Elucidation of salvage laryngectomy pathologic and clinical variables to guide further treatment intensification investigation

Objective/Hypothesis: There are limited treatment options beyond surgical salvage for patients who fail nonoperative treatment for laryngeal squamous cell carcinoma. In this study, we examine the failure patterns after surgical salvage and the potential pathologic and clinical prognostic variables that might guide further postoperative intensification investigation. Study Design: Retrospective analysis at a tertiary academic referral center. Methods: From an institutional review board-approved institutional head and neck cancer registry, a consecutive series of 147 patients who underwent salvage laryngectomy for squamous cell cancer recurrence or persistence after radiotherapy with or without chemotherapy between May 1995 and May 2016 were identified. Variables potentially associated with oncologic outcome after surgical salvage were then collected and retrospectively evaluated. Results: The projected 2-year locoregional failure rate was 21.8% (95% confidence interval [CI], 14.6%–29.0%]), and the overall survival 65% (95% CI, 57.5%–74.3%) for the entire cohort after salvage laryngectomy. On multivariable analysis, sarcomatoid/spindle cell pathology (hazard ratio [HR], 3.147; 95% CI, 1.181–8.386; P = 0.022), lymphovascular space invasion (LVSI) (positive vs. negative; HR, 2.31; 95% CI, 1.21–4.42; P = 0.011), and advanced initial American Joint Committee on Cancer 7th Edition grouped stage (stages III–IVB vs. stages I–II; HR, 1.64; 95% CI, 1.04–2.6; P = 0.035) were found to be independently associated with inferior disease-free survival. No other clinical or pathologic variables predicted failure. Conclusion: Salvage laryngectomy after nonoperative treatment failure results in successful locoregional control rates and survival in the majority of patients failing initial therapy. This should temper enthusiasm for routine treatment intensification with postoperative re-irradiation and/or other systemic treatments for the vast majority of patients. Sarcomatoid pathology, LVSI, and an advanced initial stage are associated with inferior disease-free survival. The presence of these factors may warrant further investigational study of treatment intensification after salvage laryngectomy. Level of Evidence: 4. Laryngoscope, 128:823–830, 2018.