Multidisciplinary approach in the treatment of T1 glottic cancer. The role of patient preference in a homogenous patient population

Influence of age on voice quality after transoral CO2 laser microsurgery

OBJECTIVE

To study the post-operative evolution of voice quality of patients treated by transoral CO2 laser microsurgery (TLM) according to the age.

METHODS

Patients treated by type I to VI TLM and post-operative speech therapy were prospectively recruited from our hospital. The voice quality was assessed pre-, 1-, 3- 6- and 12-month posttreatment with voice handicap index (VHI), dysphonia, roughness, breathiness, asthenia, strain (GRBAS), maximal phonation time (MPT), F0, F0 standard deviation (STD), percent jitter, percent shimmer, noise-to-harmonic ratio (NHR), vocal fold vibration assessment and speech fluency. Evolution of voice outcomes was analyzed considering age of patients (< 60 vs. ≥ 60 years).

RESULTS

Seventy-five patients completed the evaluations. Thirty-four and forty-one patients were < 60 or ≥ 60 yo, respectively. Subjective and objective voice parameters (VHI, G, R, B), jitter and fluency significantly improved from 1- to 6-month post-TLM in < 60 yo individuals. The voice parameters improved 12-month post-TLM in the ≥ 60 yo group at the exception of VHI that improved 3-month post-TLM. There were positive associations between age and 12-month NHR, G and A parameters.

CONCLUSION

The post-operative evolution of voice quality parameters may vary between patients according to the age. Preoperative VHI is predictive of 12-month subjective and objective voice outcomes.

VoiceS: voice quality after transoral CO2 laser surgery versus single vocal cord irradiation for unilateral stage 0 and I glottic larynx cancer-a randomized phase III trial

Background

Surgery and radiotherapy are well-established standards of care for unilateral stage 0 and I early-stage glottic cancer (ESGC). Based on comparative studies and meta-analyses, functional and oncological outcomes after both treatment modalities are similar. Historically, radiotherapy (RT) has been performed by irradiation of the whole larynx. However, only the involved vocal cord is being treated with recently introduced hypofractionated concepts that result in 8 to 10-fold smaller target volumes. Retrospective data argues for an improvement in voice quality with non-inferior local control. Based on these findings, single vocal cord irradiation (SVCI) has been implemented as a routine approach in some institutions for ESGC in recent years. However, prospective data directly comparing SVCI with surgery is lacking. The aim of VoiceS is to fill this gap.

Methods

In this prospective randomized multi-center open-label phase III study with a superiority design, 34 patients with histopathologically confirmed, untreated, unilateral stage 0-I ESGC (unilateral cTis or cT1a) will be randomized to SVCI or transoral CO₂-laser microsurgical cordectomy (TLM). Average difference in voice quality, measured by using the voice handicap index (VHI) will be modeled over four time points (6, 12, 18, and 24 months). Primary endpoint of this study will be the patient-reported subjective voice quality between 6 to 24 months after randomization. Secondary endpoints will include perceptual impression of the voice via roughness – breathiness – hoarseness (RBH) assessment at the above-mentioned time points. Additionally, quantitative characteristics of voice, loco-regional tumor control at 2 and 5 years, and treatment toxicity at 2 and 5 years based on CTCAE v.5.0 will be reported.

Discussion

To our knowledge, VoiceS is the first randomized phase III trial comparing SVCI with TLM. Results of this study may lead to improved decision-making in the treatment of ESGC.

Trial registration

ClinicalTrials.gov NCT04057209. Registered on 15 August 2019. Cantonal Ethics Committee KEK-BE 2019-01506

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06841-5.

