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Management of supraglottic carcinoma
Int. J. Radiation Oncology Biol. Phys., Vol. 53, No. 4, pp. 793–794, 2002 Copyright © 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0360-3016/02/$–see front matter
PII S0360-3016(02)02841-9
EDITORIAL
MANAGEMENT OF SUPRAGLOTTIC CARCINOMA WILLIAM M. MENDENHALL, M.D., RUSSELL W. HINERMAN, M.D., CHRISTOPHER G. MORRIS, M.S., ROBERT J. AMDUR, M.D.
AND
Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
the primary tumor volume calculated on pretreatment computed tomography and/or magnetic resonance imaging may be used to predict the likelihood of local control after RT (3). A recent multivariate analysis of 114 patients with supraglottic carcinomas treated with RT at the University of Florida showed that primary tumor volume had more effect than T stage on local control (p ⫽ 0.0220 and p ⫽ 0.2791, respectively) (Mendenhall WM, 2002, unpublished data.). Another issue raised by the Aarhus study is whether it is desirable to treat with moderate-dose RT and salvage the patients who have recurrences, as opposed to using more aggressive altered fractionation schedules recently shown to improve locoregional control at the expense of increased morbidity. In comparison with a recent update of our data (n ⫽ 274) (4), the series presented by Johansen et al. (1) included a high proportion of false vocal cord tumors (42% vs. 24%), T1 cancers (38% vs. 8%), and clinically negative neck (75% vs. 54%). The dose fractionation schedules used at Aarhus before 1985 were suboptimal because of low doses and split-course techniques. In contrast, twice-daily fractionation was used in 68% of patients treated with RT at the University of Florida. The 10-year results for Aarhus vs. the University of Florida were as follows: local control, 49% vs. 76%; locoregional control, 40% vs. 68%; distant metastases–free survival, 91% vs. 84%; cause-specific survival, 58% vs. 67%; and absolute survival, 33% vs. 27%. Comparison of local control after RT at Aarhus vs. University of Florida revealed the following: T1, 64% vs. 100%; T2, 63% vs. 86%; T3, 49% vs. 62%; and T4, 52% vs. 62%. The data indicate that a more aggressive fractionation schedule results in a higher likelihood of locoregional control and a modest improvement in cause-specific survival. However, there is no significant difference in overall survival between the two groups of patients. This may be because of a relatively high likelihood of intercurrent deaths due to comorbid conditions and second primary malignancies. A future challenge will be to further improve the likelihood of locoregional disease control with a functioning larynx. For some, this may be accomplished with an open or transoral partial laryngectomy. Concomitant chemotherapy and RT have been shown to improve the likelihood of cure for patients with advanced Stage III–IV disease. There will
The two major modalities used to treat supraglottic carcinomas are radiotherapy (RT) and surgery. Treatment philosophy varies significantly with geography; patients in the United States and Australia are more likely to be treated surgically, whereas those in Canada and Great Britain are more often treated with RT. There may be significant variability within a particular country, depending on institutional preferences. The philosophy espoused by Johansen et al. (1) at Aarhus University Hospital in Denmark is to treat essentially all patients with primary RT and to salvage those who have recurrence with surgery, to maximize the likelihood of larynx preservation. The approach used by at least some institutions in the United States is to treat the majority of patients surgically and to irradiate primarily only the medically infirm and those with unresectable disease. Our “intermediate” philosophy is to use RT or partial laryngectomy for patients with Stage T1–T2 and favorable Stage T3–T4 cancers and total laryngectomy for patients with advanced T3–T4 cancers, for which cases the probability of cure with RT alone is low. Weems et al. (2) reported on 195 patients treated with curative intent at the University of Florida between 1964 and 1984; 106 patients (54%) were treated with primary RT, and the remaining patients were treated with surgery alone or combined with adjuvant RT. The proportion of patients offered primary RT has increased over the past decade because of the promising results of trials using RT with concomitant chemotherapy for patients with advanced disease. There are several reasons for selecting patients who are unlikely to be cured by irradiation: (1) The chance of dying of cancer may be reduced if another, more effective locoregional treatment is used; (2) Patients may be spared the morbidity of RT (although it may be required in the adjuvant setting); (3) Approximately one-third of patients who undergo a salvage laryngectomy experience a major complication (usually an orocutaneous fistula); and (4) Patients who have advanced primary tumors that are locally controlled by radiotherapy alone are more likely to have a major complication and a nonfunctioning larynx (3). Induction chemotherapy has been used to select patients with advanced disease who are more likely to be cured with RT based on a complete or partial response. Alternatively, 793
794
I. J. Radiation Oncology
● Biology ● Physics
likely remain a subset of patients with unfavorable cancers, for whom the probability of a major complication and a functionless larynx is high, even if local control is achieved. These patients may be better off with a total laryngectomy
Volume 53, Number 4, 2002
and voice rehabilitation with a tracheoesophageal puncture or an artificial larynx. Another challenge will be to reduce the likelihood of second malignancies, particularly those arising in the upper aerodigestive tract.
