Organ Preservation With Definitive Chemoradiotherapy for T4 Laryngeal Squamous Cell Carcinoma

Abstract

Randomized trials established chemoradiotherapy as standard treatment for locoregionally advanced laryngeal cancer, but T4 patients were largely excluded from RTOG 91-11. The standard of care for T4 patients includes upfront surgical resection. Our institution has experience with organ preservation for this population. The purpose of this study was to report T4 laryngeal cancer patient outcomes, including those with large volume T4 (LVT4) disease, treated with chemoradiotherapy.We retrospectively reviewed all T4 larynx patients at our institution who received definitive chemoradiation. From January 2014 to December 2019, patients with T4 larynx were identified. LVT4 disease was defined as T4 laryngeal disease with anterior thyroid cartilage, base of tongue, or cricoid cartilage invasion. Induction chemotherapy typically consisted of 2 cycles of carboplatin (AUC = 6 on d1) and paclitaxel (100 mg/m2 on d1/d8/d15). Chemoradiation typically consisted of 4 to 6 alternating weekly cycles of paclitaxel (100 mg/m2 on d1), infusion 5-fluorouracil (600 mg/m2/d on d1-5), hydroxyurea (500 mg PO BID), and either 2 Gy daily or 1.5 Gy twice-daily irradiation followed by a 9-day treatment break (TFHX). The Kaplan-Meier method was used to estimate rates of locoregional control (LRC), distant metastasis-free survival (DMFS), overall survival (OS), and laryngectomy free-survival.Twenty-two patients met eligibility criteria and were included for analysis. Median follow-up was 43.6 months. 95% of patients were LVT4. 86% of patients received induction chemotherapy. 55% of patients were treated using a twice daily approach, while 45% were treated with daily fractionation with a median dose of 72 Gy (IQR: 70-74). Two-year locoregional control (LRC), distant metastasis-free survival (DMFS), overall survival (OS), and laryngectomy-free survival (LFS) was 90%, 85%, 91%, and 90%, respectively. Four-year LRC, DMFS, OS, and LFS was 85%, 78%, 63%, and 90%, respectively. Two patients required laryngectomy for recurrent or persistent disease. Of disease-free patients, none required laryngectomy for intractable dysfunctional larynx. 73% of patients required upfront tracheostomy and 68% required a feeding tube prior to treatment. 91% of patients demonstrated normal or understandable speech and 77% of patients were able to tolerate PO intake of soft/regular food after completion of treatment.Promising laryngectomy free survival is seen with TFHX concurrent chemoradiation for T4 laryngeal patients. T4 disease had outcomes similar to patients with less advanced disease treated on Radiation Therapy Oncology Group 91-11.