Evaluation of Voice After Definitive Radiotherapy in Patients of Early Stage Squamous Cell Carcinoma of Larynx (Glottis): A Prospective Observational Study

Post treatment voice quality is an important consideration in choosing the management option for laryngeal cancer. We assessed voice quality after radiotherapy in patients of early squamous cell carcinoma of glottis comprehensively using Videolaryngostroboscopy (VLS), Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scores and Voice Handicap Index (VHI)-10. Fifty four consenting patients of early squamous cell carcinoma of glottis (Tis, T1 and T2) awaiting definitive radiotherapy were recruited consecutively. Voice was evaluated by VLS, GRBAS scores and VHI-10 before radiotherapy as well as 3 months and 12 months after radiotherapy. There were 52 males and 2 females in the study. Hoarseness of voice was the commonest presenting symptom. Mean duration of symptoms was 2.45 months (± 0.80), ranging from 1 to 4 months. 35 (64.82%) were T1 while 19 (35.18%) were T2 lesions. They received 60-70 Gy of radiotherapy in 28-35 fractions. There was only one recurrence on follow up for 12 months. On VLS at 12 months post-RT the periodicity, phase symmetry, mucosal waves and amplitude were normal in 74.07%, 70.37%, 56.67% and 78.7% cases respectively. Complete glottic closure was obtained in 72.22%. The voice was 'acceptable' (Grade 1 or 2 on VLS parameters) in more than 90% cases. Mean total GRBAS score was 3.39 (± 2.67). Mean total VHI-10 was 6.7 (± 1.75). All indices were significantly better than pre RT levels. Good quality of voice can be expected after radiotherapy for early glottic cancer in majority of patients.

Reliability of a Multidisciplinary Multiparametric Approach in the Surgical Planning of Laryngeal Squamous Cell Carcinomas: A Retrospective Observational Study

(1) Background: Endoscopy and morphological imaging are the mainstay of the diagnostic work up of laryngeal squamous cell carcinomas (LSCCs), which can be integrated in a multidisciplinary discussion to obtain a shared pretreatment staging. (2) Methods: A retrospective evaluation of patients, managed at a tertiary university hospital in Italy and submitted to major laryngeal surgery, has been performed. Four different stagings have been defined and compared: epTN (based on endoscopy and physical ENT examination); radTN (based on CT scan); cTN (based on multidisciplinary integration of the two above); pTN based on pathology on surgical samples. Oncological outcomes have been assessed. (3) Results: Three-year relapse free and disease specific survival were 88% and 92.5%, respectively, without significant differences between partial surgeries (n = 13) and total laryngectomies (n = 32). As for the pretreatment staging, and in particular the T classification, the cTN has been revealed as more reliable than epTN and radTN alone in predicting the final pT (Cohen kappa coefficient: 0.7 for cT, 0.44 for radT, 0.32 for epT). In the partial surgery group, we did not record any positive margin nor local recurrence, with a 100% overall and disease-specific survival. (4) Conclusions: The multidisciplinary approach is fundamental in the definition of the primary lesion in LSCC, in particular in order to safely perform surgical preservation of laryngeal function, which is associated with a higher laryngectomy-free survival than irradiation but to a lower salvageability in case of recurrence.

Multimodal Evaluation of Voice Outcome in Early Glottic Cancers Treated With Definitive Radiotherapy

BACKGROUND/AIM

We employed a multimodal evaluation of voice outcome (MEVO) model to assess long-term voice outcome in early glottic cancer (EGC) patients treated with primary radiotherapy (RT). The model consisted of objective and subjective vocal evaluation during follow-up, by a dedicated Speech Pathologist and Speech Therapist.

PATIENTS AND METHODS

MEVO methodology includes Self-perception Voice Handicap Index (VHI-30), evaluation of parameters Grade (G), Roughness (R), Breathiness (B), Asthenia (A) and Strain (S) according to GRBAS scale, objective analysis and aerodynamics using the PRAAT software and laryngeal evaluation with videostroboscope (VS).

RESULTS

The MEVO methodology was described and tested on a sample of 10 EGCs submitted to definitive RT (total dose 66-70 Gy). Mean follow-up was 48.9 months (range=9-115). VHI was mild-moderate in 90% of patients; overall voice function (GRBAS) was normal-mildly impaired in 70% of patients; VS evaluation showed normal vocal cord motion in 90% of patients, but complete glottic closure in 60%. PRAAT scores confirmed these findings.

