Could laser‐assisted dissection of the pre‐epiglottic space affect functional outcome after ESL?

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.

Relationship between dysphagia and surgical treatment for supraglottic laryngeal carcinoma: A meta-analysis

OBJECTIVE

To systematically evaluate differences in swallowing disorder-related manifestations in patients with supraglottic laryngeal cancer, who underwent traditional open partial horizontal laryngectomy (OPHL) and endoscopic supraglottic laryngectomy (ESL).

METHODS

A systematic review of the literature and a meta-analysis were performed. The CNKI, Wan Fang, PubMed, EMBASE, Cochrane Library, Web of Science, and Clinical Trials databases for clinical studies data sources were investigated. The efficiency of recovery, postoperative swallowing function, and complications related to dysphagia were investigated to compare the effects of surgical procedures.

RESULTS

The meta-analysis included 8 studies with 281 patients. ESL surgery played a positive role in the recovery of patients. Preservation of the anterior epiglottic space, ventricular band, and arytenoid cartilage without destroying the external framework of the larynx can effectively reduce the risk of aspiration pneumonia in patients.

CONCLUSIONS

ESL has advantages in postoperative recovery and retention of swallowing function in patients with supraglottic laryngeal cancer.

Prognostic Features in Intermediate-Size Supraglottic Tumors Treated With Open Supraglottic Laryngectomy

OBJECTIVES/HYPOTHESIS

We investigated growth patterns and pathological features in intermediate-size laryngeal carcinoma amenable to supraglottic laryngectomy.

STUDY DESIGN

Retrospective cohort study.

METHODS

We reviewed patients who underwent an open partial horizontal laryngectomy (OPHL) type I. We analyzed pathological data, tumor sizes, overall survival, disease-specific survival, local control, and laryngeal preservation. Results were stratified between three groups: group I comprised patients with endolaryngeal carcinoma, group II comprised patients with anterior epilaryngeal carcinoma who underwent an OPHL type I + base of tongue (BOT), group III comprised patients with lateral epilaryngeal carcinoma who underwent an OPHL type I + pyriform sinus (PIR).

RESULTS

Sixty-eight patients were analyzed. The 5-year rates of overall survival, disease-specific survival, local control, and laryngeal preservation were 68.4%, 83.7%, 91.6%, and 98.3%, respectively. The tumor sizes at pathological examination were similar between the three groups (mean 27 mm, P = .80) and were associated with pathological features, notably pre-epiglottic space (PES) invasion (24.9 mm vs. 32.2 mm, P = .01), occult invaded lymph nodes (22.6 mm vs. 29.9 mm, P = .03), and trends for margins status (26.5 mm vs. 29.3 mm, P = .45). The risks of PES invasion, occult lymph nodes, and positive margins, respectively, predominated in group I (41.7%), group II (56.3%), and group III (23.3%).

CONCLUSION

In intermediate-size tumors amenable to supraglottic laryngectomy, pathological features are associated with tumor size according to group stratification based on tumor location.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1980-E1986, 2021.

Current role of primary surgical treatment in patients with head and neck squamous cell carcinoma

PURPOSE OF REVIEW

The objective of this review article is to discuss the current role of surgery as the primary treatment modality in patients with head and neck squamous cell carcinoma (HNSCC).

RECENT FINDINGS

HNSCC represents one of the cancer locations where the primary treatment modality is the most under discussion. Indeed, the respective roles of primary surgical resection followed, as necessary, by adjuvant radiotherapy or definitive chemoradiotherapy remain controversial. The results of organ preservation trials and the drastic rise in the incidence of human papillomavirus-induced oropharyngeal tumors, which are known to be highly radiosensitive, have led to an increasing use of chemoradiation-based therapies in HNSCC patients. However, no chemoradiation-based protocol has shown better oncologic outcomes than radical primary surgery. Moreover, development of minimally invasive surgical techniques, such as transoral robotic surgery, and advances in head and neck microvascular reconstruction have considerably improved the clinical outcomes of the patients and have led to a reconsideration of the role of primary surgery in HNSCC patients.

SUMMARY

Surgery should be the primary treatment modality for most resectable oral cavity cancers and for T4a laryngeal/hypopharyngeal cancers. Primary surgery could also be the preferred modality of treatment for most early (T1-T2, N0) laryngeal and hypo/oropharyngeal carcinomas when this strategy offers an opportunity to reserve radiotherapy for a potential recurrence or second primary tumor. Primary surgery should also be considered in patients with locally advanced human papillomavirus-negative oropharyngeal carcinoma.

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.