Two landmark trials studying the management of laryngeal cancer, the VA Larynx and the RTOG 91-11, shifted the treatment paradigm from primary laryngectomy to organ preservation therapy with chemotherapy or radiation. However, subsequent studies demonstrated worse functional outcomes in patients initially treated conservatively and these patients eventually required a salvage laryngectomy. This study aims to further characterize the management of laryngeal cancer by analyzing the rate of salvage laryngectomy following organ preservation therapy, time to salvage laryngectomy, and prevalence of gastrostomy tube or tracheostomy tube one year from conservative management. These markers should be considered in the management decisions of patients with laryngeal cancer.
Methods: The current study is a retrospective analysis including data from 2011 to 2021 using the TriNetX Research Network database. There were two cohorts included in this study, created using ICD-10, CPT and SNOMED codes. The first cohort consisted of patients with stage 1 or stage 2 squamous cell carcinoma (SCC) of the larynx, treated with definitive radiation, referred to as the early-stage group. The second cohort, or the advanced-stage cohort, consisted of patients with stage 3 or stage 4 SCC of the larynx who were treated with chemotherapy, radiation, or a combination. The primary outcome measured was percent of patients that went on to have a salvage laryngectomy, defined as total laryngectomy within 3 months to 5 years of post-treatment. Further, we studied the time to salvage laryngectomy in each cohort. Lastly, presence of tracheostomy and gastrostomy tube a year out from conservative management was assessed. Statistical analyses including two sample t-tests and risk ratios were conducted on the TriNetX platform.
Results: There were 645 patients included in the early-stage group and 1,504 in the late-stage group. 17.3% of the former and 13.5% of the latter went on to have salvage laryngectomy. There was greater risk of salvage laryngectomy in the early-stage group RR= 1.4 (95% CI [1.1, 1.7]). Time to salvage laryngectomy was a median of 406 days (range: 100 - 5,835 days) in the early-stage group and 377 days (range: 90 - 4,789 days) in the advanced stage group. There were 17.1% of patients in the early-stage group that had a tracheotomy three years after treatment with conservative measures compared to 25.5% of patients in the advanced stage. Additionally, 8.5% and 18.8% of patients had a gastrostomy tube in the early-stage and advanced-stage groups respectively.
Conclusions: The current study reports comparable, but slightly higher larynx preservation rates compared to landmark studies, suggesting advances in organ preservation treatment. It was observed that tracheostomy and gastrostomy tubes were prevalent in conservatively treated patients. This demonstrates that while conservative management may keep the larynx intact, there still may be loss of function. We add to the literature by reporting a larger study with long term follow-up, as well as commenting on time to salvage laryngectomy and assessing early stage in addition to late stage cancers.