Preservation of the Larynx in Laryngeal and Hypopharyngeal Cancer

In the last decade the primary treatment of laryngeal and hypopharyngeal cancer was shifted towards organ preservation, i.e. preservation of the larynx. The treatment of laryngeal cancer was changed from standard radiotherapy towards hyperfractionated radiotherapy. Hypopharyngeal cancer is nowadays mostly treated with a combination of chemotherapy and radiotherapy instead of primary surgery. Therefore, the greatest shift in treatment protocols found was for hypopharyngeal cancer. The goal of this thesis was in the first place to find out whether recurrent laryngeal cancer can be treated with preservation of the larynx and the consequences of organ preservation for the function of the “new” organ. The second goal of this thesis was to find out which treatment protocols are used in the Netherlands for hypopharyngeal cancer. Also, to find the consequences of chemoradiation protocols for surgical treatment of recurrent hypopharyngeal cancer. Chapter I is a general introduction of laryngeal and hypopharyngeal cancer. The incidences of laryngeal and hypopharyngeal cancer are mentioned. Furthermore, the biggest risk factors, being smoking and alcohol, are described. Especially, the effect of tobacco smoke on the development of laryngeal and hypopharyngeal cancer is described. Tobacco smoke contains several substances, which can cause mutations in genes. The mutations deregulate several enzyme systems and cell regulation systems, which cause degeneration of squamous cell epithelium. An overview of the other chapters of this thesis is given. In Chapter II two partial laryngectomy techniques are described. The oncological and functional results of the endoscopic CO2 laser and the frontolateral partial laryngectomy for the treatment of the recurrent glottic laryngeal cancer are described. The indications of both techniques are mentioned. Both techniques have good oncological results and less functional problems were found. With the CO2 laser 44-58% of the patients are cured with preservation of the larynx; with the frontolateral partial laryngectomy 71% was cured. It is important to realize that in case of a new recurrence, a total laryngectomy can be performed without an extra risk of failure for therapy. Both partial laryngectomy techniques, CO2 laser and frontolateral partial laryngectomy, are good treatment modalities for recurrent glottic laryngeal cancer. However, the indications for the different techniques are important and should be followed strictly. In chapter III the functional and oncological results of the third partial laryngectomy technique, cricohyoidoepiglottopexy (CHEP), is described. With the CHEP 79% of the patients are cured with preservation of the larynx. In eight patients a Flexible Endoscopic Evaluation of Swallowing (FEES) was performed to objectify problems swallowing. In none of the patients aspiration was found. Before and after the operation the voice was recorded and judged. After the operation the voice is worst. However, most patients are satisfied with there voice. The CHEP appears oncologically safe and functional for the treatment of recurrent glottic laryngeal cancer in selected patients. In chapter IV was investigated whether the quality of life is different after a partial laryngectomy versus a total laryngectomy for recurrent laryngeal carcinomas after radiotherapy. Also the voice of both groups of patients was judged. The quality of life was investigated with the EORTC Quality of Life Questionnaire (QLQ) – C30 Dutch version 3.0 and the EORTC – H & N 35 questionnaire. The only difference found was smell and taste related. The voice was judged with the Voice Handicap Index. No differences between the two groups were found. There are no big differences in quality of life after treatment with a partial or a total laryngectomy. This is mainly caused by the unexpected good quality of life after a total laryngectomy. In chapter V the treatment of hypopharyngeal cancer in the Netherlands is described. The treatment of hypopharyngeal cancer in the period 1985 – 1994 was investigated. The biggest group of patients was treated with radiotherapy alone or with combined radiotherapy and surgery. The overall 5-year disease-free survival after treatment with curative intention was 32%. The disease-free survival is better after combined surgery and radiotherapy. In chapter VI, the complications after salvage surgery in patients prior treated with radiotherapy alone or chemoradiation is described. The post-operative complication rate is significantly higher (92% vs. 50%) in the chemoradiation group. The most frequent complication found was a pharygocutaneous fistula. The quality of life, after a longer post-operative period, showed a significant difference in social functioning in disadvantage of the chemoradiation group. In the general discussion (chapter VII) the found results are discussed. The most important conclusion is that there is place for organ preservation therapy, but we must remain critical of indications and side effects of organ preservation protocols while we should realize that quality of life after total laryngectomy are not as poor as we might sometimes think

