Clinical Investigation
Organ Preservation With Concurrent Chemoradiation for Advanced Laryngeal Cancer: Are We Succeeding?

Presented at the 7th International Conference on Head and Neck Cancer, San Francisco, CA. 21st of July 2008.
https://doi.org/10.1016/j.ijrobp.2009.01.058Get rights and content

Purpose

To determine the rates of organ preservation and function in patients with advanced laryngeal and hypopharyngeal carcinomas treated with concurrent chemoradiotherapy (CRT).

Methods and Materials

Between April 1999 and September 2005, 82 patients with advanced laryngeal (67%) and hypopharyngeal carcinomas (33%) underwent conventional radiotherapy and concurrent platinum-based chemotherapy with curative intent. Sixty-two patients were male (75.6%). The median age was 59 years. Eighteen patients (22%) were in Stage III and 64 (78%) were in Stage IV. The median radiation dose was 70 Gy. The median potential follow-up was 3.9 years.

Results

Overall survival and disease-free survival were respectively 63% and 73% at 3 years. Complete response rate from CRT was 75%. Nineteen patients (23%) experienced significant long-term toxicity after CRT: 6 (7.3%) required a percutaneous endoscopic gastrostomy, 5 (6%) had persistent Grade 2 or 3 dysphagia, 2 (2.4%) had pharyngoesophageal stenosis requiring multiple dilations, 2 (2.4%) had chronic lung aspiration, and 7 (8.5%) required a permanent tracheostomy. Four patients (4.9%) underwent laryngectomy without pathologic evidence of disease. At last follow-up, 5 (6%) patients were still dependent on a gastrostomy. Overall, 42 patients (52%) were alive, in complete response, with a functional larynx and no other major complications.

Conclusions

In our institution, CRT for advanced hypopharyngeal and laryngeal carcinoma has provided good overall survival and locoregional control in the majority of patients, but a significant proportion did not benefit from this approach because of either locoregional failure or late complications. Better organ preservation approaches are necessary to improve locoregional control and to reduce long-term toxicities.

Introduction

Larynx cancer is the most common cancer subsite in head and neck oncology. For patients with advanced tumors (Stage III or IV) of the larynx and hypopharynx, treatment options are concomitant chemoradiation (CRT) with surgery as salvage, or up-front surgery followed by adjuvant radiotherapy, with or without concurrent chemotherapy. These multimodal regimens are equivalent in terms of survival, but CRT offers the potential advantage of organ preservation 1, 2, 3, 4, 5, 6, 7.

Unfortunately, organ preservation treatment protocols are associated with significant acute and late adverse effects. Therefore, quality of life and morbidity should be considered when a treatment is proposed. Quality of life relates to overall well-being including the functional, emotional, mental, social, and economic components. The most common predictors of quality of life in surviving patients with advanced laryngeal cancer receiving CRT appear to be absence of pain and lower incidence of mood disorder rather than preservation of speech function (8).

Intensity-modulated radiotherapy (IMRT) is starting to be used in the larynx and hypopharynx substites (9). Although experience with this modality is accumulating, we wanted to review our current results with conventional radiotherapy. Our goal was to determine rates of functional organ preservation and late toxicities in patients treated for advanced laryngeal and hypopharyngeal cancer at our tertiary care health center.

Section snippets

Patient and tumor characteristics

Between August 1998 and September 2005, a total of 105 patients with histologically proven laryngeal and hypopharyngeal squamous cell cancer (SCC) were treated with concurrent CRT at the Centre Hospitalier de l'Université de Montréal. Pretreatment evaluations consisted of a complete history and physical examination including direct laryngoscopy using a flexible fiberoptic endoscope. Dental evaluation was mandatory in all except edentulous patients. All patients had a complete blood count and

Treatment outcome

Overall survival, disease-free survival, and the laryngectomy-free survival were respectively 63%, 73%, and 53% at 3 years (Fig 1, Fig 2). Complete response rate with CRT was 75%. The primary tumor response rate was higher, with 88% complete response vs. 79% for nodal complete response.

Late toxicities

Nineteen patients (23%) experienced significant complications after CRT corresponding to Grade 2, 3, or 4 on the CTCAE scale. Six (7%) required a percutaneous gastrostomy (PEG), 5 (6%) had persistent Grade 2 or 3

Discussion

Few studies have addressed functional outcomes of larynx preservation protocols. The main goal of our study was to review the toxicity of laryngeal preservation treatments in our center for patient with advanced larynx or hypopharynx squamous cell carcinoma. Both subjective and objective swallowing problems are frequent and severe long-term side effects after radiotherapy for pharyngeal cancer. Swallowing dysfunction has been correlated with dose and volume parameters of the upper aerodigestive

Conclusion

In this study, half of all patients with advanced laryngeal or hypopharyngeal carcinomas treated with CRT, experienced either significant complications of laryngeal failure or locoregional relapse. For patients treated with the objective of preserving a functional larynx, PEG dependency and laryngectomy are frequent negative outcomes. More efforts and studies are necessary to further improve locoregional control, improve quality of life, and reduce late complications.

Given that survival appears

References (36)

  • B. Emami et al.

    Tolerance of normal tissue to therapeutic irradiation

    Int J Radiat Oncol Biol Phys

    (1991)
  • G. Sanguineti et al.

    Dosimetric predictors of laryngeal edema

    Int J Radiat Oncol Biol Phys

    (2007)
  • F. Eschwege et al.

    [Organ preservation in ORL oncology: Myth or reality. The case for laryngeal preservation]

    Cancer Radiother

    (1998)
  • M.M. LoTempio et al.

    Comparison of quality of life outcomes in laryngeal cancer patients following chemoradiation vs. total laryngectomy

    Otolaryngol Head Neck Surg

    (2005)
  • N.P. Trivedi et al.

    Comparison of quality of life in advanced laryngeal cancer patients after concurrent chemoradiotherapy vs total laryngectomy

    Otolaryngol Head Neck Surg

    (2008)
  • D.J. Adelstein et al.

    An Intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer

    J Clin Oncol

    (2003)
  • Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group

    N Engl J Med

    (1991)
  • A.A. Forastiere et al.

    Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer

    N Engl J Med

    (2003)
  • Cited by (0)

    Conflict of interest: none

    View full text