Radiotherapy versus open surgery versus endolaryngeal surgery (with or without laser) for early laryngeal squamous cell cancer

A comparison of the survival between laser surgery and radiation in T1aN0M0 glottic cancer: a population-based analysis and meta-analysis

OBJECTIVE

The objective of this study is to compare the overall survival (OS) and the cancer-specific survival (CSS) for patients of T_1aN₀M₀ glottic cancer who underwent laser surgery (LS) or radiation (RT).

METHODS

The data of the population-based analysis were extracted from the SEER database. The studies of the meta-analysis were identified through PubMed, EMBASE, and Cochrane databases. Cox regression analyses, the propensity score analysis (PSM), survival analyses, and the meta-analysis were performed.

RESULTS

In the population-based analysis, 2101 eligible patients were included. Multivariable Cox analyses indicated that patients accepting LS alone would obtain better OS (HR 0.77, 95% CI 0.61-0.98, p = 0.03) and CSS (HR 0.26, 95% CI 0.12-0.59, p = 0.001) than those of whom they accepted RT alone. Survival analyses before PSM and after PSM also indicated that patients who underwent LS alone would have better OS and CSS. In the meta-analysis, nine eligible studies were included. Results of the pooled effect showed that significant differences existed between LS and RT groups on OS (OR: 1.84, 95% CI 1.36-2.50, p < 0.001) and CSS (OR 3.84, 95% CI 1.17-12.52, p = 0.026), both distinctly favoring LS.

CONCLUSIONS

Compared with RT, LS may acquire better survivals for patients with T_1aN₀M₀ glottic cancer. Simultaneously, more multi-center randomized controlled trials would be warranted to prove the conclusion.

Organ preservation and oncological outcomes in early laryngeal cancer: a propensity score-based study

Background

The rates of laryngeal preservation according to therapeutic modality in patients with initial laryngeal squamous cell carcinoma (LSCC) are still controversial. This study evaluated the rates of laryngeal preservation in patients who underwent treatment with surgery or radiotherapy.

Methods

This retrospective cohort study evaluated 151 patients with stage I or II LSCC. Ninety-six patients were matched using a propensity-score and outcomes were compared within this group.

Results

Regarding overall, cancer-specific survival and larynx preservation, no differences were observed according to the therapeutic modalities, but patients who underwent radiotherapy had a higher rate of local recurrence than those who underwent surgery. Patients classified as ASA 3 or 4 and treated with radiotherapy showed a tendency of higher risk of larynx loss.

Conclusions

Patients with stage I or II laryngeal tumours can be submitted to surgery or radiotherapy with similar rates of laryngeal preservation.

Multimodal Evaluation of Voice Outcome in Early Glottic Cancers Treated With Definitive Radiotherapy

BACKGROUND/AIM

We employed a multimodal evaluation of voice outcome (MEVO) model to assess long-term voice outcome in early glottic cancer (EGC) patients treated with primary radiotherapy (RT). The model consisted of objective and subjective vocal evaluation during follow-up, by a dedicated Speech Pathologist and Speech Therapist.

PATIENTS AND METHODS

MEVO methodology includes Self-perception Voice Handicap Index (VHI-30), evaluation of parameters Grade (G), Roughness (R), Breathiness (B), Asthenia (A) and Strain (S) according to GRBAS scale, objective analysis and aerodynamics using the PRAAT software and laryngeal evaluation with videostroboscope (VS).

RESULTS

The MEVO methodology was described and tested on a sample of 10 EGCs submitted to definitive RT (total dose 66-70 Gy). Mean follow-up was 48.9 months (range=9-115). VHI was mild-moderate in 90% of patients; overall voice function (GRBAS) was normal-mildly impaired in 70% of patients; VS evaluation showed normal vocal cord motion in 90% of patients, but complete glottic closure in 60%. PRAAT scores confirmed these findings.

CONCLUSION

A multidimensional voice evaluation is time consuming, but useful to objectify vocal impact of radiotherapy. The MEVO model allowed to quantify vocal dysfunction, showing a good objective vocal outcome.

Vocal-cord Only vs. Complete Laryngeal radiation (VOCAL): a randomized multicentric Bayesian phase II trial

BACKGROUND

Radiotherapy, along with laser surgery, is considered a standard treatment option for patients with early glottic squamous cell cancer (SCC). Historically, patients have received complete larynx radiotherapy (CL-RT) due to fear of swallowing and respiratory laryngeal motion and this remains the standard approach in many academic institutions. Local control (LC) rates with CL-RT have been excellent, however this treatment can carry significant toxicities include adverse voice and swallowing outcomes, along with increased long-term risk of cerebrovascular morbidity. A recent retrospective study reported improved voice quality and similar local control outcomes with focused vocal cord radiotherapy (VC-RT) compared to CL-RT. There is currently no prospective evidence on the safety of VC-RT. The primary objective of this Bayesian Phase II trial is to compare the LC of VC-RT to that of CL-RT in patients with T1N0 glottic SCC.

METHODS

One hundred and fifty-five patients with T1a-b N0 SCC of the true vocal cords that are n ot candidate or declined laser surgery, will be randomized in a 1:3 ratio the control arm (CL-RT) and the experimental arm (VC-RT). Randomisation will be stratified by tumor stage (T1a/T1b) and by site (each site will be allowed to select one preferred radiation dose regimen, to be used in both arms). CL-RT volumes will correspond to the conventional RT volumes, with the planning target volume extending from the top of thyroid cartilage lamina superiorly to the bottom of the cricoid inferiorly. VC-RT volumes will include the involved vocal cord(s) and a margin accounting for respiration and set-up uncertainty. The primary endpoint will be LC at 2-years, while secondary endpoints will include patient-reported outcomes (voice impairment, dysphagia and symptom burden), acute and late toxicity radiation-induced toxicity, overall survival, progression free survival, as well as an optional component of acoustic and objective measures of voice analysis using the Consensus Auditory-Perceptual Evaluation of Voice.

DISCUSSION

This study would constitute the first prospective evidence on the efficacy and safety of VC-RT in early glottic cancer. If positive, this study would result in the adoption of VC-RT as standard approach in early glottic cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03759431 Registration date: November 30, 2018.

