Efficacy and toxicity profiles of two chemoradiotherapies for stage II laryngeal cancer – a comparison between late course accelerated hyperfractionation (LCAHF) and conventional fractionation (CF)

Objective: To evaluate the treatment results of late course accelerated hyperfractionation (LCAHF) compared with conventional fractionation (CF) for stage II laryngeal cancer.

Methods: Fifty-nine consecutive patients treated for stage II laryngeal cancer were retrospectively reviewed. Thirty-two patients underwent LCAHF, twice-daily fractions during the latter half with a total dose of 69?Gy. Twenty-seven patients received CF of 70?Gy.

Results: The local control rates (LCRs), overall survival (OS), and disease-specific survival (DSS) at 5 years were 80.6%, 74.0%, and 90.4%, respectively, after LCAHF and 64.7%, 68.2%, and 90.5%, respectively, after CF. There were no significant differences in LCR, OS, and DSS (p?=?.11, 0.68, and 0.69, respectively). In a small number of patients with supraglottic cancer, LCAHF was associated with a significantly higher LCR at 5 years compared with CF (100% vs. 41.7%; p?=?.02).

Conclusions: This is the first report that compared the results of LCAHF and CF for stage II laryngeal cancer. We could not find significant differences in LCR, DSS, and OS rates between LCAHF and CF groups. Although in a small number of patients with supraglottic cancer, LCAHF may improve the LCR compared with CF.     

Value of extranodal extension detected by computed tomography for predicting clinical response after chemoradiotherapy in head and neck squamous cell cancer

Objectives: Radiological extranodal extension (rENE) upon CT is obtained before concurrent chemoradiation therapy (CCRT) for head and neck squamous cell carcinoma (HNSCC). We evaluated the prognostic value of rENE, rather than pathologically proven ENE, in patients who received CCRT for HNSCC.

Materials and methods: We reviewed 117 patients. We divided the patients into rENE(+) and rENE(?) groups and evaluated overall survival (OS) and disease-specific survival (DSS), and factors affecting these outcomes.

Results: Median follow-up was 37.4 months; 31 patients (26.2%) died and 26 (22.2%) had recurrence. Thirty patients were rENE(+) and these had worse 5-year OS (74% vs. 94%, p?p?n?=?87). rENE (hazard ratio [HR] 3.57, p?p?p?p?p?p?Conclusions: CT findings suggesting ENE predicts treatment response to CCRT and prognosis, and could be used to determine the treatment modality for HNSCC.     

Assessment of preoperative psychologic distress in laryngeal cancer patients

Background: Preoperative psychologic distress is common in head and neck cancer patients and related to deleterious effects in patient treatment and recovery. Routine screening and appropriate referral of all patients with cancer for psychiatric assessment is now a part of the medical treatment.

Objects: The aim was to assess the level of preoperative psychologic distress in laryngeal cancer patients scheduled for surgical treatment.

Methods: After the Institutional Review Board approval and informed written consent, 211 patients scheduled for total or partial laryngectomy were interviewed preoperatively. Each patient was asked to fulfil the Hospital Anxiety and Depression Scale. Demographic characteristics that may relate to psychologic distress were also recorded.

Results: The mean age (+/?SD) was 62.1 (8.2) years. The surgical type was total laryngectomy (n?=?79) and partial laryngectomy (n?=?132). Median (first/third quartile) HADS score was 6 (3/10). A total of 39.6% patients had psychologic distress. The HADS score was higher for total laryngectomy patients than partial laryngectomy patients [7 (4/10) versus 5 (3/10), p?<?.05]. Age was negatively correlated with HADS score (p?=?.049).

Conclusions: Our study showed that laryngeal cancer patients scheduled for total laryngectomy had higher level of psychologic distress. Age was a predictive factor for psychologic distress.     

Age-adjusted Charlson Comorbidity Index predicts prognosis of laryngopharyngeal cancer treated with radiation therapy

Objectives: To examine the ability of comorbidity indices to predict the prognosis of laryngopharyngeal cancer and their association with treatment modalities.

