Role of Organ Preservation in Locally Advanced Hypopharyngeal Carcinoma

Hypopharyngeal carcinoma is relatively rare and has the worst prognosis of all head and neck cancers. Initially, surgery followed by postoperative radiation was the standard of care for locally advanced disease. In the recent years, various organ sparing approaches have evolved. There are mainly two schools of thought regarding larynx preservation in hypopharyngeal cancers which include either induction chemotherapy followed by response assessment for radical radiotherapy or concurrent chemoradiation. An ongoing trial is comparing the effectiveness between these two established approaches. The role of anti-EGFR therapy and immunotherapy is still being evaluated. Despite all the advancements in treatment, hypopharyngeal cancers are still associated with poor treatment outcomes.

Chemoradiotherapy but Not Radiotherapy Alone for Larynx Preservation in T3. Considerations from a German Observational Cohort Study

For advanced laryngeal cancers, after randomized prospective larynx preservation studies, nonsurgical therapy has been applied on a large scale as an alternative to laryngectomy. For T4 laryngeal cancer, poorer survival has been reported after nonsurgical treatment. Is there a need to fear worse survival also in T3 tumors? The outcomes of 121 T3 cancers treated with pCRT, pRT alone, or surgery were evaluated in an observational cohort study in Germany. In a multivariate Cox regression of the T3 subgroup, no survival difference was noted between pCRT and total laryngectomy with risk-adopted adjuvant (chemo)radiotherapy (TL ± a(C)RT) (HR 1.20; 95%-CI: 0.57–2.53; p = 0.63). However, survival was significantly worse after pRT alone than after TL ± a(C)RT (HR 4.40; 95%-CI: 1.72–11.28, p = 0.002). A literature search shows that in cases of unfavorable prognostic markers (bulky tumors of 6–12 ccm, vocal cord fixation, minimal cartilage infiltration, or N2–3), pCRT instead of pRT is indicated. In cases of pretreatment dysphagia or aspiration requiring a feeding tube or tracheostomy, gross or multiple cartilage infiltration, or tumor volume > 12 ccm, outcomes after pCRT were significantly worse than those after TL. In these cases, and in cases where pCRT is indicated but the patient is not suitable for the addition of chemotherapy, upfront total laryngectomy with stage-appropriate aRT is recommended even in T3 laryngeal cancers.

Transoral Videolaryngoscopic Surgery (TOVS)

Transoral videolaryngoscopic surgery (TOVS) for laryngopharyngeal cancer developed by Shiotani et al., uses the laparoscopic surgical system and distending laryngoscope. This method enables precise procedures and en bloc resection under a good view with videoendoscope in the structurally complex laryngopharynx. The major indications are Tis-2, and selected T3 lesions of hypopharyngeal, oropharyngeal, and supraglottic laryngeal cancer. TOVS is also considered for resectable rT1 and rT2 radiation failure cases and selected T3–4 advanced cases following neoadjuvant chemotherapy. Patients with resectable lymph node metastases are treated by neck dissection. Major contraindications are cricoarytenoid joint fixation, circumferential invasion of more than half, bilateral arytenoid invasion, and invasion to the thyroid cartilage, cricoid cartilage, hyoid bone, deep pharyngeal constrictor muscle. Oncological outcomes are good in long-term survival and larynx preservation rates with sparing radiation in half of the patients. However, advanced T stage and N3 cases showed a worse prognosis. Regarding functional outcome, swallowing function can maintain in most patients. Postoperative voice impairment can occur after wound healing. TOVS has some advantages particularly for hypopharyngeal cancer, in maneuver with smaller diameter instruments and tactile sense, and in less invasiveness without a tracheostomy, compared to other transoral surgeries.

A Nomogram for Pretreatment Prediction of Response to Induction Chemotherapy in Locally Advanced Hypopharyngeal Carcinoma

BackgroundInduction chemotherapy (IC) significantly improves the rate of larynx preservation; however, some patients could not benefit from it. Hence, it is of clinical importance to predict the response to IC to determine the necessity of IC. We aimed to develop a clinical nomogram for predicting the treatment response to IC in locally advanced hypopharyngeal carcinoma.MethodsWe retrospectively include a total of 127 patients with locally advanced hypopharyngeal carcinoma who underwent MRI scans prior to IC between January 2014 and December 2017. The clinical characteristics were collected, which included age, sex, tumor location, invading sites, histological grades, T-stage, N-stage, overall stage, size of the largest lymph node, neutrophil-to-lymphocyte ratio, hemoglobin concentration, and platelet count. Univariate and multivariate logistic regression was used to select the significant predictors of IC response. A nomogram was built based on the results of stepwise logistic regression analysis. The predictive performance and clinical usefulness of the nomogram were determined based on the area under the curve (AUC), calibration curve, and decision curve.ResultsAge, T-stage, hemoglobin, and platelet were four independent predictors of IC treatment response, which were incorporated into the nomogram. The AUC of the nomogram was 0.860 (95% confidence interval [CI]: 0.780-0.940), which was validated using 3-fold cross-validation (AUC, 0.864; 95% CI: 0.755-0.973). The calibration curve demonstrated good consistency between the prediction by the nomogram and actual observation. Decision curve analysis shows that the nomogram was clinically useful.ConclusionThe proposed nomogram resulted in an accurate prediction of the efficacy of IC for patients with locally advanced hypopharyngeal carcinoma.

282 CERVICAL ESOPHAGECTOMY USING “LARYNX ROTATION METHOD” CAN OBTAIN GOOD CLINICAL OUTCOMES.

In the treatment of cervical esophageal carcinoma (CEC), preservation of laryngeal function is required as well as curability. Therefore, chemoradiotherapy (CRT) is often selected for larynx-preservation. In our department, larynx-preserving surgery using “larynx-rotation method” is aggressively carried out even when the oral side of the tumor margin extends beyond the esophageal orifice. In this study, we analyzed the clinical outcomes of the resectable CEC and examined ``Which therapeutic modality should be selected, surgery or CRT?'' Methods In the present study, 40 patients whose primary tumor was resectable Stage II/III CEC treated in our department since 2008, whose advanced primary tumor lesion was limited within cervical esophagus, and who undergo surgery or curative CRT were enrolled. The clinical outcomes were retrospectively analyzed. Results The Op group included 25 patients. All of the Op group patients could preserve the larynx. In the CRT group, 2 patients were performed pharyngo-laryngo-cervical esophagectomy as the salvage surgery. 1- and 3-year progression-free survival rate was 80.1 and 69.3% in the Op group, and 63.0 and 31.5% in the CRT group. 1-, 3- and 5-year overall survival rate was 95.8, 80.9 and 67.4% in the Op group and 78.6, 64.3 and 46.9% in the CRT group, respectively. Although there was no significant difference, the Op group showed relatively better clinical outcomes. Conclusion Cervical esophagectomy using “larynx-rotation method” could obtain good therapeutic outcomes while preserving the larynx. Especially in case cervical esophagectomy is sufficient as the curative resection, because the surgical invasion is little and the postoperative quality of life is good while preserving the larynx and the whole stomach, surgery is considered useful treatment modality.