherapy by performing a conservative surgery instead of total laryngectomy initially planned, in patients with previously untreated laryngeal and piriform sinus squamous cell carcinoma (SCC). Study Design Retrospective study. Methods A total of 115 patients treated at Tenon Hospital with induction chemotherapy from 1985 to 1995, all with initial indication of radical surgery, were available for the study. The clinical tumor response was evaluated after three cycles of chemotherapy. According to this response, to preserve laryngeal functions, some patients had a modification of the treatment initially planned: radiation therapy essentially for complete responders, and conservative surgery for some partial responders. Results Of 69 patients with laryngeal cancer, 14 were treated by partial laryngectomy and 19 by radiation therapy; of 46 patients with piriform sinus cancer, 8 were treated by partial surgery and 12 by radiation therapy; the other patients were treated as was initially planned (total laryngectomy with partial pharyngectomy). Overall survival rates, estimated by the Kaplan‐Meier method, were not statistically different between the three treatment groups. The laryngeal functions were preserved in 54% of the patients who were alive at 3 years. Conclusion This report is a retrospective study, but these results suggest the possibility of using conservative surgery, instead of initially planned total laryngectomy, for good responders to induction chemotherapy with a small residual tumor.     

Concomitant chemoradiotherapy in pyriform sinus carcinoma

OBJECTIVES: To test the effectiveness of concurrent chemoradiotherapy in patients with pyriform sinus carcinoma and to demonstrate the feasibility of an organ preservation approach. DESIGN: Clinical trial phase 2. SETTING: University Hospital Center, St-Etienne, France. PATIENTS: The study population comprised 46 male patients with resectable stage III and IV pyriform sinus carcinoma. METHODS: Two successive chemoradiation regimens were investigated. In protocol 1 (24 patients), carboplatin was given on days 1 through 5 and 28 through 33, with an area under the curve dose of 5 mg/mL for 1 minute per day and bifractionated radiotherapy (160 rad [1.6 Gy]/fraction) delivered on days 1 through 16 and 28 through 38. A treatment break was planned on days 16 through 27. In protocol 2 (22 patients), chemotherapy was given with the same dose of carboplatin on days 1 and 21, and fluorouracil (750 mg/m(2) per day) on days 1 through 7 and 21 through 28. Radiotherapy with a single fraction of 180 rad (1.8 Gy)/d was delivered during the first 2 weeks and then 150 rad (1.5 Gy) twice a day during the next 3 weeks. MAIN OUTCOME MEASURES: Patients were evaluated for tumor response, toxic reactions, and organ preservation and survival rates. Statistical analysis of disease-free survival and overall survival was performed using the Kaplan-Meier method. RESULTS: A complete response was noted in 21 (88%) of the 24 patients following protocol 1 and 16 (73%) of the 22 patients following protocol 2. After 2 years of follow up, 16 patients (67%) (protocol 1) and 12 patients (55%) (protocol 2) retained their larynx without evidence of disease. During therapy, 15 patients (63%) (protocol 1) and 19 patients (86%) (protocol 2) required unplanned hospitalization for toxic effects. The overall survival and disease-free survival rates at 2 years were 58% (protocol 1) vs 53% (protocol 2) and 39% (protocol 1) vs 41% (protocol 2) (P =.80), respectively. CONCLUSION: Concomitant chemotherapy and bifractionated radiotherapy, although toxic, leads to good locoregional control and therefore to a significant level of laryngeal preservation.     

Does Induction Chemotherapy Still Have a Role in Larynx Preservation Strategies? The Experience of Institut Catala d'Oncologia in Stage III Larynx Carcinoma