Methods: This retrospective study included 198 patients with laryngeal, hypopharyngeal, and oropharyngeal cancers. The effect of comorbidity indices on overall survival between surgery and (chemo)-radiation therapy ((C)RT) groups was analyzed. The cumulative incidence rates for cancer mortality and other mortalities according to the age-adjusted Charlson Comorbidity Index (ACCI) and Charlson Comorbidity Index (CCI) were compared.

Results: Univariate survival analyses showed a significant association between the ACCI and overall survival in the (C)RT group, but not in the surgery group. The association between the CCI and overall survival was not significant in either group. In multivariate analyses, a high ACCI score was an independent prognostic factor in the (C)RT group (HR 2.89, 95% confidence interval (CI) 1.28–6.49), but not in the surgery group (HR 1.39, 95%CI 0.27–5.43). The higher ACCI group had increased mortality from other causes compared with the lower ACCI group (5-year cumulative incidence, 8.5% and 17.8%, respectively, p?=?.003).

Conclusion: The ACCI was a better prognostic factor than the CCI. Surgery may be more beneficial than radiation for patients with a high ACCI.     

A descriptive study highlighting the differences in the treatment protocol for oral tongue cancer in Sweden and Finland

Abstract

Background and aims: Stage II cancer of the tongue is mostly managed surgically both locally and regionally. However, indications for postoperative radiotherapy and reconstructive options vary between centers. This paper aims to describe differences in treatment in a geographically homogenous cohort.

Methods: A retrospective comparison was made between two cohorts of clinical T2N0 tongue cancer from Finland and Sweden. The Finnish cohort included 75 patients and the Swedish 54. All patients had curative intent of treatment and no previous head and neck cancer. Data analyzed consisted of pathological stage, size and thickness of tumor, frequency of reconstruction, radiotherapy delivered, and survival.

Results: The Finnish cohort included a higher proportion of patients managed with reconstructive surgery (67%) than the Swedish cohort (0%), p?<?.00001. More patients were treated with postoperative radiotherapy (84%) in the Swedish cohort than in the Finnish (54%), p?<?.0002. The Finnish cohort had a higher level of survival and included more frequent downstaging (cTNM to pTNM).

Conclusions and significance: Our data indicate a major difference in the management of T2N0 oral tongue cancer. The optimal cut-off size and growth pattern of the tumor warranting reconstruction should be further evaluated in a prospective manner considering both survival and quality of life.     

Rational choice of induction chemotherapy-based larynx preservation for hypopharyngeal cancer

Abstract

Backgroud: Induction chemotherapy, as a larynx preservation treatment, has been available for over 20 years. We conducted a retrospective study to evaluate the efficacy of this protocol with taxene, cisplatin and 5-fluorouracil in Chinese patients with hypopharyngeal cancer that chose preservation strategy.

Material and methods: 170 patients with locally advanced hypopharyngeal cancer were assigned to receive induction chemotherapy. 107 patients (63%) with complete response or partial response received larynx preservation treatment and 63 non-responders (37%) received radical surgery.

Results: Median survival time was 30 months (range: 3–59 months). 63 patients (37%) had local-regional failure and 15 (9%) had distant metastasis. Three-year LFS was 27.8% (95% CI: 23.6–32.0%). The estimated three-year overall survival rate was 44.5% (95% CI: 39.5–49.5%). There was no significant difference in the three-year survival rate between responders (44.8%) and non-responders (43.9%) (p?=?.237), however patients with a partial response had a significant decrease in survival (32.2%) (p?<?.001).

Conclusions: In patients with hypopharyngeal cancer, ICT with TPF regimen followed by RT, as a larynx preservation treatment, may be suitable for complete responders, but not partial responders.     

Ileocolic free flap reconstruction,concomitant chemotherapy and radiotherapy and assessment of speech and swallowing function during management of advanced cancer of the larynx and hypopharynx: Preliminary report

Conclusion

The new technique of ileocolic free flap reconstruction provides a better quality of life in terms of swallowing and speech for patients who have undergone laryngopharyngectomy with concomitant chemotherapy and radiotherapy (CCRT).

