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Reassessing the Role of Primary Chemoradiation Compared to Surgery for Large Volume (LV) T4 Laryngeal Cancer:
Analysis using the Surveillance-Epidemiology-End Results (SEER) Database
Joehar Hamdan DO 1,2, Mohammad Kawji MD 1,2, Lawrence Feldman MD 1
1. University of Illinois in Chicago 2. Advocate Christ Medical Center
Introduction/Purpose of Study
Randomized trials established chemo-radiotherapy
as standard treatment for advanced laryngeal
cancer. Patients with large-volume T4 disease
(LVT4) were excluded from these trials. The
purpose of this study was to report LVT4 laryngeal
cancer patient outcome, including those treated
with standard upfront laryngectomy versus those
who did not.
Background/Significance
In previously reported series of patients with T4
laryngeal tumors treated with radiation alone,
suboptimal rates of local control and diseasespecific survival were reported 1
The study
published by Knab et al.2 had brought to our
attention the need to further investigate the
convention that patients with large volume T4
(LVT4) laryngeal tumors (LT) should be treated
with upfront laryngectomy. LVT4 LTs are defined as
tumor extension > 1 cm into the base of the tongue
or extension of the tumor through the thyroid
cartilage.2 The objective of our study was to
determine the survival of patients who underwent
surgery of the primary site versus those who did
not in an effort to consider new approaches to
treatment of patients with LVT4 LTs.
Methods and Procedures
Retrospective analysis of patients with LVT4 laryngeal
cancer
were extracted from the Surveillance,
Epidemiology, and End Results (SEER 17) database
from the National Cancer Institute (NCI) for patients
diagnosed between 1996–2006. SEER is an
authoritative source of information on cancer
incidence and survival in the United States.
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Results
Methods and Procedures Continued
SEER currently collects and publishes cancer
incidence and survival data from population-based
cancer registries covering approximately 26
percent of the US population. SEER coverage
includes 23 percent of African Americans, 40
percent of Hispanics, 42 percent of American
Indians and Alaska Natives, 53 percent of Asians,
and 70 percent of Hawaiian/Pacific Islanders. The
SEER registries routinely collect data on patient
demographics, primary tumor site, tumor
morphology, and stage of cancer at the time of
diagnosis by means of using standardized
procedures and forms.4
Conclusions/Discussion Continued
In narrative, tabular, or graphic form here.
References
1. Mendenhall WM. T3-4 squamous cell carcinoma of the larynx treated with
radiation therapy alone. Semin Radiat Oncol 1998; 8: 262–269.
Subjects
Data on all male and female patients ages 30 and above
with T4a or T4b, any N and M0 or MX LT were obtained
by using American Joint Committee on Cancer (AJCC)
staging system (6th edition). We divided these patients
into three groups.
•The first group consisted of patients who had upfront
site specific surgery (tumor destruction or resection)
followed by radiation (beam RT, radioactive implants,
radioisotopes, or combination beam RT with implants or
isotopes).
•The second group consisted of those patients who
underwent surgery of the primary site but did not receive
radiation.
•The third group consisted of those who had upfront
radiation +/-chemotherapy but did not have surgery to the
primary site. Patients who did not have upfront surgery
had refused it, had other medical conditions
contraindicating it, or the reason was listed as unknown.
Induction chemotherapy is an attractive
treatment option, as it allows the assessment of tumor
response and the selection of appropriate patients for
organ preservation while improving local control and
reducing the rate of distant metastasis. Although we
were not able to determine whether or not these
patients had chemotherapy and if so, which agents
were used, in light of our findings and with advances
in treatment modalities we believe the role of induction
chemo-radiation as opposed to upfront surgery as
primary treatment for LVT4 LT requires further
investigation.
Results
The total number of patients examined were 477.
The 32 month overall survival (OS) calculated by
using the Kaplan-Meier method resulted in the
following:
•The patients who underwent surgery and postoperative XRT (N = 327) had an OS of 52.7% at 32
months, CI 95%.
•The patients who underwent surgery without
radiation therapy (N = 105) had an OS of 39.2% 32
months, CI 95%.
•The patients who had primary XRT but no surgery
(N = 45) had a OS of 52.4% at 32 months, CI 95%
Conclusions/Discussion
Treatment for head-and-neck malignancies has
evolved with recent advances in chemo
radiotherapy. These include the use of biological
agents such as EGFR, VEGF, and tyrosine kinase
inhibitors. In addition, advances in radiotherapy
(RT) such as using PET-CT-guided RT versus
conventional CT-guided radiotherapy in which the
latter overestimated tumor volume by 150%,
prolonged tolerance to chemo radiotherapy
treatment.5 Randomized trials in patients with stage
3 and 4 locally advanced LT have demonstrated
that induction chemotherapy followed by RT in
some cases has been equivalent to surgery and
resulted in a 64% rate of organ preservation.5
2 . B. R. Knab et al. Functional organ preservation with definitive
chemoradiotherapy for T4 laryngeal squamous cell carcinoma Annals of
Oncology 19: 1650–1654, 2008
3. Forastiere AA, Goepfert H, Maor M et al. Concurrent chemotherapy and
radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J
Med 2003; 349: 2091–2098.
4. Surveillance, Epidemiology, and End Results (SEER) Program
(www.seer.cancer.gov) SEER*Stat Database: Incidence - SEER 9 Regs
Limited-Use, Nov 2007 Sub (1973-2005) <Katrina/Rita Population
Adjustment> - Linked To County Attributes - Total U.S., 1969-2005 Counties,
National Cancer Institute, DCCPS, Surveillance Research Program, Cancer
Statistics Branch, released April 2008, based on the November 2007
submission.
5. Heron DE, Andrade RS, Flickinger J, et al. Hybrid PET-CT simulation for
radiation treatment planning for head-and-neck cancers: a brief technical
report. Int J Radiation Oncology Bio Phys 2004:60:1419-24
Contact information
Joe Hamdan
9906 Shady Lane
Unit 5604
Orland Park, IL 60462
T: 708-307-2451
E: [email protected]