Patients Undergoing Salvage Laryngectomy Research Articles

Elective Neck Dissection in Patients Undergoing Salvage Laryngectomy: Outcomes, Complications, and Considerations.

Objective In this study, we sought to identify the predictors for occult nodal disease (OND) and compare oncologic outcomes in patients undergoing elective neck dissection (END)at the time of salvage laryngectomy (SLE) versus the observation group. Methods A retrospective chart review was conducted involving all patients with clinically node-negative (cN0) necks who underwent SLE at atertiary academic center over 12 years. A total of 58 patients met the inclusion criteria and were divided into two groups: END (n=39) and observation (n=19). Primary endpoints were OND, regional recurrence-free survival (RRFS), and disease-specific survival (DSS). Univariate analysis was performed to establish the association between variables with Fisher's exact test and Mann-Whitney U test. Survival analysis was performed with the log-rank test. Results The cohort comprised 46 (79.3%) males and 12 (20.7%) females, with a mean age of 60 years. Pathological nodal disease was identified in five of 71 (7%) examined neck dissection specimens, with positive nodes found in levels II through IV. The only statistically significant predictor of OND was the rT3/rT4 stage (p=0.017). There were no differences in perioperative complications, RRFS (p=0.216), or DSS (p=0.298) between the END and observation groups. Conclusions In cN0 necks, the advanced recurrent T-stage (rT3-rT4) is a predictor for OND. As OND was found involving levels II, III, and IV in this study's specimens,formal lateral neck dissection should be the procedure of choice if END is to be performed alongside SLE. While END did not show a significantly higher morbidity profile versus conservative management in this cohort, the procedure did not improve loco-regional control or survival, even when stratifying by tumor stage.

Phase II Clinical Trial of Intravenous Levothyroxine to Mitigate Pharyngocutaneous Fistula in Euthyroid Patients Undergoing Salvage Laryngectomy.

Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of peri-operative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy. Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n=72). Post-operatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/day) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid stimulating hormone (TSH) were collected and dosing was adjusted accordingly. The primary endpoints were rates of fistula and fistula requiring re-operation, compared to matched historical controls. All patients were monitored for adverse effects. The rate of post-operative hypothyroidism was 21% compared to 49% in a matched historic cohort. The rate of fistula was 18.1% while the rate of fistula requiring re-operation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8% respectively, p=0.02 and 0.01). Post-operative hypothyroidism and recurrent clinical stage predicted fistula requiring re-operation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation. Post-operative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula, and fistula requiring re-operation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population.

Effects of Prior Tracheostomy on Total Laryngectomy Outcomes.

To assess whether preoperative tracheostomy (PreOT) increases risk of complications after total laryngectomy (TL) and to determine if timing of tracheostomy creation is associated with an increased risk. Retrospective cohort study. Tertiary care hospital between 2007 and 2020. Inclusion criteria were patients who underwent primary or salvage TL for oncologic treatment. Dependent variables of interest included surgical complications, such as wound dehiscence, infection, hematoma, complete flap failure, fistula formation, and stoma stenosis, as well as medical complications. Categorical variables were compared with chi-square test or Fisher exact test, and continuous variables were compared with an independent t test. Multivariable regression was conducted to assess predictors of complications after laryngectomy. A total of 306 patients were included. Primary TL was performed in 161 (53%) patients and salvage in 145 (47%) patients. Of the patients undergoing primary laryngectomy, 105 (65%) received a PreOT. Of the patients undergoing salvage laryngectomy, 86 (59%) received a PreOT. In both primary and salvage cases, there was no association between PreOT and surgical or medical complications. Additionally, there was no significant association between timing of tracheostomy and surgical complications. On multivariable analysis, the presence of a PreOT was not associated with surgical complications. In salvage cases, those with a PreOT had a significantly longer average length of stay than those without a PreOT (12 vs 9 days, P = .008). PreOT in patients undergoing primary and salvage laryngectomies was not associated with surgical or medical complications postlaryngectomy. Timing of tracheostomy in relation to laryngectomy was not found to adversely affect clinical outcomes.