REFERENCES 1. Johansen LV, Grau C, Overgaard J. Supraglottic carcinoma. Patterns of failure and salvage treatment following curatively intended radiotherapy in 410 patients. Int J Radiat Oncol Biol Phys. In press. 2. Weems DH, Mendenhall WM, Parsons JT, Cassisi NJ, Million RR. Squamous cell carcinoma of the supraglottic larynx treated with surgery and/or radiation therapy. Int J Radiat Oncol Biol Phys 1987;13:1483–1487.
3. Mancuso AA, Mukherji SK, Schmalfuss I, et al. Preradiotherapy computed tomography as a predictor of local control in supraglottic carcinoma. J Clin Oncol 1999;17: 631– 637. 4. Hinerman RW, Mendenhall WM, Amdur RJ, Stringer SP, Villaret DB, Robbins KT. Carcinoma of the supraglottic larynx: Treatment results with radiotherapy alone or with planned neck dissection. Head Neck 2002;24:456 – 467.
PII S0360-3016(02)02841-9
EDITORIAL
MANAGEMENT OF SUPRAGLOTTIC CARCINOMA WILLIAM M. MENDENHALL, M.D., RUSSELL W. HINERMAN, M.D., CHRISTOPHER G. MORRIS, M.S., ROBERT J. AMDUR, M.D.
AND
Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
the primary tumor volume calculated on pretreatment computed tomography and/or magnetic resonance imaging may be used to predict the likelihood of local control after RT (3). A recent multivariate analysis of 114 patients with supraglottic carcinomas treated with RT at the University of Florida showed that primary tumor volume had more effect than T stage on local control (p ⫽ 0.0220 and p ⫽ 0.2791, respectively) (Mendenhall WM, 2002, unpublished data.). Another issue raised by the Aarhus study is whether it is desirable to treat with moderate-dose RT and salvage the patients who have recurrences, as opposed to using more aggressive altered fractionation schedules recently shown to improve locoregional control at the expense of increased morbidity. In comparison with a recent update of our data (n ⫽ 274) (4), the series presented by Johansen et al. (1) included a high proportion of false vocal cord tumors (42% vs. 24%), T1 cancers (38% vs. 8%), and clinically negative neck (75% vs. 54%). The dose fractionation schedules used at Aarhus before 1985 were suboptimal because of low doses and split-course techniques. In contrast, twice-daily fractionation was used in 68% of patients treated with RT at the University of Florida. The 10-year results for Aarhus vs. the University of Florida were as follows: local control, 49% vs. 76%; locoregional control, 40% vs. 68%; distant metastases–free survival, 91% vs. 84%; cause-specific survival, 58% vs. 67%; and absolute survival, 33% vs. 27%. Comparison of local control after RT at Aarhus vs. University of Florida revealed the following: T1, 64% vs. 100%; T2, 63% vs. 86%; T3, 49% vs. 62%; and T4, 52% vs. 62%. The data indicate that a more aggressive fractionation schedule results in a higher likelihood of locoregional control and a modest improvement in cause-specific survival. However, there is no significant difference in overall survival between the two groups of patients. This may be because of a relatively high likelihood of intercurrent deaths due to comorbid conditions and second primary malignancies. A future challenge will be to further improve the likelihood of locoregional disease control with a functioning larynx. For some, this may be accomplished with an open or transoral partial laryngectomy. Concomitant chemotherapy and RT have been shown to improve the likelihood of cure for patients with advanced Stage III–IV disease. There will
