Larynx preservation, radiotherapy

1. Larynx Preservation
Dr. Ajay Sasidharan
Tata Memorial Hospital

2. Early glottis (T1, T2 N0)
• Treatment options:
• Radical Radiotherapy
• TLS
• Open Partial Laryngectomy

3. Treatment selection
• Disease extent to include supraglottis/subglottis
• Anterior commissure involvement
• Patients compliance
• Patients preference
• Physicians expertise
• Occupational consideration
• Voice quality
• Performance status
• Comorbidities
• Treatment cost
• Physicians bias

4. Cure, Voice Preservation, Cost
• 5 yr LC
• T1 N0 glottic cancer – 85 – 94%
• T2 N0 glottis cancer – 70 – 80%
• Ultimate LC ranges from 90-95%
• Voice preservation similar between laser and
RT, poorer for open partial laryngectomy
• Influenced by Higher Dose per fraction and Lesser OTT
• Higher cost of open partial laryngectomy
• Transoral laser excision – major complications 0% for T1, 13% for T2
Cancer. 2004 May 1;100(9):1786-92.
Management of T1-T2 glottic carcinomas.
Mendenhall WM1, Werning JW, Hinerman RW, Amdur RJ, Villaret DB.
Author information
Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida 32610-0385, USA. mendewil@shands.ufl.edu

5. Types of cordectomy

6. Radiotherapy

7. Voice quality after TLM and RT
Int J Radiat Oncol Biol Phys. 2014 Oct 1;90(2):255-60. doi: 10.1016/j.ijrobp.2014.06.032.
Voice quality after treatment of early vocal cord cancer: a randomized trial comparing laser surgery with radiation therapy.
Aaltonen LM1, Rautiainen N2, Sellman J2, Saarilahti K3, Mäkitie A4, Rihkanen H4, Laranne J5, Kleemola L5, Wigren T6, Sala E7, Lindholm P8, Grenman R7, Joensuu H3.
Author information
1
Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Central Hospital, and University of Helsinki, Helsinki, Finland. Electronic address: leena-maija.aaltonen@hus.fi.

8. Voice quality after TLM and RT
World J Oncol. 2018 Apr; 9(2): 39–45.
Published online 2018 May 1. doi: 10.14740/wjon1105w
PMCID: PMC5942206
PMID: 29760831
Current Status of Organ Preservation in Carcinoma Larynx
Tapesh Bhattacharyyaa and Cessal Thommachan Kainickalb,c

9. Early supraglottis (T1, T2 N0)
• Primary difference from early glottis cancer is rate of LN metastasis –
10-50% (average 33%)
• Surgical options –
• Open supraglottic laryngectomy
• TLM/TORS
• SCPL-CHEP
• RT (Preferred)

10. Locally advanced laryngeal cancer
(Stage III and IV)
• 25 yrs ago – Total laryngectomy plus conventional PORT
• 1991 – Induction chemotherapy (VA trial)
• 2003 – CTRT (Forastiere et al; RTOG 9111)
• 2013 – Update of RTOG 9111
• Standard of care – CTRT

11. Locally advanced laryngeal cancer
World J Oncol. 2018 Apr; 9(2): 39–45.
Published online 2018 May 1. doi: 10.14740/wjon1105w
PMCID: PMC5942206
PMID: 29760831
Current Status of Organ Preservation in Carcinoma Larynx
Tapesh Bhattacharyyaa and Cessal Thommachan Kainickalb,c

12. Induction chemotherapy in larynx preservation
• GORTEC – Adding docetaxel improves overall response
• TAX 324/323 – TPF improves survival compared to PF. The subset
analysis of laryngeohypopharyngeal cancer patients – significant
improvement of laryngectomy free survival.
• DeCIDE
• PARADIGM
• Budach et al metaanalysis (2016)
No OS/PFS benefit of NACT fb CTRT versus CTRT alone

13. Biological therapy in Organ Preservation
JAMA Otolaryngol Head Neck Surg. 2016 Sep 1;142(9):842-9. doi: 10.1001/jamaoto.2016.1228.
Cetuximab and Radiotherapy in Laryngeal Preservation for Cancers of the Larynx and Hypopharynx: A Secondary Analysis of a Randomized Clinical Trial.
Bonner J1, Giralt J2, Harari P3, Spencer S1, Schulten J4, Hossain A5, Chang SC6, Chin S5, Baselga J7.
Author information
1
Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham.
• The rates of laryngeal preservation at 2 years were 87.9% for CRT vs
85.7% for radiotherapy alone, with an HR of 0.57 (95% CI, 0.23-1.42;
P = .22).
• The HR for laryngectomy-free survival comparing CRT vs radiotherapy
alone was 0.78 (95% CI, 0.54-1.11; P = .17). This study was not
powered to assess organ preservation.

14. Outcome of salvage TL following organ
preservation therapy
Arch Otolaryngol Head Neck Surg. 2003 Jan;129(1):44-9.
Outcome of salvage total laryngectomy following organ preservation therapy: the Radiation Therapy Oncology Group trial 91-11.
Weber RS1, Berkey BA, Forastiere A, Cooper J, Maor M, Goepfert H, Morrison W, Glisson B, Trotti A, Ridge JA, Chao KS, Peters G, Lee DJ, Leaf A, Ensley J.
Author information
1
Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Medical Center, 3400 Spruce St, 5 Ravdin, Philadelphia, PA 19104, USA. randal.weber@uphs.upenn.edu
• Incidence of major and minor complications ranged from 52 – 59%
• LRC following salvage laryngectomy was 74% for arm 1 and 2 (NACT
fb RT; CTRT); and 90% for arm 3 (RT alone)
• At 24 months the OS was 69%, 71% and 76% respectively (p>0.73)
• Acceptable morbidity
• Survival post salvage TL not influenced by initial treatment

15. THANK YOU