Role of elective neck dissection with salvage laryngectomy

BackgroundElective neck dissection with salvage laryngectomy was associated with decreased quality of life, increased operative time, and increased incidence of complications; some surgeons prefer wait-and-see observation policy. However, lymph nodes recurrence after salvage total laryngectomy during follow-up period carry very poor quality of life and very poor survival rate.The aim of this study is to investigate the risk of nodal metastases in patients undergoing salvage laryngectomy and to search for predictors of occult metastases in this group of patients. Our study included 30 patients presented with recurrent laryngeal cancer after failure of organ preservation protocol. All selected patients were without detected lymph nodes both clinically and radiologically, classified as N0 according to The TNM classification.All patients were candidate for salvage total laryngectomy and had elective neck dissection performed during surgery to detect the possible occult cervical lymph node metastasis.ResultsThe positive nodal metastasis incidence was 14% in glottic, 29% in supraglottic, and 57% in trans-glottic tumors of all positive patients. The previously indicated results showed statistically significantly increased incidence of positive LN in the supraglottic tumor site and increased incidence of negative LN in the glottic site.Regarding the recurrence T stage in our study, lymph nodes were negative for metastasis in one patient with rT1 representing 4%, 6 patients with rT2 representing 26%, and for rT3 and rT4 were 65% and 4%, respectively. The nodal metastasis was positive in 3 patients with rT3 representing 43% and 4 patients with rT4 representing 57%. No patients with rT1 or rT2 showed nodal metastasis.ConclusionsOur findings demonstrated that patients with advanced local disease at recurrence undergoing salvage total laryngectomy may benefit from an elective neck dissection.

Post-Operative Hypothyroidism Predicts Fistula Development Following Salvage Oropharyngectomy

<h3>Purpose/Objective(s)</h3> Previous work has demonstrated post-operative hypothyroidism adversely affects wound healing in salvage laryngectomy. The purpose of this study is to evaluate the association between wound healing and hypothyroidism in patients undergoing salvage oropharyngectomy. <h3>Materials/Methods</h3> A single-institution retrospective case series was performed. Fifty-three patients who underwent salvage oropharyngectomy for recurrent or second primary oropharyngeal squamous cell carcinoma between 2001 and 2017 after radiation or chemoradiation were included. The principle explanatory variable was post-operative hypothyroidism, defined as thyroid stimulating hormone (TSH) greater than 5.5 mIU/L. The primary endpoints of the study were oropharyngocutaneous fistula development and fistula requiring operation within 30 days. Binary logistical regression multivariate analysis was performed. <h3>Results</h3> Post-operative fistula rate was 35% among hypothyroid patients which was significantly greater when compared to 9.1% among euthyroid patients. Moreover, 20% of patients with hypothyroidism developed a fistula requiring reoperation, while 3% of euthyroid patients developed a fistula requiring re-operative management. In a multivariate analysis, post-operative hypothyroid patients were at a 9.5-fold increased risk of developing a fistula (95% confidence interval [CI] 1.6 – 57.0, p = 0.013). Additionally, post-operative hypothyroid patients were at 13.6-fold increased risk for development of a fistula requiring reoperation (95% CI 1.2 – 160.5, p = 0.038). <h3>Conclusion</h3> Post-operative hypothyroidism in patients undergoing salvage oropharyngectomy is an independent predictor of fistula development and are more likely to require operative management after fistula development. These data support previously published work demonstrating post-operative hypothyroidism as an independent risk factor for fistula development in patients undergoing salvage laryngectomy. This study further supports the role of hypothyroidism management to modulate wound healing and post-operative wound complications.

Role of Thyroidectomy in Recurrent Laryngeal Carcinoma.

