Functional outcomes of transoral laser surgery of supraglottic carcinoma compared with a transcervical approach

Swallowing Outcomes in Open Partial Horizontal Laryngectomy Type I and Endoscopic Supraglottic Laryngectomy: A Comparative Study

Background: Effective swallowing represents the main challenge in supraglottic laryngectomy. This study aimed to assess swallowing outcome comparing endoscopic supraglottic laryngectomy (ESL) and open partial horizontal laryngectomy type I (OPHL I). Methods: A retrospective study was carried out on 20 patients that underwent supraglottic laryngectomy from 2015 to 2021: 10 underwent ESL (group A) and 10 underwent OPHL I (Group B). Patients underwent fiberoptic endoscopic evaluation of swallowing (FEES) 3 months and 12 months after surgery and videofluoroscopy swallowing studies (VFSS) 12 months after surgery. A Swallowing Outcome After Laryngectomy (SOAL) questionnaire was administered to patients to assess their life quality. Results: A naso-gastric tube was placed in two patients of Group A and in all patients of Group B. Tracheostomy was performed in two patients of Group A and in all patients in Group B and it has been closed in 100% of them. According to Donzelli’s scale, FEES and VFSS showed better results in Group A at 3 months, while at 12 months they did not show statistically significant differences between ESL and OPHL I in terms of laryngeal penetration and aspiration. The SOAL questionnaire showed satisfactory life quality. Conclusion: Swallowing evaluation by FEES and VFSS did not demonstrate statistically significant differences at 12 months post-op between two surgeries, although ESL showed less cases of laryngeal penetration and aspiration at 3 months post-op. Anyway, good results of any surgery depend on careful patient selection and the surgeon’s experience.

Intensity-Modulated Radiotherapy (IMRT) following Conservative Surgery of the Supraglottic Region: Impact on Functional Outcomes

Simple Summary

The present study has been suggested by the previous experience of our group showing that patients treated with conventional radiotherapy (named 3D conformal radiotherapy—3D-CRT) performed after conservative surgery (CS) for tumors of the supraglottic regions experienced a high rate of severe long-term toxicity. Therefore, we reported the toxicity profile of a similar cohort of patients treated with a high-precision radiotherapy technique (named intensity-modulated radiotherapy—IMRT). Moreover, to investigate the advantage of IMRT, we performed a comparison with a historical cohort treated with 3D-CRT. Results showed that patients treated with IMRT achieved a very low toxicity profile and comparison with 3D-CRT was in favor of IMRTs. Therefore, we believe that the results of the present study provide preliminary findings on the potential of IMRT in improving the toxicity profile of patients treated with surgical organ preservation strategies for laryngeal tumors.

Abstract

The aim of the present study was to investigate the role of intensity-modulated radiotherapy (IMRT) on the toxicity profile of patients treated with conservative surgery (CS) of the supraglottic (SG) region. Data on patients treated with CS and postoperative radiotherapy (PORT)-IMRT were prospectively collected. Results. In total, 20 patients were analyzed. Of these, six patients (35%) required the positioning of a temporary tracheostomy. The functional larynx preservation rate was 95%. Females had a higher risk of both endoscopic intervention and chondronecrosis, while the median age was significantly higher in patients requiring enteral nutrition. The incidence of long-term severe toxicities was lower in patients treated with IMRT than in the historical 3D-CRT cohort. Patients who had received PORT-IMRT achieved a lower rate of permanent laryngeal and swallowing dysfunctions. Overall, results from the comparison with the historical 3D-CRT cohort favor the IMRTs.

Meta-analytic comparison of robotic and transoral laser surgical procedures in supraglottic carcinoma

Objective

To assess published reports of oncological surgical success rates in patients who underwent transoral laser supraglottic surgery and robotic surgery for supraglottic cancer.

Methods

A systematic review of the literature was conducted and a meta-analysis of published data was performed. PubMed, Sage, Medline and Cochrane data sources were investigated. Overall survival rates, disease-specific survival rates, additional treatments and recurrence rates were investigated to determine the success of the surgical procedures.

