Results of 226 patients with T3 laryngeal carcinoma after treatment with transoral laser microsurgery

Survival Outcomes of Transoral Microsurgery in T3/T4a Laryngeal Tumors: Systematic Review and Meta-Analysis

OBJECTIVE

To critically evaluate oncological and functional outcomes following transoral laser microsurgery (TLM) in patients with T3/T4a glottic and supraglottic squamous cell carcinoma (SCC).

DATA SOURCES

A comprehensive search of five major databases-PubMed, Embase, Scopus, ScienceDirect, and Web of Science-was conducted using a combination of relevant keywords and MeSH terms.

REVIEW METHODS

Systematic review and meta-analysis of odds ratio (OR), hazards ratio (HR), and proportion, focusing on oncological and functional outcomes of TLM in advanced T3/T4a glottic and supraglottic tumors. A random-effects meta-analysis model was employed.

RESULTS

The review incorporated 29 cohort studies, representing a total of 1,897 patients undergoing TLM for T3/T4a glottic and supraglottic SCC. The cumulative 5-year disease-free survival (DFS) rate for T3 glottic and supraglottic tumors was 44.4% (95% CI: 47-66%) and 62.8% (95% CI: 63-81%), while the 5-year DFS for T4 glottic and supraglottic tumors was 41.1% (95% CI: 33.4-49.2%) and 32.9% (95% CI: 19.3-50.1%), respectively. T3 glottic tumors exhibited a 2.5-fold significantly higher odds of local recurrence post-TLM compared to their T3 supraglottic tumors (95% CI: 1.6-3.9, p < 0.0001). Laryngeal preservation rates for T3glottic and supraglottic tumors were 68.9% (95% CI: 48.7-83.8%) and 88.4% (95% CI: 79.4-93.8%), respectively. Both groups showed comparable rates of tracheostomy (p = 0.48) and gastrostomy performed (p = 0.17).

CONCLUSIONS

This meta-analysis suggests that TLM is a viable larynx preservation approach in select patients with T3/T4a glottic and supraglottic tumors. However, glottic tumors may have less favorable outcomes after TLM compared to those with advanced supraglottic tumors.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:15-26, 2025.

Survival, Surgical, and functional outcomes of transoral laser microsurgery for cT1-T3 supraglottic laryngeal Cancers: A systematic review

BACKGROUND

This review aimed to investigate the surgical, functional, and oncological outcomes of transoral laser microsurgery supraglottic laryngectomy (TOLM-SGL) for cT1-T3 laryngeal cancers.

METHODS

PubMed, Scopus, and Cochrane Library were searched by two independent investigators for studies investigating the surgical, functional, and oncological outcomes of TOLM-SGL using the PRISMA statements. A bias analysis was carried out with MINORS.

RESULTS

Twenty-four studies were included (937 patients), including 206 (25.9 %) cT1, 467 (58.7 %) cT2, and 123 (15.4 %) cT3 cases. Most patients were cN0 (63.9 %). The mean hospital stay of TOLM was 10.1 days. Aspiration (5.5 %), and bleeding (5.3 %) were the most prevalent complications. The laryngeal preservation rate was 93.7 %. Temporary tracheotomy was performed in 18.0 % of patients, with a mean time of decannulation of 6.8 days. A feeding tube was placed in 59.9 % of patients. The oral diet restarted after 6.4 days. Definitive gastrostomy was necessary in 2.4 % of cases. The 5-year OS and DFS were 70.1 % and 82.0 %, respectively. Distant metastasis, local, and regional recurrence occurred in 4.6 %, 11.6 %, and 5.1 % of patients. There was an important heterogeneity between studies for inclusion criteria, patient profiles, TOLM indications, and details of surgical, functional, and oncological outcomes.

CONCLUSION

TOLM supraglottic laryngectomy is a safe, and effective procedure associated with adequate functional, surgical, and oncological outcomes. Future studies are needed to define the place of TOLM in advanced LSCC; the role and timing of concomitant bilateral neck dissection, the indications of tracheotomy and feeding tube.

Treatment regimens for laryngeal and hypopharyngeal squamous cell carcinoma: a "real life" multicenter study of 2307 patients

OBJECTIVE

This retrospective multicenter study aimed to evaluate surgical versus conservative treatment in patients with hypopharyngeal and laryngeal cancer under real world conditions.

METHODS

This study included 2307 patients diagnosed with hypopharyngeal or laryngeal squamous cell carcinoma (SCC) in five German tertiary head and neck centers between 01/2004 and 12/2014. Overall, 783 patients with advanced SCC consecutively underwent laryng(opharyng)ectomy (L(P)E). Patient chart data regarding age, sex, tumor location, TNM status, grading, indication for L(P)E, treatment modalities, R status, postoperative complications, and hospitalization time were analyzed. Patients with lacking data and incomplete staging and those who refused treatment or did not comply with the recommended treatment were excluded from survival analysis.