CONCLUSION

A multidimensional voice evaluation is time consuming, but useful to objectify vocal impact of radiotherapy. The MEVO model allowed to quantify vocal dysfunction, showing a good objective vocal outcome.

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.

Vocal-cord Only vs. Complete Laryngeal radiation (VOCAL): a randomized multicentric Bayesian phase II trial

BACKGROUND

Radiotherapy, along with laser surgery, is considered a standard treatment option for patients with early glottic squamous cell cancer (SCC). Historically, patients have received complete larynx radiotherapy (CL-RT) due to fear of swallowing and respiratory laryngeal motion and this remains the standard approach in many academic institutions. Local control (LC) rates with CL-RT have been excellent, however this treatment can carry significant toxicities include adverse voice and swallowing outcomes, along with increased long-term risk of cerebrovascular morbidity. A recent retrospective study reported improved voice quality and similar local control outcomes with focused vocal cord radiotherapy (VC-RT) compared to CL-RT. There is currently no prospective evidence on the safety of VC-RT. The primary objective of this Bayesian Phase II trial is to compare the LC of VC-RT to that of CL-RT in patients with T1N0 glottic SCC.

METHODS

One hundred and fifty-five patients with T1a-b N0 SCC of the true vocal cords that are n ot candidate or declined laser surgery, will be randomized in a 1:3 ratio the control arm (CL-RT) and the experimental arm (VC-RT). Randomisation will be stratified by tumor stage (T1a/T1b) and by site (each site will be allowed to select one preferred radiation dose regimen, to be used in both arms). CL-RT volumes will correspond to the conventional RT volumes, with the planning target volume extending from the top of thyroid cartilage lamina superiorly to the bottom of the cricoid inferiorly. VC-RT volumes will include the involved vocal cord(s) and a margin accounting for respiration and set-up uncertainty. The primary endpoint will be LC at 2-years, while secondary endpoints will include patient-reported outcomes (voice impairment, dysphagia and symptom burden), acute and late toxicity radiation-induced toxicity, overall survival, progression free survival, as well as an optional component of acoustic and objective measures of voice analysis using the Consensus Auditory-Perceptual Evaluation of Voice.

DISCUSSION

This study would constitute the first prospective evidence on the efficacy and safety of VC-RT in early glottic cancer. If positive, this study would result in the adoption of VC-RT as standard approach in early glottic cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03759431 Registration date: November 30, 2018.

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.

Role of radiation oncology in modern multidisciplinary cancer treatment

Cancer care is moving from a disease‐focused management toward a patient‐centered tailored approach. Multidisciplinary management that aims to define individual, optimal treatment strategies through shared decision making between healthcare professionals and patient is a fundamental aspect of high‐quality cancer care and often includes radiation oncology. Advances in technology and radiobiological research allow to deliver ever more tailored radiation treatments in an ever easier and faster way, thus improving the efficacy, safety, and accessibility of radiation therapy. While these changes are improving quality of cancer care, they are also enormously increasing complexity of decision making, thus challenging the ability to deliver quality affordable cancer care. In this review, we provide an updated outline of the role of radiation oncology in the modern multidisciplinary treatment of cancer. Particularly, we focus on the way some developments in key areas of cancer management are challenging multidisciplinary cancer care in the different clinical settings of early, locally advanced, and metastatic disease, thus highlighting some priority areas of research.

Outcomes of carotid-sparing IMRT for T1 glottic cancer: Comparison with conventional radiation

OBJECTIVES

We aim to report oncologic outcomes after conventional radiotherapy (ConRT) using opposed lateral beams and intensity-modulated radiation therapy (IMRT) for tumor (T)1 nodal (N)0 T1 N0 glottic squamous cell carcinoma.

STUDY DESIGN

Retrospective case-control study.

METHODS

We retrospectively reviewed demographic, disease, and treatment characteristics for patients treated at our institution during 2000 to 2013.