Results

The meta-analysis included 24 studies; 1617 studies were excluded. There were no statistically significant differences between the transoral laser supraglottic surgery and transoral robotic supraglottic surgery groups in terms of overall survival (77.0 per cent and 82.4 per cent respectively) and disease-specific survival (75.8 per cent and 87.0 per cent respectively). There was recurrence in 164 out of 832 patients (19.7 per cent) in the transoral laser supraglottic surgery group and in only 6 out of 66 patients (9 per cent) in the transoral robotic supraglottic surgery group.

Conclusion

Transoral laser surgery and robotic surgery appear to have comparable and acceptable oncological success rates.

Functional outcomes in early (T1/T2) supraglottic cancer: a systematic review

OBJECTIVES

Organ preserving surgery (OPS) and radiotherapy (RT) are both accepted treatment options for early stage supraglottic cancer (SGC). Radiation has supplanted surgery in most cases, because of the perception that surgery results in poorer functional outcomes. However, evidence suggests that OPS with a neck dissection may be associated with improved survival. Our objective was to conduct a systematic review of the literature to compare functional outcomes of OPS and RT for early SGC.

METHODS

We searched Medline, EMBASE and Cochrane Central Register of Controlled Trials to identify studies. Studies were included if they reported functional outcomes on 10 or more patients with early stage SGC treated with radiation or OPS, including open partial laryngectomy, transoral laser microsurgery (TLM) or transoral robotic surgery (TORS). Two reviewers independently screened articles for relevance using pre-determined criteria.

RESULTS

From 7720 references, we included 10 articles (n = 640 patients). 50% (n = 320) of patients were treated with surgery. Three head-to-head RT versus OPS papers were included, however different outcome measures were used for each group. Intractable aspiration management (including total laryngectomy or permanent tracheostomy) following OPS was reported in five papers representing 186 patients; the definitive intractable aspiration management rate was 2.6% (95% CI 1.0-6.8%). Four papers reported permanent G-tube rate for the surgical group (n = 198), calculating a rate of 5.3% (95% CI 2.6-10.5%), this was not reported for the RT group in any papers. One study reported quality of life. Two studies reported objective voice measures.

CONCLUSIONS

This systematic review revealed a paucity of objective measures and significant data heterogeneity, rendering the comparison of functional outcomes following OPS versus RT for early SGC limited. Future research should include objective measures of functional outcomes including laryngectomy rate, g-tube rate, tracheostomy dependence, quality of life, and voice quality measures.

CO2 Transoral Microsurgery for Supraglottic Squamous Cell Carcinoma

The present study analyzed the results of the endoscopic approach to T1, T2 and selected T3 supraglottic carcinoma with the aim of reviewing functional and oncologic outcomes after different types of endoscopic supraglottic laryngectomies. This is a retrospective clinical study of 42 consecutive patients (mean age of 61.8 years, 33 males, 9 females) treated by the senior author for supraglottic squamous cell carcinoma with a transoral CO₂ laser approach and reviewed from November 2010 to September 2017. Surgical procedures were classified according to the European Laryngological Society. In addition to the standardized transoral supraglottic laryngectomies, we introduced a modified type IVb by sparing the inferior third of the arytenoid if not directly involved in the tumor. Swallowing was evaluated with the Swallowing Performance Status Scale reported by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. Survival probabilities were estimated using Kaplan-Meier curves. Two type I, 2 type IIa, 2 type IIb, 3 type IIIa, 12 type IIIb, 13 type IVa, 3 type modified IVb, and 5 type IVb supraglottic laryngectomies were performed. Twenty-one patients (50%) underwent primary neck dissection. The pathologic TNM classification according to the 8th edition of the American Joint Committee on Cancer system was as follows: 9 pT1cN0, 2 pT1N0, 1 pT1N1, 7 pT2cN0, 1 rypT2cN0, 9 pT2N0, 4 pT2N1, 2 ypT2N1, 2 pT3cN0, 2 rypT3cN0, 1 pT3N1, and 2 pT3N2b. Mean follow-up was 3.4 years (range of 9 months to 6 years). According to the Kaplan-Meier analysis, 5-year disease-specific survival, local-relapse-free survival, nodal-relapse-free survival, overall laryngeal preservation and overall survival of patients without previous head and neck radiotherapy/open surgery were 100%, 95.2%, 87.8%, 100%, and 64.6%, respectively. Patients who underwent type I, IIa, and IIb resections (n = 6) started oral feeding the day after surgery, patients who underwent type III-IVb modified resections (n = 31) started oral feeding 3-4 days after surgery, and patients who underwent standard type 4b resections (n = 5) started oral feeding 7 days after surgery. Three months after surgery, patients without a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed significantly better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing in 8 and 66.7% of cases, respectively (p = 0.006072); patients with a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed not statistically significant better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing at 3 months in 16.7% and 50% of cases, respectively (p = 0.23568). Transoral CO₂ laser supraglottic laryngectomy is an oncologic sound alternative to traditional open neck surgery and chemo-radiotherapy. Recovery of swallowing is significantly worsened after total resection of the arytenoid. Modified type IVb procedure leaving intact, when possible, the inferior third of the arytenoid and consequently the glottic competence, improves functional outcome.