RESULTS

A slight but significant increase was observed in L(P)E, referring to an increasing rate of tumor recurrence. While T1/2N0M0 laryngeal and hypopharyngeal cancer patients showed comparable overall survival (OS) for surgical and conservative treatment, surgery showed significantly better OS in lymph node-positive individuals and locally advanced tumor stages. Tumor recurrence occurred in more than one-third of the cases. In particular, in early glottic cancer recurrence, L(P)E represents a curative and safe treatment option, whereas in supraglottic and hypopharyngeal cancer, L(P)E was associated with reduced survival rates. Notably, 36% of patients with supraglottic cancer and 59% of patients with hypopharyngeal cancer recurrence could only be treated with palliative care.

CONCLUSION

Comparable survival rates were demonstrated for cT1/2N0M0 laryngeal and hypopharyngeal SCC compared with primary chemo-/radiotherapy and larynx-preserving surgery. Better OS was achieved after surgery in nodal-positive patients and in those with locally advanced disease. Tumor recurrence should be anticipated in up to 39% of cases. Glottic cancer recurrence can be successfully and safely treated with L(P)E, whereas OS is reduced in hypopharyngeal cancer and possibly in supraglottic cancer.

Transoral laser microsurgery for supraglottic carcinomas: results of a prospective multicenter trial (SUPRATOL)

Background

A limited number of single institutions have published retrospective cohort studies on transoral laser microsurgery for supraglottic laryngectomy (TLM-SGL). These studies have shown that the oncologic outcomes of TLM-SGL are comparable to those of open SGL. However, there is limited information available regarding swallowing rehabilitation and quality of life (QoL).

Patients and methods

SUPRATOL is a prospective, multicenter trial assessing the functional outcomes of TLM-SGL +/- adjuvant radio-(chemo)-therapy. The primary endpoint was aspiration-free swallowing at 12 months, as established using fibreoptic endoscopic evaluation of swallowing (FEES) and defined as a grade < 6 on the penetration-aspiration scale. Secondary endpoints were swallowing- and voice-related QoL, the prevalence of temporary and permanent tracheostomy and percutaneous gastrostomy, local control, laryngectomy-free survival, overall survival, and disease-free survival, as well as the influence of treatment centers on outcomes.

Results

From April 2015 to February 2018, 102 patients were recruited from 26 German Otorhinolaryngology (ORL) hospitals. All patients had TLM-SGL and 96.1% underwent uni- or bilateral, mostly selective neck dissection. To 47.0% of patients, adjuvant radio-(chemo)-therapy (R(C)T) was administered. The median follow-up period was 24.1 months. At 12-month follow-up, completed by 84.3% of patients, 98.2%, 95.5%, and 98.8% were free of aspiration when tested with saliva, liquid, or pulp. Adjuvant R(C)T, pT category, and type of resection had no significant influence on swallowing rehabilitation. A total of 40.2% of patients had been tracheotomized, and in 46.1% of patients, a PEG tube was inserted. At the 24-month follow-up, 5.3% of patients still required a tracheostomy, and 8.0% continued to use a percutaneous endoscopic gastrostomy (PEG) tube. Deterioration of swallowing- and voice-related QoL was observed immediately after treatment, but patients recovered, and baseline values were reached again. The Kaplan-Meier 2-year rates for local control, laryngectomy-free survival, overall survival, and disease-free survival were 88%, 92%, 93%, and 82%, respectively.

Conclusions

Our prospective multicenter trial shows that, at 12 months post-TLM-SGL +/- R(C)T, 95.5%-98.8% of patients achieved aspiration-free swallowing. Morbidity was higher than previously reported. The rates of permanent tracheostomy and gastrostomy tube placement correspond to previous cohort studies. The 2-year oncologic outcomes are within the reported range.

Clinical trial registration

https://drks.de/search/en/trial/DRKS00004641, identifier (DRKS00004641).

Can Hounsfield unit density value accurately predict prelaryngeal invasion in laryngeal carcinoma cases

OBJECTIVE

The Hounsfield unit density value (HUDV) is a relative quantitative measurement of radio density used by radiologists in the interpretation of computed tomography (CT) images. Our aim is to investigate the role of HUDV in evaluating pre-epiglottic space (PES) involvement of laryngeal carcinoma.

METHODS

Seventy-four patients treated for laryngeal carcinoma in our clinic between 2014 and 2019 were included in the study. The invasion status of PES was determined radiologically and pathologically. HUDV was measured with a circular selected region of interest, with a constant size of 10 mm2 for PES. The relationship between patological PES invasion, radiological PES invasion, and HUDV was evaluated.

RESULTS

Measuring HUDV to determine PES invasion (74.3 %) was significantly higher than​​ conventional CT evaluation (59.5 %) (p = 0.001). The agreement coefficient (kappa value) of the conventional CT evaluation and the HUDV regarding PES involvement was 0.673, which was interpreted as 'good'.

CONCLUSION

HUDV could be used as an additional tool in diagnosing pre-epiglottic space invasion in laryngeal cancer.

