Individualized Dynamic Prediction Model for Patient-Reported Voice Quality in Early-Stage Glottic Cancer

OBJECTIVE

Early-stage glottic cancer (ESGC) is a malignancy of the head and neck. Besides disease control, preservation and improvement of voice quality are essential. To enable expectation management and well-informed decision-making, patients should be sufficiently counseled with individualized information on expected voice quality. This study aims to develop an individualized dynamic prediction model for patient-reported voice quality. This model should be able to provide individualized predictions at every time point from intake to the end of follow-up.

STUDY DESIGN

Longitudinal cohort study.

SETTING

Tertiary cancer center.

METHODS

Patients treated for ESGC were included in this study (N = 294). The Voice Handicap Index was obtained prospectively. The framework of mixed and joint models was used. The prognostic factors used are treatment, age, gender, comorbidity, performance score, smoking, T-stage, and involvement of the anterior commissure. The overall performance of these models was assessed during an internal cross-validation procedure and presentation of absolute errors using box plots.

RESULTS

The mean age in this cohort was 67 years and 81.3% are male. Patients were treated with transoral CO2 laser microsurgery (57.8%), single vocal cord irradiation up to (24.5), or local radiotherapy (17.5%). The mean follow-up was 43.4 months (SD 21.5). Including more measurements during prediction improves predictive performance. Including more clinical and demographic variables did not provide better predictions. Little differences in predictive performance between models were found.

CONCLUSION

We developed a dynamic individualized prediction model for patient-reported voice quality. This model has the potential to empower patients and professionals in making well-informed decisions and enables tailor-made counseling.

Intensity-Modulated Radiation Therapy for Early-Stage Squamous Cell Carcinoma of the Glottic Larynx: A Systematic Review and Meta-Analysis

PURPOSE

Early-stage squamous cell carcinoma of the glottic larynx is commonly treated with 2-dimensional or 3-dimensional conventional radiation therapy (CRT). Despite its use in other head and neck cancers, intensity-modulated radiation therapy (IMRT) remains controversial in this patient population.

METHODS AND MATERIALS

A systematic review was performed by querying 3 databases (Pubmed, Embase, Web of Science) for articles published between December 1, 2000 and September 2, 2022. Included studies reported outcomes in at least 10 patients treated with IMRT for early-stage glottic cancer. Data were extracted and reported following PRISMA standards. Pooled outcomes were estimated using random-effects models. Primary outcome was the rate of local failure (LF) following IMRT. Secondary outcomes included rates of regional failure (RF) following IMRT and rates of LF and RF following CRT.

RESULTS

A total of 15 studies (14 retrospective, 1 prospective) consisting of 2083 patients were identified. IMRT was used in 873 patients (64% T1, 28% T2). Multiple treatment (partial larynx, single vocal cord carotid sparing) and image-guided radiation therapy techniques were used. The pooled crude rate of LF was 7.6% (95% confidence inverval [CI], 3.6%-11.5%) and actuarial LF rates at 3 and 5 years were 6.3% (95% CI, 2.2%-10.3%) and 9.0% (95% CI, 4.4%-13.5%), respectively. The pooled crude rate of RF after IMRT was 1.5% (95% CI, 0.5%-2.5%). On metaregression analysis, increased rate of LF was significantly associated with T2 disease (P < .001) and grade 2 to 3 histology (P < .001). Treatment with CRT was reported in 738 patients (76% T1, 22% T2). Among the studies reporting outcomes of both modalities, there was no significant difference in LF (log odds ratio; P = .12) or RF (log odds ratio; P = .58) between IMRT or CRT.

CONCLUSIONS

In patients with early-stage glottic cancer, retrospective data suggests local and regional control are similar for patients treated with IMRT and CRT. Additional prospective studies with uniform methods of volume delineation and image guidance are needed to confirm the efficacy of IMRT.

The Comparison of Electroacoustic and Subjective Voice Quality in Type 3 and 4 Transoral Laser Cordectomy for Early-Stage Glottic Carcinoma

One of the main issues in early-stage glottic carcinoma management is the voice quality following different types of treatment modalities. In type 3 and 4 transoral laser cordectomies, the voice outcomes can show significant differences due to the extent of the vocal muscle resection. This study aims to compare the voice quality in patients who underwent type 3 and 4 laser cordectomy for early-stage glottic carcinoma. A total of 30 patients who underwent type 3 (15 patients) and type 4 (15 patients) laser cordectomy for T1a glottic carcinoma between May 2018 and 2020 were included in this retrospective comparative study. Electroacoustic voice analysis and Voice Handicap Index-10 were performed in the postoperative twelfth month and the outcomes were compared between two laser cordectomy groups. The mean age of all patients was 48.6 ± 4.2 years. Noise-to-harmonic ratio, jitter, shimmer, pitch perturbation quotient and amplitude perturbation quotient values were significantly different between two groups (p < 0.05). Fundamental frequency and Voice Handicap Index-10 scores showed no statistically significant difference (p > 0.05). This study reports significantly better results for type 3 against type 4 laser cordectomy by means of objective voice analysis outcomes, except fundamental frequency. On the other hand, self-reported subjective analysis showed very similar results for both groups. Further studies combining data with multiple objective and subjective analyses with larger patient series and longer follow-up are warranted.