Oncological Outcomes Following Transoral CO2 Laser Microsurgery for T1 Glottic Cancer

The objective of this study is to analyze oncological outcomes for treatment of Tis and T1 glottic squamous cell carcinoma after transoral laser microsurgery. This study is retrospective analysis of previously untreated, suspected lesion of glottis, staged cT1a and cT1b squamous cell carcinoma in a tertiary care hospital and 53 patients were included in the study. End points for analysis were local control, overall and disease specific survival rates. The local control, ultimate local control with laser alone, 3-year overall survival, 3-year disease specific survival and organ preservation rates were 86.7, 90.5, 92.4, 98.1 and 98.1% respectively. The involvement of anterior commissure did not show any significant impact on local control or survival. TLM is safe and effective treatment of early glottis cancer, associated with less morbidity and a high percentage of local control, survival and organ preservation rates.

Functional outcomes of supraglottic squamous cell carcinoma treated by transoral laser microsurgery compared with horizontal supraglottic laryngectomy in patients younger and older than 65 years

The treatment of supraglottic carcinoma remains a controversial issue. Five accepted surgical and non-surgical oncological treatments have been currently established: standard horizontal supraglottic laryngectomy (HSL), supraglottic CO2 laser microsurgery (TLM), transoral robotic surgery, radiotherapy alone and radiotherapy in combination with chemotherapy. Some studies have shown that complications of head and neck surgeries increase significantly in patients over 65 years compared to younger patients. We designed a retrospective analysis to assess the rate of complications and functional outcomes of patients treated by TLM and HSL in cases of T1-T3 supraglottic squamous cell carcinomas (SCC) in a tertiary University Hospital. Results were compared between patients younger and older than 65 years. We found significant differences in the rate of aspiration pneumonia (p = 0.026), mean time to decannulation (p = 0.001) and mean hospital stay (p = 0.007) in patients treated by TLM, which was higher and longer in the group of patients over 65 years of age. Regarding HPL, we only found significant differences in the mean time to decannulation (p = 0.001), which was longer in the group of patients younger than 65 years. According to our results, TLM or HPL can both be a safe surgical option for patients older than 65 years, but previous evaluation of lung function before surgery is mandatory because of an increased risk of aspiration pneumonia in patients with lung problems, especially when treated by TLM. Concerning functional outcomes in patients older than 65 years, TLM reduces the postoperative rate of tracheostomy, mean time required for decannulation and mean hospital stay compared with HPL. However, no significant difference in the occurrence of aspiration pneumonia, dysphagia or in the mean length of NGT feeding was found.

Treatment of early stage Supraglottic squamous cell carcinoma: meta-analysis comparing primary surgery versus primary radiotherapy

Objectives

For early stage supraglottic squamous cell carcinoma (SCC), single modality treatment either in the form of primary organ preservation surgery alone or radiation alone is recommended. Thus, a definite treatment strategy for early stage supraglottic SCC remains undefined. The primary objective of this study was to conduct a systematic review and meta-analysis comparing the oncologic outcomes of surgery and radiotherapy in early stage (Stage I and II) T1 N0 and T2 N0 supraglottic SCC.

Methods

Systematic methods were used to identify published and unpublished data. Two reviewers independently screened all titles, abstracts and articles for relevance using predefined criteria. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Five studies met the inclusion criteria for disease specific mortality with a total of 2864 pooled patients. 5-year disease specific mortality was lower in the surgery group (ORs 0.43, 95% CI 0.31–0.60). Four studies met the inclusion criteria for 5-year overall mortality with a total of 2790 pooled patients. Five-year overall mortality was lower in surgery group (ORs 0.40, 95% CI 0.29–0.55).