TLM Outcomes in Elderly Patients with Glottic Pre-Malignancy and Early Malignancy; A 12-Year Retrospective Study

INTRODUCTION

UK population ageing and associated cancer risk predicts an increase in the prevalence of laryngeal cancer in elderly patients. Whilst trans-oral laser microsurgery (TLM) has been demonstrated to achieve excellent control of early disease with few complications, data specifically related to its safety and efficacy in older patients is lacking. We report the largest series to date.

OBJECTIVES

To assess the safety and efficacy of TLM in elderly patients with glottic pre-malignancy and early malignancy.

METHODS

A retrospective review and statistical analysis of the clinical records of patients aged 70 or over undergoing TLM for early and premalignant glottic disease.

RESULTS

The records of 106 patients over the age of 70 were identified. Thirteen records were excluded, 4 due to failure to meet the inclusion criteria (stage I/II disease, primary site of lesion in the glottis) and 9 due to incomplete follow up data capture. Most surgeries (>70%) were performed as a day case or overnight admission, with only 2 admissions >2 days. One patient required hospital readmission with dysphagia, resulting in an altered diet. No patients required tracheostomy or tube feeding. No treatment related deaths or intensive care admissions were observed. Ten patients had recurrent disease within 5 years; 1 received radiotherapy, 1 underwent salvage laryngectomy, the remainder had further TLM without complication. Five-year disease specific survival rates were >90%.

CONCLUSION

Our results demonstrate that TLM is safe and effective for elderly patients, with outcomes comparable to those reported in large, non-age selected cohorts. Although our patients underwent more conservative cordectomy types (I-III) than those with similar disease stages reported elsewhere, our recurrence rates were not higher. This supports the oncological effectiveness of surgery whilst reducing the risk of associated functional compromise.

Survival results of 3786 patients with stage I or II laryngeal squamous cell carcinoma: a study based on a propensity score

Introduction

Laryngeal squamous cell carcinoma is the second most prevalent malignancy among head and neck tumors, and the treatment of patients with stage I or II disease can be performed with surgery or radiation therapy. National population studies describing therapeutic results comparing these modalities are unusual, but they can be very important to direct treatment guidelines.

Objective

To evaluate the survival results of patients with laryngeal squamous cell carcinoma at clinical stages I or II, according to the main therapeutic modalities used.

Methods

Cross-sectional, population-based study using the database of Fundação Oncocentro de São Paulo from January 2000 to March 2019. Inclusion criteria were patients with laryngeal squamous cell carcinoma in clinical stages cT1-2N0. To compensate for the non-random allocation of patients and the imbalance between confounding variables between groups, we used the propensity score methodology.

Results

A total of 3786 patients met the inclusion criteria. Regarding the cT stage, there were 2171 patients (57.3%) with cT1 tumors. Patients in the public health system had a longer time between diagnosis and treatment (p < 0.001). The analysis by propensity score showed that patients treated with surgery had a tendency towards better disease-specific survival (p  = 0.012). Comparing radiotherapy alone versus its combination with radiochemotherapy, radiotherapy alone showed a tendency towards a better survival rate (p < 0.001).

Conclusion

Analysis by propensity score identified better results for disease-specific survival in patients with laryngeal squamous cell carcinoma at clinical stages I and II treated by surgery when compared to radiotherapy.

Long Term Oncological Results of Transoral Laser Microsurgery for Early and Moderately Advanced Glottic Carcinoma in Primary and Salvage Settings

The aim of the study is to document the long term oncological results of trans-oral laser microsurgery (TLM) for early and moderately advanced glottic cancer in primary and salvage settings. In this prospective cohort study 43 consecutive patients of glottic cancer (T1-30, T2-7, and selected T3 with mobile cords-6) were recruited. TLM was performed in these 35 primary and 8 previously treated cases. In our series, the local disease control rate with TLM was 90% (27/30) for T1 disease, 71.4% (5/7) for T2 cancer and 66.6% (4/6) for T3 lesions. The overall disease control rates after subsequent treatment for locoregional recurrences were 100% (30/30), 85.7% (6/7) and 83.3% (5/6) for T1, T2, and T3 glottic cancers respectively. The 5-years disease free survival rate for primary cases was 100% and 50% for salvage cases. The 5-years local disease control rate was 96.4% and 41.67% in primary and salvage TLM settings respectively. The 5-years laryngectomy free rates were 96.3% and 18.75% for primary and salvage cases respectively. TLM offers a minimally invasive and oncologically robust treatment option for early glottic cancer with an overall disease free survival of 100% at 5 years noted for primary untreated cases in this experience. TLM for post radiation salvage cases has however been disappointing and alternate larynx preserving option of open partial laryngectomy needs to be considered in this setting.

SEOM clinical guidelines for the treatment of head and neck cancer (2017)

Head and neck cancer (HNC) is defined as malignant tumours located in the upper aerodigestive tract and represents 5% of oncologic cases in adults in Spain. More than 90% of these tumours have squamous histology. In an effort to incorporate evidence obtained since 2013 publication, Spanish Society of Medical Oncology (SEOM) presents an update of HNC diagnosis and treatment guideline. The eighth edition of TNM classification, published in January 2017, introduces important changes for p16-positive oropharyngeal tumours, for lip and oral cavity cancer and for N3 category. In addition, there are new data about induction chemotherapy and the role of immunotherapy in HNC.

Conventional fractionation should not be the standard of care for T2 glottic cancer

Background

The aim of this study was to report outcomes and late toxicity following hypofractionated accelerated radiotherapy for T2 glottic cancers. We highlight the importance of hypofractionated treatments with shorter overall treatment times, in improving outcomes for T2 glottic cancers. We also compare the biologically effective dose of hypofractionated regimes, with conventional fractionation.

Methods

One hundred twelve patients with T2 glottic cancer were treated between January 1999 and December 2005. All patients were prescribed a hypofractionated accelerated radiotherapy dose of 52.5 Gray in 3.28 Gray per fraction, delivered over 22 days. Radiobiological calculations were used to assess the relationship of fraction size and overall treatment time on local control outcomes and late toxicity.

