Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 40, Num. 3, 2003, pp. 113-115

Indian Journal of Cancer, Vol. 40, No. 3, (July - September 2003) , pp. 113-115

Case Report

Salvage Chemotherapy and Surgery for Radio Recurrent Carcinoma Glottis

Varghese BT, Ramdas K,* Sebastian P, Nair MK*

Departments of Surgical Oncology and *Radiation Oncology, Regional Cancer Centre, Trivandrum -695011, India. Correspondence to: Bipin T. Varghese. E-mail: bipin@rcctvm.org

Code Number: cn03018

ABSTRACT:

Chemoradiotherapy is increasingly used in advanced laryngeal cancers. Failures are generally managed by surgery. They include histologically confirmed recurrent or residual disease or a symptomatic life threatening treatment sequelae. Tumour recurrence or residivism can be managed by chemotherapy when radical surgery is either refused by the patient or if the general condition of the patient do not permit it. However surgery becomes inevitable when life threatening treatment sequelae like absolute pharyngo-oesophageal stricture and aspiration sets in.

Key Words: Chemotherapy, Methotrexate, Post radiotherapy, Stricture, Total laryngopharyngectomy.

Introduction

A unique case of successful salvage of an advanced radiorecurrent carcinoma of larynx by combination chemotherapy and radical surgery is being reported. Medline search indicates that the present case report is the first objective documentation of total disappearance of a advanced radiorecurrent carcinoma of larynx by chemotherapy alone. The current treatment options of larynx and hypopharynx cancers and the role of chemotherapy in salvaging post radiotherapy (RT) recurrences are discussed.

Case Report

A 56-year-old man who was diagnosed and treated by chemo Radiation for Carcinoma right vocal cord in may 1999 and was disease free till may 2001 presented with mild stridor and dysphagia. The radiotherapy was given using 2 lateral opposed portals delivering 50cGy/15 Fractions to the midplane over 3 weeks time by a telecobalt machine. Direct laryngoscopy (DLS) revealed recurrent growth in the right pyriform sinus, which was biopsied, and proven to be Squamous Cell Carcinoma. The right hemilarynx was fixed and left showed restricted mobility. We did a tracheostomy and decided to salvage the disease with chemotherapy, as the patient was not willing for salvage surgery. After 4 courses of chemotherapy with methotrexate (MTX), DLS on

4/9/01 showed fixed right hemilarynx (H.L) restricted movement of left H.L. and reduced glottic space but no tumour was seen in the pyriform sinus. Two more courses of chemotherapy were given and follow up flexible pharyngolaryngoscopy under local anesthesia on 5/10/2001, showed no growth in the pyriform fossa (PF). Since he could take liquids and semisolid without much difficulty he was advised to close follow up. However on 9/9/02 he presented with worsening of dysphagia and aspiration and a repeat DLS under local anesthesia revealed a tight post RT stricture and suspicious recurrence in the postcricoid area. Both cords were fixed in adduction and P.Fs and endolarynx were normal. However biopsy of the suspicious recurrence was negative. CT scan of the pharynx and larynx showed a soft tissue mass in the postcricoid region with obliteration of lumen suggestive of postcricoid stricture and recurrence (Figure 1). On 1/10/02 he presented with absolute dysphagia and aspiration and hence we planned for a salvage pharyngolaryngectomy for the symptomatic radiation sequelae after explaining the possibility of negative report for malignancy in the operated specimen also, for which he consented.

A total laryngopharyngectomy was done on 25/10/02. To our surprise we found that the stricture was absolute and about 4 cms of the pharyngo-oesophageal lumen was absent (Figure 2). On probing the proximal end with a hemostat the track of the pin hole stricture was found to open into the subglottic region of the larynx. The entire larynx with the strictured segment was widely excised and the pharyngo-oesophageal continuity was restored with a tubed Pectoralis Major Myocutaneous (PMMC) Flap from the left side. (Figure 3).

Microscopy showed hyperplastic stratified squamous epithelium with moderate dysplastic changes. Scattered foci of squamous metaplasia were noted. Subepithelial region showed lymphoplasmacytic infilteration. He is disease free after 1 year of follow up and has undergone a prophylactic flexible videoendoscopic balloon dilatation for an impending sticture at the lower anastomotic site.