Conclusions

This is the first study to examine the management of early stage supraglottic SCC using meta-analytic methodology. Our results suggest that primary surgery may result in decreased disease specific and overall mortality compared to primary radiotherapy.

Oncological and complication assessment of CO2 laser-assisted endoscopic surgery for T1-T2 glottic tumours: clinical experience

Several therapeutic options are used for treatment of early stage glottic carcinoma (Tis/T1/T2): open partial laryngectomy (OPL), radiotherapy and CO2 laser-assisted endoscopic surgery. Laser surgery has gradually gained approval in the management of laryngeal cancer. We present our experience in endoscopic laser surgery for early stage glottic carcinomas. This was a retrospective analysis of 72 patients with T1-T2 glottic cancer treated with laser cordectomy between 2006 and 2012. All patients had at least a 36-month follow-up period. Percentages for disease-specific survival, disease-free survival (DFS) and laryngeal preservation rates were 98.6%, 84.7% and 97.2% respectively. Considering neoplastic features that could predict long-term oncological outcome, tumoural involvement of anterior commissure and pathological staging (pT) significantly correlate with local recurrence (p = 0.021 and p = 0.035) and with a lowered DFS (p = 0.017 and p = 0.023). Other variables such as clinical staging, type of cordectomy, involvement of other structures and surgical margin status showed no significant impact on oncological endpoints. CO2 laser surgery is a reliable technique for T1-T2 glottic cancer considering oncological outcomes. The recurrence rate seems to be affected by involvement of anterior commissure and pT stage.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Prognostic role of margin status in open and CO2 laser cordectomy for T1a-T1b glottic cancer

INTRODUCTION

Cordectomy by laringofissure and transoral laser surgery has been proposed for the treatment of early glottic cancer.

OBJECTIVES

The aim of this retrospective study was to evaluate the prognostic value of margin status in 162 consecutive cases of early glottic carcinoma (Tis-T1) treated with CO2 laser endoscopic surgery (Group A) or laryngofissure cordectomy (Group B), and to compare the oncologic and functional results.

METHODS

Clinical prognostic factors, local recurrence rate according to margin status, overall survival and disease-free survival were analyzed.

RESULTS

Margin status is related to recurrence rate in both groups (p<0.05) without significant differences between open and laser cordectomy (p>0.05). The 5 years overall survival and disease-free survival were respectively 90.48% and 85.71% in Group A; 88.14% and 86.44% in Group B (p>0.05). Lower tracheostomy rate, earlier recovery of swallowing function and shorter hospital stay were observed in Group A (p<0.05).

CONCLUSIONS

Margin status has a prognostic role in T1a-T1b glottic cancer. Transoral laser surgery showed similar oncologic results of open cordectomy, with better functional outcomes.

Comparison of Functional Outcomes after Endoscopic versus Open-Neck Supraglottic Laryngectomies

Objectives:

Endoscopic supraglottic laryngectomy (ESL) by carbon dioxide laser for selected T1-T3 supraglottic squamous cell carcinomas is a sound procedure with oncological results comparable to those obtained by open-neck supraglottic laryngectomy (ONSL). The aim of this study was to retrospectively evaluate functional outcomes after ESL in comparison with ONSL.

Methods:

We performed perceptual voice evaluation by GRBAS (grade, roughness, breathiness, asthenicity, strain), subjective analysis by Voice Handicap Index, objective analysis with the Multidimensional Voice Program, swallowing evaluation with the M. D. Anderson Dysphagia Inventory, video nasal endoscopic examination of swallowing, videofluoroscopy, and analysis of hospitalization time, need for and duration of feeding tube and tracheotomy, and complication and aspiration pneumonia rates in a group of 14 patients treated with ESL. These results were compared to those obtained in a historical group of 14 patients matched for T category who were treated with ONSL at the same institution. Statistical analysis was performed with the Mann-Whitney U and Pearson χ2 tests.

Results:

Comparison of comprehensive voice analysis, M. D. Anderson Dysphagia Inventory, and complication and aspiration rates showed no statistically significant differences between the Two groups. However, significant differences were found for video nasal endoscopic examination of swallowing (p = .03), videofluoroscopy (p = .03), hospitalization (p = .0001), feeding tube duration (p = .0001), and tracheotomy duration (p = .0001).