Head and neck cancer patients' preferences for individualized prognostic information: a focus group study

BACKGROUND: Head and Neck cancer (HNC) is characterized by significant mortality and morbidity. Treatment is often invasive and interferes with vital functions, resulting in a delicate balance between survival benefit and deterioration in quality of life (QoL). Therefore, including prognostic information during patient counseling can be of great importance. The first aim of this study was to explore HNC patients' preferences for receiving prognostic information: both qualitative (general terms like "curable cancer"), and quantitative information (numbers, percentages). The second aim of this study was to explore patients' views on "OncologIQ", a prognostic model developed to estimate overall survival in newly diagnosed HNC patients. METHODS: We conducted a single center qualitative study by organizing five focus groups with HNC patients (n = 21) and their caregivers (n = 19), categorized in: 1) small laryngeal carcinomas treated with radiotherapy or laser, 2) extensive oral cavity procedures, 3) total laryngectomy, 4) chemoradiation, 5) other treatments. The patients' perspective was the main focus. The interview guide consiste

Keys to successful implementation of routine symptom monitoring in head and neck oncology with “Healthcare Monitor” and patients' perspectives of quality of care

Background: Value-based health care is increasingly used to facilitate a systematic approach during follow-up of patients. We developed Healthcare Monitor (HM): a structure of electronic patient-reported outcome measures (ePROs) for the longitudinal follow-up of head and neck cancer (HNC) patients. This study shares key lessons from implementation and seeks to provide insight into how patients experience HM. Methods: We conducted a mixed-methods study using quantitative data from a nonrandomized retrospective survey of patients who received HM (n = 45) vs standard care (n = 46) and qualitative data from structured interviews (n = 15). Results: Implementation of HM included significant challenges. Finding common ground among clinicians, administrators, and IT staff was most important. Qualitative findings suggest that patients experienced better doctorpatient communication and increased efficiency of the consultation using HM. Patients felt better prepared and experienced more focus on critical issues. Quantitative analysis did not show significant differences. Conclusions: Integration of HM into routine care for HNC patients may have increased patient-centered care and facilitated screening of symptoms. However, future research is needed to analyze the potential benefits more extensively

Early and long-term morbidity after total laryngopharyngectomy

To determine the early and long-term morbidity of patients treated with a total laryngopharyngectomy and reconstruction using a jejunum interposition or gastric pull-up procedure. It is a retrospective study; and it is conducted in tertiairy referral center. Sixty-three patients were included in whom 70 reconstructions were performed (51 jejunum interpositions and 19 gastric pull-up procedures) between 1990 and 2007. The studied parameters were success rate of the reconstruction, early and long-term complication rate, and functional outcome including quality of life. Subjective quality of life analysis was determined by two questionnaires: the EORTC Quality of Life Questionnaire (QLQ)-C30 Dutch version 3.0, and the EORTC-Head and Neck (H & N 35). The success rates were 84 and 74%, respectively. The procedures were associated with a high complication rate (63% after jejunum interposition and 89% after gastric pull-up), and a lengthy rehabilitation. Surviving patients were found to have a good long-term quality of life. Complete oral intake was achieved in 97%, and speech rehabilitation in 95%. These procedures are associated with significant morbidity, high complication rates, lengthy rehabilitation, but a good long-term quality of life

Detecting head and neck lymph node metastases with white light reflectance spectroscopy; a pilot study