Objectives

To compare and contrast the swallowing and speech outcomes of patients who underwent total laryngopharyngectomy with ileocolic free flap reconstruction and to analyze the survival rate after surgery and CCRT.

Material and methods

This was a follow-up study of 12 patients with advanced (stages III, IVA and IVB) laryngeal and hypopharyngeal cancer who underwent major surgery, CCRT (with one exception) and ileocolic free flap reconstruction.

Results

All patients were able to tolerate single-stage combined management comprising total laryngopharyngectomy with or without radical neck dissection plus ileocolic free flap reconstruction and postoperative CCRT (with one exception), without immediate morbidity or mortality. Eleven patients were diagnosed with hypopharyngeal cancer and one with laryngeal cancer. The mean interval between surgery and CCRT was 34.1 days. The mean follow-up period was 16.5 months. Four patients died during the follow-up period as a result of local recurrence (n=2), distant metastasis (n=1) and suicide (n=1). One patient was alive with disease despite neck recurrence.     

Current trends in initial management of laryngeal cancer: the declining use of open surgery

The role of open surgery for management of laryngeal cancer has been greatly diminished during the past decade. The development of transoral endoscopic laser microsurgery (TLS), improvements in delivery of radiation therapy (RT) and the advent of multimodality protocols, particularly concomitant chemoradiotherapy (CCRT) have supplanted the previously standard techniques of open partial laryngectomy for early cancer and total laryngectomy followed by adjuvant RT for advanced cancer. A review of the recent literature revealed virtually no new reports of conventional conservation surgery as initial treatment for early stage glottic and supraglottic cancer. TLS and RT, with or without laser surgery or CCRT, have become the standard initial treatments for T1, T2 and selected T3 laryngeal cancer. Photodynamic therapy (PDT) may have an emerging role in the treatment of early laryngeal cancer. Anterior commissure involvement presents particular difficulties in application of TLS, although no definitive conclusions have been reached with regard to optimal treatment of these lesions. Results of TLS are equivalent to those obtained by conventional conservation surgery, with considerably less morbidity, less hospital time and better postoperative function. Oncologic results of TLS and RT are equivalent for glottic cancer, but with better voice results for RT in patients who require more extensive cordectomy. The preferred treatment for early supraglottic cancer, particularly for bulkier or T3 lesions is TLS, with or without postoperative RT. The Veterans Administration Study published in 1991 established the fact that the response to neoadjuvant CT predicts the response of a tumor to RT. Patients with advanced tumors that responded either partially or completely to CT were treated with RT, and total laryngectomy was reserved for non-responders. This resulted in the ability to preserve the larynx in a significant number of patients with locally advanced laryngeal cancer, while achieving local control and overall survival results equivalent to those achieved with initial total laryngectomy. Following this report, similar “organ preservation” protocols were employed in many centers. By 2003, results of the RTOG 93-11 trial, utilizing CCRT as initial treatment, were published, demonstrating a higher rate of laryngeal preservation with this protocol. Surgery was reserved for treatment failures. This concept changed the paradigm for management of advanced laryngeal cancer, greatly reducing the number of laryngectomies performed. While supracricoid laryngectomy has been employed for selected patients, total laryngectomy is the usual procedure for salvage of failure after non-surgical treatment.     