Surgery for Supraglottic Laryngeal Cancer

Although total laryngectomy continues to be important treatment of supraglottic laryngeal cancer, the management of early-stage disease has evolved from primary radiation/chemoradiation to consideration of partial laryngectomy surgery. Surgeon experience and careful patient selection can lead to excellent oncologic and functional outcomes for these techniques. However, advanced stage tumors and salvage situations are challenging and the ability to eradicate disease and preserve function should be carefully considered. Contraindications to supraglottic laryngectomy depend on surgical approach, as do complications. With adequate patient selection, high rates of cure and function can be achieved with both open and transoral supraglottic laryngectomy procedures.

Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.

Oncological and functional outcomes following treatment of T1a glottic squamous cell carcinoma with transoral laser microsurgery

Background

Laryngeal cancers of glottic origin comprise a large proportion of head and neck malignancies. Transoral laser microsurgery (TLM) and radiation therapy are mainstays in the treatment of early stage glottic cancer, but debate persists as to which modality is functionally superior. Furthermore, there is a paucity of North American data related to functional and oncological outcomes in T1a glottic cancer. Here, we assessed oncological and functional outcomes of T1a glottic squamous cell carcinoma (SCC) with TLM to supplement evidence from jurisdictions outside North America.

Methods

This study is a retrospective cohort study performed from a prospectively collected tertiary center institutional TLM database. Patients who were diagnosed with T1a glottic SCC and underwent TLM as their primary treatment were included. Functional outcomes were analyzed using the Voice Handicap Index-10 (VHI-10) questionnaire. Ultimate control with TLM only was considered to be those patients with locoregional control with repeat TLM procedures, but without addition of other modalities. Student’s t-test was used to test significance and Kaplan–Meier survival analysis was used to assess oncological outcomes.

Results

48 patients met study criteria. The mean follow-up time was 74 months. The 5-year locoregional, ultimate control with TLM only and laryngeal preservation rates were 83.2%, 90.4% and 100%, respectively. The overall survival and disease-specific survival were 87.2% and 100%, respectively. VHI-10 scores were available for 13/48 patients and mean scores improved non-significantly from pre-op (mean: 11.23; range: 2 to 30; median: 10) and post op (mean: 7.92; range: 0 to 18; median: 8) scoring (p-value = 0.15). Sub-stratification of voice data revealed a significant improvement between pre and post-operative scores (mean difference − 10.6, 95% CI: − 0.99 to − 20.21, p-value = 0.035) for patients with abnormal pre-operative scores (VHI > 11).

Conclusion

To our knowledge, the current work represents one of the first North American studies to report both functional and oncologic outcomes for TLM treatment of T1a glottic SCC. The oncologic and functional outcomes presented here add to existing evidence in favor of TLM as a safe and effective primary treatment option for early staged T1a glottic cancer.

Graphical abstract

Hemoglobin Absorption Spectral Imaging (H.A.S.I.): a novel optical staining technique for microlaryngoscopy

PURPOSE

Optical image enhancement techniques are widely used in endoscopy to improve the visualization of blood vessels for diagnostic and therapeutic purposes. These techniques are monitor-based and therefore not available for direct microscopy. In this study, a novel optical microscope filter, Hemoglobin absorption spectral imaging (H.A.S.I.) was tested for use in microlaryngoscopy.

METHODS

A novel dichroic filter was designed to improve contrast in small blood vessels by highlighting transmission in the spectrum range of hemoglobin absorption maxima. A surgical microscope equipped with the novel H.A.S.I. filter was installed in one operating room in our institution. 68 consecutive patients referred to our ENT department for endoscopy were examined using white light and the novel H.A.S.I. filter during microlaryngoscopy. Surgeons described the blood vessels of the vocal cords using a classification chart and assessed for suspected malignancy using both white light and H.A.S.I.

RESULTS

77 consecutive microlaryngoscopies were performed on 68 patients. 142 vocal cords were visualized in microlaryngoscopy and the blood vessels classified according to the chart. With white light, 152 blood vessel characteristics were documented and 157 with H.A.S.I. Notably, pathologies like benign horizontal blood vessel changes, leukoplakia, and vertical blood vessel changes like dots and loops were seen more frequently with H.A.S.I. Finally, seven lesions were treated by transoral laser microsurgery (TLM) with H.A.S.I. to test the practicability of the method for microlaryngoscopic laser surgery.

CONCLUSION

This is the first study describing H.A.S.I. as an optical staining method for microlaryngoscopy. In our experience, the method was practical and improved the evaluation of vocal cord blood vessels. In some cases, the use of H.A.S.I. led to a change in diagnosis and treatment. Also, H.A.S.I. was found to be helpful in microlaryngeal laser surgery for demarcating resection margins. This is, to our knowledge, the first optical staining method integrated into a surgical microscope and can be conveniently used during microlaryngeal laser surgery and does not require further equipment.

Current indications for adjuvant treatment following transoral laser microsurgery of early and intermediate laryngeal cancer

PURPOSE OF REVIEW

This review summarizes the information in the literature on the indications for adjuvant therapy after transoral laser microsurgery (TLM) for early/intermediate stage laryngeal cancer.