Results

The 5-year overall survival was 67%, the 5-year local control was 82%, and the 5-year disease-specific survival was 90%. The respective 5-year local control for T2a and T2b disease was 88.8 and 70.8% (p = 0.032). Severe late toxicity occurred in two patients (1.8%). Radiobiological calculations showed an increase in local control of nearly 12%, with a 10 Gray increase in biologically effective dose.

Conclusion

This study has demonstrated that accelerated hypofractionated regimes have improved local control and similar late toxicity compared with conventional fractionation schedules. This supports the use of hypofractionated regimes as the standard of care for early glottic laryngeal cancers.

Evaluating Post-Radiotherapy Laryngeal Function with Laryngeal Videostroboscopy in Early Stage Glottic Cancer

Objective

Dysphonia is common among patients with early stage glottic cancer. Laryngeal videostroboscopy (LVS) has not been routinely used to assess post-radiotherapy (RT) voice changes. We hypothesized that LVS would demonstrate improvement in laryngeal function after definitive RT for early-stage glottic cancer.

Study design

Blinded retrospective review of perceptual voice and stroboscopic parameters for patients with early glottic cancer and controls.

Setting

High-volume, single-institution academic medical center.

Subjects and methods

Fifteen patients underwent RT for Tis-T2N0M0 glottic cancer and were evaluated with serial LVS exams pre- and post-RT. Stroboscopic assessment included six parameters: vocal fold (VF) vibration, VF mobility, erythema/edema, supraglottic compression, glottic closure, and secretions. Grade, roughness, breathiness, asthenia, strain (GRBAS) voice perceptual scale was graded in tandem with LVS score. Assessments were grouped by time interval from RT: pre-RT, 0–4, 4–12, and >12 months post-RT.

Results

60 LVS exams and corresponding GRBAS assessments were reviewed. There were significant improvements in ipsilateral VF motion (P = 0.03) and vibration (P = 0.001) and significant worsening in contralateral VF motion (P < 0.001) and vibration (P = 0.008) at >12 months post-RT. Glottic closure significantly worsened, most prominent >12 months post-RT (P = 0.01). Composite GRBAS scores were significantly improved across all post-RT intervals.

Conclusion

LVS proved to be a robust tool for assessing pre- and post-RT laryngeal function. We observed post-RT improvement in ipsilateral VF function, a decline in contralateral VF function, and decreased glottic closure. These results demonstrate that LVS can detect meaningful changes in VF and glottic function and support its use for post-RT evaluation of glottic cancer patients.

T1-2 glottic cancer treated with radiotherapy and/or surgery

BACKGROUND

The optimal treatment strategy for stage I-II glottic squamous cell carcinoma (SCC) is not well-defined. This study analyzed treatment results and prognostic factors.

PATIENTS AND METHODS

This is a single-institution retrospective analysis of 244 patients with T1-2 glottic SCC who underwent normofractionated radiotherapy (RT) and/or surgery between 1990 and 2013. The primary endpoint was relapse-free survival (RFS).

RESULTS

Median age was 65 years (range: 36-92 years), the majority (82%) having stage I disease. Definitive RT was used in 82% (median dose: 68 Gy, 2 Gy per fraction). Median follow-up was 59 months. The 5‑year RFS rates were 83 and 75% (p = 0.05) for stage I and 62 and 50% (p = 0.47) for stage II in the RT and surgery groups, respectively. Multivariate analyses indicate T1 vs. T2 and RT vs. surgery as independent prognostic factors for RFS, with hazard ratios of 0.38 (95% confidence interval, CI: 0.21-0.72) and 0.53 (95% CI: 0.30-0.99), respectively (p < 0.05). The 5‑year overall and cause-specific survival rates in the whole cohort were 92 and 96%, respectively, with no significant differences between treatment groups. Anterior commissure involvement was neither a prognostic nor a predictive factor. The incidence of secondary malignancies was not significantly different between patients treated with and without RT (22 vs. 9% at 10 years, respectively, p = 0.18).

CONCLUSION

Despite a possible selection bias, our series demonstrates improved RFS with RT over surgery in stage I glottic SCC.

Laryngeal cancer: United Kingdom National Multidisciplinary guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Significantly new data have been published on laryngeal cancer management since the last edition of the guidelines. This paper discusses the evidence base pertaining to the management of laryngeal cancer and provides updated recommendations on management for this group of patients receiving cancer care.

Transoral laser microsurgery versus radiotherapy for T1 glottic carcinoma: a systematic review and meta-analysis

Transoral laser microsurgery (TLM) and radiotherapy (RT) are both accepted treatment modalities for glottic cancer. The objective of the study was to assess the oncologic outcomes and life quality of TLM in comparison with RT for T1 glottic carcinoma. We searched Medline/PubMed, Web of knowledge, EMBASE, the Cochrane Library, the Wiley online library, Springer, Google, China National Knowledge Infrastructure (CNKI), etc. We screened the literature, assessed the quality of the studies, and extracted the relevant data through the establishment of inclusion and exclusion criteria. Meta-analysis was done using the Cochrane collaboration' s RevMan 5.0 for data analysis. A total of 11 studies were included in this meta-analysis. The laryngeal preservation for patients undergoing TLM was significantly better than that for RT (P < 0.00). The laser surgery significantly improved the overall survival of patients with T1 glottic carcinoma (P = 0.04). No statistically significant differences were found between TLM and RT regarding the local control (P = 0.91). The funnel plot demonstrates no apparent publication bias in the overall survival and laryngeal preservation comparison. Our meta-analysis suggested that laser surgery was a preferred method than radiotherapy with respect to significantly better overall survival and laryngeal preservation. But the local control was not significant different. Further prospective randomized controlled studies will be needed.

Salvage total laryngectomy after external-beam radiotherapy: A 20-year experience

BACKGROUND

The purpose of this study was to present our evaluation of the clinical and functional outcomes after salvage total laryngectomy (STL).

METHODS

We conducted a retrospective review of 218 patients who underwent STL between 1994 and 2014.