Pathologically Negative Excision for Biopsy-Proven Early Glottic Carcinoma

In certain instances, patients who underwent endoscopic laser excision (ELE) for biopsy-proven early glottic carcinoma do not show any evidence of carcinomatous cells on histopathologic analysis. Our study aims to determine the incidence of this phenomenon. A retrospective analysis of patients with biopsy-proven early glottic squamous cell carcinoma who underwent ELE was conducted. 121 patients with a mean age of 68.2 ± 10.7 were included in this study. Initial biopsy showed carcinoma in situ in 38 patients, (31.4%), T1a in 41 patients (33.9%), and T1b in 42 patients (34.7%). Following ELE, a pathologically negative excision was seen in 26 patients (21.5%). Disease recurrence occurred in 3 patients who had a pathologically negative excision (11.5%). Following repeat ELE, all patients remained disease free. A significant number of early glottic carcinoma present with small volume disease which may be eradicated with diagnostic biopsy alone.

Prognostic factors and a dynamic model on cancer-specific survival for T1a N0 M0 glottic cancer: A population-based analysis and clinical validation

OBJECTIVES

The survival rate varies tremendously in T_1a N₀ M₀ glottic cancer patients, which may be associated with the difference on patients' characters, such as age, treatment, and marital status. The objective of this study is to identify the vital factors and construct a dynamic prognostic model for predicting the cancer-specific survival (CSS) of patients with T_1a N₀ M₀ glottic cancer.

DESIGN, SETTING, AND PARTICIPANTS

The data of T_1a N₀ M₀ glottic cancer patients were extracted retrospectively from the SEER database between 2004 and 2015, which were randomly divided into the training dataset (70%) and the validation dataset (30%). The training cohort was used to identify independent prognostic factors and build the prognostic nomogram. While the validation cohort was used to validate the applicability of the newly constructed model.

MAIN OUTCOME MEASURES

The model was evaluated with the discrimination, the calibration, and the clinical benefit. The external data collecting from a medical center were used to validate the performance of the prognostic model.

RESULTS

Totally, 3286 eligible patients in the data of the SEER database and 139 eligible patients in our external clinical cohort were finally identified. 5 independent prognostic factors (age, marital status, Grade, primary site surgery, and chemotherapy) were identified and applied to develop the dynamic prognostic tool. C-indexes, receiver operating characteristic curves, calibration curves, and decision curve analyses proved that the prognostic nomogram showed excellent predictive accuracy, ability, and prognostic value. Using internal and external cohorts, the validation of the model also proved its reliability.

CONCLUSION

Prognostic factors for T_1a N₀ M₀ glottic cancer were identified. The novel web-based prognostic prediction tool may be beneficial in clinical decision-making and has value in risk stratification, personalized treatment, and clinical trial design.

Longitudinal Patient-Reported Voice Quality in Early-Stage Glottic Cancer

OBJECTIVE

Patient-reported voice quality is an important outcome during counseling in early-stage glottic cancer. However, there is a paucity of adequate longitudinal studies concerning voice outcomes. This study aimed to investigate longitudinal trajectories for patient-reported voice quality and associated risk factors for treatment modalities such as transoral CO₂ laser microsurgery, single vocal cord irradiation, and local radiotherapy.

STUDY DESIGN

A longitudinal observational cohort study.

SETTING

Tertiary cancer center.

METHODS

Patients treated for Tcis-T1b, N0M0 glottic cancer were included in this study (N = 294). The Voice Handicap Index was obtained at baseline and during follow-up (N = 1944). Mixed-effects models were used for investigating the different trajectories for patient-reported voice quality.

RESULTS

The mean follow-up duration was 43.4 (SD 21.5) months. Patients received transoral CO₂ laser microsurgery (57.8%), single vocal cord irradiation (24.5%), or local radiotherapy (17.5%). A steeper improvement during the first year after treatment for single vocal cord irradiation (-15.7) and local radiotherapy (-12.4) was seen, compared with a more stable trajectory for laser surgery (-6.1). All treatment modalities showed equivalent outcomes during long-term follow-up. Associated risk factors for different longitudinal trajectories were age, tumor stage, and comorbidity.