RECENT FINDINGS

A high rate of 'nonevaluable' margins after TLM significantly complicates decision-making concerning adjuvant therapy. However, consensus grows that second-look TLM in patients with multiple superficial and deep positive margins is more sensible than sending these patients systematically for adjuvant radiotherapy (RT).

SUMMARY

The classical adagium: 'Failure to achieve negative margins indicates need for adjuvant RT' does not translate automatically to patients with glottic cancer treated by TLM. Rather, specifically patients with multiple superficial positive margins and positive deep margins after TLM need careful judging what constitutes the best additional adjuvant treatment. Second-look resection is nowadays regarded as the preferred adjuvant treatment for many of these patients whereas RT is reserved for those in whom a second look TLM is judged unlikely to result in 'true negative margins.' Additionally, when the pathology of the re-resection reveals multiple foci of residual disease or suggests again a resection with positive margins, adjuvant postoperative RT is likely to result in a better local control. If this strict selection of patients for adjuvant RT is adhered to carefully, oncological and functional results will be optimal.

Oncologic results and quality of life in patients with T3 glottic cancer after transoral laser microsurgery

PURPOSE

CO₂ transoral laser microsurgery (CO2 TOLMS) is an alternative approach to non-surgical organ preservation in selected T3 glottic squamous cell carcinoma (SCC). This study aimed to assess the oncologic results and quality of life (QOL) of patients with T3 glottic SCC after CO2 TOLMS.

METHODS

Of the 44 patients who underwent CO2 TOLMS, 38 underwent QOL evaluations. QOL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 and head and neck module, Voice Handicap Index-30, and M. D. Anderson Dysphagia Inventory at least 6 months postoperatively.

RESULTS

The patients were predominantly male (98%), with a median age of 61 years. Cordectomy type included 1 type III, 4 type IV, 31 type V, and 8 type VI according to European Laryngological Society classification. Two patients (5%) had cervical lymph node metastasis and 21 patients (48%) underwent postoperative radiotherapy. With a mean follow-up of 65 months for all patients, 10 (23%) had tumor recurrence (9 local, 1 distant). After salvage surgery, four patients lived without disease, and the larynx was preserved in two. The 5-year local control and overall and disease-specific survival rates were 78%, 75%, and 84%, respectively. The overall laryngeal preservation rate was 82% (36/44). Most patients had satisfactory QOL.

CONCLUSIONS

In selected T3 glottic SCC cases, CO2 TOLMS can achieve favorable oncologic results and a satisfactory QOL.

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.

Longitudinal analysis of Voice Handicap Index in early glottic cancer patients treated with transoral laser microsurgery: age, gender, stage and time dependence

Objectives

Transoral laser microsurgery is an increasingly common treatment modality for glottic carcinoma. This study aimed to determine the effect of age, gender, stage and time on voice-related quality of life using the Voice Handicap Index-10.

Methods

Primary early glottic carcinoma patients treated with transoral laser microsurgery were included in the study. Self-reported Voice Handicap Index testing was completed pre-operatively, three months post-operatively, and yearly at follow-up appointments.

Results

Voice Handicap Index improvement was found to be dependent on age and tumour stage, while no significant differences were found in Voice Handicap Index for gender. Voice Handicap Index score was significantly improved at 12 months and 24 months. Time versus Voice Handicap Index modelling revealed a preference for non-linear over linear regression.

Conclusion

Age and stage are important factors, as younger patients with more advanced tumours show greater voice improvement post-operatively. Patient's Voice Handicap Index is predicted to have 95 per cent of maximal improvement by 5.5 months post-operatively.

Open Partial Horizontal Laryngectomies for T3⁻T4 Laryngeal Cancer: Prognostic Impact of Anterior vs. Posterior Laryngeal Compartmentalization

Open partial horizontal laryngectomies (OPHLs) are well-established and oncologically safe procedures for intermediate–advanced laryngeal cancers (LC). T–N categories are well-known prognosticators: herein we tested if “anterior” vs. “posterior” tumor location (as defined in respect to the paraglottic space divided according to a plane passing through the arytenoid vocal process, perpendicular to the ipsilateral thyroid lamina) may represent an additional prognostic factor. We analyzed a retrospective cohort of 85 T3–4a glottic LCs, treated by Type II or III OPHL (according to the European Laryngological Society classification) from 2005 to 2017 at two academic institutions. Five-year overall survival (OS), disease-specific survivals (DSS), and recurrence-free survivals (RFS) were compared according to tumor location and pT category. Anterior and posterior tumors were 43.5% and 56.5%, respectively, 78.8% of lesions were T3 and 21.2% were T4a. Five-year OS, DSS, and RFS for T3 were 74.1%, 80.5%, and 63.4%, respectively, and for T4a 71.8%, 71.8%, and 43%, respectively (p not significant). In relation to tumor location, the survival outcomes were 91%, 94.1%, and 72.6%, respectively, for anterior tumors, and 60.3%, 66.3%, and 49.1%, respectively, for posterior lesions (statistically significant differences). These data provide evidence that laryngeal compartmentalization is a valid prognosticator, even more powerful than the pT category.