Management of recurrent laryngeal cancer presents a major challenge, and salvage laryngectomy is complicated by previous oncologic treatments. Thyroidectomy as part of salvage laryngectomy adds a nonnegligible degree of morbidity. The purpose of this study is to assess the rate of thyroid gland invasion in patients undergoing salvage laryngectomy to determine relevant predictive factors. Case series with chart review. Department of Otorhinolaryngology, Head and Neck Surgery, Guy's Hospital, London, United Kingdom. A retrospective review of patients undergoing salvage laryngectomy between 2009 and 2019 was undertaken. Preoperative cross-sectional imaging and histopathological analysis were performed to define evidence and predictors of thyroid gland invasion (TGI). Fifty-one patients had salvage laryngectomy. Histological evidence of TGI was found in 4 patients (7.8%). No significant relationship was found between histological TGI and subsite of primary carcinoma, degree of differentiation, T staging, or radiological TGI. Preoperative computed tomography had a high negative predictive value for TGI. Thyroidectomy should be carefully considered in patients undergoing salvage laryngectomy, and its extent should be defined on an individual basis. Total thyroidectomy should not routinely be performed in salvage laryngectomy or pharyngolaryngectomy in patients with no preoperative radiological evidence of TGI on cross-sectional imaging, unless there is intraoperative evidence of TGI.

Woody hardness classification impact on salvage laryngectomy functional outcomes

PurposePost-radiation therapy salvage surgeries are challenging for surgeons due to tissue fibrosis. The woody hardness classification is valuable in differentiating the degree of neck stiffness, but its clinical utility has not been evaluated. We applied it to patients undergoing salvage laryngectomy to study the impact of woody hardness on postoperative outcomes. Materials and methodsA retrospective observational study was performed on patients undergoing salvage laryngectomy between 2014 and 2019. Patients were assigned into the A (extremely woody hard), B (moderately woody hard), or C (mildly woody hard) woody hardness class. The primary outcome was pharyngoesophageal stricture development. Secondary outcomes included time to pharyngoesophageal stricture, pharyngocutaneous fistula development, time to pharyngocutaneous fistula, development of post-operative complications, and tracheoesophageal puncture complications. ResultsFifty-one patients were included in the study: Class A 1 patient, Class B 30 patients, and Class C 20 patients. The single Class A patient was grouped with the Class B patients. The development of a pharyngoesophageal stricture shows consistent negative association with woody hardness despite most analyses not reaching statistical significance. These associations are robust to a number of confounding variables in multivariate logistic and time to event analyses. Furthermore, the time to event analysis controlling for squamous cell carcinoma diagnosis led to a statistically significant association between woody hardness (i.e., A/B higher risk) and time to stricture (HR=5, p=0.02). ConclusionsThis study suggests that this classification may be useful in predicting pharyngoesophageal stricture formation in salvage laryngectomy patients and could be used to implement stricture preventive measures.

Elective neck dissection during salvage laryngectomy: A systematic review and meta-analysis.

The primary objective was to determine the rate of occult cervical nodal metastasis in patients undergoing elective neck dissection (END) during salvage laryngectomy. The secondary objective was to compare survival and postoperative complication rates between patients undergoing END versus observation. A medical librarian performed a comprehensive search for END outcomes in laryngeal cancer patients undergoing salvage laryngectomy after primary chemoradiation therapy. Seventeen retrospective studies and 1 prospective study met inclusion criteria, with a total of 1,141 patients (799 END, 350 observed). The rate of nodal positivity was 11% among patients who underwent END during their salvage laryngectomy. Three studies and 155 patients were included in a 5-year overall survival (OS) analysis with no significant difference in OS (95% confidence interval [CI]: 0.82-2.22). After inclusion of six studies and 494 patients (249 END, 245 observed), the risk of fistula formation was not statistically different (95% CI: 0.61-2.56). Due to significant heterogeneity between studies and inadequate data, most patients could not be included in the meta-analysis of outcomes. Salvage laryngectomy patients undergoing END have an occult nodal positivity rate of 11%. Meta-analysis showed no statistically significant differences in 5-year OS between patients undergoing END versus observation. Laryngoscope, 130:899-906, 2020.

Intraoperative Fluorescent Angiography Predicts Pharyngocutaneous Fistula After Salvage Laryngectomy.