RESULTS

One hundred fifty-three patients (71%) were treated using ConRT and 62 (29%) using IMRT. The median follow-up for all patients was 68 months. There was no statistically significant difference in 5-year local control between patients with T1a versus T1b disease (94% vs. 89%, respectively, P = 0.5). Three-year locoregional control for patients treated with ConRT was 94% compared to 97% with IMRT (P = 0.4). Three-year overall survival (OS) for patients treated with ConRT was 92.5% compared with 100% with IMRT (P = 0.1). Twelve of 14 patients with local recurrence underwent salvage surgery with 5-year ultimate locoregional control of 98.5% and 97.1% in the ConRT and IMRT cohorts, respectively (P = 0.7). Multivariate analysis showed age < 60 years (P < 0.0001) and pretreatment Eastern Cooperative Oncology Group performance status <2 (P = 0.0022) to be independent correlates of improved OS. Postradiation cerebrovascular events were in four patients in the ConRT cohort (3%), whereas no patients in the IMRT cohort suffered any events.

CONCLUSION

Because the oncologic outcomes for patients treated with IMRT were excellent and IMRT allows for carotid sparing, we have transitioned to IMRT as our standard for most patients with T1 glottic cancer.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:146-153, 2020.

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.

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.

Integrated rehabilitation after total laryngectomy: a pilot trial study

BACKGROUND

Acquisition and acceptance of the alaryngeal voice, psychological state, and Quality of Life (QoL) of laryngectomized patients.

METHODS

Thirty-two patients who underwent total laryngectomy were included in the study; 17 of them were treated by a psychologist and a speech therapist (experimental group); 15 performed only speech therapy (control group).

RESULTS

The experimental group showed a significant improvement in all parameters of the INFVo scale, in the score of the Environment subscale and in the total score of the I-SECEL (Self-Evaluation of Communication Experiences after Laryngeal Cancer); in the Depression, Obsession-Compulsion and Paranoia areas of the SCL-90-R (Symptom Check List-90-Revised); and in the Social area (REL) of the WHOQOL-B (World Health Organization Quality of Life Scale-Brief).

CONCLUSIONS

An integrated rehabilitative approach to laryngectomized patients improves emotional state and psychosocial aspects and promotes acceptance and use of the new voice and recovery of a better quality of life.

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.

Current Status of Organ Preservation in Carcinoma Larynx

Organ preservation in carcinoma larynx is a long debated topic. There are multiple organ preserving approaches in the management of carcinoma larynx depending on various factors. Radical radiotherapy (RT) and conservation laryngeal surgery have shown equivalent results in early laryngeal cancer. Concurrent chemoradiation (CTRT) is the standard treatment in stage III and IV laryngeal cancer with intact cartilage and functional larynx. Patients with cartilage destruction or dysfunctional larynx are not the candidates for organ preservation. This systematic review is aimed at discussing the evolution of different organ preserving approaches, their efficacy, impact on voice quality, their pitfalls and future directions.

Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Purpose To update the guideline recommendations on the use of larynx-preservation strategies in the treatment of laryngeal cancer. Methods An Expert Panel updated the systematic review of the literature for the period from January 2005 to May 2017. Results The panel confirmed that the use of a larynx-preservation approach for appropriately selected patients does not compromise survival. No larynx-preservation approach offered a survival advantage compared with total laryngectomy and adjuvant therapy as indicated. Changes were supported for the use of endoscopic surgical resection in patients with limited disease (T1, T2) and for initial total laryngectomy in patients with T4a disease or with severe pretreatment laryngeal dysfunction. New recommendations for positron emission tomography imaging for the evaluation of regional nodes after treatment and best measures for evaluating voice and swallowing function were added. Recommendations Patients with T1, T2 laryngeal cancer should be treated initially with intent to preserve the larynx by using endoscopic resection or radiation therapy, with either leading to similar outcomes. For patients with locally advanced (T3, T4) disease, organ-preservation surgery, combined chemotherapy and radiation, or radiation alone offer the potential for larynx preservation without compromising overall survival. For selected patients with extensive T3 or large T4a lesions and/or poor pretreatment laryngeal function, better survival rates and quality of life may be achieved with total laryngectomy. Patients with clinically involved regional cervical nodes (N+) who have a complete clinical and radiologic imaging response after chemoradiation do not require elective neck dissection. All patients should undergo a pretreatment baseline assessment of voice and swallowing function and receive counseling with regard to the potential impact of treatment options on voice, swallowing, and quality of life. Additional information is available at www.asco.org/head-neck-cancer-guidelines and www.asco.org/guidelineswiki .