BACKGROUND: Radiotherapy with concurrent cisplatin is the standard alternative to total laryngectomy for patients with locally advanced laryngeal cancer. The value of induction chemotherapy in larynx-preservation therapies remains unknown. Hyperfractionation radiotherapy might improve disease-free survival. METHODS: From August 1993 to August 2004, 71 patients with T3N0-1 larynx tumors and eligible for total laryngectomy received induction chemotherapy with three cycles of cisplatin plus fluorouracil. Clinical tumor response was assessed by indirect laryngoscopy and computed tomography scan. Patients with complete response received hyperfractionation radiotherapy, whereas those without complete response were proposed for total laryngectomy. RESULTS: A total of 71 consecutive patients were included. Thirty-three patients achieved complete response to induction chemotherapy (46.5%), four of them presented a tumor relapse, and all underwent salvage surgery. Seventy-six percent of surviving patients preserved a functional larynx. Despite not achieving complete response, 15 patients refused total laryngectomy and received hyperfractionation radiotherapy. Seven patients presented a tumor relapse and salvage surgery was performed in three of them. Fifty percent of surviving patients preserved a functional larynx. Twenty-two patients without complete response underwent total laryngectomy; three of them presented a tumor relapse but none could be rescued. With a median follow up of 68 months, 5 five-year overall survival, 5-year disease-free survival, and 5-year larynx function preservation survival rates were 68% (confidence interval [CI], 57-80), 75% (CI, 64-87), and 42% (CI, 29-54), respectively. No differences in overall survival were observed between groups. Five-year disease-free survival of patients without complete response who received hyperfractionation radiotherapy was significantly lower than that of the other two groups (P < .02). Ten patients with larynx preservation and no tumor relapse had chronic toxicity that caused the loss of larynx function: seven patients required permanent tracheotomy, two died from pneumonia, and one patient died as a result of a laryngeal necrosis. CONCLUSIONS: Patients with complete response to induction chemotherapy in laryngeal carcinoma have a high probability of cure after hyperfractionation radiotherapy. However, hyperfractionation radiotherapy induces a high degree of toxicity that reduces the laryngeal function preservation rate and may jeopardize overall survival.     

Functional outcomes of patients with advanced pyriform sinus cancer treated with extended near-total laryngopharyngectomy and free fasciocutaneous flap reconstruction

The objective of this study was to evaluate the functional results in patients with advanced pyriform sinus cancer treated with extended near-total laryngopharyngectomy (ENTLP) and free fasciocutaneous flap reconstruction. We reviewed the medical records of patients with pyriform sinus cancer who were treated at Kaohsiung Chang Gung Memorial Hospital, a tertiary medical center in Taiwan, between June 1998 and December 2008. This retrospective study enrolled the patients who had a stage III or IV pyriform sinus cancer and was surgically treated with ENTLP and free fasciocutaneous flap reconstruction. Thirteen patients meeting the inclusion criteria were enrolled. Three patients had stage III cancer, and ten had IVa. All were men with the age distribution ranged from 38 to 75 years. The average length of hospitalization was 19 days. Twelve (92.3%) patients could develop shunt speech postoperatively, and eight (61.5%) patients used shunt speech for their routine conversation. Eleven (84.6%) patients could ultimately return to an oral diet; the remaining two (15.4%) patients stayed dependent on a feeding tube for part or all of their nutrition. Two patients died from distant metastases, and one patient died from complications of postoperative concurrent chemoradiotherapy, while the other ten patients survived until the last follow-up without evidence of locoregional tumor recurrence. In conclusion, in the surgical treatment of patients with locally advanced pyriform sinus cancer, ENTLP and free fasciocutaneous flap reconstruction is an oncologically safe, voice-conserving, and prosthesis-free procedure which offers satisfactory functional speech and swallowing outcomes.     

Pacientes con carcinoma localmente avanzado de hipofaringe. Resultados a lo largo de un periodo de 30 años

Introduction and objectivesThe treatment of locally advanced carcinomas of the hypopharynx may include surgery or several combinations of radiotherapy and chemotherapy as organ preservation strategies. The objective of the present study is to analyze the results of locally advanced hypopharyngeal carcinoma patients treated in a single centre over a 30-year period.MethodsRetrospective chart review of 278 patients with T3-T4 hypopharyngeal carcinomas treated between 1985 and 2015 at a tertiary institution.ResultsAs much as 15.5% of the patients received only palliative treatment. Surgery, usually followed by radiotherapy or chemoradiotherapy was offered to 38.1% of the patients, and radiotherapy or chemoradiotherapy alone was offered to the remaining 46.6% of the patients. Cause-specific survival at 5 years was 39.7% (95% CI 33.7-45.7) for the whole sample. Surgery achieved better local control of the disease, but these figures did not translate into an increase of cause-specific survival for T3 tumours. Five-year survival free of laryngeal dysfunction for patients who received conservative treatment was 36.4%. In a multivariate analysis, only T4 local extension, N2-3 category, and posterior hypopharyngeal wall location related significantly with cause-specific survival.ConclusionsThere were no significant differences in cause-specific survival related to treatment modality for T3 carcinomas. On the other hand, surgery achieved a significant increase in cause-specific survival for T4 hypopharyngeal carcinomas.