CONCLUSION

Longitudinal patient-reported voice quality after treatment for early-stage glottic cancer is heterogeneous and nonlinear. Most improvement is seen during the first year of follow-up and differs between treatment modalities. No clinically significant differences in long-term trajectories were found. Insight into longitudinal trajectories can enhance individual patient counseling and provide the foundation for an individualized dynamic prediction model.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The robotic-assisted extended "Sistrunk" approach for tumors of the upper aerodigestive tract with limited transoral access: First description of oncological and functional outcomes

We report on the first clinical experience with the robotic-assisted extended "Sistrunk" approach (RESA) for access to constrained spaces of the upper aerodigestive tract. This prospective case cohort study include six patients that underwent RESA if transoral exposure could not be achieved. Three patients received previous radiation. Patients were postoperatively followed until week 16 for perioperative complications, surgical margins, and functional outcomes. In all patients RESA allowed adequate exposure and resection with negative margins. Three patients who underwent salvage surgery experienced a minor or intermediate grade postoperative bleeding. No patient developed a pharyngocutaneous fistula. Three patients recovered their swallowing to their preoperative status and the remaining three experienced an improvement. All patients experienced complete recovery of their voice. RESA has the potential to provide a new organ preservation approach for head and neck cancer (HNC) not amenable to transoral exposure and thus warrants further prospective clinical studies.

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

Voice Outcomes after Radiotherapy for Laryngeal Cancer

Objective The study was aimed to assess changes in voice outcomes after radiotherapy in laryngeal cancer patients.

Materials and Methods The study included 60 laryngeal cancer patients treated with definitive radiotherapy or chemoradiotherapy between 2005 and 2012. The primary endpoint of this study was to assess abnormalities of the patients’ voices after the treatment. The Thai version of the Voice Handicap Index (VHI) and xerostomia questionnaire were conducted by telephone. Videostroboscopic examination was done to objectively assess voice outcomes.

Results The median age of patients was 63 years. Most patients had glottic cancer (84.1%) and T1–2 disease (84.1%). The median time from treatment to the study was 46 months. In terms of the total VHI score, most patients were in the normal and slight handicap groups (22% and 71.4%, respectively). Only 4.8% and 1.6% of the patients were in moderate and severe handicap group, respectively. Twenty-eight patients had significant xerostomia. Videostroboscopy examination was done in 23 patients and most common findings were telangiectasia (95.7%), abnormal mucosal wave (47.8%), and abnormal glottic closure configuration (34.8%). Regarding total VHI score, lower radiation dose, conventional radiation dose per fraction, longer period after treatment, and significant xerostomia status were significantly correlated with worse voice outcomes. There were no statistically significant correlations between the videostroboscopic findings and VHI scores.

Conclusion Voice outcomes in most of laryngeal cancer patients treated with radiotherapy had a normal or mild handicap at more than 1 year of follow-up. Only 4.8% and 1.6% of the patients had moderate and severe voice outcome handicap, respectively.

Prognostic factors of patients with initially diagnosed T1a glottic cancer: Novel nomograms and a propensity-score matched cohort analysis

The option of T1a glottic cancer treatments remarkably varied in different countries. This study aimed to construct predictive models to predict overall survival (OS) and cancer-specific survival (CSS) of patients with initially diagnosed T1a glottic cancer. And we used propensity score matching (PSM) to reassess the effect of treatments.Data of patients with initially diagnosed T1a glottic cancer were extracted from the Surveillance, Epidemiology, and End Results database. Patients with complete information were randomly divided into the training and the validation cohorts (7:3). Cox regression was conducted to screen significant predictors of the OS and the CSS. PSM was performed to mimic randomized controlled trials. Survival analyses were performed by Kaplan-Meier survival methods, and log-rank tests were utilized.A total of 2342 patients met the inclusion criteria. Survival analyses showed that patients who underwent primary site surgery would have better OS and CSS. Univariate analyses and multivariate analyses proved that stage, N stage, primary site surgery, and chemotherapy significantly affected both the OS and the CSS. Predictive nomograms were established to predict patients' prognosis. Finally, the OS and the CSS for patients who underwent primary site surgery alone were significantly longer than those who underwent radiation alone before and after PSM.We constructed nomograms predicting the OS and the CSS of patients with initially diagnosed T1a glottic cancer. Compared to our previous studies, this study indicated that primary site surgery may be superior to radiation and chemotherapy. At present, chemotherapy should be not recommended for T1a glottic cancer patients.

Is Single Cord Irradiation Going to Be a New Standard for T1a Glottic Carcinoma?