RESULTS

Seventy percent of patients originally had T1 or T2, N0 tumors and 73% had definitive external-beam radiotherapy (EBRT) alone. A majority utilized tracheoesophageal prosthesis (77%) and were gastrostomy free (80%) at last follow-up. The 5-year disease control and overall survival (OS) rates were 65% and 57%, respectively. Patients with a disease-free interval after initial treatment <2 years were more likely to develop a recurrence (p = .001) and die of disease (p = .032) after STL. The disease-free interval after EBRT impacted disease control (p < .001), with 5-year disease control of 92% for >5-year disease-free interval and 60% for <2-year disease-free interval.

CONCLUSION

Most patients remain disease-free after STL, achieve intelligible tracheoesophageal speech, and maintain an oral diet. Delayed recurrence after initial treatment portends better survival and may indicate a distinct biological profile. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1962-E1968, 2016.

Transoral CO2 Laser Microsurgery Outcomes for Early Glottic Carcinomas T1-T2

Introduction

 Transoral laser microsurgery (TLM) has won territory in larynx oncology, establishing itself as an effective option in treatment of glottic, supraglottic, and hypopharynx tumors. Its advantages include limited resections, a reduction in number of tracheostomies, and the use of nasogastric tubes. Moreover, its oncological benefits are similar to those from open surgery in patients with early or advanced stages, when correctly selected.

Objective

 The objective of this study is to review oncologic outcomes obtained with the treatment of a series of glottic tumors, treated by TLM.

Methods

 Retrospective analysis of patients previously untreated, diagnosed with squamous cell carcinoma of the glottis (T1a, T1b, T2) in a tertiary university hospital. Endpoints for analysis were local control, overall and disease-specific survival, and larynx preservation rate.

Results

 The study group included 58 patients that met the inclusion criteria: 57 (98.3%) men and 1 (1.7%) woman. Mean age was 65.5 ± 10.7 years (Min: 46/Max: 88). The tumor stages of the patients included were 30 T1a, 11 (19%) T1b, and 17 (29.3%) T2. Three-year overall survival rate was 89.7% (Fig. 1), and three-year disease-specific survival rate was 96.5%, three-year local control rate was 98.3%, and three-year organ preservation rate was 98.3%.

Conclusion

 TLM is a safe and effective option in the treatment of glottis carcinomas, associated with less morbidity and a high percentage of local control, overall survival, specific survival, and organ preservation.

Voice outcomes following radiation versus laser microsurgery for T1 glottic carcinoma: systematic review and meta-analysis

OBJECTIVE

Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using transoral laser microsurgery or radiation therapy.

DATA SOURCES

PubMed, Web of Science, and Scopus (1997-2013).

REVIEW METHODS

These data sources were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed only with studies that included both treatment modalities, to reduce heterogeneity and maximize rigor; random effects modeling was used to pool results.

RESULTS

Eighteen publications were identified that reported VHI data following surgery and radiotherapy for T1 glottic carcinoma. No studies were randomized. When studies that reported multiple T-stages or systematic treatment selection bias were excluded, 8 retrospective cohort studies describing 362 patients were suitable for meta-analysis. Follow-up time (mean, 47 months; range, 1-298 mo) and extent of surgical excision varied across studies. Six studies showed no VHI difference between treatment arms; 2 favored radiotherapy over surgery (1 of which reported transmuscular cordectomy for all surgical patients); and none favored surgery. Meta-analysis showed no significant difference in posttreatment VHI between radiotherapy and surgery (mean difference, -5.52; 95% confidence interval, -11.40, 0.36; heterogeneity I (2) = 61%, P = .01).

CONCLUSION

VHI scores were comparable following transoral laser microsurgery and radiation therapy for T1 glottic carcinoma in the current literature, suggesting no clinically significant difference in functional voice outcomes between treatment types.

Secular trends in the survival of patients with laryngeal carcinoma, 1995-2007

BACKGROUND

Recent reports suggest a decline over time in the survival of patients newly diagnosed with laryngeal cancer in spite of developments in treatment practices. Our study set out to determine whether the survival of patients with laryngeal cancer in Ontario has changed over time.

METHODS

This population-based cohort study of patients diagnosed with laryngeal cancer in the province of Ontario between 1995 and 2007 used data extracted from linked provincial administrative and registry databases. Its main outcomes were overall survival, laryngectomy-free survival, and survival ratio relative to an age- and sex-matched general population.

RESULTS

The 4298 patients newly diagnosed with laryngeal cancer during the period of interest were predominantly men (n = 3615, 84.1%) with glottic cancer (n = 2787, 64.8%); mean age in the group was 66 years (interquartile range: 59-74 years). Patient demographics did not significantly change over time. Overall, 5-year survival was 57.4%; laryngectomy-free survival was 45.4%. Comparing patients from three eras (1995-1998, 1999-2003, 2004-2007) and adjusting for age, sex, and comorbidity status, we observed no differences in overall survival or laryngectomy-free survival over time. The 5-year relative survival ratio for patients with laryngeal cancer compared with an age- and sex-matched group from the general population was 81.1% for glottic cancer and 44.5% for supraglottic cancer.

CONCLUSIONS

In patients with a new diagnosis of laryngeal cancer, overall and laryngectomy-free survival have remained unchanged since the mid-1990s. New methods to improve survival and the rate of laryngeal preservation in this patient population are needed.

Radiotherapy versus open surgery versus endolaryngeal surgery (with or without laser) for early laryngeal squamous cell cancer

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 2, 2002 and previously updated in 2004, 2007 and 2010.Radiotherapy, open surgery and endolaryngeal excision (with or without laser) are all accepted modalities of treatment for early-stage glottic cancer. Case series suggest that they confer a similar survival advantage, however radiotherapy and endolaryngeal surgery offer the advantage of voice preservation. There has been an observed trend away from open surgery in recent years, however equipoise remains between radiotherapy and endolaryngeal surgery as both treatment modalities offer laryngeal preservation with similar survival rates. Opinions on optimal therapy vary across disciplines and between countries.