Conclusions:

Endoscopic supraglottic laryngectomy had a significantly lower functional impact on swallowing than ONSL, even though it was not subjectively perceived by patients, and was associated with less morbidity and a shorter hospitalization time.

Endoscopic submucosal dissection as minimally invasive treatment for superficial pharyngeal cancer: a phase II study (with video)

BACKGROUND AND AIMS

Although endoscopic submucosal dissection (ESD) has been applied for superficial pharyngeal cancer, no prospective trials have been reported. To investigate the efficacy and safety of ESD for superficial pharyngeal cancer, we conducted a prospective phase II trial.

METHODS

Fifty-four patients with 73 lesions were enrolled from September 2010 to August 2014, and ESD was performed. The primary endpoint was the complete resection rate. Secondary endpoints were safety, recurrence-free survival, overall survival, and incidence of metachronous pharyngeal cancer.

RESULTS

Fifty-four patients had stage 0-III cancer: stage 0, n = 22; stage I, n = 14; stage II, n = 17; and stage III, n = 1. The en bloc resection rate was 100%, and the complete resection rate was 79.5% (58/73 lesions; 95% confidence interval, 68%-88%). No serious adverse events related to ESD were encountered. Four patients required nasogastric intubation and feeding. No patients required percutaneous endoscopic gastrostomy and tracheotomy. Swallowing, speech, and airway functions were preserved in all patients. One of the 54 patients died of an unrelated illness. Median follow-up was 27 months (range 6-55 months). Local cervical lymph node metastasis was observed in 1 patient, and the case was salvaged successfully with lymph node dissection. The 3-year overall and recurrence-free survival rates were 97.7% and 98.1%, respectively. Cumulative development of multiple cancers of the pharynx at 3 years was 18.4%.

CONCLUSIONS

ESD appears to be a safe and effective minimally invasive treatment in patients with superficial pharyngeal cancer. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000003623.).

Transoral Endoscopic Head and Neck Surgery: The Contemporary Treatment of Head and Neck Cancer

Traditional open surgical approaches are indicated for treatment of select tumor subsites of head and neck cancer, but can also result in major cosmetic and functional morbidity. Transoral surgical approaches have been used for head and neck cancer since the 1960s, with their application continuing to evolve with the changing landscape of this disease and recent innovations in surgical instrumentation. The potential to further reduce treatment morbidity with transoral surgery, while optimizing oncologic outcomes, continues to be investigated. This review examines current literature evaluating oncologic and quality-of-life outcomes achieved through transoral head and neck surgery.

Clinical outcomes with transoral robotic surgery for supraglottic squamous cell carcinoma: Experience of a French evaluation cooperative subgroup of GETTEC

BACKGROUND

Transoral, minimally invasive, organ preservation surgeries are increasingly used to treat laryngopharyngeal carcinomas to avoid the toxicity associated with combined chemoradiotherapy (CRT) regimens. This study investigated the efficiency, safety, and functional outcomes of using transoral robotic surgery (TORS) to perform supraglottic laryngectomy (SGL).

METHODS

This was a multicenter study using a case series with planned data collection from 2009 to 2012 for patients with supraglottic squamous cell carcinomas (SCCs) who underwent an SGL using TORS.

RESULTS

Eighty-four of the 262 patients underwent TORS for a supraglottic SCC. Within 24 hours of surgery, 24% of the patients began an oral diet. The median use of a feeding tube was 8 days for 76% of other patients. Definitive percutaneous gastrostomy feeding was necessary for 9.5% of the patients. Twenty-four percent of the patients did require a tracheostomy, and the median use was 8 days. One percent of the patients had a definitive tracheostomy. Aspiration pneumonia was observed in 23% of the patients during the postoperative course, and was responsible for the death of 1 patient. Postoperative bleeding occurred in 18% of the patients. Based on the pathology results, 51% of the patients received adjuvant radiation therapy.

CONCLUSION

TORS for SGL, in the intermediate stage of SCC, provides a safe procedure with good functional outcomes and fast recovery times; however, adverse events are possible. Consequently, this technique requires good selection criteria for the patients to reduce the risk of postoperative complications. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1097-E1101, 2016.

