organ-preservation strategies in head and neck cancernew england journal of medicine 1991; 324:...
TRANSCRIPT
![Page 1: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/1.jpg)
Organ-Preservation Strategies in head and neck cancer
Teresa Bonfill Abella
Oncologia Mèdica
Parc Taulí Sabadell. Hospital Universitari
![Page 2: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/2.jpg)
![Page 3: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/3.jpg)
Larynx Hypopharynx
![Page 4: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/4.jpg)
![Page 5: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/5.jpg)
Witch is the optimal primary endpoint? - Larynx preservation rate - Larynguectomy- FS? - Survival Rate at 2, 5, 10 years? - QoL ………………………………………….
“The goal of treatment is to achieve larynx preservation with good function without compromising survival”
![Page 6: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/6.jpg)
Summary of the Relevant Literature
![Page 7: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/7.jpg)
Surgery + RT Surveillance
PF x 3
no response surgery + RT surveillance
response RT +/- salvage surgery
3 randomized studies:
- VA - EORTC 24891 - GETTEC
larynx
hypopharynx
T3 larynx
VALCSG. N Engl J Med 1991
Lefebvre JL et al. J Natl Cancer Inst 1996
Richard JM et al. Oral Oncol 1998
Induction chemotherapy
![Page 8: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/8.jpg)
New England Journal of Medicine 1991; 324: 1685-1690
332 pts, laryngeal SCC stage III/IV
Surgery
Surgery +/- RT
IC x 2
Cisplatin 100mg/m2, D1
5FU 1000mg/m2/d x 5d q3w
RT: 5000cGy/25fx Adjuvant RT
Definitive RT
RT: 6600-7600cGy
IC x 1
Residual disease Poor
respond
2yr DFS OS Recur at
primary
Recur at
regional
Distant
mets Laryngectomy-
free survival
Surgery 75% 68% 2% 5% 17%
IC RT 65% 68% 12% 8% 11% 39%
p value 0.12 0.98 0.001 NS 0.001
T1/T2 9%
T3 65%
T4 26%
Glottis 37%
Supraglottis 63%
Veterans Affairs Laryngeal Cancer Study Group
LPR: 64% (2y)
![Page 9: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/9.jpg)
Journal of National Cancer Institute 1996; 8: 890-899
194 pts, hypopharynx SCC stage II/III/IV
Surgery
Surgery +/- RT
IC x 2
Cisplatin 100mg/m2, D1
5FU 1000mg/m2/d x 5d q3w
RT: 5000cGy/25fx Adjuvant RT
Definitive RT
RT: 7000cGy
IC x 1
Residual disease Poor
respond
5yr DFS OS Recur at
local
Recur at
regional
Distant
mets Laryngectomy-
free survival
Surgery 32% 35% 17% 23% 36%
IC RT 25% 30% 12% 19% 25% 42% (2y)
35% (5y)
p value NS NS NS NS 0.041
T2 20%
T3 75%
T4 5%
Pyriform
sinus 78%
Aryepiglottic
fold 22%
EORTC 24891
![Page 10: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/10.jpg)
Trial/ site of tumour
N Therapy aproach Larynx Preservation
LFS
Survival Difference
VALCSG
(larynx)
332 S RT
vs
PF1x3 RT
64%(2y)
39%(2y)
No difference
EORTC 24891 (hypopharynx)
202 S RT
vs
PFx3 RT
40,5% (5y) 42% (2y)
35% (5y)
No difference
1CDDP 100mg/m²/ev d1
5-FU 1000mg/m²/ev d 1-5 (ic)
every 3w x 3courses
Induction PF + RT can be effective in preserving the
larynx in a high percentage of patients, without
compromising overall survival
Induction chemotherapy
![Page 11: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/11.jpg)
PF induction
RT-CT concomitantly (cisplatin days 1, 22 and 43)
RT
no response surgery + RT surveillance
response RT +/- salvage surgery
RTOG 91-11 (USA) larynx
Forastiere A et al. N Engl J Med 2003
Chemoradiotherapy
T2 12%
T3 78%
T4 10%
Supraglottis 69%
Glottis 31%
N=547pt 1CDDP 100mg/m²/ev d1
5-FU 1000mg/m²/ev d 1-5 (ic)
every 3w x 3courses