OBJECTIVES

To compare the effectiveness of open surgery, endolaryngeal excision (with or without laser) and radiotherapy in the management of early glottic laryngeal cancer.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 8); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 18 September 2014.

SELECTION CRITERIA

Randomised controlled trials comparing open surgery, endolaryngeal resection (with or without laser) and radiotherapy.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified only one randomised controlled trial, which compared open surgery and radiotherapy in 234 patients with early glottic laryngeal cancer. The overall risk of bias in this study was high.For T1 tumours, the five-year survival was 91.7% following radiotherapy and 100% following surgery and for T2 tumours, 88.8% following radiotherapy and 97.4% following surgery. There were no significant differences in survival between the two groups.For T1 tumours, the five-year disease-free survival rate was 71.1% following radiotherapy and 100.0% following surgery, and for the T2 tumours, 60.1% following radiotherapy and 78.7% following surgery. Only the latter comparison was statistically significant (P value = 0.036), but statistical significance would not have been achieved with a two-sided test.Data were not available on side effects, quality of life, voice outcomes or cost.We identified no randomised controlled trials that included endolaryngeal surgery. A number of trials comparing endolaryngeal resection and radiotherapy have terminated early because of difficulty recruiting participants. One randomised controlled trial is still ongoing.

AUTHORS' CONCLUSIONS

There is only one randomised controlled trial comparing open surgery and radiotherapy but its interpretation is limited because of concerns about the adequacy of treatment regimens and deficiencies in the reporting of the study design and analysis.

Oncological and functional outcome after surgical treatment of early glottic carcinoma without anterior commissure involvement

INTRODUCTION

Glottic carcinoma can be successfully diagnosed in its early stages and treated with high percentage of success. Organ preservation and optimal functional outcomes could be achieved with wide array of surgical techniques for early glottic cancer, including endoscopic approaches or open laryngeal preserving procedures, making surgery the preferred method of treatment of early glottic carcinoma in the last few years.

MATERIAL AND METHODS

Prospective study was done on 59 patients treated for Tis and T1a glottic carcinoma over a one-year time period in a tertiary medical center. Patients were treated with endoscopic laser cordectomy (types II-IV cordectomies according to European Laryngological Society classification of endoscopic cordectomies) and open cordectomy through laryngofissure. Follow-up period was 60 months. Clinical and oncological results were followed postoperatively. Voice quality after the treatment was assessed using multidimensional voice analysis 12 months after the treatment.

RESULTS

There were no significant differences between oncological and functional results among two groups of patients, though complications were more frequent in patients treated with open cordectomy.

CONCLUSION

Endoscopic laser surgery should be the first treatment of choice in treatment of early glottic carcinomas, though open approach through laryngofissure should be available for selected cases where anatomical factors present limiting adequate tumor removal.

Transoral laser surgery for laryngeal cancer

Transoral laser microsurgery (TLM) was pioneered in the early 1970s as an approach to treat laryngeal pathology with precision and minimal thermal damage to the vocal cords. Over the last four decades, TLM has become an integral part of the treatment paradigm for patients with laryngeal cancer. TLM is one of the primary treatment options for early-stage laryngeal tumors. However, in recent years, surgeons have begun to develop TLM into a more versatile approach which can be used to address advanced laryngeal tumors. Although functional outcomes following TLM for advanced laryngeal disease are scarce, survival outcomes appear to be comparable with those reported for organ preservation strategies employing external beam radiation therapy (EBRT) and chemotherapy. In addition, TLM plays an important role in the setting of recurrent laryngeal cancer following primary irradiation. TLM has been demonstrated to decrease the need for salvage total laryngectomy resulting in improved functionality while retaining comparable oncologic outcomes. The aim of this review is to elucidate the indications, techniques, and oncological outcomes of TLM for advanced laryngeal cancers.

Laser interstitial thermal therapy with and without MRI guidance for treatment of brain neoplasms – A systematic review of the literature

Background and objectives:

The use of laser interstitial thermal therapy (LITT) under magnetic resonance imaging (MRI) guidance has been reported on in the literature in close to 16,000 patients with various forms of malignant and benign neoplasms. This includes studies with over 7600 patients with malignant head and neck cancer; over 250 with malignant (and refractory to other therapies) head and neck cancer; over 6600 with liver cancer; and over 1100 with benign neoplasms. As well, LITT under MRI guidance has been studied in malignant (and refractory to other therapies) lung and breast cancers with close to 300 cases reported on in the literature. To date, the sum total experience of LITT with or without MRI guidance in treating brain neoplasms has not been reported on. It is the intention of this review to do so.

Methods:

A systematic review of the literature was undertaken to identify all studies where one or more patients were treated with LITT with or without MRI guidance (LITT±MRI) for brain neoplasms. The following sources were searched (from 1990 to present): PubMed, Cochrane Review of RCTs, Technology Assessment websites (NICE, CTAF, CADTH, BCBS TEC), clinical guidelines for treating malignant brain neoplasms (NCCN, AANS), relevant clinical journals where the use of LITT would be reported on; and the websites of companies involved in the manufacture and market of these types of products.

Results:

Twenty-three articles (22 peer-reviewed and one abstract) were identified. After duplicate studies (n=6) were removed, 17 studies with 169 patients were identified who received LITT±MRI (mean age, 54±13.3 years; ratio male/female, 66%/34%). Most patients were reported on in the literature as case series. One study however, examined use of LITT + brachytherapy in a randomized fashion. These 169 patients were further broken out by type of tumor(s) and outcomes evaluated. Ninety-nine patients were treated for glioblastoma, recurrent malignant gliomas and, recurrent glioblastomas using LITT as a follow-on/salvage therapy (average age, 58.9 years). LITT used as the sole or as adjunctive therapy appeared to prolong survival (when evaluated against historical cohorts of patients with similar baseline characteristics) versus best/palliative care in this group. This was especially true where LITT was used in brain malignancies refractory to other therapies. Twenty-four patients (average age, 40.9 years) were treated for astrocytomas (WHO I–III) and LITT was used mainly with

Conclusions:

The largest cohort of patients with recurrent glioblastoma/malignant glioma demonstrated longer survival times with stable to improved KI after LITT. These results compare favorably to second craniotomy procedures for malignant gliomas. Secondly, LITT appears to provide reasonable outcomes in patients where a second craniotomy may not be indicated (deep/inaccessible tumors or tumors in/near areas of eloquence). More published studies are required, most especially in patients with metastatic disease and in less aggressive type cancers based on the small numbers of patients studied in these groups.

