Transoral laser microsurgery as primary treatment for selected T3 glottic and supraglottic cancers

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.

Laryngeal Preservation Strategies

Over the last 2 decades, the paradigm of laryngeal cancer management has pivoted toward preserving laryngeal function without sacrificing oncologic outcomes. Transoral laser microsurgery has diminished the role of open laryngeal surgery. For early-stage laryngeal cancer, the common primary modalities are endoscopic laryngeal surgery and narrow field radiation. Total laryngectomy followed by either radiation or chemoradiation is option for advanced laryngeal cancer. In experienced hands and following meticulous patient selection, supracricoid laryngectomy may serve as a viable alternative to total laryngectomy to preserve laryngeal function. Total laryngectomy is still the recommended treatment in those with airway compromise and/or laryngeal dysfunction.

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

N/A Laryngoscope, 2024 Laryngoscope, 2024.

Oncological features and outcomes of laryngeal cancer surgery: a multicentric study

BACKGROUND

Laryngeal cancer (LC) is among of the most frequent head and neck cancers, associated to a high social impact and mortality. Unfortunately, the current treatment outcomes of LC are often scant, with different factors affecting patient's prognosis (i.e., advanced age, advanced disease stage, lymph node involvement, tumor pathological features, type of intervention). The aims of the present study were: 1) to evaluate the epidemiological and clinical features of patients affected by LC; and 2) to focus on tumor risk factors affecting patient's overall survival (OS) and recurrences.

METHODS

A retrospective analysis of all patients affected by LC and surgically treated at two different hospital settings has been performed.

RESULTS

Two hundred twenty-five patients were enrolled in the present study; of these 189 were males (84%) and 36 (16%) were females. The most frequently performed surgery was total laryngectomy. Thirty-two (14.2%) patients experienced local recurrence, while 15 patients (6.6%) had regional recurrence and 15 distant metastases. Multivariate analysis showed that locoregional recurrence was associated to the occurrence of distant metastases (P=0.002, HR=25,35). Analyzing OS, the only statistically significant factor that correlated with an increased risk of mortality (P<0.015, HR=2,45) was locoregional recurrence.

CONCLUSIONS

The present study confirms the literature data about age and sex distribution of LC, about tumors localization, lymph nodes metastasis and distant metastasis incidence and OS rate, based on T and N stage. Interestingly, within this series, the presence of locoregional recurrence or distant metastasis is related to a worst prognosis and a lower overall survival rate.

Transoral robotic supraglottic laryngectomy: Long-term functional and oncologic outcomes

OBJECTIVES

Minimally invasive transoral organ preservation surgeries are being increasingly used for supraglottic tumors. This study investigates the long-term functional and oncologic outcomes of transoral robotic supraglottic laryngectomy (TORS-SGL).

MATERIALS AND METHODS

Twenty-three patients with supraglottic laryngeal cancer who underwent TORS-SGL between 2012 and 2015 at a tertiary referral hospital were retrospectively analyzed with at least 5 years of follow-up. The head and neck tumor council and the multidisciplinary oncological board decided whether the patients were suitable for robotic surgery, and the necessity of adjuvant radiotherapy or chemotherapy. Inclusion criteria was histopathological diagnosis of squamous cell carcinoma of the larynx.

RESULTS

Twenty-one patients with T1-T3 supraglottic squamous cell carcinoma were included in this study. Mean follow-up was 48.8 months. Local control was 94.4 % at 2 years and 85.9 % at 5 years. Disease-free survival and overall survival were 85.7 % and 81 % at 2 years and 69.3 % and 57.1 % at 5 years, respectively. There was no permanent tracheostomy or prolonged swallowing dysfunction among patients. Age, perineural and lymphovascular invasion were found to be risk factors affecting overall survival.

CONCLUSION

TORS-SGL is a feasible, safe and reliable approach with excellent functional results for T1, T2, and selected T3 supraglottic tumors, providing acceptable long-term oncologic results when compared to alternative treatment modalities.

Prognostic role of surgical margins in patients undergoing transoral robotic surgery after neo-adjuvant chemotherapy

PURPOSE

To define if positive and close surgical margins are associated to worse prognosis in patients who underwent transoral robotic surgery (TORS) after neoadjuvant chemotherapy (NCT).

