Comparing surgical and nonsurgical larynx‐preserving treatments with total laryngectomy for locally advanced laryngeal cancer

Abstract

BACKGROUND:The declining 5-year overall survival (OS) of patients with laryngeal cancer has been associated with increased nonsurgical management of stage III/IV disease. To further assess this hypothesis, the authors evaluated recent OS trends and patterns of use between larynx-preserving approaches with chemoradiation (CRT) or partial laryngectomy (PL) and total laryngectomy (TL) stratified by tumor and nodal burden. METHODS: The National Cancer Data Base was used to identify 8703 patients with stage III/IV (excluding T1 tumors) laryngeal squamous cell carcinoma treated between 2003 and 2011 with CRT or upfront PL or TL with or without adjuvant therapy. OS was analyzed using the Kaplan-Meier method and a Cox proportional hazards model. RESULTS: Among patients with non-T4, low nodal burden (T2N1 or T3N0-N1) disease, no survival differences were observed between CRT, PL, and TL. Patients who had non-T4, high nodal burden (T2-T3N2-N3) disease who underwent TL with or without adjuvant treatment had a higher risk of death compared with those who received CRT (hazard ratio, 1.25; 95% CI, 1.04-1.51; P = .016). For T4N0-N3 tumors, TL compared with CRT was associated with improved OS (hazard ratio, 0.80; 95% CI, 0.62-0.92; P = .002). No statistically significant difference in outcome was noted between CRT and PL for all stage groups. The use of CRT has declined and receipt of TL has increased since 2006 for T4 disease, whereas PL rates have remained stably low. CONCLUSIONS: No survival differences were noted between surgical and nonsurgical approaches for patients with non-T4, low nodal burden laryngeal cancer. Patients with non-T4, high nodal burden disease may benefit from definitive CRT. Total laryngectomy remains advantageous in patients with T4 disease. Cancer 2019;125:3367-3377.

Laryngeal Compartmentalization Does Not Affect the Prognosis of T3-T4 Laryngeal Cancer Treated by Upfront Total Laryngectomy

“…In this respect, the updated guidelines of ASCO rightly recommended TL for patients with large-volume T4 and/or poor pre-treatment laryngeal functions, since such a mutilating surgical procedure has nonetheless shown to be associated with better survival and, surprisingly, even superior quality of life compared to CRT or RT alone [ 4 ]. Facing this highly heterogeneous population of advanced LCs, and the even more differentiated gamma of therapeutic options available, each with its pros and cons, the relative paucity of information about which subgroup of patients might preferably benefit from primary OP protocols vs. upfront TL is definitively worrisome [ 19 ].…”

“…This topic was further addressed by Patel et al in a recent national database analysis, underling that there are no differences in survival between surgical (TL and OPHL) and non-surgical approaches (CRT) for non-T4 lesions with low nodal burden, while non-T4 tumors with high nodal burden benefit more from CRT. Nevertheless, it was pointed out that TL remains advantageous in patients with T4 LC [ 19 ]. According to these findings, adequate local control is more critical in patients with limited nodal involvement, as they have a relatively lower risk of distant metastasis, while patients with higher N categories are more exposed to distant failure.…”

Recurrence of laryngeal squamous cell carcinoma in patients undergoing organ preservation therapy: are there symptoms associated with recurrence?

“…There is currently, however, a global trend toward therapeutic strategies aiming at organ preservation. Laryngeal neoplasm therapies are based on three main alternatives: total laryngectomy, partial laryngectomies and radiotherapy associated or not with systemic therapy 6,7 . These options are determined not only by local control of the disease but also by organ functionality.…”

Efficacy of non-surgical larynx-preservation comprehensive treatment in advanced laryngeal carcinoma

“…However, for certain patients, total laryngectomy must be performed, which drastically affects quality of life. Although important clinical trials have confirmed the possibility of laryngeal organ preservation in the treatment of advanced laryngeal cancer, [ 1 , 2 ] the best larynx-preservation strategy continues to be debated. [ 3 , 4 ] Here, we evaluated the efficacy of nonsurgical comprehensive treatment that sought to preserve laryngeal function for patients with advanced laryngeal carcinoma.…”