Role of endolaryngeal surgery (with or without laser) versus radiotherapy in the management of early (T1) glottic cancer: a systematic review

BACKGROUND

Treatment options for early glottic cancer include transoral microsurgery or radiotherapy (RT). There is continuing debate about which is the superior treatment.

METHODS

The literature was searched from 1996 to 2011 using MEDLINE, EMBASE, and Cochrane Library. A quality assessment of each included study was conducted and reported.

RESULTS

There is no evidence in favor of 1 treatment modality when considering likelihood of local control or overall survival. There is a suggestion that RT may be associated with less measureable perturbation of voice as compared to surgery, but no significant differences were seen in patient perception. The likelihood of laryngeal preservation may be higher when surgery can be offered as initial treatment.

CONCLUSION

For patients with early (T1) glottic cancer, treatment options include the equally effective endolaryngeal surgery, with or without laser, or radiation therapy. The choice between treatment modalities should be based on patient and clinician preferences and general medical condition.

Laryngeal cancer management in a small, rural, multidisciplinary team setting: 15-year review

Background:

The Cumberland Infirmary, Carlisle, serves a largely remote, rural population of 330 000. The aim of this study was to report the treatment and survival figures for patients treated for laryngeal cancer at this centre.

Methods:

The study included 209 consecutive patients with squamous cell carcinoma of the larynx diagnosed between 1996 and 2010 at the Cumberland Infirmary.

Results:

Disease-specific survival was 100 per cent for stage one, 76 per cent for stage two, 87 per cent for stage three and 46 per cent for stage four. In total, 76 patients (36 per cent) had a laryngectomy, either as primary treatment or as a salvage procedure.

Conclusion:

Our tumour-specific survival rate was very high, and this success may be due in part to high rates of surgical intervention. Survival data compared favourably with other centres, despite less radical radiotherapy regimes. Laryngeal cancer can be managed effectively in a small, relatively remote, multidisciplinary team setting.

Survival outcome depending on different treatment strategies in advanced stages III and IV laryngeal cancers: an audit of data from two European centres

In light of continued uncertainty regarding efficacy of treatment of Stages III and IV laryngeal tumours, this study aims to evaluate organ-preservation strategies, comprising radiotherapy and chemoradiotherapy versus surgical treatment (laryngectomy ± adjuvant treatment) by encompassing the long-established practice at two internationally acclaimed tertiary centres not previously presented in published literature. Retrospective review was conducted of non-randomised prospectively maintained Stages III and IV disease patient databases at two tertiary centres: Sahlgrenska University Hospital (SU) in Gothenburg, Sweden, and Aberdeen Royal Infirmary (ARI) in Aberdeen, Scotland. Primary outcome measures included 3-year overall, disease-specific survival and local control depending on treatment. A total of 176 patients were identified. Sixty-five patients (37 %) presented with Stage III tumours, of which 51 patients received organ-preserving treatment and 14 underwent total laryngectomy. The corresponding figures for the 111 patients (63 %) presenting with Stage IV disease were 42 and 69. Three-year overall and disease-specific survival for Stage III was 58 and 73 %, respectively. The corresponding figures for Stage IV disease were 42 and 53 %. The choice of treatment did not appear to significantly influence survival for Stage III (p = 0.56) or IV (p = 0.93) disease. The choice of treatment, whether organ preservation or surgery, does not seem to significantly influence the overall or disease-specific survival. Therefore, other factors such as quality of life and voice and efficacy of salvage treatments are perhaps more likely to indicate the preferred treatment options, but larger randomised trials are needed.

Transoral laser surgery versus radiotherapy for tumour stage 1a or 1b glottic squamous cell carcinoma: systematic review of local control outcomes

Background:

Previous literature reviews comparing transoral laser surgery versus radiotherapy for glottic carcinoma treatment have analysed ‘early stage’ disease as one group. The current review aimed to assess local control outcomes, comparing these two treatment modalities, specifically for either tumour stage 1a or stage 1b lesions.

Methods:

The three authors conducted independent, structured literature searches. Simple weighted means were calculated.

Results:

Thirty-six publications were analysed. Three-year local control rates for tumour stage 1a tumours were 88.9 per cent for transoral laser surgery (n = 1308) and 89.3 per cent for radiotherapy (n = 2405). For tumour stage 1b tumours, the local control rates were 76.8 per cent for transoral laser surgery (n = 194) and 86.2 per cent for radiotherapy (n = 492).

Conclusion:

From this analysis of level four evidence, there was no demonstrable difference in local control rates for tumour stage 1a glottic squamous cell carcinoma treated by transoral laser surgery or radiotherapy. There was a trend towards improved local control of tumour stage 1b tumours treated with radiotherapy, but this finding was based on a limited number of published outcomes (n = 194).

The recruitment of patients to trials in head and neck cancer: a qualitative study of the EaStER trial of treatments for early laryngeal cancer

We aimed to investigate the factors contributing to poor recruitment to the EaStER trial "Early Stage glottic cancer: Endoscopic excision or Radiotherapy" feasibility study. We performed a prospective qualitative assessment of the EaStER trial at three centres to investigate barriers to recruitment and implement changes. Methods used included semi-structured interviews, focus groups and audio-recordings of recruitment encounters. First, surgeons and recruiters did not all accept the primary outcome as the rationale for the trial. Surgeons did not always adhere to the trial eligibility criteria leading to variations between centres in the numbers of "eligible" patients. Second, as both treatments were considered equally successful, recruiters and patients focused on the pragmatics of the different trial arms, favouring surgery over radiotherapy. The lack of equipoise was reflected in the way recruiters presented trial information. Third, patient views, beliefs and preferences were not fully elicited or addressed by recruiters. Fourth, in some centres, logistical issues made trial participation difficult. This qualitative research identified several major issues that explained recruitment difficulties. While there was insufficient time to address these in the EaStER trial, several factors would need to be addressed to launch further RCTs in head and neck cancer. These include the need for clear ongoing agreement among recruiting clinicians regarding details in the study protocol; an understanding of the logistical issues hindering recruitment at individual centres; and training recruiters to enable them to explain the need for randomisation and the rationale for the RCT to patients.