METHODS

A retrospective cohort study was carried out at a tertiary referral center. The primary outcome was local-regional control (LRC), and the results were summarized with hazard ratios (HR) and 95% confidence intervals (CIs).

RESULTS

A total of 308 patients (median age: 62.0, IQR: 55.0-68.2) were included. Univariable analysis showed a significant reduced LRC for patients with positive margins (HR = 1.82, 95% CI: 1.02-3.24). However, they were not associated with worse LRC after adjusting for adverse tumor variables (HR = 0.81, 95% CI: 0.40-1.65). ROC analysis was performed on 123 patients with negative margins (AUC: 0.54) measuring an optimal threshold of 1.25 mm (sensitivity = 60.0%; specificity = 50.5%). Univariable analysis showed non-significant differences between close and wide negative margins (HR = 1.44, 95% CI: 0.59-3.54).

CONCLUSIONS

A positive surgical margin is not an independent predictor of tumor control and survival. A threshold of 1.25 mm was identified as the most appropriate to define close margins, but no difference was measured after distinguishing negative margins in close and wide margins.

Salvage transoral laser microsurgery for early local recurrence of glottic squamous cell cancer

BACKGROUND

For recurrent laryngeal cancer, the feasibility of salvage transoral laser microsurgery (TLM) remains controversial. This study compared the efficacy of TLM and open partial laryngectomy (OPL) for treatment of early local recurrence of glottic squamous cell cancer (GSCC) and confirm the effectiveness of salvage TLM as a treatment option.

METHODS

This retrospective study involved 55 patients with early local recurrent GSCC treated with TLM, and the oncologic outcomes, functional outcomes, hospitalization time and complications were compared with a group of 40 recurrent GSCC patients matched for clinical variables of TLM group, treated by OPL by the same team of surgeons.

RESULTS

The 5-year overall survival and disease-specific survival rates were 65.8% and 91.5%, respectively, for 55 patients with rT_is-rT₂ stage treated by TLM and 77.1% and 94.7%, respectively, for 40 patients with rT_is-rT₂ stage treated by OPL (OPL group). In the TLM and OPL groups, the local control rates after 5 years were 77.5% and 79.3%, respectively, and the laryngeal preservation rates were 94.4% and 83.6%, respectively (p > 0.05). Compared with the OPL group, the complication rate (1.82%) and hospitalization duration (5.42 ± 2.26 days) were significantly lower in the TLM group (p < 0.05). Compared with the OPL group, postsurgical health-related quality of life and quality of voice were significantly better in the TLM group (p < 0.001).

CONCLUSION

Salvage TLM can be used as an effective treatment option for suitable patients after a full, comprehensive, and careful assessment of the characteristics of early locally recurrent glottic carcinoma.

Neoadjuvant chemotherapy combined with transoral robotic surgery for stage III and IV laryngeal and hypopharyngeal carcinomas

OBJECTIVES

To analyze the oncological and functional outcomes of patients with stage III-IV laryngo-hypopharyngeal cancer who underwent neoadjuvant chemotherapy (NAC) with subsequent transoral robotic surgery (TORS).

MATERIALS AND METHODS

A single-center retrospective cohort study included a total of 100 patients (median age of 67.0) affected by stage III-IV supraglottic or hypopharyngeal cancer. All patients underwent NAC followed by TORS and risk-adjusted adjuvant therapy. The primary outcome was recurrence-free survival (RFS).

RESULTS

The median follow-up time was 24.0 months. Estimated 2-year (95% CI) OS, DSS, and RFS were 75% (66% - 85%), 84% (76% - 92%), and 65% (56% - 76%), respectively. Among the 11 patients who relapsed on the primary site, 3 underwent salvage total laryngectomy, 3 underwent salvage CRT, and the others receive palliation or supportive care. At 6 months from surgery, 17 patients were still tracheostomized or had a stoma retainer, while 15 were gastrostomy dependent. At the Cox multivariable analysis, the clinical stage at presentation, the number of NAC cycles, and the presence of LVI were found to be independently correlated with the RFS.

CONCLUSION

This study demonstrates that NAC followed by TORS can obtain good tumor control, survival, and organ preservation rates in stage III-IV laryngo-hypopharyngeal 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.