Transoral robotic surgery versus conventional surgery in treatment for squamous cell carcinoma of the upper aerodigestive tract

BACKGROUND

The purpose of our work was to compare a group of patients undergoing transoral robotic surgery (TORS group) for squamous cell carcinoma of the upper aerodigestive tract and a matched group of patients undergoing conventional surgery (conventional surgery group) for the same indication.

METHODS

In this retrospective single-center study, 26 patients were included in each group.

RESULTS

There were significantly fewer tracheotomies in the TORS group (p < .001). The mean durations of feeding by nasogastric tube and hospitalization were shorter for the TORS group (p = .001). There was no significant difference in disease-free survival at 3 years (p = .76). Mean treatment cost was $7124 lower for the TORS group (p = .03).

CONCLUSION

This comparative study shows that robotic technology can be used to treat selected squamous cell carcinomas of the upper aerodigestive tract, reducing morbidity and treatment costs while providing equivalent cancer control at 3 years.

Laser endoscopic microsurgery of laryngeal cancers

Introduction The aim of our study is to present our experience in treating laryngeal cancers with endoscopic CO₂ laser surgery.

Materials and Methods This retrospective study was conducted from January 2008 to December 2012 at Antoine Lacassagne Center of Nice. The functional and oncologic results of this surgical technique were analyzed and discussed.

Results The average length of hospital stay was 2.5 days. Phonatory results were considered excellent in 75% of our patients who maintained satisfactory phone communication skills after their interventions. Chronic hoarseness was the most common reason for bilateral or extended cordectomies. On the oncologic basis, histologic exam showed 90% of our margins were normal. The clinical control showed excellent laryngeal preservation in 94.23%. In 5 years, the overall survival was estimated at 96.15%.

Conclusion This study shows the benefit of the laser endoscopic microsurgery for the preservation of laryngeal functions and the local histologic control, essentially for early stage laryngeal cancers.

Salvage Transoral Laser Supraglottic Laryngectomy after Radiation Failure: A Report of Seven Cases

Objectives:

We evaluated the oncological and functional outcomes of salvage transoral laser supraglottic laryngectomy after radiation failure. In addition, we demonstrated the usefulness of laser surgery in patients with recurrent supraglottic cancer.

Methods:

Between December 1999 and May 2011, 7 patients (6 men and 1 woman) underwent transoral laser supraglottic laryngectomy after radiation failure. We conducted 4 different types of endoscopic supraglottic laryngectomy. In the cases with lymph node metastasis, we performed neck dissection at the time of laser surgery.

Results:

All patients had recurrent squamous cell carcinoma confirmed on the surgical specimen. Two patients were classified as having T1 disease, 2 as having T2 disease, and 3 as having T3 disease with preepiglottic space involvement. The 2- and 5-year overall survival rates were 85.7% and 68.6%, respectively. There was a recurrence at 8 months of follow-up after laser surgery in 1 patient; he underwent successful salvage total laryngectomy. The ultimate local control rate was 100%, and the laryngeal preservation rate was 85.7%. The hospitalization times ranged from 2 to 32 days (mean, 15.6 days). The mean decannulation time was 10.7 days (range, 5 to 30 days). All patients started oral feeding within 1 to 3 days after surgery.

Conclusions:

Salvage transoral laser supraglottic laryngectomy following radiation failure seems a feasible and oncologically safe procedure in recurrent supraglottic cancers ranging from T1 to selected T3 with minimal preepiglottic space involvement. It can be an option for minimally invasive organ preservation surgery with lesser morbidity for recurrent supraglottic cancer.

Results of transoral laser microsurgery for supraglottic carcinoma in 277 patients

The objective of the study was to evaluate the oncological and functional results of transoral laser microsurgery (TLM) in patients with supraglottic laryngeal squamous cell carcinoma. Between June 1980 and December 2006, 277 patients with squamous cell supraglottic carcinoma of all stages were treated by primary carbon dioxide laser microsurgery. All treatments were performed with curative intention. The goal was the complete tumor removal with preservation of functionally important structures of the larynx. The administered treatment was exclusively TLM with or without selective or modified radical neck dissection in 215 cases (78 %); TLM with postoperative radiotherapy was performed in 62 cases (22 %). Data were analyzed using the Kaplan–Meier method. The median follow-up was 65 months. We achieved a 5-year local control rate of 85 % for pT1/pT2, 82 % for pT3, and 76 % for pT4. The 5-year overall, recurrence-free and disease-specific survival rates for stages I and II were 76, 81, and 92 %, for stages III and IVa 59, 65, and 81 %, respectively. With respect to local control and survival, these results are comparable with the results achieved by conventional partial and total resection of the larynx, while being superior to primary (chemo)radiotherapy. Transoral laser microsurgery results in a low morbidity, rapid recovery, and superior function compared with standard therapy.

