In comparing disease-free survival between the two groups, we observed better results in patients who underwent laryngectomy, with In order to explore this difference, we went on to compare disease-free survival in the different clinical stages T and N between the two groups. Thus, we kept the two sites grouped in the subsequent analyses.
Comparative data for disease-free survival by different staging are shown in Table 2. Over the last few decades, there has been a shift in the treatment strategy for larynx cancer with advanced locoregional disease.
There was an increase in the number of patients undergoing radiotherapy and chemotherapy and a decrease in the number of those treated with surgery. According to the guidelines of the American Society of Clinical Oncology, disease management in association with larynx preservation was considered appropriate for most patients with T3 and T4 tumors without invasion into soft tissues through the cartilage.
American Society of Clinical Oncology clinical practice guideline for the use of larynx-preservation strategies in the treatment of laryngeal cancer. In our study, we found greater disease-free survival in patients with larynx or hypopharynx squamous cell carcinoma who were initially treated with surgery compared to those included in organ-preserving protocols. A multivariate analysis further corroborated this finding, in spite of the surgical group including patients with more advanced tumors.
This clearly differs from some studies advocating conservative treatment in cases of advanced carcinomas of the larynx and hypopharynx. This difference was better characterized when contrasting the groups across the different T and N classifications. At this point, better oncological results were observed in patients with T3 and T4a tumors mainly T4a undergoing surgical treatment, which is partly in agreement with the literature.
Larynx preservation clinical trial design: key issues and recommendations: a consensus panel summary. Factors predictive of survival in advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg. Currently, what appears to be most generally accepted is that T4a tumors with coarse cartilage invasion and laryngeal extravasation should be preferentially treated with surgery.
Nevertheless, for T3 tumors, a course of conduct has not been well established yet. Diagnosis and treatment of recurrent laryngeal cancer following initial nonsurgical therapy.
Our study shows a trend towards better outcomes with surgery on intermediate tumors, which certainly encourages further studies.
As for lymph node status, when we stratified neck staging, we observed disease-free survival only in N0 and N1 cases, with better results in the surgical group as well. This was probably due to a worse prognosis inherent in the regional disease, diluting any benefit the surgical treatment could bring. In our study, the presence of cervical metastasis impacted on the decrease in disease-free survival also in the multivariate analysis. Our main finding is the identification of laryngectomy as the best therapeutic modality for advanced tumors of the larynx and hypopharynx.
In a first analysis, it may seem strange to group the two distinct sites in a joint analysis. Furthermore, both the univariate and multivariate analyses showed, respectively, that the anatomical site larynx or hypopharynx was neither an associated nor a predictive variable with respect to the risk of recurrence or persistence of disease in these patients. Thus, we chose to keep the total sample in the subsequent analyses. One of the limitations of the study is the relative heterogeneity of the groups because it is a historical cohort and not a randomized study.
The surgical arm groups together patients who underwent total laryngectomy, pharyngolaryngectomy or partial laryngectomy, with or without dissection, and with an adjuvant in some cases.
The non-surgical arm, on the other hand, gathers exclusive radiotherapy, concurrent radiotherapy and chemotherapy, some cases of induction chemotherapy followed by radiotherapy and chemotherapy, and patients who did not complete the three cycles of concurrent chemotherapy. There are many different therapeutic modalities being compared, which makes it difficult to define the real benefit deriving from each one.
Similarly, there is the inherent information bias of retrospective studies, which is in fact difficult to discriminate statistically. The selection of patients for each of the therapeutic arms may also be debated. However, it was mostly done at random as external referral of patients to our health care service. Still, the study has invaluably contributed to answering an essential question: is the current indiscriminate indication of organ-preserving protocols a sound practice in cases of moderately advanced larynx or hypopharynx tumor?
The answer is no. It is essential that these patients be evaluated by a head and neck surgeon in an attempt to perform precise staging and provide an adequate definition of the treatment to be used multidisciplinarily. Certainly, further studies are required to define the exact cut-off point from which it is no longer possible or safe to attempt non-surgical treatment. Our study contributes to that end accordingly.
Based on three prospective studies that assessed patients with advanced and resectable larynx or pharynx tumors, we evaluated the criteria for better indicating organ-preserving protocols. TALK Score: development and validation of a prognostic model for predicting larynx preservation outcome. In a multicenter retrospective study with patients with larynx cancer, 65 were in clinical stage III, 51 underwent organ-preserving protocols, and 14 underwent laryngectomy.
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Patient Saf Surg. PubMed Google Scholar Crossref. Accessed February 6th, J Surg Educ. Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study. Arch Surg. Am J Surg. A survey of study habits of general surgery residents. A national survey of educational resources utilized by the Resident and Associate Society of the American College of Surgeons membership. Am Surg. PubMed Google Scholar. Improvement in American Board of Surgery In-Training Examination performance with a multidisciplinary surgeon-directed integrated learning platform.
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