The two major modalities used to treat supraglottic carcinomas are radiotherapy (RT) and surgery. Treatment philosophy varies significantly with geography; patients in the United States and Australia are more likely to be treated surgically, whereas those in Canada and Great Britain are more often treated with RT. There may be significant variability within a particular country, depending on institutional preferences. The philosophy espoused by Johansen et al. (1) at Aarhus University Hospital in Denmark is to treat essentially all patients with primary RT and to salvage those who have recurrence with surgery, to maximize the likelihood of larynx preservation. The approach used by at least some institutions in the United States is to treat the majority of patients surgically and to irradiate primarily only the medically infirm and those with unresectable disease. Our “intermediate” philosophy is to use RT or partial laryngectomy for patients with Stage T1–T2 and favorable Stage T3–T4 cancers and total laryngectomy for patients with advanced T3–T4 cancers, for which cases the probability of cure with RT alone is low. Weems et al. (2) reported on 195 patients treated with curative intent at the University of Florida between 1964 and 1984; 106 patients (54%) were treated with primary RT, and the remaining patients were treated with surgery alone or combined with adjuvant RT. The proportion of patients offered primary RT has increased over the past decade because of the promising results of trials using RT with concomitant chemotherapy for patients with advanced disease. There are several reasons for selecting patients who are unlikely to be cured by irradiation: (1) The chance of dying of cancer may be reduced if another, more effective locoregional treatment is used; (2) Patients may be spared the morbidity of RT (although it may be required in the adjuvant setting); (3) Approximately one-third of patients who undergo a salvage laryngectomy experience a major complication (usually an orocutaneous fistula); and (4) Patients who have advanced primary tumors that are locally controlled by radiotherapy alone are more likely to have a major complication and a nonfunctioning larynx (3). Induction chemotherapy has been used to select patients with advanced disease who are more likely to be cured with RT based on a complete or partial response. Alternatively, 793
794
I. J. Radiation Oncology
● Biology ● Physics
likely remain a subset of patients with unfavorable cancers, for whom the probability of a major complication and a functionless larynx is high, even if local control is achieved. These patients may be better off with a total laryngectomy
Volume 53, Number 4, 2002
and voice rehabilitation with a tracheoesophageal puncture or an artificial larynx. Another challenge will be to reduce the likelihood of second malignancies, particularly those arising in the upper aerodigestive tract.
REFERENCES 1. Johansen LV, Grau C, Overgaard J. Supraglottic carcinoma. Patterns of failure and salvage treatment following curatively intended radiotherapy in 410 patients. Int J Radiat Oncol Biol Phys. In press. 2. Weems DH, Mendenhall WM, Parsons JT, Cassisi NJ, Million RR. Squamous cell carcinoma of the supraglottic larynx treated with surgery and/or radiation therapy. Int J Radiat Oncol Biol Phys 1987;13:1483–1487.
3. Mancuso AA, Mukherji SK, Schmalfuss I, et al. Preradiotherapy computed tomography as a predictor of local control in supraglottic carcinoma. J Clin Oncol 1999;17: 631– 637. 4. Hinerman RW, Mendenhall WM, Amdur RJ, Stringer SP, Villaret DB, Robbins KT. Carcinoma of the supraglottic larynx: Treatment results with radiotherapy alone or with planned neck dissection. Head Neck 2002;24:456 – 467.