Magnetic resonance diagnosis of laryngeal chondritis after transoral laser microsurgery for laryngeal cancer

Objective

Laryngeal chondritis (LC) is a rare complication of carbon dioxide transoral laser microsurgery (CO₂ TOLMS) for laryngeal tumours and can pose a diagnostic challenge. Its magnetic resonance (MR) features have not been previously described. This study aims to characterise a cohort of patients who developed LC after CO₂ TOLMS and describe its clinical and MR findings.

Methods

Clinical records and MR images of all patients presenting with LC after CO₂ TOLMS between 2008 and 2022 were reviewed.

Results

Seven patients were analysed. Timing of LC diagnosis ranged from 1 to 8 months after CO₂ TOLMS. Four patients were symptomatic. Abnormal endoscopic findings included suspected tumour recurrence in 4 patients. MR documented focal or extensive signal changes involving the thyroid lamina and para-laryngeal space with T2 hyperintensity, T1 hypointensity and intense contrast enhancement (n = 7), and minimally reduced mean apparent diffusion coefficient (ADC) values (1.0-1.5 x 10^-3 mm²/s) (n = 6). A favourable clinical outcome was achieved in all patients.

Conclusions

LC after CO₂ TOLMS has a distinctive MR pattern. When tumour recurrence cannot be confidently excluded based on imaging, antibiotic therapy, close clinical and radiological follow-up and/or biopsy are recommended.

Outcomes of Laryngeal Cancer Surgery after Open Partial Horizontal Laryngectomies with Lateral Cervical Approach

Background: Open partial horizontal laryngectomies (OPHL) are one of the surgical techniques used for the conservative management of laryngeal cancers. The aims of this study are to analyze the oncological and functional results of a group of patients affected by laryngeal squamous cell carcinoma (LSCC) treated with OPHL, performed using a minimally invasive technique. Methods: This is a prospective case−control study. We enrolled 17 consecutive patients with LSCC treated with OPHL through a lateral cervical approach (LCA). Patients were evaluated using their Penetration Aspiration Scale score (liquid, semiliquid and solid) and Voice Handicap Index (VHI) at three different endpoints: 15 days (T1), 3 months (T2), and 6 months (T2) after surgery. Results: The functional outcomes of the LCA are stackable with that of the classical anterior cervical approach in terms of respiration, swallowing, and speech. One-way ANOVA was performed to evaluate the variances of PAS and VHI scores at the three different observation points. No statistically significant differences were observed between OPHL- PAS scores for liquid (p = 0.1) at the three different observation points. A statistically significant improvement was observed in the OPHL- PAS score for semisolids and solids (p < 0.00001) between T1 and T3 (p = 0.0001) and for solids between T2 and T3 (p < 0.00001). The improvement of VHI-10 was statistically significative (p < 0.00001) at the three different observation points (T1−T2 and T2−T3). Conclusion: The LCA is a potential approach for laryngeal surgery in selected cases. The preoperative staging and planning are of the utmost importance to ensure oncological radicality. The main advantage of this approach is the preservation of the healthy tissues surrounding the larynx and the functional and oncological outcomes are stackable with the classic anterior cervical approach.

Open partial horizontal laryngectomy for T2-T3-T4a laryngeal cancer: oncological outcomes and prognostic factors of two Italian hospitals

PURPOSE

The purpose of this study was to analyse the oncologic results of open partial horizontal laryngectomy (OPHL) and to assess the prognostic factors that could affect the survival of patients affected by T2, T3 and T4a laryngeal cancer. Using this data, we aim to identify clinical criteria to select patients amenable to conservative surgery, and to facilitate a more targeted approach in the management of advanced laryngeal cancer.

METHODS

A retrospective study was performed in patients who underwent OPHL type II for laryngeal squamous cell carcinoma from January 2005 to December 2018. We analysed a total of 170 patients; 21(12.36%) cases were staged as pT2, 116 (68.23%) as pT3 and 33 (19.41%) as pT4a.

RESULTS

Five-year overall survival (OS) was 80.9%, 79.3%, 70.4% for T2, T3 and T4 respectively. Disease-specific survival (DSS) was 90.4%, 85.3% and 77.4%. Posterior tumour extension, perineural invasion and N status showed to considerably influence survival in both uni- and multivariate analyses.