Purpose and Objective: To evaluate the disease-free survival, overall survival, dosimetric, and voice handicap index (VHI) results of T1a glottic invasive squamous cell carcinoma (SCC) patients who underwent hypofractionated single vocal cord irradiation (HSVCI).

Materials and Methods: The data of 18 patients with stage T1a glottic SCC were collected prospectively and analyzed retrospectively between July 2016 and July 2019. Patients were immobilized using a custom-fitted thermoplastic face and shoulder mask in hyperextension position. The CT scan was performed with 1-mm-thick slices. A planned target volume (PTV) margin of 3 mm was given to clinical target volume (CTV) in all directions, and 13 organs at risk were identified. Patients were prescribed a total of 5760–5808 cGy in 15–16 fractions. Patients had daily cone-beam computed tomography (CBCT), and the treatment was carried out with the physician. VHI test was applied to patients before and at the end of radiotherapy (RT) and 1, 2, 3, 4, and 6 months after the completion of RT.

Results: Local control and overall survival rate is 100% for a median of 18 months (6–44 months) of follow-up. A patient was diagnosed with 2nd primary lung cancer and active treatment still continues. All patients completed the treatment within the scheduled time. Grade 1–2 dysphagia and dermatitis occurred in all patients, and no grade 3 and above side effects were observed. The mean values of VHI were 37.00, 39.83, 38.28, 17.17, 12.22, 8.56, and 6.06 at the beginning of RT, at the end of RT, and 1, 2, 3, 4, and 6 months after RT, respectively.

Conclusion: Compared to surgery and conventional laryngeal radiotherapy, HSVCI is an alternative treatment method for T1a glottic cancer by reducing the treatment time to 3 weeks, facilitating recurrence treatment, and providing effective sound quality without compromising local control. Considering that ~80% of recurrences in glottic cancer occur within the first 2 years, 100% local control in a median of 18 months is extremely successful, but long-term follow-up is essential to observe possible late side effects.

Surgery versus radiotherapy: Long term outcomes of T1 glottic cancer

Aim

The aim of this study was to compare the outcomes, patterns of failure and laryngeal preservation rates in patients with T1N0 glottic cancer treated with surgery or radiotherapy.

Materials/methods

Retrospective study of T1N0 glottic cancer patients treated in our institution between January 2007 and December 2017. Histologically proven squamous cell carcinoma patients, treated with upfront cordectomy/partial laryngectomy (S group) or radiotherapy (RT group) were included. Elective treatment of the neck was not permitted. Local failure (LF), disease-free survival (DFS), ultimate disease-free survival (UDFS), laryngectomy-free survival (LFS), disease-specific mortality (DSM) and overall survival (OS) were evaluated.

Results

Two hundred and one patients were eligible (172 S group, 29 RT group), with a median follow-up of 38.8 months. Overall, 33 (16%) patients had a recurrence, 30 (17%) in the S group and 3 (10%) in the RT group. Local failure was the predominant site of failure (28 S, 2 RT). Overall, of all those that were salvaged, 17 (8%) underwent total laryngectomy (15 S, 2 RT). There was no significant difference in the 5-year cumulative incidence of LF (20.8% S, 8.1% RT, p = 0.138), 5-y LFS (85.0% vs. 91.7%, p = 0.809), 5-y DFS (67.5% vs. 82.1%, p = 0.343), 5-y UDFS (82.5% vs. 90.3%, p = 0.647) and 5-y OS (84.5% vs. 90.3%, p = 0.892). Multivariate analysis showed no correlation between initial treatment and the analyzed outcomes.

Conclusion

Primary surgery or radiotherapy were similar first line options, since they do not differ in all outcomes. Patients' and physician's preferences must be considered when choosing first treatment.

Comparison of Current Surgical and Non-Surgical Treatment Strategies for Early and Locally Advanced Stage Glottic Laryngeal Cancer and Their Outcome

For the treatment of early and locally advanced glottic laryngeal cancer, multiple strategies are available. These are pursued and supported by different levels of evidence, but also by national and institutional traditions. The purpose of this review article is to compare and discuss the current evidence supporting different loco-regional treatment approaches in early and locally advanced glottic laryngeal cancer. The focus is kept on randomized controlled trials, meta-analyses, and comparative retrospective studies including the treatment period within the last twenty years (≥ 1999) with at least one reported five-year oncologic and/or functional outcome measure. Based on the equipoise in oncologic and functional outcome after transoral laser surgery and radiotherapy, informed and shared decision-making with and not just about the patient poses a paramount importance for T1-2N0M0 glottic laryngeal cancer. For T3-4aN0-3M0 glottic laryngeal cancer, there is an equipoise regarding the partial/total laryngectomy and non-surgical modalities for T3 glottic laryngeal cancer. Patients with extensive and/or poorly functioning T4a laryngeal cancer should not be offered organ-preserving chemoradiotherapy with salvage surgery as a back-up plan, but total laryngectomy and adjuvant (chemo) radiation. The lack of high-level evidence comparing contemporary open or transoral robotic organ-preserving surgical and non-surgical modalities does not allow any concrete conclusions in terms of oncological and functional outcome. Unnecessary tri-modality treatments should be avoided. Instead of offering one-size-fits-all approaches and over-standardized rigid institutional strategies, patient-centered informed and shared decision-making should be favored.