Preservation of organ function in head and neck cancer

Preservation of function is a crucial aspect for the evaluation of therapies applied in the field of head and neck cancer. However, preservation of anatomic structures cannot automatically be equated with preservation of function. Functional outcome becomes increasingly important particularly for the evaluation of alternative treatment options with equivalent oncological outcomes.AS A RESULT, PRESENT STUDIES TAKE INTO ACCOUNT THREE TOPIC AREAS WITH VARYING EMPHASIS: (1) the effects of cancer therapy on essential physiological functions, (2) additional therapy-induced side-effects and complications, and (3) health-related quality of life. The present article summarizes vital aspects of clinical research from recent years. Functional outcomes after surgical and non-surgical treatment approaches are presented according to tumor localization and staging criteria. Additional methodological aspects relating to data gathering and documentation as well as challenges in implementing the results in clinical practice are also discussed.

Factors leading to the use of alternate treatment modalities following transoral laser excision of T1 and T2 glottic squamous cell carcinoma

BACKGROUND

CO(2) transoral laser surgery and radiotherapy are both recognized as acceptable treatments for early glottic squamous cell carcinoma (SCC) with similar rates of cure. The reasons why some of the patients in our series undergoing laser resection as their primary modality of treatment subsequently underwent radiotherapy or chemoradiotherapy will be discussed.

METHODS

Retrospective study between January 2003 and August 2010 of all T1 and T2 glottic SCCs treated with laser resection at a major tertiary centre. Tis lesions were excluded. A review of the cases in which primary control with laser resection was not achieved was undertaken. Failure was defined as patients treated initially with laser resection who subsequently received radiotherapy, combined chemoradiotherapy or open surgery for the same tumour. Factors leading to failure were analysed, including tumour location, histology, stage and patient factors.

RESULTS

Thirty-one patients were identified, with the majority (27) having T1 disease. Mean number of laser excisions per patient was 1.7. Local control rate was 71% with laser alone. One patient had nodal recurrence with no primary recurrence. Mean follow-up was 32 months. Of the nine patients in whom local control was not achieved with laser alone, all had tumour at or crossing the anterior commissure. Four patients were deemed potentially curable with further excision but chose radiotherapy. Two patients were deemed appropriate for radiotherapy and chemoradiotherapy. Three patients had loco-regional recurrence and underwent laryngectomy. All had anterior commissure involvement.

CONCLUSION

Transoral laser excision is a safe, function-preserving treatment of early glottic SCC. Anterior commissure involvement was the major factor for potential failure with laser resection in T1 and T2 glottic tumours.

Definitive radiation therapy for early glottic cancer: experience of two fractionation schedules

OBJECTIVES

The authors would report the results of definitive radiation therapy (RT) for early glottic cancer by two different radiation dose schedules.

METHODS

From February of 1995 till June of 2008, 157 patients with T1-2N0 glottic cancer were treated with curative RT at Samsung Medical Center. All patients had squamous cell carcinoma, and there were 89 patients (56.7%) with T1a, 36 (22.9%) with T1b, and 32 (20.4%) with T2. Two different radiation dose schedules were used: 70 Gy in 35 fractions to 64 patients (40.8%, group A); and 67.5 Gy in 30 fractions to 93 patients (59.2%, group B). The median treatment durations were 50 days (range, 44 to 59 days) and 44 days (range, 40 to 67 days) in the groups A and B, respectively.

RESULTS

The median follow-up durations were 85 and 45 months for the groups A and B. No severe late complication of RTOG grade 3 or higher was observed, and there was no difference in acute or chronic complication between the groups. Twenty-four patients experienced treatment failure: local recurrence only in 19 patients; regional recurrence only in one; combined local and regional recurrence in four; and systemic metastasis in none. The overall 5-year disease-free survival and disease-specific survival rates were 84.7% and 94.8%. The disease-free survival rate in the group B was better (78.3% vs. 90.8%, P=0.031). This difference was significant only in T1 stage (83.4% vs. 94.6%, P=0.025), but not in T2 (62.7% vs. 60.6%, P=0.965). Univariate analysis showed that the tumor extent, cord mobility, T-stage, and the dose schedule had significant influence on the disease-free survival, and multivariate analysis showed that only the tumor extent and the dose schedule were associated with the disease-free survival.

CONCLUSION

Superior disease-free survival could be achieved by 2.25 Gy per fraction without increased toxicity over shorter RT duration, when compared with 2.0 Gy per fraction.

Definitive radiotherapy for early stage glottic cancer by 6 MV photons

Purpose

To evaluate the clinical outcome of early glottic cancer (GC) treated by primary radiotherapy (RT) with 6 MV photons.

Methods and materials

We retrospectively reviewed the medical records of 695 consecutive patients with T1N0 and T2N0 GC treated between 1983 and 2005 by RT in our institution. Clinical outcome in terms of local control (LC), overall survival (OS) and cause- specific survival (CSS) rate were evaluated.

Results

The median follow-up time was 10.5 years. The 10-year actuarial LC rates were as follows: T1A, 91%; T1B, 87%; T2, 77%. The 10-year OS were as follows: T1, 74.2%; T2, 70.7%. The 10-year CSS were as follows: T1, 97.7%; T2, 97.1%.

Poorly differentiated histology and tumor biologically effective dose < 65 Gy₁₅ were adverse factors in both LC of T1 and T2 disease. Involvement of anterior commissure was an adverse factor in both LC and CSS of T1 disease. Subglottic extension was associated with poor LC in T2 disease whereas hemoglobin <13.0 was associated with poor LC and CSS of T2 disease.

Conclusion

Primary RT remains an option among the various standard treatments for early GC. Clinical treatment outcome by 6MV photons is similar and comparable to historic data of Cobalt-60 and 2 MV photons.