Technology to assess tissue perfusion is exciting with translational potential, although data supporting its clinical applications have been lagging. Patients who have undergone radiation are at particular risk of poor tissue perfusion and would benefit from this expanding technology. We designed a prospective clinical trial using intraoperative indocyanine green angiography to evaluate for wound-healing complications in patients undergoing salvage laryngectomy after radiation failure. This prospective trial included patients undergoing salvage laryngectomy at a National Cancer Institute-designated tertiary cancer center between 2016 and 2018. After tumor extirpation and prior to reconstruction, 10mg indocyanine green dye was infused and the fluorescence (FHYPO) and ingress rate of the pharyngeal mucosa recorded. The primary outcome measure was formation of a pharyngocutaneous fistula (PCF). Patients who developed a PCF had significantly lower FHYPO (87 vs 172, p < 0.001) and ingress rates (6.7 vs 15.8, p = 0.043) compared with those who did not develop a fistula. There were no fistulas in patients with FHYPO > 150 (n = 21) or ingress > 15 (n = 15). There was a 50% fistula rate in patients with FHYPO ≤ 103 (n = 10) and ingress rate ≤ 6 (n = 6). Intraoperative indocyanine green angiography can assess hypoperfusion in patients and predict risk of PCFs after salvage laryngectomy, and can thus intraoperatively risk-stratify patients for postoperative wound-healing complications.

Salvage laryngectomy following organ-preservation therapy – An evidence-based review

Salvage total laryngectomy is often indicated in patients with recurrent or persistent laryngeal cancer after radiation or chemoradiation treatment. This article reviews and discusses key considerations regarding salvage laryngectomy. Within this article, a review of the salvage laryngectomy incidence in the major organ preservation trials, survival rates, predictors of outcomes, complication rates, and the roles of elective neck dissection and free tissue transfer for reconstruction in patients undergoing salvage laryngectomy is provided.

Hypothyroidism and Wound Healing After Salvage Laryngectomy

Patients undergoing salvage laryngectomy are predisposed to radiation-induced hypothyroidism and impaired wound healing secondary to the tissue effects of prior treatment. The impact of hypothyroidism on postoperative wound healing is not established. A single-institution retrospective case series was performed. The inclusion criteria specified preoperatively euthyroid adults who underwent salvage laryngectomy with concurrent neck dissection between 1997 and 2015 for persistent or recurrent laryngeal squamous cell carcinoma after radiation or chemoradiation therapy (n = 182). The principal explanatory variable was postoperative hypothyroidism, defined as thyroid-stimulating hormone (TSH) higher than 5.5 mIU/L. The primary end points of the study were pharyngocutaneous fistulas and wounds requiring reoperation. Multivariate analysis was performed. The fistula rate was 47% among hypothyroid patients versus 23% among euthyroid patients. In the multivariate analysis, the patients who experienced hypothyroidism in the postoperative period had a 3.6-fold greater risk of fistula [95% confidence interval (CI) 1.8–7.1; p = 0.0002]. The hypothyroid patients had an 11.4-fold greater risk for a required reoperation (24.4 vs 5.4%) than the euthyroid patients (95% CI 2.6–49.9; p = 0.001). The risk for fistula (p = 0.003) and reoperation (p = 0.001) increased with increasing TSH. This corresponds to an approximate 12.5% incremental increase in the absolute risk for fistula and a 10% increase in the absolute risk for reoperation with each doubling of the TSH. Postoperative hypothyroidism independently predicts postoperative wound-healing complications. The association of hypothyroidism with fistula formation may yield opportunities to modulate wound healing with thyroid supplementation or to provide a biomarker of wound progression.

Hypothyroidism and Wound Healing After Salvage Laryngectomy.

Patients undergoing salvage laryngectomy are predisposed to radiation-induced hypothyroidism and impaired wound healing secondary to the tissue effects of prior treatment. The impact of hypothyroidism on postoperative wound healing is not established. A single-institution retrospective case series was performed. The inclusion criteria specified preoperatively euthyroid adults who underwent salvage laryngectomy with concurrent neck dissection between 1997 and 2015 for persistent or recurrent laryngeal squamous cell carcinoma after radiation or chemoradiation therapy (n=182). The principal explanatory variable was postoperative hypothyroidism, defined as thyroid-stimulating hormone (TSH) higher than 5.5mIU/L. The primary end points of the study were pharyngocutaneous fistulas and wounds requiring reoperation. Multivariate analysis was performed. The fistula rate was 47% among hypothyroid patients versus 23% among euthyroid patients. In the multivariate analysis, the patients who experienced hypothyroidism in the postoperative period had a 3.6-fold greater risk of fistula [95% confidence interval (CI) 1.8-7.1; p=0.0002]. The hypothyroid patients had an 11.4-fold greater risk for a required reoperation (24.4 vs 5.4%) than the euthyroid patients (95% CI 2.6-49.9; p=0.001). The risk for fistula (p=0.003) and reoperation (p=0.001) increased with increasing TSH. This corresponds to an approximate 12.5% incremental increase in the absolute risk for fistula and a 10% increase in the absolute risk for reoperation with each doubling of the TSH. Postoperative hypothyroidism independently predicts postoperative wound-healing complications. The association of hypothyroidism with fistula formation may yield opportunities to modulate wound healing with thyroid supplementation or to provide a biomarker of wound progression.