CONCLUSION

The oncological outcomes from our study show that OPHL for advanced laryngeal cancer can guarantee a high percentage of success. Accurate patient selection is of utmost importance to differentiate advanced disease amenable to conservative surgery, and treatment options should consider selected criteria based on tumour and patient features.

Patient-reported outcomes in human papillomavirus-related oropharyngeal cancer

This review explores how human papillomavirus-related oropharyngeal cancer affects health-related quality of life (HR-QoL) and the role patient-reported outcomes (PROs) can play in optimizing treatment. PRO measures (PROMs) are comprehensive, subjective assessments of patients' day-to-day HR-QoL. Developed through a scientifically robust, multistage process, PROMs offer insight into patients' symptoms, function, and satisfaction with care. The use of PROMs can increase symptom awareness, stimulate discussion, and enhance shared decision-making between patients and healthcare providers.

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.

A Multidisciplinary Team Guided Approach to the Management of cT3 Laryngeal Cancer: A Retrospective Analysis of 104 Cases

The optimal treatment for T3 laryngeal carcinoma (LC) is still a matter of debate. Different therapeutic options are available: Transoral laser microsurgery (TLM), open partial horizontal laryngectomies (OPHLs), total laryngectomy (TL), and organ preservation protocols (radiation therapy (RT) or chemo-radiation (CRT)). This study aimed to retrospectively evaluate oncologic outcomes of 104 T3 LCs treated by surgery or non-surgical approaches from January 2011 to December 2016 at a single academic tertiary referral center. Each case was evaluated by a multidisciplinary team (MDT) devoted to the management of head and neck cancers. We divided the cohort into two subgroups: Group A, surgical treatment (TLM, OPHLs, TL) and Group B, non-surgical treatment (RT, CRT). For the entire cohort, two- and five-year overall survival (OS) rates were 83% and 56%, respectively. The two- and five-year disease-free survival (DFS) rates were 75% and 65%, and disease-specific survival rates were 93% and 70%, respectively. The N category was a significant independent prognosticator for OS (p = 0.02), whereas Group B was significantly and independently associated with DFS (HR 4.10, p = 0.006). Analyzing laryngo-esophageal dysfunction-free survival as an outcome, it was found that this was significantly lower in higher N categories (p = 0.04) and in cases that underwent non-surgical treatments (p = 0.002). Optimization of oncologic outcomes in T3 LCs may be obtained only by a comprehensive MDT approach, considering that different treatment options have heterogenous toxicity profiles and indications.

Limitations and Opportunities in Open Laryngeal Organ Preservation Surgery: Current Role of OPHLs

The current trend for treatment of intermediate-early advanced laryngeal cancer is essentially oriented toward preservation of organ and laryngeal function, and with a good potential for treating the disease. This goal can be achieved by adopting open laryngeal organ preservation surgery (OLOPS), at present mainly represented by open partial horizontal laryngectomies (OPHLs). An approach using rigorous selection criteria based on both the general condition of the patient and the local and regional extent of the disease gives excellent oncological and functional results in untreated patients. Similar outcomes, albeit slightly worse, are also obtainable in radio-recurrent and laser-recurrent patients. Troublesome postoperative management and the inconsistency of functional recovery are the main limitations for extensive application of this therapeutic strategy. The future direction is represented by simplification of the indications identifying iso-prognostic sub-categories within the T-stage, wider consensus on rehabilitation protocols, hybrid approaches to the larynx, and open minimally invasive access.

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.

Leveraging patient-reported outcomes data to inform oncology clinical decision making: Introducing the FACE-Q Head and Neck Cancer Module

BACKGROUND

Existing patient-reported outcome measures (PROMs) used to assess patients with head and neck cancer have methodologic and content deficiencies. Herein, the development of a PROM that meets a range of clinical and research needs across head and neck oncology is described.

METHODS

After development of the conceptual framework, which involved a literature review, semistructured patient interviews, and expert input, patients with head and neck cancer who were treated at Memorial Sloan Kettering Cancer Center were recruited by their surgeon. The FACE-Q Head and Neck Cancer Module was completed by patients in the clinic or was sent by mail. Rasch measurement theory analysis was used for item selection for final scale development and to examine reliability and validity. Scale scores for surgical defect and adjuvant therapy were compared with the cohort average to assess clinical applicability.

