When different modalities available, one with maximum chance of cure should be used. When different modalities have same results, one offering better quality of life, with organ, function preservation and good cosmetic results should be used

1. JC : Landmark studies in organ
preservation protocol

2. Introduction -
Treatment considerations in H& N cancers –
• Highest loco- regional control
• Anatomical with functional preservation
• Stage I / II Single modality ( Surgery or RT )
• Stage III / IV Combined modality
Surgery + RT (in most patients)- used to be
the treatment modality
Chemotherapy + RT – organ preservation
protocol

3. • When different modalities available, one with
maximum chance of cure should be used
• When different modalities have same results,
one offering better quality of life, with organ,
function preservation and good cosmetic
results should be used

4. Functional larynx –
• Respiration
• Phonation
• Swallowing
• Protection of lower airway
• Patient is able to eat and speak without a
permanent tracheostomy at a point when no
recurrence is expected ( > 2yrs after treatment )

5. Post laryngectomy –
• diminished sense of smell and therefore taste
• difficulty in swallowing, related to changes in
the pharyngeal anatomy
• emotional and cosmetic effects of both losing
an organ
• living with a permanent tracheostoma
• Voice Quality

7. Prospective, randomized study
Previously untreated advanced (Stage III or IV)
laryngeal squamous carcinoma
Compare the results of induction chemotherapy
followed by definitive radiation therapy with
conventional laryngectomy and postoperative
radiation

8. Methods –
Exclusion - Patients with T1N1 carcinomas,
unresectable cancers, distant metastases,
previous radiation therapy

9. Treatment regimen –
Chemotherapy
• Induction chemotherapy
- Cisplatin 100mg/m2 rapid IV followed by 5FU
1000mg/m2/day for five days
- Chemo repeated on days 22 and 43
- Assessed 18 to 21 days after second cycle of
chemo – clinical and IDL

10. • Complete response – complete disappearance of
clinically evident tumour
• Partial response – At least 50% reduction in sum
of product of longest dimension and its
perpendicular for each tumour
– Patients with atleast a partial response and no
progression of neck disease received 3rd cycle of
chemo, followed by RT
– Any lesser – surgery and post op RT

11. Radiation –
Definitive radiation therapy - 66 to 76 Gy to the
primary tumor site.

12. Surgery –
- Wide-field total laryngectomy
- Horizontal partial laryngectomy.

13. Conclusion –
Estimated 2 yr survival –
68 %
Laryngeal preservation –
64 %

14. • Reanalysed in 1998 – for voice and swallowing
outcomes
• Voice preservation better with chemoRT
• Swallowing problems similar even after 2
years

15. EORTC
• Prospective, randomized
• European Organization for Research and
Treatment of Cancer (EORTC) in 1990
• Compare a larynx-preserving treatment
(induction chemotherapy + definitive RT with
conventional treatment in previously untreated
and operable patients with histologically proven
squamous cell carcinomas of the pyriform sinus
or aryepiglottic fold

17. EORTC 24954
• Comparing 2 different CT regimens –
• Sequential arm – 2 cycles as in previous trial –
responders received two more cycles and RT
• Alternate arm – Cisplatin and 5fu CT on weeks 1,4,7,10;
RT in the other weeks
• Hence – lesser overall dose of chemo with lesser S/E
• Similar survival and laryngeal preservation in both
arms, lesser complications in alternate arm due to dose
difference

19. GORTEC trial 2000-01
• Cisplatin, 5FU and Docetaxel
• 2 arms – TPF and PF
• End point – overall survival and disease free
survival
• No significant difference in 5 or 10 year survivals
• 3 yr larynygeal preservation was ~70% in TPF

20. • Data on quality of life seem to favor
chemoradiation for organ preservation
• If rates of disease control are equal, more
weight should be given to individual patient
factors in determining treatment