Surgical options in radiotherapy-failed early glottic cancer

After failure of curative radiotherapy (RT), surgery is the main therapeutic option to control recurrent laryngeal cancer. Recurrences after RT for T1–T2 tumours of the glottic larynx are often diagnosed at a more severe stage than the original disease and, thus, usually treated by radical approaches. Our aim is to investigate the feasibility of more conservative strategies for proper treatment of post-RT recurred glottic cancer. We collected and reviewed our files from 1990 to 2006, selecting 75 patients which matched the following inclusion criteria: (1) patient was originally diagnosed with early stage squamous cell carcinoma of the glottic larynx (stage I–II according to 2010 TNM), (2) patient was treated by RT with curative intent, (3) patient presented a recurrence of disease after RT which was surgically treated at our Institution. T stage at first diagnosis was T1a in 41 cases (55 %), T1b in 12 (16 %) and T2 in 22 (29 %). At clinical examination of RT-recurred lesions, we documented advanced lesions (rT3–rT4) in 29 out of 75 patients (39 %). Overall, an upstage was reported for 56 % RT-recurred cancers, while 37.3 % remained at the same stage than the original tumour and 6.7 % were downstaged. Twelve patients (16 %) underwent salvage partial laryngectomy (SPL), while 63 (84 %) received a salvage total laryngectomy (STL). Multivariate analysis showed that rTNM according to the AJCC-UICC of 2010 was the only prognostic factor for both disease-free survival (p = 0.042) and overall survival (p = 0.004). Considering the prognostic impact of rT and rN we documented a statistical significance only in terms of overall survival for both factors (p = 0.004 and p = 0.04, respectively). Although STL remains the most frequent treatment choice for failures after RT in laryngeal carcinomas, SPL represents a valid option for selected patients with limited recurrence and can deliver good oncologic and functional results if performed according to careful indications.     

Concurrent chemoradiotherapy with cisplatin and fluorouracil for locally advanced hypopharyngeal carcinoma

CONCLUSIONS: The concurrent administration of cisplatin and fluorouracil (CCRT) during radiotherapy after induction chemotherapy had better results than induction chemotherapy followed by radiotherapy alone (CT+RT) for overall survival, laryngeal preservation, and locoregional control in patients with locally advanced hyopharyngeal cancer. OBJECTIVES: To report treatment results comparing CCRT with CT+RT in locally advanced hypopharyngeal cancer. PATIENTS AND METHODS: Sixty-six consecutive patients treated with curative intent were analyzed retrospectively. Thirty-eight patients were treated with induction chemotherapy followed by definitive RT, and 28 patients with induction chemotherapy followed by concurrent chemoradiotherapy. All patients had more than three cycles of continuous infusion of cisplatin and 5-fluorouracil every 3 weeks. The median dose of irradiation was 70 Gy in the CT+RT group and 68.4 Gy in the CCRT group, respectively. RESULTS: The overall 5-year survival rates were 24% for the CT+RT group and 42% for the CCRT group (p=0.031). The 3-year pharyngolaryngectomy-free survival rates were 32% for the CT+RT group and 63% for the CCRT group (p=0.032). The 3-year locoregional control rate for CCRT was significantly better than that for the CT+RT (52% vs 23%, p=0.004). Acute hematologic toxicity appeared in 39% of the CT+RT patients and 75% of the CCRT patients.     

Predictors of prolongation in radiation treatment time in a veteran population treated with chemoradiation for oropharyngeal cancer

Background: Prolonged radiation treatment time (RTT) is associated with worse tumor control. Here we identify and determine the implications of factors that predict treatment prolongation in Veterans Affairs (VA) patients undergoing chemoradiation.

Methods: Chart review from July 2000 to October 2013. 81 patients with advanced stage oropharyngeal cancer treated with chemoradiation.

Results: Twenty-nine patients (35.8%) had RTT prolonged by ≥10 days. Prolongation mainly resulted from acute treatment toxicity (n?=?22, 76%). There was no significant difference in RTT for patients treated with concurrent cisplatin versus cetuximab, or in patients treated with or without induction chemotherapy. One-/three-year locoregional control and overall survival rates of 83.4%/76.3% and 83.5%/63.6% for patients without prolonged RTT versus 61.8%/61.8% and 82.8%/73.8% for those with prolongation (p?>.05).

Conclusions: Prolonged RTT is a significant predictor of worse locoregional control and predominantly resulted from treatment side effects. More aggressive regimens with induction and concurrent chemotherapy did not predispose to prolonged RTT.     

Post-operative complications of salvage total laryngectomy forpost-radiotherapy recurrent laryngeal cancer using pectoralis major myocutaneous flaps

Background: Salvage surgery for laryngeal cancer recurring after radiotherapy is difficult and complications readily occur. Our institution has adopted the pharyngeal interposition graft (PIG) using a pectoralis major myocutaneous (PMMC) flap, which has copious blood flow, for preventing post-irradiation pharyngocutaneous fistula.