![Page 12: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/12.jpg)
2yr DFS OS Intact
larynx
LR
control LFS
Distant
mets
A: RT 27% 56
% 70% 56%
53%
38%
(5y)
22%
B: CCRT 36% 54
% 88% 78%
66%
45%
(5y)
12%
C:
ICRT 38%
55
% 75% 61%
59%
43%
(5y)
15%
p
0.02(C v
A)
0.006(B v
A)
NS
0.005(B v
C)
0.001(B v
A)
0.004(B v
C)
0.001(B v
A)
0.49(BvC)
0.01 (AvB)
0.03(B v
A) Difficulties in Speech/swallow : similar (2y) 15%
RTOG 91-11 (USA) larynx
Chemoradiotherapy
Forastiere A et al. N Engl J Med 2003
![Page 13: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/13.jpg)
![Page 14: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/14.jpg)
![Page 15: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/15.jpg)
Toxicity: - The rate of high grade toxic effects was greater in Ch-based regimens
81% (Chi->RT), 82% (Ch-RT) & 61% (XRT) - The mucosal toxicity of concurrent RT-CDDP was nearly twice as
frequent as the mucosal toxicity of the other two treatments during RT
- No differences in late toxicity or speech or swallowing function were demonstrated between treatment groups
![Page 16: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/16.jpg)
Calais G, et al. ASCO 2006, abstract 5506.
GORTEC 2000-01
Induction CT Larynx Preservation
Primary Objective: larynx preservation rate
Larynx or hypopharynx
tumors
Resectable tumors or
nodes requiring total
(pharyngo[P] laryngectomy)
No previous treatment
TPF arm Docetaxel (75 mg/m² d1)
Cisplatin (75 mg/m² d1)
5-FU (750 mg/m²/dx5)
Q 3 weeks x 3 cycles
PF arm
Cisplatin (100 mg/m²) 5-FU (1000 mg/m²/dx5)
Q 3 weeks x 3 cycles
Non-responders:
Total
(P)laryngectomy
+ post-op RT
Responders:
RT
Response
to
induction
treatment
Yes
No
Induction chemotherapy
Pointreau et al. ASCO 2006
T2 18%
T3 67%
T4 15%
![Page 17: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/17.jpg)
Induction chemotherapy GORTEC 2000-01
![Page 18: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/18.jpg)
Pointreau Y, et al. Cancer/Radiotherapie. 2006:10:493, Abstract C03;
Calais G, et al. ASCO 2006, Abstract 5506.
GORTEC 2000-01
Grade 3/4 Acute Toxicities
NCI/CTC Grade 3/4* TPF PF p
Mucositis 4.6 7.8 0.49
Neutropenia 55.6 37.3 0.01
Febrile neutropenia 13.9 7.8 0.24
Thrombocytopenia 1.9 7.8 0.09
Deaths 3.6 2.9 0.71
% of patients
*Among patients treated with RT alone, no differences were observed between
the 2 arms in: xerostomia, fibrosis, larynx edema, dysphagia, % of patients with
permanent feeding tube.
Induction chemotherapy
![Page 19: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/19.jpg)
Sequential therapy for locally advanced larynx and hypopharynx cancer: Subgroup analysis from TAX 324
study
Induction chemotherapy
TAX 324
![Page 20: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/20.jpg)
Induction chemotherapy
TAX 324
ASCO 2008
-Significant improvement in PFS (Hazard Ratio 0.61 (0.40-0.96) p=0.033 -Strong trend for OS (Hazard Ratio 0.67 (0.41-1.11) p =0.12
![Page 21: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/21.jpg)
Five phase III trials
(VALSG, EORTC 24891, RTOG 91-11, GORTEC 2000-01, TAX 324)
STUDY LFS LPR
VETERANS (L)
EORTC 24891 (H)
RTOG 91-11 PF (L)
RTOG 91-11 QT+RT (L)
GORTEC 2000-01 PF (L&H)
GORTEC 2000-01 TPF (L&H)
TAX 324 PF (L&H)
TAX324 TPF (L&H)
39% (2y)
42% (2y) 35% (5y)
59% (2y) 43% (5y)
66% (2y) 45% (5y)
37% (3y)
53%(3y)
32% (3y)
52%(3y)
64% (2y)
75%(2y)
88%(2y)
57% (3y)
70%(3y)
![Page 22: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/22.jpg)
TREMPLIN: French randomized phase II study of laryngeal preservation
TPF x 3
No resp. S + PORT
Resp.