Occult Nodal Disease Prevalence and Distribution in Recurrent Laryngeal Cancer Requiring Salvage Laryngectomy.

The indications for neck dissection concurrent with salvage laryngectomy in the clinically N0 setting remain unclear. Our goals were to determine the prevalence of occult nodal disease, analyze nodal disease distribution patterns, and identify predictors of occult nodal disease in a salvage laryngectomy cohort. Case series with planned data collection. Tertiary academic center. Patients with persistent or recurrent laryngeal squamous cell carcinoma (LSCC) after radiation/chemoradiation failure undergoing salvage laryngectomy with neck dissection. We analyzed a single-institution retrospective case series of patients between 1997 and 2014 and identified those who had clinically N0 (cN0) necks (n = 203). Clinical and pathologic data, including nodal prevalence and distribution, were collected and statistical analyses performed. Overall, cN0 necks had histologically positive occult nodes in 17% (n = 35) of cases. Univariate predictors of occult nodal positivity included recurrent T4 stage (34% T4 vs 12% non-T4; P = .0003) and supraglottic subsite (28% supraglottic vs 10% nonsupraglottic; P = .0006). Histologically positive nodes associated with supraglottic primaries were most frequently positive in ipsilateral levels II and III (17% and 16%). Positive nodes for glottic LSCC were most frequently positive in the ipsilateral and contralateral paratracheal nodes (11% and 9%). Histologically positive occult nodes are identified in 17% of cN0 patients undergoing salvage laryngectomy with neck dissection. Occult nodal disease varies in frequency and distribution based on tumor subsite. Predictors of high (>20%) occult nodal positivity include T4 tumors and supraglottic subsite. In glottic LSCC, the most frequent sites of occult nodal disease are the paratracheal nodal basins.

Pectoralis major flap reconstruction in the prevention of wound breakdown and fistula formation after salvage laryngectomy: a controlled study

Abstract Patients undergoing salvage laryngeal surgery after high-dose radiotherapy or concurrent chemotherapy/radiation therapy regimen are more prone to develop pharyngocutaneous fistulas (PCFs). The fistula rates reported are as high as 70%. The aim of this study was to assess the effectiveness of pectoralis major muscle flap (PMF) in prevention of fistula formation and in enhancing wound healing in patients undergoing salvage laryngectomy. We compared results from patients of salvage laryngectomy repaired with pectoralis major flap with those of a similar group repaired by primary wound closure in 36 consecutive patients. Group A included 16 patients who underwent PMF following salvage total laryngectomy (12 male and four female patients; median age 56 years; interquartile range, 49.8–61.8). The other group included 20 patients who underwent primary closure of the wound without PMF (group B) (15 male and five female patients; median age 43 years; interquartile range, 36–54). Minimum follow-up in both groups was 3 months. The incidence of PCF in group A was 6.2% and that of wound gap was 6.2%, and there was no carotid blowout. The results in group B were as follows: 60% PCF rate and poor wound healing with gapping in 40% of patients and carotid blowout in 25% of patients (P < 0.001). The mean duration to fistula closure was 20 days in group A compared with 57.5 days in group B. Pectoralis major flap will give the patients the advantages of less fistula formation, good wound healing, early oral feeding, short hospital stay and protection against catastrophic vascular blowouts.

Elective neck dissection during salvage total laryngectomy--a beneficial prognostic effect in locally advanced recurrent tumours.