Objective and self-evaluation voice analysis after transoral laser cordectomy and radiotherapy in T1a-T1b glottic cancer

Voice quality outcome becomes an important factor in the choice of the therapeutic option. The differences between radiotherapy and laser cordectomy have been extensively debated in the literature. We analyzed the vocal outcomes after carbon dioxide (CO₂) laser cordectomy and radiotherapy treatment for T1a-b early glottic cancer by means of objective and subjective voice evaluation. A retrospective study was performed on 56 cancer patients, 30 treated with cordectomy and 26 with radiotherapy. All patients underwent laser cordectomy which was performed under general anesthesia using a surgical microscope in laryngeal suspension. The laser we used was an Ultrapulse one, 10.6-μm wavelength, and a power setting of 2 to 4 W in an Ultrapulse mode was selected. Two different sets of data were recorded: (a) voice acoustic analysis (jitter, shimmer, fundamental frequency and noise/harmonic ratio) and (b) voice handicap index (VHI). Data collected were statistically analyzed using SPSS 20.0 for Windows. Jitter, shimmer, and signal-to-noise ratio were significantly altered in both glottic cancer patient groups as compared to the control group. On the contrary, no statistically significant alteration of the fundamental frequency was found in both treatment groups. Interestingly, jitter and shimmer values were significantly more compromised in transoral laser surgery patients as compared with radiotherapy-treated patients. The VHI was also significantly altered in both cancer patient groups as compared to the control group. More importantly, however, the self-evaluation voice analysis was not significantly different between the two treatment groups, contrary to what we observed for two of the four parameters measured in the objective voice analysis. Given the importance of the self-perception of the voice quality, no treatment can be considered superior from the patients' point of view. Therefore, we suggest that priority should be given to the endoscopic surgery, due to lower costs, lower morbidity, and shorter hospitalization.

Transoral laser microsurgery versus radiation therapy in the management of T1 and T2 laryngeal glottic carcinoma: which modality is cost-effective within the UK?

OBJECTIVES

To identify the most cost-effective treatment strategy in patients with early stage (T1 and T2) cancers of the laryngeal glottis.

DESIGN

A Markov decision model populated using data from updated systematic reviews and meta-analyses, with attributable costs from NHS sources. Data on local control and mortality were obtained from updates of existing systematic reviews conducted for the NICE guideline on cancer of the upper aerodigestive tract. Procedure costs were sourced from NHS reference costs 2013/14 by applying tariffs associated with the appropriate health resource group code SETTING: The UK National Health Service.

POPULATION

Patients with early stage (T1 and T2) cancers of the laryngeal glottis.

INTERVENTIONS

Transoral laser microsurgery (TLM) and radiation therapy (RT).

MAIN OUTCOME MEASURES

Total costs, incremental costs and quality adjusted life years (QALYs) over a 10-year time horizon.

RESULTS

Radiation therapy as the initial treatment strategy was found to be more expensive (£2654 versus £623) and less effective (QALY reduction of 0.141 and 0.04 in T1a and T1b-T2 laryngeal cancers, respectively) than TLM. The dominance of TLM for T1a cancers was unchanged in most scenarios modelled in sensitivity analysis. For T1b-T2 laryngeal cancers, the result changed in numerous scenarios. In probabilistic sensitivity analysis, TLM was found to have a 71% and 58% probability of being cost-effective in T1a and T1b-T2 laryngeal cancers, respectively.

CONCLUSIONS

Transoral laser microsurgery is a cost-effective strategy to adopt in the management of T1a laryngeal cancers. Uncertainty remains over the optimal strategy to adopt in T1b-T2 laryngeal cancers.