RESULTS

The sample consisted of 219 patients who completed the draft scales. Fourteen independently functioning scales were analyzed. Item fit was good for all 102 items, and all items had ordered thresholds. Scale reliability was acceptable (person separation index was >0.75 for all scales; Cronbach α values were >.87 for all scales; test-retest ranged from 0.86 to 0.96). The scales performed well in a clinically predictable way, demonstrating functional and psychosocial differences across disease sites and with adjuvant therapy.

CONCLUSIONS

The scales forming the FACE-Q Head and Neck Cancer Module were found to be clinically relevant and scientifically sound. This new PROM now is validated and ready for use in research and clinical care.

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.

Lateral cervical approach for open laryngeal surgery: Technical notes

BACKGROUND

Transoral minimally invasive techniques for laryngeal cancer have been proposed to preserve healthy tissues. The aim of this study was to describe a minimally invasive procedure for all laryngectomies with/without neck dissection using a lateral cervical approach.

METHODS

A monolateral or bilateral neck incision at the level of the anterior border of the sterno-cleido-mastoid muscle is performed in accordance with the side of the neck dissection. The harvesting of an anterior myocutaneous (AMC) cervical flap, including skin, platysma, fascia superficialis, anterior jugular veins, homohyoid and sternohyoid muscles is performed. A neck dissection is executed through the same skin incision. Contraindication is represented by extralaryngeal spread with the involvement of the strap muscles. Supra-hyoid, sternohyoid, and homohyoid muscles and hyoid bone are preserved.

CONCLUSION

Open partial/total laryngectomies through a lateral cervical approach are feasible and safe. This surgical access with an AMS cervical flap allows to simultaneously perform neck dissections and the removal of the entire laryngeal specimen.

A Critical Reappraisal of Primary and Recurrent Advanced Laryngeal Cancer Staging

Objectives:

Laryngeal squamous cell carcinoma (LSCC) can involve different anatomic subunits with peculiar surgical and prognostic implications. Despite conflicting outcomes for the same stage of disease, the current staging system considers different lesions in a single cluster. The aim of this study was to critically discuss clinical and pathologic staging of primary and recurrent advanced LSCC in order to define current staging pitfalls that impede a precise and tailored treatment strategy.

Methods:

Thirty patients who underwent total laryngectomy in the past 3 years for primary and recurrent advanced squamous cell LSCC were analyzed, comparing endoscopic, imaging, and pathologic findings. Involvement of the different laryngeal subunits, vocal-fold motility, and spreading pattern of the tumor were blindly analyzed. The diagnostic accuracy and differences between clinicoradiologic and pathologic findings were studied with standard statistical analysis.

Results:

Discordant staging was performed in 10% of patients, and thyroid and arytenoid cartilage were the major diagnostic pitfalls. Microscopic arytenoid involvement was significantly more present in case of vocal-fold fixation ( P = .028). Upstaging was influenced by paraglottic and pre-epiglottic space cancer involvement, posterior commissure, subglottic region, arytenoid cartilage, and penetration of thyroid cartilage; on the contrary, involvement of the inner cortex or extralaryngeal spread tended to be down-staged. Radiation-failed tumors less frequently involved the posterior third of the paraglottic space ( P = .022) and showed a significantly worse pattern of invasion ( P < .001).

Conclusions:

Even with the most recent technologies, 1 in 10 patients with advanced LSCC in this case series was differently staged on clinical examination, with cartilage involvement representing the main diagnostic pitfall.

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.

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.

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.

Conservative treatment for advanced T3-T4 laryngeal cancer: meta-analysis of key oncological outcomes

GOAL

Controversies exist regarding the treatment of advanced laryngeal carcinomas. The purpose of this systematic review was to evaluate the oncologic outcomes of both transoral laser and open partial laryngectomies for advanced (T3-T4) squamous cell laryngeal cancers management.