Introduction: A challenge in the treatment of patients with head and neck cancer is the management of occult cervical lymph node (LN) metastases. Single-fiber reflectance (SFR) spectroscopy has the potential to detect physiological tissue changes that occur in a positive LN. This pilot study aimed to investigate whether SFR spectroscopy could serve as an alternative or additional technique to detect cervical lymph node metastases. Materials and Methods: We performed intraoperative SFR spectroscopy measurements of LNs with and without malignancies. We analyzed if physiological and scattering parameters were significantly altered in positive LNs. Results: Nine patients with a total of nineteen LNs were included. Three parameters, blood volume fraction (BVF), microvascular saturation (StO2), and Rayleigh amplitude, were significantly lower in positive LNs. They were combined into one optical parameter ‘delta’, using discriminant analysis. Delta was significantly decreased in positive LNs, p = 0,0006. It had a high diagnostic accuracy where the sensitivity, specificity, PPV, and NPV were 90,0%, 88.9%, 90,0%, and 88.9%, respectively. The area under the ROC curve was 96.7% (95% confidence interval 89.7–100.0%). Conclusion: This proof of principle study is a first step in the development of an SFR spectroscopy technique to detect LN metastases in real time. A next step towards this goal is replicating these results in LNs with smaller metastases and in a larger cohort of patients. This future study will combine SFR spectroscopy with fine-needle aspiration, using the same needle, to perform preoperative in vivo measurements.</p

Physicians’ clinical prediction of survival in head and neck cancer patients in the palliative phase

Background: The prognosis of patients with incurable head and neck cancer (HNC) is a relevant topic. The mean survival of these patients is 5 months but may vary from weeks to more than 3 years. Discussing the prognosis early in the disease trajectory enables patients to make well-considered end-of-life choices, and contributes to a better quality of life and death. However, physicians often are reluctant to discuss prognosis, partly because of the concern to be inaccurate. This study investigated the accuracy of physicians’ clinical prediction of survival of palliative HNC patients. Methods: This study was part of a prospective cohort study in a tertiary cancer center. Patients with incurable HNC diagnosed between 2008 and 2011 (n = 191), and their treating physician were included. Analyses were conducted between July 2018 and February 2019. Patients’ survival was clinically predicted by their physician ≤3 weeks after disclosure of the palliative diagnosis. The clinical prediction of survival in weeks (CPS) was based on physicians’ clinical assessment of the patient during the outpatient visits. More than 25% difference between the actual survival (AS) and the CPS was regarded as a prediction error. In addition, when the difference between the AS and CPS was 2 weeks or less, this was always considered as correct. Results: In 59% (n = 112) of cases survival was overestimated. These patients lived shorter than predicted by their physician (median AS 6 weeks, median CPS 20 weeks). In 18% (n = 35) of the cases survival was correctly predicted. The remaining 23% was underestimated (median AS 35 weeks, median CPS 20 weeks). Besides the differences in AS and CPS, no other significant differences were found between the three groups. There was worse accuracy when predicting survival closer to death: out of the 66 patients who survived 6 weeks or shorter, survival was correctly predicted in only eight (12%). Conclusion: Physicians tend to overestimate the survival of pal

Screening for synchronous esophageal second primary tumors in patients with head and neck cancer

Patients with head and neck squamous cell carcinoma (HNSCC) have an increased risk of developing esophageal second primary tumors (ESPTs). We aimed to determine the incidence, stage, and outcome of synchronous ESPTs in patients with HNSCC in a Western population. We performed a prospective, observational, and cohort study. Patients diagnosed with HNSCC in the oropharynx, hypopharynx, any other sub-location in combination with alcohol abuse, or patients with two synchronous HNSCCs, between February 2019 and February 2020 underwent screening esophagogastroduodenoscopy (EGD). ESPT was defined as presence of esophageal squamous cell carcinoma (ESCC) or high grade dysplasia (HGD). Eighty-five patients were included. A lesion suspected for ESPT was detected in 14 of 85 patients, which was pathologically confirmed in five patients (1 ESCC and 4 HGD). The radiotherapy field was extended to the esophagus in two of five patients, HGD was treated with endoscopic resection in three of five patients. None of the ESPTs were detected on MRI and/or CT-scan prior to EGD. Of the remaining nine patients, three had low grade dysplasia on histology whereas the other six patients had benign lesions. Incidence of synchronous ESPT was 5.9% in our cohort of HNSCC patients. All ESPTs were diagnosed at an early stage and treated with curative intent. We recommend that screening for synchronous ESPTs should be considered in a selected group of patients with HNSCC