Systematic review and meta-analysis of T1 glottic cancer outcomes comparing CO2 transoral laser microsurgery and radiotherapy

BACKGROUND

The objective of this study is to compare the oncologic outcomes of CO₂ transoral laser microsurgery (TLM) and radiotherapy (RT) for treatment of T1 glottic carcinoma.

METHODS

A literature search was conducted in the following databases: Medline/PubMed, Web of Science, EMBASE, and the Cochrane Library. Search results were screened, and publications comparing oncologic outcomes of T1N0M0 glottic carcinoma treated with TLM or RT were included. Data was extracted independently by two authors, and publication quality was graded according to the Oxford Centre for Evidence-based Medicine. Meta-analysis was performed for overall survival, disease specific survival, laryngeal preservation, and local control.

RESULTS

Sixteen studies were included in the meta-analysis, the majority being retrospective cohort studies with two prospective cohort studies. Included studies were rated as either Level II or III evidence. Meta-analysis favoured treatment with TLM for T1 glottic carcinoma patients for the following outcomes: overall survival (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.07-2.14; P = 0.02), disease specific survival (OR, 2.70; CI, 1.32-5.54; P = 0.007), and laryngeal preservation (OR, 6.31; CI, 3.77-10.56; P < 0.00001). There was no difference in local control between TLM and RT in T1 glottic cancer (OR, 1.19; CI, 0.79-1.81; P = 0.40).

DISCUSSION

Our study provides a current and thorough comparison of TLM and RT outcomes in T1 glottic carcinoma. Limitations of our study include lack of randomized control trials, and non-randomized allocation of patients to treatment groups. Our meta-analysis suggests that TLM is the superior modality in terms of overall survival, disease specific survival, and laryngeal preservation. Future prospective randomized controlled studies are required for confirming these findings and developing appropriate clinical practice guidelines.

LEVEL OF EVIDENCE

2A; as per the Centre of Evidence Based Medicine.

Long-Term Experience of Chemoradiotherapy Combined with Deep Regional Hyperthermia for Organ Preservation in High-Risk Bladder Cancer (Ta, Tis, T1, T2)

This article reports on the different treatments for bladder cancer and related effects on frequency of bladder preservation, disease‐free survival, and overall survival, with a focus on the efficacy and safety of chemoradiotherapy combined with regional deep hyperthermia of high‐risk bladder cancer after transurethral resection of bladder tumor.

Background.

The aim of this study was to evaluate the efficacy and safety of chemoradiotherapy (RCT) combined with regional deep hyperthermia (RHT) of high‐risk bladder cancer after transurethral resection of bladder tumor (TUR‐BT).

Materials and methods.

Between 1982 and 2016, 369 patients with pTa, pTis, pT1, and pT2 cN0–1 cM0 bladder cancer were treated with a multimodal treatment after TUR‐BT. All patients received radiotherapy (RT) of the bladder and regional lymph nodes. RCT was administered to 215 patients, RCT + RHT was administered to 79 patients, and RT was used in 75 patients. Treatment response was evaluated 4–6 weeks after treatment with TUR‐BT.

Results.

Complete response (CR) overall was 83% (290/351), and in treatment groups was RT 68% (45/66), RCT 86% (178/208), and RCT + RHT 87% (67/77). CR was significantly improved by concurrent RCT compared with RT (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.05–5.12; p = .037), less influenced by hyperthermia (OR, 2.56; 95% CI, 0.88–8.00; p = .092). Overall survival (OS) after RCT was superior to RT (hazard ratio [HR], 0.7; 95% CI, 0.50–0.99; p = .045). Five‐year OS from unadjusted Kaplan‐Meier estimates was RCT 64% versus RT 45%. Additional RHT increased 5‐year OS to 87% (HR, 0.32; 95% CI, 0.18–0.58; p = .0001). RCT + RHT compared with RCT showed a significantly better bladder‐preservation rate (HR, 0.13; 95% CI, 0.03–0.56; p = .006). Median follow‐up was 71 months. The median number of RHT sessions was five.

Conclusion.