Evaluation of swallowing function after supracricoid laryngectomy as a primary or salvage procedure

The primary functional issues following conservative therapy for advanced laryngeal cancer concern swallowing. Here, we evaluated the recovery of swallowing after supracricoid partial laryngectomy (SCL) in patients with primary or recurrent laryngeal cancer. We evaluated the swallowing recovery in 27 SCL patients through oropharyngoesophageal scintigraphy, and we evaluated their quality of life using EORTC questionnaires. Four patients underwent total laryngectomy during follow-up. Patients who retained their larynges were able to feed without nutritional support and without tracheostoma. The only significantly different parameter between the primary and salvage cases was the time elapsed to the removal of nasogastric/PEG tubes, which was longer in salvage cases. SCL has been demonstrated as a valuable option for primary and recurrent laryngeal cancer patients. The present data demonstrate good functional results, particularly in terms of swallowing after previous treatments and in primary settings. The combination of oropharyngoesophageal scintigraphy and questionnaires appears to be an adequate, standardizable approach to assessing swallowing function after SCL.

Voice outcomes following radiation versus laser microsurgery for T1 glottic carcinoma: systematic review and meta-analysis

OBJECTIVE

Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using transoral laser microsurgery or radiation therapy.

DATA SOURCES

PubMed, Web of Science, and Scopus (1997-2013).

REVIEW METHODS

These data sources were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed only with studies that included both treatment modalities, to reduce heterogeneity and maximize rigor; random effects modeling was used to pool results.

RESULTS

Eighteen publications were identified that reported VHI data following surgery and radiotherapy for T1 glottic carcinoma. No studies were randomized. When studies that reported multiple T-stages or systematic treatment selection bias were excluded, 8 retrospective cohort studies describing 362 patients were suitable for meta-analysis. Follow-up time (mean, 47 months; range, 1-298 mo) and extent of surgical excision varied across studies. Six studies showed no VHI difference between treatment arms; 2 favored radiotherapy over surgery (1 of which reported transmuscular cordectomy for all surgical patients); and none favored surgery. Meta-analysis showed no significant difference in posttreatment VHI between radiotherapy and surgery (mean difference, -5.52; 95% confidence interval, -11.40, 0.36; heterogeneity I (2) = 61%, P = .01).

CONCLUSION

VHI scores were comparable following transoral laser microsurgery and radiation therapy for T1 glottic carcinoma in the current literature, suggesting no clinically significant difference in functional voice outcomes between treatment types.

Oncologic results of the surgical salvage of recurrent laryngeal squamous cell carcinoma in a multicentric retrospective series: emerging role of supracricoid partial laryngectomy

BACKGROUND

Several studies in the last decade evaluated conservative surgical procedures and, in particular, supracricoid operations as an alternative to total laryngectomy for the salvage of recurrences of laryngeal squamous cell carcinoma (SCC) after a first attempt of organ preservation.

METHODS

The clinical records of 68 consecutive patients primarily treated by irradiation or endoscopic surgery and surgically salvaged by total laryngectomy or supracricoid partial laryngectomy in 2 large university hospitals in Italy from 2004 to 2010 were reviewed.

RESULTS

The survival was not affected by the primary treatment or by salvage modality. The only parameter always keeping a prognostic value is the involvement of resection margins of salvage surgery. Patients with early relapse seem to have a worse prognosis than patients with a delayed relapse (p = .05 at Cox multivariate analysis and p = .048 at Wilcoxon test for overall survival [OS] from the primary treatment).

CONCLUSION

Supracricoid operations, if the indications are careful, can prove reliable salvage procedures.

Role of endolaryngeal surgery (with or without laser) versus radiotherapy in the management of early (T1) glottic cancer: a systematic review

BACKGROUND

Treatment options for early glottic cancer include transoral microsurgery or radiotherapy (RT). There is continuing debate about which is the superior treatment.

METHODS

The literature was searched from 1996 to 2011 using MEDLINE, EMBASE, and Cochrane Library. A quality assessment of each included study was conducted and reported.