Prediction of Posterior Paraglottic Space and Cricoarytenoid Unit Involvement in Endoscopically T3 Glottic Cancer with Arytenoid Fixation by Magnetic Resonance with Surface Coils

Discrimination of the etiology of arytenoid fixation in cT3 laryngeal squamous cell carcinoma (SCC) is crucial for treatment planning. The aim of this retrospective study was to differentiate among possible causes of arytenoid fixation (edema, inflammation, mass effect, or tumor invasion) by analyzing related signal patterns of magnetic resonance (MR) in the posterior laryngeal compartment (PLC) and crico-arytenoid unit (CAU). Seventeen patients affected by cT3 glottic SCC with arytenoid fixation were preoperatively studied by state-of-the-art MR with surface coils. Different signal patterns were assessed in PLC subsites. Three MR signal patterns were identified: A, normal; B, T2 hyperintensity and absence of restriction on diffusion-weighted imaging (DWI); and C, intermediate T2 signal and restriction on DWI. Signal patterns were correlated with the presence or absence of CAU and PLC neoplastic invasion. Patients were submitted to open partial horizontal or total laryngectomy and surgical specimens were analyzed. Pattern A and B did not correlate with neoplastic invasion, while Pattern C strongly did (Spearman’s coefficient = 0.779, p < 0.0001; sensitivity: 100%; specificity: 78%). In conclusion, MR with surface coils is able to assess PLC/CAU involvement with satisfactory accuracy. In absence of Pattern C, arytenoid fixation is likely related to mass effect and/or inflammatory reaction and is not associated with neoplastic invasion.

Management of locally advanced T3-4 glottic laryngeal carcinomas

OBJECTIVES

To assess five-year local control and ultimate local control rates of patients treated for locally advanced T3-4 glottic carcinoma with surgery only, radiotherapy only, or surgery plus radiotherapy. Cancer-specific survival, overall survival and rates of malignancy development were also assessed.

METHODS

A retrospective review was conducted on patients from 1967 to 2015, with analysis of local control, ultimate local control, overall survival and cancer-specific survival performed using Kaplan-Meier and Cox regression.

RESULTS

Of 169 eligible patients, the majority (59 per cent) were treated with surgery plus radiotherapy, with laryngectomy being the most common surgical procedure. Local control and ultimate local control rates were higher with surgery only (94.1 per cent) and surgery plus radiotherapy (87.9 and 86.8 per cent respectively), compared to radiotherapy only (46.8 and 52.4 per cent) (both p < 0.001). Cancer-specific survival, overall survival and malignancy development did not differ between groups.

CONCLUSION

Surgery, with or without radiotherapy, offers significantly higher five-year local control and ultimate local control for patients with advanced glottic carcinoma, compared to radiotherapy only.

Three-Dimensional Map of Isoprognostic Zones in Glottic Cancer Treated by Transoral Laser Microsurgery as a Unimodal Treatment Strategy

Introduction

The Union for International Cancer Control–American Joint Committee on Cancer TNM staging system for glottic squamous cell carcinoma (SCC) includes different types of lesions defined by the involvement of specific subsites in each T category. Our study aims to identify different subcategories according to tumor local extension and determine oncologic outcomes after treatment by transoral laser microsurgery (TLM) alone.

Methods

We retrospectively evaluated 410 patients affected by previously untreated pT1-pT3 glottic SCC treated by TLM alone from January 2005 to December 2015 at the Departments of Otorhinolaryngology—Head and Neck Surgery, Universities of Genoa and Brescia, Italy. All patients had at least 2 years of follow-up. Clinical, radiological, surgical, and histopathological data were reviewed and tumors divided into six subcategories: I, pT1a not involving the anterior commissure (AC); II, pT1b involving the AC; III, pT2 extending superficially to the supraglottis or the subglottis; IV, pT2 infiltrating the vocal muscle; V, pT3 involving the anterior paraglottic space; VI, pT2 or pT3 with vertical extension across the AC with/without involvement of the pre-epiglottic space. Recurrence-free survival (RFS), local control with laser alone (LCL), and organ preservation (OP) were defined as the primary oncologic outcomes.

Results

The 2, 5, and 10-year RFS for the entire series were 85.7, 80.3, and 73.8%, LCL rates 93.8, 92.1, and 89.6%, and OP rates 96.8, 95.9, and 93.5%, respectively. However, when comparing the rates of RFS, LCL, and OP for each subcategory, important differences emerged. In particular, subcategories V and VI showed a significantly increased risk of local recurrence [hazard ratio (HR) = 9.2 and 13.3, respectively]. These subcategories also had a significantly reduced probability to achieve LCL (HR: 73.6 and 93.5, respectively) and OP (HR: 6.4 and 8.1, respectively).

Conclusion

The present classification in subcategories allows introducing the concept of a three-dimensional map of isoprognostic zones in glottic SCC treated by TLM alone as a useful tool in its management by a multidisciplinary tumor board.