Elective neck dissection during salvage laryngectomy is controversial. The goal of our study was to evaluate the effect of elective neck dissection during salvage laryngectomy in patients with locally advanced disease at recurrence. Multicentre, retrospective study. Two tertiary medical centres. Eighty-seven patients treated by salvage laryngectomy. Disease-Free and Overall Survival. Fifty-seven patients underwent salvage total laryngectomy for locally advanced recurrent squamous cell carcinoma of the larynx, and 30 patients underwent salvage laryngectomy for limited recurrent disease. Elective lateral neck dissection was performed in 48 patients. The groups were similar in age, sex, initial TNM stage and pre-operative treatment. Survival analysis showed that both disease-free survival and overall survival were improved in patients with locally advanced disease who underwent elective neck dissection. This beneficial effect was not demonstrated in patients with limited disease at recurrence. Multivariate analysis showed that the extent of the recurrent disease as well as elective neck dissection was associated with improved disease-free survival and overall survival. Elective neck dissection during salvage total laryngectomy seems to improve survival in patients with advanced local disease at recurrence. The role of neck dissection in the treatment of smaller tumours awaits further studies.

Outcomes and Oncologic Considerations for Elective Neck Dissection in Patients Undergoing Salvage Laryngectomy

Objectives: Most patients treated with organ-preservation schemas for laryngeal cancer have no nodal disease at the time of recurrence. The oncologic benefit of an elective neck dissection (END) in a patient with clinically N0 neck at the time of salvage laryngectomy (SL) is still controversial. We sought to determine the oncologic outcomes for END and identify predictors for pN(+) status. Methods: Retrospective chart review of 180 patients who underwent laryngectomy between 2004 and 2013 was performed. Fifty-eight patients met inclusion criteria and the cohort was divided into 2 groups depending upon the END status. Demographics, pathology, and oncologic outcomes were compared. Results: The study was comprised of 46 (79.3%) males and 12 (20.7%) females with a mean age of 60.5 years (range, 24-88 years; SD = 10 years). Nineteen patients (32.8%) were managed conservatively while 39 (67.2%) had END, uni- or bilateral. Out of a total of 71 ENDs, 5 necks in 4 patients had positive nodal disease. The only statistically significant predictor for pN(+) status was T-stage ( P = .017). Contrary to other reports, tumor location (glottis vs. supraglottic) was not a factor. The 5-year disease-free survival was 53.8%, and it was significantly lower for patients who underwent an END ( P = .032). Conclusions: We found that 7% of the dissected necks had positive disease, and the only predictor for pN(+) status was tumor T-stage. END did not improve locoregional control or survival compared to observation. Our findings suggest END is warranted in patients presenting with locally advanced recurrences, while observation might be preferable in other instances.

Larynx-Preserving Intensity Modulated Radiation Therapy for Laryngeal and Hypopharyngeal Carcinoma