The multimodal treatment consisted of a maximal TUR‐BT followed by RT; concomitant platinum‐based chemotherapy combined with RHT in patients with high‐grade bladder cancer improves local control, bladder‐preservation rate, and OS. It offers a promising alternative to surgical therapies like radical cystectomy.

Implications for Practice.

Radical cystectomy with appropriate lymph node dissection has long represented the standard of care for muscle‐invasive bladder cancer in medically fit patients, despite many centers reporting excellent long‐term results for bladder preserving strategies. This retrospective analysis compares different therapeutic modalities in bladder‐preservation therapy. The results of this study show that multimodal treatment consisting of maximal transurethral resection of bladder tumor followed by radiotherapy, concomitant platinum‐based chemotherapy combined with regional deep hyperthermia in patients with Ta, Tis, T1–2 bladder carcinomas improves local control, bladder‐preservation rate, and survival. More importantly, these findings offer a promising alternative to surgical therapies like radical cystectomy. The authors hope that, in the future, closer collaboration between urologists and radiotherapists will further improve treatments and therapies for the benefit of patients.

Organ Function Preservation Failure after (Chemo)Radiotherapy in Head and Neck Cancer: A Retrospective Cohort Analysis

Objective

The aim of the current study was to determine the incidence of organ function preservation failure (OFPF) in patients with head and neck squamous cell carcinoma (HNSCC) treated by (chemo)radiotherapy and to identify its risk factors.

Study Design

Retrospective cohort analysis.

Setting

Tertiary cancer care center.

Subjects and Methods

A single-center retrospective cohort analysis was done (n = 703) in which OFPF after (chemo)radiotherapy was assessed. OFPF was defined as local failure or pure functional failure in the absence of local failure because of major surgical intervention (total laryngectomy, commando resection, permanent tracheostomy) or feeding tube dependence >2 years.

Results

OFPF occurred in 153 patients (21.8%). Reasons for OFPF were local failure in 103 patients (14.6%) and functional failure in 50 patients (7.2%). Evidence of functional failure included need for total laryngectomy (n = 9, 1.3%), commando resection (n = 2, 0.3%), permanent tracheostomy (n = 16, 2.3%), and/or long-term feeding tube for functional reasons (n = 23, 3.3%). In a Cox proportional hazards model, OFPF was worse for patients with T4 tumors (hazard ratio [HR] <0.5 and P < .001 for all other stages), for laryngeal vs oropharyngeal cancer (HR, 1.83; 95% confidence interval [CI], 1.20-2.79, P = .005, hypopharyngeal not significant), and for smokers (HR, 1.68; 95% CI, 1.10-2.56, P = .015). Exploratory multivariate analysis by tumor site showed that T4 tumor and pretreatment tracheostomy were the strongest predictive factors for OFPF in laryngeal and hypopharyngeal carcinoma while T4 tumor and smoking were predictive for poor OFPF in oropharyngeal carcinoma.

Conclusion

This work shows a detrimental effect of smoking on functional outcomes after (chemo-)radiotherapy for HNSCC. Moreover, T4 tumor, laryngeal subsite, and pretreatment tracheostomy are strong predictors of OFPF.

Comparative efficacy of six therapies for Hypopharyngeal and laryngeal neoplasms: a network meta-analysis

Background

Hypopharyngeal and laryngeal neoplasms are both fatal and hard to catch in early stages. Yet which treatment is the most efficacious one still remain unanswered. This network meta-analysis (NMA) was conducted to investigate effectiveness of six therapies being utilized in clinical practice nowadays.

Methods

PubMed and Embase were retrieved to synthesize data. Direct and indirect evidence was combined to compare efficacy of treatments. A relative ranking of the six regimens was calculated by the surface under the curve ranking area (SUCRA).

Results

A total of 28 trials with 9109 patients were included in our NMA. Five endpoints investigated included 3/5-year overall survival (3/5-OS), 3/5-year disease free survival (3/5-DFS) and 5-year overall survival rate (5-OSR). In terms of all efficacy outcomes, radiotherapy combined with surgery (RT + S) proved to be better than other therapies while radiotherapy (RT) alone also performed well. Induction chemoradiotherapy (ICRT) was the best regarding 3-DFS (SUCRA = 0.846) while current chemoradiotherapy (CCRT) ranked first in 5-DFS (SUCRA = 0.933) according to SUCRA results. No significant differences were demonstrated in 5-DFS and 5-OSR as shown in the results of NMA.

Conclusions

RT combined with surgery turned out to be optimal therapy of all the outcomes while the efficacy of RT was relatively poorer in the treatment of patients with larynx stage III-IV and hypopharynx stage II-IV. Also, the good performance of CCRT and ICRT in terms of DFS made them as secondary recommended therapies. There is no significant difference between surgery and transoral laser microsurgery (TLM) alone.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5412-z) contains supplementary material, which is available to authorized users.