Glottic laser surgery: outcomes according to 2007 ELS classification

The aim of the present investigation was to analyze the oncological results of a series of early stage glottic carcinomas treated with CO(2) laser-assisted endoscopic surgery. We focused on prognosis factors with significant impact on local control and disease-free survival (DFS). This retrospective study was conducted on a series of 177 consecutive patients with pT1-T2 glottic carcinomas treated with CO(2) laser-assisted endoscopic surgery in the period 2000-2007. All considered patients had at least a 24-month follow-up period (mean follow-up 49.1 ± 23.0 months). The overall survival and the disease-specific survival rates were respectively 90.8 and 98.8%. The rates of local control with primary laser surgery, ultimate local control with laser alone, and laryngeal preservation were 86.3, 94.3, and 97.7%, respectively. Arytenoids (p = 0.006) and limited subglottic involvements (p = 0.0002) have a significant impact on DFS. Endoscopic laser surgery is the gold standard in the treatment of early glottic carcinoma because of high local control rates with laser alone, day surgery modality, very low morbility, good post-operative voice quality in most of the cases, and low costs.

Transoral laser microsurgery outcomes with early glottic cancer: the Dalhousie University experience

Objective:

To report the results of transoral laser microsurgery for the treatment of early glottic cancer at our institution.

Design:

Cohort study. Retrospective review of charts of patients diagnosed with tumour stage 1 or 2 (early stage; no nodes or metastases), previously untreated, primary glottic cancer, treated with transoral laser microsurgery at the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada. The minimum follow-up period was two years.

Setting:

Tertiary care head and neck cancer centre.

Participants:

Fifty-three patients treated between January 2002 and November 2007.

Outcome measure:

Kaplan–Meier survival analysis for disease-free survival, overall survival and laryngectomy-free survival, at five years.

Results:

The group comprised 46 men and seven women, with a mean age of 66 years (range 30–84 years). Mean follow up was 40 months (range 12–89 months). There were four cases of complications (7.5 per cent). Kaplan–Meier survival analysis revealed a five-year disease-free survival (including salvage) of 96.2 per cent, a five-year overall survival (all causes) of 88.8 per cent and a five-year laryngectomy-free survival of 98.1 per cent.

Conclusion:

Transoral laser microsurgery is a safe and effective initial treatment for early laryngeal cancer, and has high rates of laryngeal preservation and disease-free survival.

Early outcomes after transoral CO2 laser resection of laryngeal and hypopharyngeal squamous cell carcinoma: one centre's experience

Objectives:

To review early oncological outcomes following transoral CO2 laser resection of laryngeal and hypopharyngeal squamous cell carcinoma.

Design:

Retrospective review of hospital electronic database.

Setting:

Large district general hospital in England, UK.

Main outcome measures:

Patients' three-year disease-specific survival and disease-free survival were evaluated, including post-operative complications, voice quality and swallowing status.

Results:

Seventy-seven patients (16 women and 61 men) were identified. Transoral laser excision of squamous cell carcinoma of the larynx was undergone by 65 patients, and the same procedure in the hypopharynx by 12. Patients with laryngeal cancer had statistically better disease-specific survival than those with hypopharyngeal cancer (p = 0.021), although the cumulative disease-free survival probability was 0.71 for both larynx and hypopharynx groups. Patients who underwent laryngectomy following failed laser treatment or as a salvage procedure had poorer outcomes.

Conclusions:

The overall results of this study were comparable with those of other, larger studies. At three-year follow up, cumulative disease-specific survival probabilities were 0.92 and 0.71 for laryngeal and hypopharyngeal squamous cell carcinoma, respectively.

Head and neck cancer

Most head and neck cancers are squamous cell carcinomas that develop in the upper aerodigestive epithelium after exposure to carcinogens such as tobacco and alcohol. Human papillomavirus has also been strongly implicated as a causative agent in a subset of these cancers. The complex anatomy and vital physiological role of the tumour-involved structures dictate that the goals of treatment are not only to improve survival outcomes but also to preserve organ function. Major improvements have been accomplished in surgical techniques and radiotherapy delivery. Moreover, systemic therapy including chemotherapy and molecularly targeted agents--namely, the epidermal growth factor receptor inhibitors--has been successfully integrated into potentially curative treatment of locally advanced squamous-cell carcinoma of the head and neck. In deciding which treatment strategy would be suitable for an individual patient, important considerations include expected functional outcomes, ability to tolerate treatment, and comorbid illnesses. The collaboration of many specialties is the key for optimum assessment and decision making. We review the epidemiology, molecular pathogenesis, diagnosis and staging, and the latest multimodal management of squamous cell carcinoma of the head and neck.

Bcl-2 expression predicts radiotherapy failure in laryngeal cancer

Early stage laryngeal cancer can be effectively cured by radiotherapy or conservative laryngeal surgery. In the UK, radiotherapy is the preferred first line treatment. However, up to 25% of patients with T2 tumours will demonstrate locally persistent or recurrent disease at the original site, requiring salvage surgery to achieve a definitive cure. Patients experiencing treatment failure have a relatively poor prognosis. A retrospective analysis was conducted consisting of 124 patients with early stage (T1–T2, N0) laryngeal squamous cell carcinoma. In total, 62 patients who failed radiotherapy were matched for T stage, laryngeal subsite and smoking history to a group of 62 patients successfully cured by radiotherapy. Using immunohistochemistry the groups were compared for expression of apoptotic proteins: bcl-2, bcl-X_L, bax, bak and survivin. Radioresistant laryngeal cancer was associated with bcl-2 (P<0.001) and bcl-X_L (P=0.005) expression and loss of bax expression (P=0.012) in pretreatment biopsies. Bcl-2 has an accuracy of 71% in predicting radiotherapy outcome. The association between expression of bcl-2, bcl-X_L and bax with radioresistant cancer suggests a potential mechanism by which cancer cells avoid the destructive effects of radiotherapy. Predicting radioresistance, using bcl-2, would allow the clinician to recommend conservative laryngeal surgery as an alternative first line treatment to radiotherapy.