Purpose/Objective(s): To report outcomes of patients with laryngeal or hypopharyngeal carcinoma treated with definitive intensity-modulated radiation therapy (IMRT). Materials/Methods: The clinical records of all patients with laryngeal and hypopharyngeal squamous cell carcinomas treated with definitive IMRT at our institution between January 2004 and December 2011 were retrospectively reviewed. Fifty patients were reviewed. All patients would have required a total laryngectomy. Forty-two (84%) patients received concurrent chemotherapy, 6 (12%) received no chemotherapy, and 2 (4%) received adjuvant chemotherapy. Of patients who received concurrent chemotherapy, the majority of them (24 patients, 48%) received cisplatin alone; 6 patients (12%) received cetuximab alone, 8 (16%) received both cetuximab and cisplatin, and 6 (12%) received other chemotherapy regimens. Kaplan-Meier survival analysis and univariate Log-rank statistics were applied. Results: Median follow-up was 26.0 months (range, 4.0-106.0 months). Median age was 61 years (range, 35-83 years); 39 (78%) were male. There were 35 (70%) laryngeal and 15 hypopharyngeal cancers. Twelve (24%), 29 (58%), and 2 (4%) patients were diagnosed clinical stages III, IVA, and IVB, respectively. All patients were prescribed 7000 cGy in 35 daily fractions; however, 2 patients were unable to complete the full treatment. There were 16 local, 7 regional, and 15 distant failures. For all patients, local control (LC), locoregional control (LRC), and overall survival (OS) at 2 years were 73%, 68%, and 63%, respectively. The 2 year LC, LRC and OS for laryngeal cancer were 77%, 75%, and 70%, respectively. For hypopharyngeal cancer, LC, LRC, and OS at 2 years were 54%, 45%, and 47%, respectively. LC and LRC were not significantly different between sites, but there was a trend toward improved OS in patients with laryngeal cancer, (P Z 0.06). Eleven patients underwent salvage laryngectomy (9 laryngeal and 2 hypopharyngeal). Altogether, 34 (68%) patients had a feeding tube placed; 6 (12.5%) before, 25 (50%) during, and 3 (6%) after radiation therapy. At the time of last follow up, only 14 patients (28%) remained feeding tube dependent. Outcomes looking at tumor volume, CTV expansion, and other dosimetric properties will be reported later. Conclusions: The use of IMRT achieved encouraging local and regional tumor control in patients with hypopharyngeal and laryngeal cancer. There is a trend toward worse overall survival in patients with hypopharyngeal compared to laryngeal carcinoma. Feeding tube placement and dependency were common treatment related toxicities but were preferred to the loss of a lung powered voice. Author Disclosure: C. Kreofsky: None. Y.I. Garces: None. D.L. Price: None. K.A. Price: None. R.L. Foote: None.

Definitive Chemoradiation (CRT) for Organ Preservation in Locally Advanced Squamous Cell Carcinoma of the Hypopharynx (SCC-HP): Oncological Outcomes and Late Toxicity

Purpose/Objective(s): To report outcomes of patients with laryngeal or hypopharyngeal carcinoma treated with definitive intensity-modulated radiation therapy (IMRT). Materials/Methods: The clinical records of all patients with laryngeal and hypopharyngeal squamous cell carcinomas treated with definitive IMRT at our institution between January 2004 and December 2011 were retrospectively reviewed. Fifty patients were reviewed. All patients would have required a total laryngectomy. Forty-two (84%) patients received concurrent chemotherapy, 6 (12%) received no chemotherapy, and 2 (4%) received adjuvant chemotherapy. Of patients who received concurrent chemotherapy, the majority of them (24 patients, 48%) received cisplatin alone; 6 patients (12%) received cetuximab alone, 8 (16%) received both cetuximab and cisplatin, and 6 (12%) received other chemotherapy regimens. Kaplan-Meier survival analysis and univariate Log-rank statistics were applied. Results: Median follow-up was 26.0 months (range, 4.0-106.0 months). Median age was 61 years (range, 35-83 years); 39 (78%) were male. There were 35 (70%) laryngeal and 15 hypopharyngeal cancers. Twelve (24%), 29 (58%), and 2 (4%) patients were diagnosed clinical stages III, IVA, and IVB, respectively. All patients were prescribed 7000 cGy in 35 daily fractions; however, 2 patients were unable to complete the full treatment. There were 16 local, 7 regional, and 15 distant failures. For all patients, local control (LC), locoregional control (LRC), and overall survival (OS) at 2 years were 73%, 68%, and 63%, respectively. The 2 year LC, LRC and OS for laryngeal cancer were 77%, 75%, and 70%, respectively. For hypopharyngeal cancer, LC, LRC, and OS at 2 years were 54%, 45%, and 47%, respectively. LC and LRC were not significantly different between sites, but there was a trend toward improved OS in patients with laryngeal cancer, (P Z 0.06). Eleven patients underwent salvage laryngectomy (9 laryngeal and 2 hypopharyngeal). Altogether, 34 (68%) patients had a feeding tube placed; 6 (12.5%) before, 25 (50%) during, and 3 (6%) after radiation therapy. At the time of last follow up, only 14 patients (28%) remained feeding tube dependent. Outcomes looking at tumor volume, CTV expansion, and other dosimetric properties will be reported later. Conclusions: The use of IMRT achieved encouraging local and regional tumor control in patients with hypopharyngeal and laryngeal cancer. There is a trend toward worse overall survival in patients with hypopharyngeal compared to laryngeal carcinoma. Feeding tube placement and dependency were common treatment related toxicities but were preferred to the loss of a lung powered voice. Author Disclosure: C. Kreofsky: None. Y.I. Garces: None. D.L. Price: None. K.A. Price: None. R.L. Foote: None.