RESULTS

There is no evidence in favor of 1 treatment modality when considering likelihood of local control or overall survival. There is a suggestion that RT may be associated with less measureable perturbation of voice as compared to surgery, but no significant differences were seen in patient perception. The likelihood of laryngeal preservation may be higher when surgery can be offered as initial treatment.

CONCLUSION

For patients with early (T1) glottic cancer, treatment options include the equally effective endolaryngeal surgery, with or without laser, or radiation therapy. The choice between treatment modalities should be based on patient and clinician preferences and general medical condition.

Role of endolaryngeal surgery (with or without laser) compared with radiotherapy in the management of early (T1) glottic cancer: a clinical practice guideline

AIMS

To provide evidence-based practice guideline recommendations concerning the role of endolaryngeal surgery (with or without laser) compared with radiation therapy for patients with early (T1) glottic cancer, assessing survival, locoregional control, laryngeal preservation rates, and voice outcomes.

METHODS

The medline, embase, and Cochrane Library databases were searched to identify relevant studies from 1996 to 2011. Recommendations were formulated based on that evidence and on the expert opinion of Cancer Care Ontario's Head and Neck Cancer disease site group. The systematic review and practice guideline were externally reviewed by practitioners in Ontario, Canada.

RESULTS

The available evidence was of a level insufficient to demonstrate a clear difference between treatment options when considering the likelihood of local control or overall survival. Although the evidence was mainly retrospective, there was a suggestion that, compared with surgery, radiotherapy might be associated with less measureable perturbation of voice without a significant difference in patient perception. The likelihood of laryngeal preservation may be higher when surgery can be offered as initial treatment.

CONCLUSIONS

For patients with early (T1) glottic cancer, the evidence is insufficient to demonstrate a difference between endolaryngeal surgery (with or without laser) and external-beam radiation therapy. The choice between treatment modalities has been based on patient and clinician preferences and general medical condition.

Definitive radiotherapy for T1 glottic squamous cell carcinoma: a 15-year Cruces University Hospital experience

PURPOSE

To evaluate the treatment outcomes for T1 N0 glottic carcinoma after definitive radiotherapy.

METHODS

One hundred and seventeen patients treated with radical radiotherapy from 1990 to 2006 were retrospectively reviewed. The median follow-up duration for the entire group was 92 months (range 4-227). A median dose of 70 Gy (range 63-70 Gy) was administered. We determined the rates of local control (LC), regional control, overall survival (OS) and cause-specific survival (CSS) at 5, 10 and 15 years by Kaplan-Meier product-limit method. The Cox regression analysis was performed to identify significant prognostic factors for LC and survival. The incidence of secondary malignancies is also reported.

RESULTS

The 5-, 10- and 15-year LC rates for the whole group were 84, 80.2 and 80.2 %, respectively. There were 20 local recurrences, of which 19 were salvaged with laryngectomy, giving an ultimate control rate of 90.6 %. The 5-/10-/15-year OS and CSS rates were 81.2 %/66.1 %/48.3 % and 90.6 %/90.6 %/90.6 %, respectively. None of the parameters analyzed exhibited a statistically significant relationship with LC. The age ≥65 years had a statistically significant effect on OS (but not in CSS), with a hazard ratio of 2.45 (95 % confidence interval 1.29-4.66; p = 0.006). During follow-up, 26 patients (22 %) developed a secondary malignancy. Only two patients (1.7 %) presented with severe toxicity (edema and mucositis).

CONCLUSIONS

Radiotherapy alone offers a high likelihood of LC and an excellent CSS rate. In addition, the surgical approach for the salvage is a successful option.

Clinical outcome of early glottic carcinoma in Serbia

OBJECTIVE

Proposed methods for treating early glottic carcinoma are cordectomy through laryngofissure, laser cordectomy, and radiotherapy. The aim of the study was to conduct comprehensive study to evaluate oncological and functional results of different treatment modalities for Tis and T1 glottic carcinoma, identify prognostic factors for the outcome of treatment and decide where we stand in applying worldwide standards of early glottic carcinoma treatment.