Aims/objectives: The purpose of this study was to examine the incidence of post-operative complications of salvage total laryngectomy (STL) using the PMMC flap for post-radiotherapy recurrent laryngeal cancer at our institution.

Material and methods: From among 162 patients with laryngeal cancer who had been treated at Tokyo Medical University Hospital between January 2014 and March 2018, we enrolled 11 patients who had undergone STL applying a PMMC flap. We examined patient backgrounds (age, gender, subtype, stage), initial therapy (radiotherapy/chemoradiotherapy), radiation dose, irradiation area, surgery type (with/without neck dissection) and postoperative complications.

Results: No severe systemic complications were encountered. Pharyngocutaneous fistula occurred as a severe local complication in one patient (8.3%) and wound infection as a mild local complication in one patient (8.3%).

Conclusions: Rates of post-operative complications following STL tended to be lower at our institution than those reported for other institutions.

Significance: PIG may be a useful surgical procedure in STL.     

Adjuvant role of radiation therapy for locally advanced laryngeal cancer without pathological lymph node metastasis

Conclusion The application of adjuvant RT to reduce recurrence should be tailored in cases of pathologically negative node metastasis. Objectives The treatment modality following surgical resection of advanced laryngeal cancer is determined by adverse factors. Aside from lymph node metastasis (LNM) or positive margins, definite risk factors supporting adjuvant radiation therapy (RT) have not been clearly suggested. The aim of this study was to analyze the risk factors for advanced laryngeal cancer without LNM and the role of RT. Materials and methods Pathologically T3 and T4-staged laryngeal squamous cell carcinoma without LNM were reviewed. The patients were classified into RT (+) (n?=?22) and RT (?) (n =?38) groups. Results Five-year overall survival (OS) of the RT (+) and RT (?) groups was 84.4% and 83.8%, respectively. Five-year disease-specific survival of the RT (+) and RT (?) groups was 88.4% and 93.9%. Five-year local control rate of the RT (+) and RT (?) groups was 94.7% and 91.3%. The factors affecting OS were smoking history and recurrence history (p?=?0.02). By multivariate analysis, smoking history and recurrence history were determining factors for 5-year OS (p?=?0.024 and p?=?0.047, respectively).     

Role of postoperative adjuvant radiotherapy for locally advanced laryngeal cancer: a meta-analysis

Background: Studies have shown mixed results on the role of postoperative adjuvant radiotherapy (PORT) in surgically managed locally advanced laryngeal cancer.

Objectives: The aim of this study is to review and investigate the role of PORT in patients with locally advanced laryngeal cancer using meta-analysis.

Materials and methods: Relevant studies were searched using PubMed and eligible information has been extracted. Then, meta-analysis of hazard ratio (HR) was performed to evaluate the role of PORT in locally advanced laryngeal cancer.

Results: This meta-analysis included 7 published studies containing 2007 patients. For overall survival (OS), patients of locally advanced laryngeal cancer who were treated with PORT have a combined hazard ratio (HR) of 0.67 with 95%CI (0.56, 0.79), compared to those who were not treated with PORT, which was significantly associated with better survival. PORT was also associated with a better disease-free survival (DFS) and local control rate (LCR) in patients with locally advanced laryngeal cancer. The pooled HR and 95%CI for DFS and LCR were 0.72 (0.53, 0.99) and 0.29 (0.09, 0.99), respectively.

Conclusions and significance: This study suggested that PORT could improve the survival of patients with surgically managed locally advanced laryngeal cancer.     

Predicting feeding tube and tracheotomy dependence in laryngeal cancer patients

Conclusions: The two scales reliably measure laryngeal edema and dysfunction in laryngeal cancer patients. The eight categories from these scales, and abnormal pharyngeal squeeze, can be used to form a new rating scale intended to help clinicians identify and circumvent swallowing complications after chemo-irradiation.

Objectives: The objectives were to compare two laryngeal edema rating scales in laryngeal cancer patients and determine if post-radiation +/? chemotherapy edema predicts dependence on a feeding tube and/or tracheostomy.