Surgery versus radiation for T1 glottic carcinoma: Second primary considerations

Although early glottic carcinoma is managed with radiation therapy (RT) or surgery, there is limited data on differences in second primary cancers of the larynx. We utilized the Surveillance, Epidemiology, and End Results (SEER) database to query T1 glottic carcinomas and assess the incidence of second primary laryngeal malignancies. Cumulative hazard for second primary laryngeal malignancies was compared with the log-rank method. Among 844 surgical and 2,272 RT cases, observed-to-expected incidence ratios of laryngeal second primaries were 10.19 (5.89-16.55) and 6.87 (4.64-9.81) per 10 thousand person-years, respectively. Mean person-years at risk were comparable at 8.16 years (surgery) and 8.01 years (RT), and relative increased risk of laryngeal second primary was 20.95 (surgery) versus 14.09 (RT) per 10 thousand person-years. Mean times to development of a second primary were also comparable (304 vs. 305 months, P = 0.898). Thus, second laryngeal primary development is analogous between cases treated with surgery alone versus RT. Continued discussion and investigation of surgery versus RT for early glottic squamous cell carcinoma will need to leverage these findings, along with ongoing investigation of voice and survival outcomes, to develop more well-informed treatment algorithms. Laryngoscope, 129:2713-2715, 2019.

Voice outcome after unilateral ELS type III or bilateral type II resections for T1-T2 glottic carcinoma: Results after 1 year

Background

Voice outcome was assessed in patients with extended T1 and limited T2 glottic carcinoma, treated with a unilateral type III or a bilateral type II resection according to the European Laryngological Society (ELS) classification.

Methods

Objective evaluation (acoustic and aerodynamic parameters), perceptual evaluation (GRBAS), and patients' self‐assessment (voice handicap index [VHI]) were performed before and 1 year after treatment. Results were evaluated according to ELS resection type and the involvement of the anterior commissure.

Results

The majority of voice parameters in all resection subgroups showed an improvement of the mean score 1 year postoperatively. Grade of dysphonia varied between 1.15 and 1.66 postoperatively and VHI score varied from 23.3 to 24.5.

Conclusion

Voice outcome after ELS unilateral type III or a bilateral type II resection for extended T1 and limited T2 glottic carcinoma is good with mild to very moderate perceptive dysphonia and low self‐reported voice impairment.

Nature and role of surgical margins in transoral laser microsurgery for early and intermediate glottic cancer

PURPOSE OF REVIEW

Summarize recent findings regarding the impact of margin status on oncologic outcomes and organ preservation, as well as evaluate possible management policies of close and positive margins after transoral laser microsurgery (TLM) for Tis-T2 glottic carcinomas.

RECENT FINDINGS

Impact of margin status on survival rates remains controversial, whereas some authors found close and positive margins to be independent risk factors for recurrence and poorer survival rates, others did not find any significant variations compared with negative ones. A common trend can be observed in performing a watchful waiting policy or second look TLM in patients with close-superficial and positive single-superficial margins. Further treatment seems preferable in case of deep and positive multiple superficial margins.

SUMMARY

Positive margins are present in up to 50% of patients treated by TLM, even though a high rate of false positivity, reaching 80%, has been described. Close and positive single superficial margins seem to be linked to higher recurrence rates compared with negative margins, even though watchful wait and see policy, especially when performed by adjunctive visual aids like Narrow Band Imaging, maintains good final oncological and organ preservation outcomes. Further treatments are required in case of deep margin positivity.

Primary and salvage laser surgery of 341 glottic cancers-Comparison of treatment outcomes between University Head Neck Tertiary Referral Center and Local Head Neck Department

OBJECTIVE

The main goal was to compare the clinical data of patients with T1 and T2 glottic cancer treated with CO₂ transoral laser microlaryngoscopy (TLM) in the Tertiary Referral University Department of Otolaryngology, Head Neck Surgery, Poznan and the local Department of Otolaryngology, Oncology and Maxillofacial Surgery, Bydgoszcz.

MATERIAL AND METHODS

Unified databases for the 7-year period January 2005-December 2011 were created to compare these two cohorts. The database contained 341 patients: 231 from the tertiary center and 110 from the local department, of which 298 (87%) were men, and 43 (13%) were women.