Transoral Laser Microsurgery for Supraglottic Cancer

INTRODUCTION

Transoral laser microsurgery (TLM) is an accepted and effective treatment strategy for supraglottic carcinomas. Early supraglottic carcinoma has excellent outcomes independently of the treatment approach. The role of TLM for the treatment of locally advanced tumors is debated. Particularly, the functional outcomes after TLM have to be proven by functional assessment of large cohorts of patients. This study analyzes the oncologic and functional outcomes after TLM for supraglottic carcinomas.

PATIENTS AND METHODS

Ninety-one patients with pT1-pT4a supraglottic carcinomas treated between January 2002 and December 2012 were analyzed. Distribution of tumors (UICC 2010) was 11 patients with pT1, 31 patients with pT2, 36 patients with pT3, and 13 patients with pT4a tumors. Node status was positive in 40 (43.6%) patients; 61 (67.1%) patients had stage III or IVa disease. Local control and survival were estimated using the Kaplan-Meier method. For the assessment of functional outcomes, the MD Anderson Dysphagia Inventory (MDADI), the Voice Handicap Index-10 (VHI-10), and the performance status scale for head and neck cancer [Performance Status Scale for Head and Neck (PSS-HN)] were used.

RESULTS

The median age was 62 years (range, 33-88 years). Fourteen (15.4%) patients developed a local or locoregional recurrence. The 5-year local control rate and 5-year ultimate local control rate were 72 and 92%, respectively. The 5-year overall survival rate was 63%. Twelve (13.2%) patients needed temporary tracheostomy. Sixty-eight (74.0%) patients had a nasogastric feeding tube post-operatively. At 1-year post-operative follow-up, only three patients were PEG dependent. The median VHI-10 score was 35, the median MDADI composite score was 80, and the median score of the domain "normalcy of diet" in the PSS-HN was 91.

CONCLUSION

The oncologic outcomes are comparable to the results of open surgery for early and advanced supraglottic carcinomas. Functional swallowing outcome is superior to open surgery and to concomitant chemoradiation. Patients treated with TLM perceive low levels of voice- and swallowing-related quality of life impairment.

Comparison of Treatment Outcomes for T3 Glottic Squamous Cell Carcinoma: A Meta-Analysis

Objectives

This study compared the survival outcomes, local control rate, and laryngeal preservation rate of various treatment strategies in the treatment of T3 squamous cell carcinoma of the glottis using proportional meta-analyses.

Methods

Twenty-five retrospective case-series studies were included in these analyses. Treatment strategies were classified as total laryngectomy (TL), open partial laryngectomy (PL), transoral laser microsurgery (TLM), chemo-radiation therapy (CRT), and radiation therapy (RT) alone.

Results

The overall survival rate and disease-specific survival rate among laryngeal preservation treatments did not differ from the overall survival rate of TL. However, the local control rate was lower with RT than TL and PL, and laryngeal preservation rates of TLM and CRT were higher than RT alone.

Conclusion

Consideration of preservation of laryngeal function is necessary when treating T3 glottic squamous cell carcinoma. PL, TLM, and, CRT are considered more appropriate initial laryngeal preservation strategies if available.

MicroRNA‑195 is associated with regulating the pathophysiologic process of human laryngeal squamous cell carcinoma

MicroRNAs (miRNAs) have been reported to be associated with the modulation of tumor development, including alterations associated with the development of human laryngeal squamous cell carcinoma (LSCC). The present study was designed to investigate whether miRNA‑195 was associated with the pathophysiologic process of human LSCC and to identify its potential roles and underlying molecular mechanisms. To determine whether miRNA‑195 serves a role in LSCC, reverse transcription‑quantitative polymerase chain reaction was used to detect miRNA‑195 expression in LSCC tissues. The tumor‑suppressive effect of miRNA‑195 was determined by in vitro assays. Gain‑of‑function studies using miRNA‑195 mimics were performed to investigate cell viability, migration and invasion, and apoptosis in the AMC‑HN‑8 cell line. Western blotting was performed to reveal the molecular mechanisms of miRNA‑195 and its downstream signaling pathways in the LSCC AMC‑HN‑8 cell line. The present study demonstrated that miRNA‑195 is downregulated in primary LSCC tumors. Upregulating miRNA‑195 in vitro suppressed cell viability, migration and invasion in AMC‑HN‑8 cells. Overexpression of miRNA‑195 alone in AMC‑HN‑8 cells was sufficient to induce cell apoptosis, as identified by terminal deoxynucleotidyl transferase dUTP nick end labeling assay. Compared with the high expression of miRNA‑195 in AMC‑HN‑8 cells, the expression levels of vascular endothelial growth factor receptor‑II protein and downstream signaling pathway proteins, which were associated with cell viability, migration, invasion and apoptosis, were markedly decreased compared with control or miRNA‑195 negative control treatment group. Together, these data suggest the therapeutic potential of miRNA‑195 in modulating cell growth, migration and apoptosis during the pathophysiological progression of LSCC and that miRNA‑195 may serve as a potential therapeutic target in human LSCC.

Does CT help in predicting preepiglottic space invasion in laryngeal carcinoma?

OBJECTIVE

Evaluating preepiglottic space involvement in laryngeal cancer by CT may lead misinterpretation. We sought to understand the causes of misinterpretation in evaluating the preepiglottic space by CT and assessed the effects of misinterpretation in treatment plans of patients with laryngeal squamous cell carcinomas.