INTRODUCTION

A systematic review of literature was led searching for articles mentioning the following terms: advanced (T3-T4) laryngeal cancer AND laser; AND open partial laryngectomy; AND transoral laser microsurgery; AND cordectomy; AND conservative surgery; AND tracheohyoidopexy or tracheohyoidoepiglottopexy; AND supratracheal partial laryngectomy; AND supracricoid partial laryngectomy; AND cricohyoidopexy or cricohyoidoepiglottopexy. Then a quantitative analysis was carried on papers published after 1980.

DISCUSSION

The search identified 110 publications, and a total of 21 articles satisfied inclusion criteria and were selected for quantitative synthesis. 10 out of 21 studies had a good quality score, 10 were fair and only one rated a poor score. The pooled disease-free survival (DFS) was 79% (95% CI 74-85), and pooled overall survival (OS) was 71% (95% CI 64-78) at 5 years from all 1921 patients included in the study, with significant heterogeneity (I ² = 89.7% and I ² = 90.4%), respectively. Significant heterogeneity value (p = 0.118) was seen by comparing transoral laser and open partial laryngectomies in terms of DFS.

CONCLUSION

The two surgical techniques are both valid conservative surgical options for advanced laryngeal cancer treatment.

Lateral cervical approach for supracricoid partial laryngectomy

INTRODUCTION

The supracricoid partial laryngectomy has been described for the treatment of T3 laryngeal glottic and supraglottic tumors as well as upfront and salvage surgery. Good oncological and functional outcomes are expected, while the post-operative rehabilitation can be quite difficult for the patient. Early and late complications can occur especially in salvage surgery. Neck dissection according to the T stage is often associated with the resection of the primary tumor.

OBJECTIVE

To verify the feasibility of a minimally invasive procedure for supracricoid partial laryngectomy by adopting the lateral cervical approach.

METHODS/RESULTS

A 61-year old man affected by a cT3N0 glottic cancer already treated 10years prior with radiotherapy for oropharyngeal cancer underwent supracricoid laryngectomy using the lateral approach. The key point of the procedure was a subfascial dissection with the harvesting of anterior cervical flap including skin, fat, platysma, fascia superficialis, anterior jugular veins, homo- and sterno-hyoid muscles.

CONCLUSION

Supracricoid laryngectomy by a lateral approach is feasible and safe; it allows to perform a simultaneous neck dissection and the removal of the entire laryngeal specimen preserving ample healthy tissue compared to the classic anterior approach.

Impact of stage, management and recurrence on survival rates in laryngeal cancer

A retrospective, longitudinal study of 1,616 patients with primary laryngeal squamous cell carcinoma (LSCC) at a single center in Norway during 1983–2010 was undertaken to investigate overall survival, disease specific survival, disease-free survival, prognostic factors for overall survival, and impact of recurrence among all-stage laryngeal cancer patients over 15 years' follow-up. The prognostic impact of gender, age, smoking/alcohol, subsite, tumour, node and metastasis staging, period and modality of treatment were evaluated using Kaplan-Meier and Cox proportional hazard analyses. The importance of recurrence on survival was assessed based on case fatality rates. Five-year overall survival was 56.8%, 64.0% and 38.8%, and disease-specific survival was 80.2%, 87% and 61.6%, respectively, for the entire cohort and for glottic and supraglottic LSCC. Old age, advanced-stage LSCC and supraglottic cancer were associated with lower overall survival. The risk of disease-specific death plateaued after five years and varied significantly by subsite. Multivariate analysis of glottic LSCC revealed that surgical treatment improved overall survival, whereas old age, alcohol, T3-T4 status, positive N-status and no treatment were associated with worse survival. In supraglottic LSCC, age, alcohol, and positive N-status had a significant impact on overall survival by multivariate analysis. Five-year overall survival and disease-specific survival among patients with recurrent disease were 34% and 52%, respectively. In conclusion, marked difference in overall survival between glottic and supraglottic LSCC underline the importance of subsite-specific survival analysis. T-status and primary surgical management is essential only for glottic LSCC, emphasizing the importance of correct disease classification. Inferior outcomes in supraglottic LSCC are associated with old age, positive N-status, and improved follow-up routines are necessary. Primary tumor control is essential since recurrence impairs survival considerably in all subsites. The potential benefit of a primary surgical approach towards T3 LSCC awaits further investigation.