RT + cetuximab
RT + cisplatin
Randomized phase II, GORTEC-GETTEC)
Larynx/hypopharynx suitable for TL
N=153
ASCO 2009 i ASCO 2011 JCO 2013
![Page 23: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/23.jpg)
![Page 24: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/24.jpg)
![Page 25: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/25.jpg)
![Page 26: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/26.jpg)
![Page 27: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/27.jpg)
• From these studies we have learnt that:
None of the ch-based protocols has provided better results than surgery
except in terms of larynx preservation
- Ch combined with RT has allowed to preserve a significant number of larynx without compromising survival
- PF followed by RT and Ch-RT show similar efficacy in LFS - LCR and LPR were significantly improved with Ch-RT
- Ch decreased the incidence of DM without impact in OS
- TPF is better than PF in LFS & PFS - Chemoradiotherapy & Induction Chemotherapy are alternatives
-TPF-based ICT followed CRT or BRT was feasible but had
substantial overall toxicity
![Page 28: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/28.jpg)
There is currently no good evidence base from larynx preservation trials with which to assess
the functional outcomes achieved with different larynx preservation strategies
![Page 29: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/29.jpg)
The Oncologist 2010;15 (suppl3): 25-29
![Page 30: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/30.jpg)
![Page 31: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/31.jpg)
Suggested approaches to management
![Page 32: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/32.jpg)
![Page 33: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/33.jpg)
T1, T2
• TT Intent to preserve the larynx
• RT or larynx preservation surgery
• tt selection depends on: pt factors, local expertise & rehabilitation services
• Concurrent Ch-RT only in:
– Stage III, T2 N+ pts whom total LT is the only surgical option OR larynx-preservation surgery is expected to yield an unsatisfactory functional outcome OR organ-preservation surgical expertise is unavailable
“Narrow –margin excision” followed by postoperative radiation therapy IS NOT an acceptable treatment
approach”
![Page 34: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/34.jpg)
T3, T4
• Organ preservation surgery, Ch-RT , Chi RT and Rt alone offer potential for larynx preservation without compromising survival
• Tt selection depends on: pt factors, local expertise and rehabilitation services
• Pt with tumor penentration through cartilage into soft tissues are considered poor candidates for larynx-preservation approach. LT is recommended in these cases
![Page 35: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/35.jpg)
Factors associated with decreased larynx-preservation outcomes:
• Male gender
• Anemia (at start of treatment)
• Smoking
• Advanced T stage
• Clinically detectable impaired vocal cord mobility
• Subglottic extension
• Involvement of anterior commissure
• Large tumor volume
• Invasion of specific anatomic sites (determined by CT or MRI)
![Page 36: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/36.jpg)
Recommended management approach for treatment of resectable T3-4 N0-3 laryngeal cancer
JCO, Vol 31, No7 (march1), 2013:pp840-844
![Page 37: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/37.jpg)
CONCLUSIONS
• Larynx-preservation therapy is intended to offer improved function and quality of life without compromising survival.
• All patients with T1-T2 should be treated initially with intent to preserve the larynx.
• Pt with T3- selected T4 should be offered a larynx-preservation treatment option.
• Chemoradiotherapy & Induction Chemotherapy are alternatives
![Page 38: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/38.jpg)
CONCLUSIONS
• Preservation of the laryngeal structure is not considered a functional success if persistent dysphagia, aspiration, or chronic tracheostomy.
• Selection of treatment for laryngeal cancer should always depend on patient factors, local expertise, and appropiated support and rehabilitative services.
• A multidisciplinary team with specialized expertise is necessary to ensure optimal outcomes.
![Page 39: Organ-Preservation Strategies in head and neck cancerNew England Journal of Medicine 1991; 324: 1685-1690 332 pts, laryngeal SCC stage III/IV Surgery Surgery +/- RT IC x 2 Cisplatin](https://reader031.vdocument.in/reader031/viewer/2022013022/5f5d235bef34581c0c0b6b54/html5/thumbnails/39.jpg)