METHODS

Specimen histopathology reports of 102 (99 male, 3 female) patients who underwent total or partial laryngectomy due to supraglottic and/or transglottic laryngeal carcinoma were reviewed. Neck CTs were also re-assessed for preepiglottic space involvement by three radiologists. The initial surgical treatment choices were re-examined according to the current radiological evaluation in combination with pathological results of the specimens and physical examination findings in the patients. Interobserver agreement regarding image interpretation was based on a kappa analysis.

RESULTS

The interclass correlation coefficient in predicting preepiglottic space invasion was 0.74; this was considered 'good.' Among the three radiologists, sensitivity, specificity, accuracy of CT in detecting preepiglottic space involvement were 86-93%, 75-93%, and 77-93%, respectively, while the negative and positive predictive values were 97-98% and 38-50%, respectively. Given the previous treatments applied, false-positive diagnoses for PES involvement resulted in overtreatment in 2.9% of cases. False-negative diagnoses of PES involvement (1.9% of cases) did not result in any undertreatment.

CONCLUSIONS

Although CT is a practical and inexpensive imaging tool for evaluating laryngeal carcinomas, the PPV of CT in assessing preepiglottic space invasion, especially in advanced tumors, is low and may lead to overtreatment.

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.

Reasonable limits for transoral laser microsurgery in laryngeal cancer

PURPOSE OF REVIEW

Transoral laser microsurgery (TLM) is widely acknowledged to offer several advantages in the treatment of early and selected intermediate-advanced laryngeal cancers. Nevertheless, a number of issues are still under debate. The purpose of this review is to discuss the reasonable limits for TLM in laryngeal cancer to highlight its most appropriate and reproducible indications, putting this therapeutic tool in the right perspective within a comprehensive frame of alternative treatment strategies such as open partial laryngectomies and nonsurgical organ preservation protocols.

RECENT FINDINGS

Inadequate laryngeal exposure, anterior commissure involvement in the cranio-caudal plane (T2), invasion of the posterior paraglottic space with arytenoid fixation, massive infiltration of the preepiglottic space, and even minor thyroid cartilage erosion (T3) represent the most controversial applications of TLM in management of glottic and supraglottic cancer.

SUMMARY

Published oncological results appear to be satisfactory when TLM is applied to T1-T2 and accurately selected T3 glottic and supraglottic cancers with favourable exposure. Caution should be used for more advanced tumours.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

Systematic review on T3 laryngeal squamous cell carcinoma; still far from a consensus on the optimal organ preserving treatment

OBJECTIVE

The optimal treatment of patients with T3 laryngeal carcinoma is controversially challenged by open partial laryngectomies (OPL), transoral laser microsurgery (TLM) and radiation therapy alone (RT) or combined with chemotherapy (ChRT). Treatment guidelines, experts' opinions and clinical studies are highly contradictory. The aim of this study is to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies.

METHODS

A review of the literature published in the time period 2003-2015 was conducted via the PubMed database (www.pubmed.org) and Scopus database (www.scopus.com) with the search terms "T3 laryngeal squamous cell cancer treatment". Data from clinical studies involving patients with T3 laryngeal cancer (n > 10) subjected to TLM, OPL, ChRT or RT, were pooled. In the absence of controlled studies, prospective and retrospective clinical trials with minimum 5-year follow-up were acceptable, provided that they included a description of patient eligibility criteria, so as to exclude studies with serious selection bias.

RESULTS

Literature lacks studies with homogenous populations regarding TNM staging, preoperative/postoperative treatment or anatomical subsite. This raises substantial controversies and prohibits the conduction of a meta-analysis. Data for qualitative analysis were pooled from 8 studies (n = 1226). OPL and TLM both offer patients high survival and organ preservation rates. Preoperative induction chemotherapy seems to significantly compromise overall survival.

CONCLUSIONS

Multicenter studies referring to homogenous populations, at least regarding staging and anatomical subsite, are needed. No safe conclusions can be drawn given the heterogeneity in patient cohorts, study design and evaluation of results in the existing literature.

A retrospective review in the management of T3 laryngeal squamous cell carcinoma: an expanding indication for transoral laser microsurgery

BACKGROUND

The purpose of this study was to evaluate the functional and oncological outcomes of patients treated for T3 laryngeal squamous cell carcinoma. Specifically comparing transoral laser microsurgery and radiotherapy/chemoradiotherapy treatment modalities.

METHOD

A retrospective review of patients treated for T3 laryngeal SCC between 2002 and 2010 was undertaken.

RESULTS

Forty-nine patients were included. 15 cases were glottic, (9 treated with TLM, 6 with RT/CRT), 33 supraglottic (6 treated with TLM, 27 with RT/CRT) and 1 subglottic subsite (treated with RT/CRT). There was no statistical difference between treatment groups for 24 month locoregional control (72.3 %), overall survival (glottis 86.7 %, supraglottic 70.4 %) and disease specific survival (glottic 93.3 % and supraglottic 74.1 %). Overall laryngeal preservation (84.9 %) was also similar in both groups.