Methods: A retrospective chart review between 2005–2008 revealed 28 laryngeal cancer patients status post-radiation +/? chemotherapy, with video laryngoscopies performed within 6 months after treatment. Four raters evaluated videos based on the Laryngopharyngeal Edema Scale (LES) and the Reflux Finding Score (RFS). Tracheostomy and feeding tube outcomes were then correlated with the two scales.

Results: Feeding tube and tracheostomy dependence were associated with pre-treatment vocal cord paralysis, advanced T stage, and chemoradiation. Eight categories from the LES and RFS scales were significantly associated with the need for a feeding tube.     

Adjuvant therapy improves survival in pT4aN0 oral cavity squamous cell carcinoma with bone invasion

ObjectiveThe prognostic significance of bone invasion in oral cavity squamous cell carcinoma (OCSCC) after accounting for tumor size, nodal spread, and surgical margins is controversial. The aim of this study is to determine whether patients with pT4aN0 oral cavity squamous cell carcinoma with bone invasion have improved overall and disease-free survival with adjuvant treatment.MethodsWe conducted a retrospective review of medical records from 64 patients with stage pT4aN0 due to mandibular involvement who underwent surgery from 2000 to 2020. Kaplan-Meier analysis compared disease-free survival and overall survival between groups who underwent surgery only versus surgery and adjuvant therapy. The prognostic impact of adjuvant therapy was assessed using multivariate analysis and reported as hazard ratios.ResultsThere were no statistically significant differences in clinicopathologic features or mean follow-up between patients who received surgery only and patients who received surgery with RT/CCRT (radiotherapy/concurrent chemoradiation therapy). 5-year disease-free (42.5% versus 65.9%, p = 0.02) and overall survival (43.6% versus 69.0%, p = 0.014) were improved in groups who received surgery and RT/CCRT. Regression analysis controlling for clinicopathologic characteristics, including tumor size, identified radiation as an independent predictor of improved disease-free survival (HR: 0.04, p < 0.001) and overall survival (HR: 0.10, p < 0.001).ConclusionAdjuvant RT/CCRT in patients with pT4N0 OCSCC with mandibular bone involvement is associated with improved disease-free and overall survival. This association was significant regardless of tumor pathologic features such as size or margin status. These findings may help guide physicians in counseling patients regarding risks and benefits of adjuvant RT/CCRT and inform practice guidelines.     

Primary definitive radiotherapy with or without chemotherapy for squamous cell carcinoma of the temporal bone

We aimed to evaluate the impact of concurrent chemoradiotherapy (CCRT) on the survival of patients with squamous cell carcinoma of the temporal bone. We retrospectively analyzed the data of 13 consecutive patients who were treated by definitive radiation therapy (RT) or CCRT as the initial treatment between 1999 and 2012. There were 5 patients with stage II disease, 5 with stage III, and 3 with stage IV, as classified according to the University of Pittsburgh system. Among these, 2, 4, and 3 patients, respectively, were treated by CCRT; whereas the remaining (3 patients with stage II and 1 with stage III) were treated by RT alone. Median follow-up duration was 39 months (12–106 months) in all cases, and 61.5 months (17–70 months) in censored cases. The 5-year overall survival (OS) rates were 51 % in all patients, and 40, 100, and 0 % in patients with stage II, stage III, and stage IV disease, respectively. In patients with stage II and III disease, the 5-year OS rates were 80 % in the CCRT group and 50 % in the RT-alone group. We found better prognosis in patients with stage II and III disease who were treated by CCRT. Only 2 patients treated by CCRT experienced adverse events more than grade 3, which were neutropenia and dermatitis. There was no late adverse event of bony necrosis. Our study results indicate that CCRT is safe and very effective as a first-line treatment for stage II and III squamous cell carcinoma of the temporal bone.     