RESULTS

Cordectomy type I-IV was performed in 250 (73%) patients, cordectomy type V-VI in 84 (25%) patients, and cordectomy enlarged to epiglottic petiole in 7 (2%) patients. Local recurrence was observed in 96 (28%) cases. Among these cases, 81 (87.5%) patients had salvage surgery: 43 re-cordectomy, 10 open partial laryngectomy, and 28 total laryngectomy. The outcomes for the whole cohort, Tertiary Referral Center and Local Department respectively were as follows: larynx preservation rate was 91.8%, 93.6%, and 88%; 3-year disease specific survival was 97.4%, 97.9%, and 93.3%; 3-year overall survival was 93.5%, 96.6%, and 85.5%; 5-year disease specific survival was 95.2%, 95.2%, and 96.3%; and 5-year overall survival was 84.5%, 88.7%, and 76%, respectively.

CONCLUSION

Comparison of the cohorts showed that outcomes of primary treatment were similar but there were noticeable differences in salvage treatment efficacy, favoring patients from the Tertiary Referral Center. Lasers Surg. Med. 50:311-318, 2018. © 2017 Wiley Periodicals, Inc.

Laser surgery versus radiotherapy for T1a glottic carcinoma: a meta-analysis of oncologic outcomes

OBJECTIVES

A meta-analysis was conducted to compare oncologic outcomes for patients of T1a glottic carcinoma who were treated with laser surgery (LS) or radiotherapy (RT).

METHODS

All related studies published up to October 2016 were acquired by searching PubMed, EMBASE, and Cochrane were conducted by two authors, with the index words: vocal, glottis, larynx, laser, surgery, cordectomy, radiotherapy, radiation, irradiation, carcinoma, and cancer. Relative studies which compared oncologic outcomes between LS and RT were included.

RESULTS

A total of nine eligible studies were included for the analysis, which contained two prospective studies and seven retrospective studies. LS has increased larynx preservation (OR = 3.86, 95% CI = 1.47-10.13, p = .006) compared with RT group. No statistical difference was observed between LS group and RT group in terms of local control, overall survival, and disease-specific survival. There was a slight trend in terms of local control, overall survival, and disease-specific survival that all favored LS, although all data did not reach the level of statistical significance.

CONCLUSIONS

The results of this meta-analysis indicate that LS may be a better option for the treatment of T1a glottic carcinoma because patients underwent LS may benefit from increased larynx preservation compared with RT. However, more multi-center randomized controlled trials would be urgently needed to prove these differences.

The voice quality after laser surgery versus radiotherapy of T1a glottic carcinoma: systematic review and meta-analysis

Background and objectives

The voice quality assessment of laser surgery (LS) in comparison with radiotherapy (RT) remains uncertain in T1a glottic carcinoma treatment. This systematic review and meta-analysis were conducted to compare the voice quality of the two treatments.

Methods

Searches were conducted in PubMed, EMBASE, and Cochrane with the following index words: glotti*, layn*, vocal cord, vocal, surgery, cordectomy, laser, radiation, irradiation, radiotherapy, cancer, and carcinoma for relative studies that compared the voice quality between LS and RT. Random-effect models were used, and heterogeneity was assessed.

Results

A total of 14 studies were included in the analysis, consisting of 1 randomized controlled trial, 1 prospective study, and 12 retrospective studies. RT has increased the maximum phonation time (MPT; mean difference [MD] =−1.89, 95% confidence interval [CI] =−3.66 to −0.11, P=0.04) and decreased the fundamental frequency (MD =14.06, 95% CI =10.30–17.83, P<0.00001) in comparison with LS. No statistical difference was observed between the two groups in terms of Voice Handicap Index, Jitter, Shimmer, and airflow rate.

Conclusion

RT may be a better choice for T1a glottic carcinoma treatment compared with LS because patients undergoing RT may have the advantage of increased MPT and decreased fundamental frequency. However, more multicenter, randomized, controlled trials are urgently needed to verify these differences.

Transoral Laser Microsurgery in Early Glottic Lesions

PURPOSE OF REVIEW

To give an overview of the evolvement of transoral laser microsurgery (TLM) in the treatment of early glottic carcinoma and highlight the contribution of recent literature.

RECENT FINDINGS

The indications and limits of TLM have been well specified. Effects on swallowing have been well documented. Introduction of narrow-band imaging (NBI) and diffusion-weighted magnetic resonance has been shown of additional value for outcome. The first reports on transoral robotic surgery show that it may be of added value in the future.

SUMMARY

TLM for early glottic carcinoma (Tis-T2) has very good oncological outcomes with indications of higher larynx preservation in TLM than that in radiotherapy. The anterior commissure is a risk factor if involved in the cranio-caudal plane, and reduced vocal fold mobility is a risk factor when this is due to arytenoid involvement. The best voice results are achieved when the anterior commissure can be left intact along with part of the vocal fold muscle although even in larger resections, patient self-reported voice handicap is still limited.