Salvage Laryngectomy, Decision Making to Optimize the Result: Neck Dissection? Salivary Bypass? Flap‐Assisted Closure?

Program Description: How does a surgeon decide to optimize the outcome after performing a salvage laryngectomy? The goal of this miniseminar is to help the surgeon understand the decision-making process for the reconstruction of the hypopharynx after salvage laryngectomy using evidence from 2 large national retrospective reviews. In addition, the role of withholding neck dissection to reduce morbidity will be discussed. Substantial time will be left at the end of the presentation to discuss specific case examples and have the faculty discuss perioperative and postoperative management. Educational Objectives: (1) Cite the current evidence for flap-assisted closure for patients undergoing salvage laryngectomy. (2) Evaluate the risks and benefits of performing neck dissection for salvage patients. (3) Use case examples to demonstrate management relating to choice for neck dissection, use of the salivary bypass tube, and choice of flap-assisted reconstruction.

Charged Particle Therapy for Nasal Cavity and Paranasal Sinus Malignancies: A Systematic Review and Meta-analysis

Purpose/Objective(s): To report outcomes of patients with laryngeal or hypopharyngeal carcinoma treated with definitive intensity-modulated radiation therapy (IMRT). Materials/Methods: The clinical records of all patients with laryngeal and hypopharyngeal squamous cell carcinomas treated with definitive IMRT at our institution between January 2004 and December 2011 were retrospectively reviewed. Fifty patients were reviewed. All patients would have required a total laryngectomy. Forty-two (84%) patients received concurrent chemotherapy, 6 (12%) received no chemotherapy, and 2 (4%) received adjuvant chemotherapy. Of patients who received concurrent chemotherapy, the majority of them (24 patients, 48%) received cisplatin alone; 6 patients (12%) received cetuximab alone, 8 (16%) received both cetuximab and cisplatin, and 6 (12%) received other chemotherapy regimens. Kaplan-Meier survival analysis and univariate Log-rank statistics were applied. Results: Median follow-up was 26.0 months (range, 4.0-106.0 months). Median age was 61 years (range, 35-83 years); 39 (78%) were male. There were 35 (70%) laryngeal and 15 hypopharyngeal cancers. Twelve (24%), 29 (58%), and 2 (4%) patients were diagnosed clinical stages III, IVA, and IVB, respectively. All patients were prescribed 7000 cGy in 35 daily fractions; however, 2 patients were unable to complete the full treatment. There were 16 local, 7 regional, and 15 distant failures. For all patients, local control (LC), locoregional control (LRC), and overall survival (OS) at 2 years were 73%, 68%, and 63%, respectively. The 2 year LC, LRC and OS for laryngeal cancer were 77%, 75%, and 70%, respectively. For hypopharyngeal cancer, LC, LRC, and OS at 2 years were 54%, 45%, and 47%, respectively. LC and LRC were not significantly different between sites, but there was a trend toward improved OS in patients with laryngeal cancer, (P Z 0.06). Eleven patients underwent salvage laryngectomy (9 laryngeal and 2 hypopharyngeal). Altogether, 34 (68%) patients had a feeding tube placed; 6 (12.5%) before, 25 (50%) during, and 3 (6%) after radiation therapy. At the time of last follow up, only 14 patients (28%) remained feeding tube dependent. Outcomes looking at tumor volume, CTV expansion, and other dosimetric properties will be reported later. Conclusions: The use of IMRT achieved encouraging local and regional tumor control in patients with hypopharyngeal and laryngeal cancer. There is a trend toward worse overall survival in patients with hypopharyngeal compared to laryngeal carcinoma. Feeding tube placement and dependency were common treatment related toxicities but were preferred to the loss of a lung powered voice. Author Disclosure: C. Kreofsky: None. Y.I. Garces: None. D.L. Price: None. K.A. Price: None. R.L. Foote: None.