Elevation of C-reactive protein during concurrent chemoradiotherapy is a poor predictive factor for head and neck cancer

ObjectiveThe prognostic role of pretreatment C-reactive protein (CRP) has been reported for head and neck cancer. However, little is known about the relationship between the changes in CRP levels during treatment and prognosis. This study aimed to investigate the correlation between CRP elevation during concurrent chemoradiotherapy (CCRT) and survival outcomes.MethodsThe medical records of patients with oropharyngeal, hypopharyngeal, and laryngeal cancer treated with CCRT at the University of Tsukuba Hospital and National Hospital Organization Mito Medical Center from April 2014 to December 2019 were retrospectively reviewed. Patients were divided into normal (<0.3 mg/dl) and elevated (≥0.3 mg/dl) CRP groups according to the CRP level after the first cycle of cisplatin. The primary endpoint was progression-free survival (PFS).ResultsA total of 74 patients were enrolled, of whom 36 (49%) showed elevated CRP levels after the first cycle of cisplatin. The 3-year PFS was 83.3% and 61.0% in the normal and elevated CRP groups, respectively, showing significant differences between the two groups.ConclusionElevated CRP levels after the first cycle of cisplatin is an objective predictive marker for survival in patient with head and neck squamous cell carcinoma treated with CCRT.     

Impact of treatment modality on survival in patients with stage IV laryngeal cancer: A population-based propensity score analysis.

IntroductionThe treatment of advanced stage laryngeal suffered a major shift away from surgery and towards larynx-preservation alternatives after the publication of major clinical trials. But its applicability in real-world situations is not consensual.Materials and methodsWe reviewed a population-based database from Brazil regarding patients treated for laryngeal cancer and selected those with stage IV disease at presentation. Survival analysis was realized by the Cox proportional hazards method and propensity scores were used to compensate for non-random allocation to different treatment arms.ResultsA total of 5577 patients were included in the analyses, with 4243 staged as CS IVa, 1010 as CS IVb and 324 as CS IVc. In univariate and multivariate analysis, gender, cT stage, cN stage, cM stage and treatment modality were significant predictors of disease-specific survival. In patients with CS IVa, age, gender, payment modality, location within the larynx, cT and cN stages and treatment modality were significant. After propensity score adjustment, treatment modality remained significant, favoring primary surgery with disease-specific survival (HR: 0.5041, 95% CI: 0.4494–0.5644, p < 0.001) and overall survival (HR: 0.5485, 95% CI: 0.4955–0.6072, p < 0.001) as outcomes of interest. Patients staged as cT4a cN0 were selected and analyzed as a distinct subset. In multivariate analysis, treatment modality was the only variable with significant prognostic impact with improved outcome for surgery-based treatment (HR: 2.521, 95% CI: 1.897–3.350, p < 0.001).ConclusionsThe extrapolation of clinical trials to the real-world facilities must be carefully weighted. The setting of trial conduction may influence its outcome and may not be reproducible. Our results show that patient selection and the facilities of clinical trials may play a significant role in the success of non-surgical approaches to non-metastatic stage IV laryngeal cancer.     

Unknown primary squamous cell carcinoma of the head and neck: retrospective analysis of 80 cases

Objectives: The management of patients with cervical metastasis in head and neck cancer of unknown primary (HNCUP) remains controversial. This current multicenter retrospective study investigated the treatment outcomes of patients with HNCUP.

Methods: The study included patients who were treated curatively at 12 institutions in Japan from January 2006 to December 2015.

Results: Eighty patients with HNCUP were included. The median follow-up period was 34 months. The three-year overall survival (OS), disease-specific survival (DSS), regional relapse-free survival (RRFS), local progression-free survival (LPFS), and distant metastasis-free survival (DMFS) rates were 72.5%, 80.3%, 74.0%, 89.7%, and 86.9%, respectively. Nodal status was a significant factor for OS, DSS, RRFS, and DMFS; and extracapsular extension (ECE) was significant for OS and DSS. There was a distinct difference between the survival rates of patients with N1–2a and N2b–3 disease. RT was a significant positive factor for LPFS (3-year LPFS, RT 93.0% vs. no RT 83.0%, p?=?.043).

Conclusions: For N2a as well as N1 disease without ECE, a single treatment modality, including ND or RT alone is acceptable. When ND alone is performed, thorough monitoring should be continued during follow-up to identify the emergence of the primary lesion.