A Multidisciplinary Team Guided Approach to the Management of cT3 Laryngeal Cancer: A Retrospective Analysis of 104 Cases

Abstract

The optimal treatment for T3 laryngeal carcinoma (LC) is still a matter of debate. Different therapeutic options are available: Transoral laser microsurgery (TLM), open partial horizontal laryngectomies (OPHLs), total laryngectomy (TL), and organ preservation protocols (radiation therapy (RT) or chemo-radiation (CRT)). This study aimed to retrospectively evaluate oncologic outcomes of 104 T3 LCs treated by surgery or non-surgical approaches from January 2011 to December 2016 at a single academic tertiary referral center. Each case was evaluated by a multidisciplinary team (MDT) devoted to the management of head and neck cancers. We divided the cohort into two subgroups: Group A, surgical treatment (TLM, OPHLs, TL) and Group B, non-surgical treatment (RT, CRT). For the entire cohort, two- and five-year overall survival (OS) rates were 83% and 56%, respectively. The two- and five-year disease-free survival (DFS) rates were 75% and 65%, and disease-specific survival rates were 93% and 70%, respectively. The N category was a significant independent prognosticator for OS (p = 0.02), whereas Group B was significantly and independently associated with DFS (HR 4.10, p = 0.006). Analyzing laryngo-esophageal dysfunction-free survival as an outcome, it was found that this was significantly lower in higher N categories (p = 0.04) and in cases that underwent non-surgical treatments (p = 0.002). Optimization of oncologic outcomes in T3 LCs may be obtained only by a comprehensive MDT approach, considering that different treatment options have heterogenous toxicity profiles and indications.

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

“…In those patients where, according to the NCCN guidelines, indications for neck dissection are not clear or debatable [ 15 ], as in selected T3 glottic cancers treated by TLM, T1-small T2 supraglottic cancers treated by transoral approaches, and recurrent/persistent LC failed after CRT and previously staged as cN0 [ 34 ], this information might be of great help in choosing to electively treat in one-stage or not both the T and N sites. In fact, as previously demonstrated, very few T3 glottic cancers fail regionally [ 13 , 35 ], while the role of neck dissection after CRT failure in cN0 neck is still controversial, some authors supporting an aggressive policy [ 36 ] and others maintaining a more cautious attitude [ 37 ].…”

“…All patients had been submitted to surgery after multidisciplinary team (MDT) discussion and preoperative counseling between head and neck surgeons, and radiation and medical oncologists. Patients were selected for upfront TL if not amenable to OP strategies, either surgical (transoral laser microsurgery (TLM), or OPHL) and non-surgical CRT protocols [ 13 ]. Other selection criteria for inclusion this retrospective analysis were: (1) no history of previous LC; (2) no history of previous laryngeal treatments; (3) availability of imaging and endoscopies performed no more than 4 weeks before surgery; (4) final histopathologic report confirming squamous cell carcinoma (SCC); (5) and final pathologic staging of pT3-pT4a LC.…”

Open partial horizontal laryngectomy and adjuvant (chemo)radiotherapy for laryngeal squamous cell carcinoma: results from a multicenter Italian experience

“…In line with such an assumption, a recent review of the literature by Riga et al [7] demonstrated that in T3 LC surgical management provides better survival and organ-preservation rates than non-surgical options. In 2019, Marchi et al [10] published their series of 104 T3 LC treated by non-surgical regimens or surgery (TLM, OPHL, and TL). Both DFS and DSS were better in the surgical group as a whole, while LEDFS was superior in the TLM subgroup.…”

“…This has greatly helped in having a much clearer picture of the possible oncologic and functional outcomes obtainable by different types of OPHLs in carefully selected patients, as well as reporting on different patient series in the international literature [7,8]. Though the mainstream suggests the use of OPHLs in cT2-T3 N0-N1 LCs not eligible for TLM (due to suboptimal laryngeal exposure or borderline extension to certain delicate areas like pre-epiglottic and/or paraglottic spaces), for which the use of adjuvant therapy is not expected at all [9,10], others reported remarkable oncologic and functional outcomes even for more advanced lesions such as cT3 with arytenoid fixation or frank T4a for anterior extension through the thyroid cartilage [8]. Clearly, when applied to such advanced LCs as an alternative to TL or CRT, OPHLs present the risk of needing adjuvant treatments once the final pathologic report shows adverse risk factors like gross thyroid cartilage invasion, close margins, pN > 2a, extranodal extension, or presence of both perineural (PNI) and lympho-vascular invasion (LVI).…”

Value and Quality of Care in Head and Neck Oncology

“…The optimal collaboration and concertation of all involved disciplines, both medical and allied health professions, is an important basis for quality of care [37]. The importance of MDTs and their impact on outcomes is increasingly investigated and recognized [38][39][40][41]. Their implementation and optimization have been submitted to study [39,42,43].…”