CONCLUSION

Our institution is expanding the application of TLM to selected patients with T3 laryngeal carcinoma. Oncological outcomes have not been jeopardized by this approach and the treatment is well tolerated by patients with few complications.

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.

[The value of supracricoid partial laryngectomy in moderately advanced laryngeal cancer (T3-T4a)]

BACKGROUND

Transoral laser microsurgery (TLM) is the method of choice for partial laryngectomy in Germany. In advanced stages, chemoradiotherapy is increasingly indicated for organ preservation.

OBJECTIVE

This report considers the indications for and outcomes of supracricoid partial laryngectomy (SPL), also known as crico-hyoido-(epiglotto)-pexy, as an option for surgical organ preservation in moderately advanced laryngeal cancer (T3-T4a), in the well-defined gap between TLM and chemoradiotherapy protocols in Germany.

METHODS

Retrospective evaluation of functional and oncological outcomes of all SPLs conducted between 2008 and 2014. During this period, 17 SPLs with resection of rpT2 (n = 2), (r)pT3 (n = 11), and (r)pT4a (n = 4) were performed with resection of one arytenoid. Mean age was 58 years (range 47-75 years). In 5 patients, SPL was for a first or second local recurrence after TLM or open partial laryngectomy. Adjuvant radiotherapy was received by 7 patients staged pT4a or pN+.

RESULTS

Salvage laryngectomy with adjuvant radiotherapy was required by 2 patients. The remaining patients (n = 15) had a mean tumor-free follow-up of 4 years with a functional intact larynx: these patients can eat and drink, have a closed tracheotomy, and a good voice. After 3 years tumor-free follow-up with a functional intact larynx, 2 patients died due to cardiac comorbidity at the age of 76 years.

DISCUSSION

SPL is a rare but valuable option for surgical larynx preservation in stage pT3-4a laryngeal cancer.

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.

Laryngeal cancer in Finland: A 5-year follow-up study of 366 patients

BACKGROUND

The purpose of this study was to acquire nationwide data on the management and outcome of laryngeal squamous cell carcinoma (SCC) in Finnish university hospitals over a 5-year posttreatment follow-up.

METHODS

All records of patients diagnosed and treated for primary laryngeal SCC during 2001 to 2005 were reviewed.

RESULTS

Three hundred sixty-six patients with laryngeal cancer were identified, 360 of whom had laryngeal SCC. Three hundred forty-two patients with laryngeal SCC (95%) were treated with curative intent. Five-year disease-specific survival (DSS) for T1a, T1b, T2, T3, and T4 glottic SCC was 100%, 95%, 78%, 79%, and 53%, respectively. The corresponding figures for T1 to T4 supraglottic SCC were 68%, 54%, 72%, and 59%.

CONCLUSION

Results of this nationwide study give a general overview of the outcome of unselected patients treated with unified guidelines. Patients with T2 tumors, usually treated with radiotherapy (RT), had a worse prognosis than expected. This patient group warrants further investigation and possibly treatment intensification.

T3-T4 laryngeal cancer in The Netherlands Cancer Institute; 10-year results of the consistent application of an organ-preserving/-sacrificing protocol

BACKGROUND

Both organ-preserving concurrent (chemo)radiotherapy ((C)RT) and organ-sacrificing surgery (total laryngectomy) are used for treatment of advanced laryngeal cancer. The purpose of this study was to present the assessment of our treatment protocol for T3 (C)RT and T4 disease (total laryngectomy + postoperative RT).

METHODS

We conducted a retrospective cohort study in 182 consecutive patients (1999-2008). The primary outcome was overall survival (OS) in relation to stage and treatment.

RESULTS

One hundred two patients received RT (82.4% T3), 20 patients CRT (60.0% T3), and 60 patients total laryngectomy + RT (91.7% T4). Five-year OS: T3 52%, T4 48%, for RT 50%, for CRT 43%, and for total laryngectomy + RT 52%. Five-year laryngectomy-free interval was 72% after RT, and 83% after CRT.

CONCLUSION

There were no differences in survival according to T classification or treatment modality. Because the majority of T3 laryngeal cancers were treated with (C)RT and the majority of T4 with total laryngectomy + RT, this gives food for thought on whether the present protocol for T3 laryngeal cancer is optimal.

Advances in the management of squamous cell carcinoma of the head and neck

Squamous cell carcinoma of the head and neck (SCCHN) is the sixth most common cancer worldwide. The main risk factors for cancers of the oral cavity, larynx, oropharynx, and hypopharynx are alcohol and tobacco use. In addition, the human papillomavirus (HPV) is an established cause of oropharyngeal cancer. An experienced multidisciplinary team is necessary for adequate management and optimal outcome. The treatment of locally advanced disease generally requires various combinations of radiotherapy, surgery, and systemic therapy, but despite this aggressive multimodal treatment, 40% to 60% of the patients will relapse. In this report, we will discuss recent advances in the management of SCCHN, including new developments in molecular biology, imaging, and treatment.

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.