Traditional transcutaneous approaches in head and neck surgery

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.

Clinical outcomes of endoscopic mucosal resection and endoscopic submucosal dissection as a transoral treatment for superficial pharyngeal cancer

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been introduced for the treatment of superficial pharyngeal cancer.

METHODS

Sixty superficial pharyngeal cancers in 45 patients were treated by EMR or ESD. Resectability and curability, complications, and survival were analyzed retrospectively.

RESULTS

The en bloc resection and curative resection rate were higher with ESD (100; 81.6%) than with EMR (59; 50%). In subgroup analysis with regard to tumor size ≤ 10 mm, both resection rates were comparative. All the patients had preserved larynx and swallowing, speech, and airway function. Two of the 45 patients died of other diseases, local recurrence was observed in 4 of 18 patients with noncurative resection with a median observation period of 38 months. No recurrence was observed in patients with curative resection.

CONCLUSIONS

ESD or EMR for superficial pharyngeal cancer is minimally invasive treatment and lesions larger than 10 mm should be referred for ESD.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Laser surgery for early to moderately advanced glottic, supraglottic, and hypopharyngeal cancers

Current practice standards for the treatment of early to moderately advanced laryngeal and hypopharyngeal cancer demand both achievement of cure and preservation of laryngeal structure and function to the greatest extent possible. The oncologic and functional results of transoral laser microsurgery (TLM) for early glottic cancer appear to be comparable to those of radiotherapy, with a higher rate of laryngeal preservation and a lower cost. TLM for early and moderately advanced supraglottic and hypopharyngeal cancers offers similar results with regard to survival and local control to those obtained with open surgical approaches. In addition, functional results of TLM are superior to those of open approaches because tracheotomies are usually avoided, rehabilitation of swallowing is faster, and hospital stay is shorter. TLM, when applicable, has become the preferred modality for surgical treatment of most early to moderately advanced cancers of the larynx and selected tumors of the hypopharynx.

Transoral laser microsurgery for laryngeal cancer: a primer and review of laser dosimetry

Transoral laser microsurgery (TLM) is an emerging technique for the management of laryngeal and other head and neck malignancies. It is increasingly being used in place of traditional open surgery because of lower morbidity and improved organ preservation. Since the surgery is performed from the inside working outward as opposed to working from the outside in, there is less damage to the supporting structures that lie external to the tumor. Coupling the laser to a micromanipulator and a microscope allows precise tissue cutting and hemostasis; thereby improving visualization and precise ablation. The basic approach and principles of performing TLM, the devices currently in use, and the associated dosimetry parameters will be discussed. The benefits of using TLM over conventional surgery, common complications and the different settings used depending on the location of the tumor will also be discussed. Although the CO₂ laser is the most versatile and the best-suited laser for TLM applications, a variety of lasers and different parameters are used in the treatment of laryngeal cancer. Improved instrumentation has lead to an increased utilization of TLM by head and neck cancer surgeons and has resulted in improved outcomes. Laser energy levels and spot size are adjusted to vary the precision of cutting and amount of hemostasis obtained.

[The current role of partial surgery as a strategy for functional preservation in laryngeal carcinoma]

With the current advances and recent organ preservation protocols for intermediate or advanced stage laryngeal cancer, based on chemotherapy, the role of surgery seemed replaced except for surgical rescue of tumours not responding to these treatments, total laryngectomy being the surgical option. This type of non-surgical treatment is offered as a strategy for organ preservation, as opposed to total laryngectomy. However, we believe that there are two organ-preservation strategies, surgical and non-surgical. A wide spectrum of surgical techniques is available and such techniques lead to excellent results, both oncological and functional (speech and swallowing). The aim of this paper is to present options for organ-preserving surgery for laryngeal cancer. A review of surgical techniques available for functional preservation in cancer of the larynx at intermediate or advanced stage is presented. In addition to classic approaches such as vertical partial laryngectomy and horizontal or supraglottic laryngectomy, options for conservative laryngeal surgery have improved significantly over the past two decades. Minimally invasive surgery, transoral laser surgery, and supracricoid partial laryngectomy have become important laryngeal preservation approaches for patients with laryngeal cancer. Surgery must define its role in the multidisciplinary treatment of advanced cancers of the larynx, which at present often favours (chemo)radiotherapy protocols.