Discussion

With the advent of the concept of organ preservation¹ the role of primary surgical management of larynx and hypopharynx has come down considerably. Salvage laryngectomy² is done when an organ preservation protocol fails i. e. where there is residual disease, recurrence or very rarely when the entire larynx is mutilated by radiation.³ A therapeutic decision of salvage surgery is often difficult due to the inherent problems in getting a tissue diagnosis of residual or recurrent disease. Even in presence of clinically frank residual/recurrent disease it is difficult to demonstrate histologically, viable malignant cells in the punch biopsy specimen taken endoscopically, because of the effect of radiotherapy at the periphery of the disease. Although CT scans accurately delineate malignant tumour and it's extend at presentation, after radiotherapy it often fails to distinguish residual disease from radiation sequelae. Positron Emission Tomography (PET) with flurodeoxyglucose holds some promise in this role.⁴

The role for primary surgical management is particularly higher for advanced hypopharyngeal cancers compared to laryngeal cancers.⁵ It is also noted that salvage laryngopharyngectomy carries a worse prognosis compared to laryngectomy. It is technically more difficult and many of them require reconstruction of the pharynx. Although chemotherapy is generally regarded as a blunt weapon against head and neck cancer,⁶ its judicious use in combination with radiation therapy yields excellent curative results.^7,8 Furthermore methotrexate used concomitantly with R.T has been shown to lower the rate of salvage operations in recurrent carcinomas.⁹ In the present case eventhough post chemoRT biopsy revealed evidence of recurrence, after 6 doses of Methotrexate there was total disapearance of tumour which was documented in the final histopathological examination of the laryngopharyngectomy specimen. Hence we believe that the present case is one among the few reports of successful salvage of recurrent carcinoma of larynx and hypopharynx by chemotherapy. The subsequent removal of a disease free larynx for a symptomatic post treatment stricture is also unique. The stricture was within the radiotherapy portal and could be due to the sequelae of radiation. Laurell et al in their study on proximal oesophageal strictures after radiotherapy reported an incidence of 3.4% and a probability of dose response pattern for this effect.¹⁰

The present case is being shown to highlight the role of chemotherapy in salvaging post RT recurrence where surgery with its accompanying morbidity is refused by the patient and also to highlight the inevitable role of surgery in further management of the symptomatic life threatening post treatment sequelae.

Conclusion

Chemotherapy has been widely accepted as a treatment modality for advanced larynx and hypopharynx cancers. It is a viable alternative to salvage surgery in larynx and hypopharynx cancers in selected situations. However salvage surgery becomes inevitable in presence of associated life threatening symptoms of post radiation sequelae like severe aspiration absolute dysphagia etc.

References

1. Urba SG, Forastiere AA, Wolf GT, Esclamado RM, McLaughlin PW, Thornton AF. Intensive induction chemotherapy and radiation for organ preservation in patients with advanced resectable head and neck carcinoma. J Clin Oncol 1994;12:946-53.
2. Brugere  J, Rodriguez J, Point D. Development of pharyngo-laryngeal surgery after radiotherapy. Bull cancer 1989;76:735-43.
3. Parsons JT. The effect of radiation on normal normal tissues. In: Million RR, Cassisi NJ, editors. Management of Head and Neck Cancer. A multidisciplinary approach. Philadelphia: JB Lippincott; 1984. pp. 173-208.
4. O'Brien PC. Tumor recurrence or treatment sequelae following radiotherapy for larynx cancer. J Surg Oncol 1996;63:130-5.
5. Silver CE, Levin RJ. The hypopharynx. In: Silver CE, Ferlito A, editors. Surgery for cancer of larynx and related structures. 2nd edn. London: WB Saunders Company; 1996. pp. 207.
6. Price LA, Hill BT. Chemotherapy in head and neck cancer. Scott Browns otolaryngology. 5th edn. London: Butterworth; 1995. Vol 1. pp. 498-511.
7. Okamoto M, Takahashi H, Yao K, Inagi K, Nakayama M, Nagai H. Clinical impact of using chemoradiotherapy as a primary treatment for hypopharyngeal cancer. Acta Otolaryngol Suppl 2002;547:11-4.
8. Wolf GT, Bradford CR, Urba S, Smith A, Eisbruch A, Chepeha DB, et al. Immune reactivity does not predict chemotherapy response, organ preservation, or survival in advanced laryngeal cancer. Laryngoscope 2002;112:1351-6.
9. Gupta NK, Swindell R. Concomitant methotrexate and radiotherapy in advanced head and neck cancer: 15-year follow-up of a randomized clinical trial. Clin Oncol (R Coll Radiol) 2001;13:339-44.
10. Laurell G, Kraepelien T, Mavroidis P, Lind BK, Fernberg JO, Beckman M, et al. Stricture of the proximal esophagus in head and neck carcinoma patients after radiotherapy. Cancer 2003;97:1693-700.

Copyright 2003 - Indian Journal of Cancer

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