Decision making in advanced larynx cancer: An evidenced based review
Section snippets
Background
Advanced laryngeal cancer will affect over 4500 North Americans in 2018. These cancers include those classified as T3 or T4 as well as stage III or IV. The disease and its therapy often cripple essential functions including speech, swallowing and breathing. Thus, over time oncologists have changed their mantra from “survival at all costs” to “survival with maximum functional and quality of life outcomes;” making the treatment of advanced laryngeal cancer a fine balancing act.
Treatment paradigms
Scoping review methods
A scoping review of the literature in the bibliographic databases in PubMed/MEDLINE was performed, focusing on advanced laryngeal cancers and outcomes including survival and laryngeal/organ preservation.
Search strategy: A scoping review was conducted using the PubMed database (1947 to present), focusing on advanced laryngeal cancers and outcomes including survival and laryngeal/organ preservation. The database was searched for English-language studies between the database start date and May
T3 laryngeal cancers
Perhaps the greatest controversy in the treatment of advanced laryngeal cancers revolves around T3 disease. The VA and RTOG 91-11 trials presented data showing matching survival with CRT compared to TL for all T3 disease. In 2006, Hoffman et al. performed the first data validation of the landmark trials and questioned their applicability to all advanced laryngeal cancers [4]. Their analysis of 150,000 cases from the National Cancer Database (NCDB) showed that the survival of laryngeal cancers
T4 laryngeal cancer
Unlike T3 laryngeal cancers, the evidence for the management of T4 and stage IV laryngeal cancers is much clearer. Since the VA and RTOG 91-11 trials proposed that select T4 laryngeal cancer may have excellent function and survival outcomes with organ preservation, CRT has likely been over-applied to these patients. These studies focused on “low volume” T4 cancers without overt cartilage destruction. Unfortunately, many centers failed to recognize this caveat and widely applied CRT to any T4
Stage III/IV – advanced laryngeal cancer
When data combining stage III/IV (advanced) laryngeal cancers examines the same question, similar data arises. Megwalu et al. demonstrated that CCRT in this population is associated with poorer 5-year overall survival compared to surgical treatment (44% vs 39%; P < 0.001) and this effect was sustained on multivariable analysis [6]. Harris et al., using the SEER database, demonstrated that patients with both T3 and T4a cancers have improved overall and disease free survival with TL + PORT
Salvage surgery, non-functioning larynx and outcomes
A thorough systematic review and meta-analysis on salvage surgery demonstrated a 5-year survival rate of 48% in patients with advanced laryngeal cancer [36]. In the recurrent setting, particularly for those with advanced stage of disease at presentation who were initially treated with CCRT, the standard of care remains TL. In patients who have already been treated with CCRT, re-irradiation is an option but is associated with a significant risk of chondroradionecrosis and yields inferior
Functional outcomes - patient attitudes and preferences
In light of improved overall and disease-free survival with primary surgery amongst T4 and many T3 laryngeal cancers, it is also important to evaluate the functional outcomes in this cohort. In a study of T4 larynx cancers, who have undergone TL + PORT, 82% had a normal to only slightly impaired swallowing score [33]. This same group also established that more than 80% of these patients have acceptable vocal ability, after insertion and use of a voice prosthesis. These findings confirm
Conclusion
The treatment of advanced laryngeal cancer is more complex than the landmark trials have led us to believe. Monumental efforts have been made to allow patients to maximize survival while preserving their larynx; however, a growing body of literature tells us that not all T3 or T4 laryngeal cancers were created equal. As we move forward into an era of highly personalized medicine, we must not only consider the tumor stage in planning therapy, but we must tailor treatment to the specific tumor
Conflicts of interest
The authors have no conflicts of interest related to this study.
Financial/grant support/disclosure
None.
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Cited by (18)
A preliminary analysis of prognostic genes in advanced laryngeal squamous cell carcinoma patients with postoperative radiotherapy
2023, Pathology Research and PracticeCitation Excerpt :Notably, TL followed by radiotherapy may achieve a better survival rate compared with a nonsurgical approach in patients with poor pretreatment laryngeal function, especially in those having locally advanced lesions (extensive T3 or T4a) [4,7]. Upfront surgery is recommended in patients with advanced LSCC, unless there is adequate assessment of pre-treatment function, a good resourced multidisciplinary team, and feasibility for long-term follow-up [8,9]. Hence, surgery combined with postoperative radiotherapy is still a therapy option for advanced cancer of larynx.
Upfront surgical organ-preservation strategy in advanced-stage laryngeal cancer
2022, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :Currently, two organ preservation strategies are available for the treatment of advanced-stage LC in fit patients: concomitant chemo-radiotherapy (CRT) followed by salvage surgery in cases of treatment failure; conservative surgery followed by adjuvant therapy in cases of high-risk histologic features. The choice between these two options is influenced by various factors: laryngeal sub-site of the primary tumour; tumour and lymph nodes stages; expected functional and oncologic results; expertise of the multidisciplinary team; availability of personnel and facilities dedicated to rehabilitation; patients' decision and general conditions [7,8]. Moreover, this choice between a surgical or non-surgical approach may be guided by the response to a possible induction chemotherapy [5].
Organ preservation in laryngeal and hypopharyngeal cancer
2019, Oral OncologyHead and Neck Cancer: United Kingdom National Multidisciplinary Guidelines, Sixth Edition
2024, Journal of Laryngology and Otology