METHODS

Prospective study was conducted on 221 patients treated with Tis and T1 glottic carcinoma from 1998 to 2003 (72 patients were treated endoscopically with CO2 laser, 75 patients with cordectomy through laryngofissure and 74 with radiotherapy), with follow-up period from 38 to 107 months. Important demographic and clinical variables were analyzed. Voice quality after the treatment was assessed using multidimensional voice analysis.

RESULTS

Comparing oncological results of three modalities of treatment, there were no significant differences. Functional results of treatment were better after laser cordectomy and primary radiotherapy than following the open cordectomy. Five-year survival rate was almost identical in all three groups of patients, and important prognostic factors for survival were age and histological grade of the tumor.

CONCLUSION

Considering that the choice of treatment in our country is also greatly influenced by other paramedical factors, such as distance from treatment facility, reliability of follow-up, significant time delay of radiotherapy because of small number of radiology centers and strong patients' surgeon and treatment preference, we consider endoscopic laser surgery highly efficient and preferred choice of treatment for early glottic carcinoma.

Predictors of radiotherapy outcome in patients with T2 supraglottic carcinoma

The decision regarding treatment of early supraglottic carcinoma remains controversial. Single institution clinical data of patients with T2 supraglottic carcinoma treated exclusively with radiotherapy in terms of prognostic factors and treatment results were analyzed. Patient-related factors that would potentially by useful for optimal therapeutic decision to be undertaken were especially investigated. Between 1994 and 2004, 78 patients with T2 supraglottic carcinoma underwent radiotherapy (RT) in Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Poland. There were 54 (69%) males and 24 (31%) females in the median age of 61 years. There were 17 (22%) patients with N+. Median body mass of patients before (BM0) and after RT (BM1) was 74 kg (range 45.2-130 kg) and 72.9 kg (range 49.9-122.5 kg), respectively. Median hemoglobin concentrations before (Hb0) and after (Hb1) RT were 14.3 and 13.4 g/dl, respectively. Median change of Hb concentration during RT (dHb) was -0.8 g/dl. All were treated up to total doses (TD) ranged from 62.5 to 72 Gy. The overall treatment time (OTT) ranged from 30 to 70 days. Estimates of local control (LC), ultimate local control (uLC), and overall survival (OS) were calculated using the Kaplan-Meier method. Log rank statistics, Cox proportional hazard model and step-wise Cox regression hazard model were employed to identify prognostic factors for LC, uLC, and OS in univariate and multivariate analyses. The 5-year LC, RC, uLC and OS rates were 85, 92, 88, and 56%, respectively. In multivariate analysis N+ (p = 0.01) and prolonged OTT (p = 0.03) significantly decreased LC. Females (p = 0.02), higher BM0 (p = 0.03), and HB0 (p = 0.006) significantly prolonged OS. Patient-related factors like gender, hemoglobin concentration, and body mass may predict treatment outcome. Radiotherapy is effective for T2 supraglottic carcinoma of the larynx unless higher dose intensity is provided. Involved regional lymph nodes significantly deteriorate locoregional cure.

Laser surgery versus radiotherapy for T1-T2N0 glottic cancer: a meta-analysis

BACKGROUND

Laser surgery and radiotherapy are commonly used to treat glottic cancer.

OBJECTIVE OF REVIEW

To compare outcomes and cost of laser surgery versus radiotherapy for T1-T2N0 glottic cancer.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials, Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Embase, Web of Science (1990-2010) were searched electronically. Three Chinese journals in otolaryngology were searched manually.

EVALUATION METHOD

Retrieved studies were analyzed with Review Manager 5.0 software. Methodological and outcome heterogeneity was analyzed using the χ(2) test and the I(2) test. Homogeneous and heterogeneous data were analyzed using a fixed random effect model.

RESULTS

Eleven studies involving 1,135 patients were included in the analysis. The cure rate did not differ between patients receiving laser surgery versus radiotherapy. Results on voice preservation were inconclusive. The overall cost for laser surgery was lower.

CONCLUSIONS

The quality of the reported clinical studies is limited. No level I data are available. Nonetheless, our analysis suggests that laser surgery and radiotherapy produce comparable outcomes.