CO2 laser surgery of supraglottic carcinoma: our experience over 6 years

INTRODUCTION AND OBJECTIVES

The study goal was to analyze the oncologic and functional outcomes of transoral laser microsurgery in the treatment of carcinoma of the supraglottic larynx.

MATERIAL AND METHODS

A total of 53 patients were included in this retrospective review between 2000 and 2006. The follow-up period was more than 2 years and the mean follow-up for all patients was 49 months.

RESULTS

Tumour extension was as follows: T1 in 12 (22.6%), T2 in 37 (69.8%) and T3 in 4 (7.5%). Forty-seven patients (88.7%) had neck dissections. Nineteen patients (35.8%) received adjuvant radiotherapy. Kaplan-Meier estimates for disease-specific survival were 80%, 74.11% and 65%, at 2, 3 and 5 years, respectively. The overall functional laryngeal preservation rate was 90.56%. (48 of 53), and local control 81.13%. During follow up, 13.2% of patients developed local recurrence, 11.3% regional recurrence and 5.7% loco-regional recurrence. Patients started swallowing early after surgery, with a mean time of 5.83 days, and the mean hospital stay was 14.69 days. Complications included 20.75% who suffered pneumonia and 11.32% with bleeding. Only one patient (1.88%) received total laryngectomy due to the impossibility of swallowing.

CONCLUSIONS

With careful selection of patients, laser supraglottic laryngectomy is a safe and effective treatment for cancer of the supraglottic larynx.

Endoscopic horizontal partial laryngectomy by CO(2) laser in the management of supraglottic squamous cell carcinoma

BACKGROUND

The objective of this study was to evaluate the results of endoscopic horizontal supraglottic laryngectomy (EHSL) by CO(2) laser.

METHODS

Between 1996 and 2005, 78 patients underwent a horizontal supraglottic laryngectomy operation (HSL) with an external approach and 70 underwent laser EHSL, as treatment for supraglottic laryngeal squamous cell carcinoma (LSCC). We evaluated oncological endpoints, comparing the external and the endoscopic approach.

RESULTS

Among patients primarily treated by EHSL, the 5-year disease-specific survival (DSS) was 89% (vs 80% in the external approach group). Statistical analysis did not reveal significant differences between the 2 groups as for survival nor for organ preservation. The most significant clinical predictor for DSS is neck relapse (p < .0001).

CONCLUSIONS

This study confirms the effectiveness of laser EHSL in which oncological outcome is similar to the external approach and functional results are probably better. Neck management in this setting is fundamental to warrant the best survival.

Transoral laser surgery for laryngeal cancer: outcome, complications and prognostic factors in 275 patients

AIM

Curative treatment options for laryngeal carcinoma include primary radiation therapy, open surgical techniques and transoral laser surgery (TLS). In the last decade, TLS has become an important tool in the treatment of laryngeal cancer and has become the standard approach in many institutions. The aim of this study was to review the experience of a single center institution with TLS for early and advanced laryngeal cancer.

METHODS

We retrospectively analyzed 275 patients who underwent TLS in regard to the survival outcome and surgical complications.

RESULTS

The 5-year disease-free survival estimate was 90.3% and the 10-year disease-free survival estimate was 88.2%. The 5-year larynx preservation rate estimate was 88.2% and the 10-year larynx preservation rate estimate was 87.3%. The disease-free survival was significantly worsened by the variables T and N (p=0.0003; p<0.001, respectively). Two percent of all patients required intraoperative tracheostomy and the rate of minor postoperative complications was 17%. There were no fatal complications.

CONCLUSIONS

We conclude that TLS is a valid treatment method for early laryngeal carcinoma. Selected cases of advanced carcinomas may also benefit from TLS.