Primary treatment of the anterior vocal commissure squamous carcinoma

Factors Impacting Provider Treatment Decision-Making in Early Glottic Cancer

OBJECTIVES

Transoral laser microsurgery (TLMS) and radiotherapy (XRT) are mainstays of treatment for early glottic carcinoma (EGC). Here, we investigated case-dependent provider treatment preferences and identify factors which impact decision-making in EGC.

METHODS

This cross-sectional survey of laryngologists, head-and-neck surgeons, and radiation oncologists presented five diagrammatic cases of progressively advanced EGC (T1/2, N0). Respondents indicated preference for TLMS or XRT and ranked factors which influenced their recommendation for each case. Analysis utilized descriptive statistics, Fischer's exact tests, and Kruskal-Wallis tests for nonparametric data.

RESULTS

A total of 141 complete responses (69.5% laryngologists) were received. Most respondents practiced in academic settings (93.5%) and within multidisciplinary teams (94.0%). Anterior commissure involvement was the most important a priori tumor factor for case-independent treatment recommendation (Likert Scale: 4.22/5), followed by Laterality (Likert Scale: 4.02/5). Across all specialties, TLMS was recommended for unilateral T1a lesions. Laryngologists continued recommending TLMS in T2 lesions (41.0%) more than head-and-neck surgeons (5.0%) and radiation oncologists (0.0%). Across all cases, survival and voice outcomes were the most important clinical factors impacting treatment decisions. Radiation oncologists weighed voice more heavily than laryngologists in more complex presentations of EGC (rank: 1.6 vs. 2.7, Kruskall-Wallis: p < 0.05).

CONCLUSIONS

In more complex clinical presentations of EGC, preference for TLMS compared to XRT differed across specialists, despite similar rankings of factors driving these treatment recommendations. This may be driven by differing experiences and viewpoints on case-dependent voice outcomes following TLMS versus XRT, suggesting a need for increased understanding of how tumor location and depth impact voice outcomes.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:3686-3694, 2024.

Oncological Outcomes of Transoral Laser Microsurgery for Early Stage Glottic Cancer with Involvement of the Anterior Commissure

OBJECTIVES

To assess the value of carbon dioxide transoral laser microsurgery (CO2 TOLMS) for early-stage glottic cancer with special regard to involvement of the anterior commissure (AC).

STUDY DESIGN

Single-center retrospective cohort study.

SETTING

Grade-A tertiary hospital.

METHODS

A retrospective analysis of patients with early-stage (Tis-T2) glottic cancer who underwent CO2 TOLMS. All patients had at least 2 years of follow-up. The univariate and multivariate survival analyses were used to identify the risk factors for recurrence and the Kaplan-Meier method was used to analyze OS and DSS rates.

RESULTS

A total of 102 patients were included in the study. Eleven patients (10.78%) had recurrence. The univariate analysis showed that the recurrence was associated with the AC classification, T staging, tumor size, and tobacco use (P < .05). However, on multivariate analysis, the AC classification was the only independent risk factor for recurrence (P < .001, HR = 3.179). AC classification were distributed as follows: 59 (57.84%) AC0, 29 (28.43%) AC1, 8 (7.84%) AC2, and 6 (5.88%) AC3, 2-year/5-year OS and DSS rates were progressively reduced in the AC0, AC1, AC2, and AC3 groups (P < .001). At the same T staging, the OS rates incrementally decreased as the level of involvement of the AC became higher (P = .004).

CONCLUSION

CO2 TOLMS is an effective treatment for early-stage glottic cancer. AC involvement is an independent risk factors for recurrence and poor prognosis. The AC classification system may be better at grading the prognosis of patients with early-stage glottic cancer and has prognostic value independent of T staging.

Transoral laser microsurgery for T1 glottic cancer with anterior commissure: Identifying clinical and radiological variables that predict oncological outcome

PURPOSE

The involvement of the anterior commissure (AC) is regarded to be a risk factor for poor results after transoral laser microsurgery (TLM) for early glottic cancer. The objective of this study was to determine how AC-related clinical and radiological factors affected oncological outcomes in a cohort of patients with T1 stage early glottic carcinoma involving the anterior commissure who were treated with TLM with negative surgical margins.

METHODS

Retrospective analysis was performed on clinical, radiological, and follow-up data of patients consecutively treated with TLM at a tertiary academic center between November 2011 and August 2021 for T1 glottic squamous cell carcinoma involving the anterior commissure. Recurrence-free survival (RFS), local control with laser alone (LCL), laryngeal preservation (LP), and overall survival (OS) rates (Kaplan-Meier) were the primary outcome metrics.

RESULTS

In our series, 5-year OS probability was 75.1%, RFS was 64.8%, LCL was 73.8%, and LP was 83.4%. OS and RFS were higher in patients with early stages of AC pattern than in patients with advanced stage (p = 0.004, p = 0.034, respectively). Vertical extension ratio was found to be associated with OS and RFS (p = 0.023, p = 0.001, respectively), and thyroid cartilage interlaminar angle with LCL by multiple Cox regression analysis (p = 0.041).

CONCLUSION

TLM remains a valuable treatment option for AC involvement. AC3 type involvement and elevated vertical extension ratio were associated with negative prognosis. There have been signs that thyroid cartilage with a narrow angle increases recurrence. Alternative modalities should be kept in mind in the treatment decision of these cases.

Diagnostic Accuracy of Preoperative CT and Endoscopy Staging in Early Laryngeal Cancer

OBJECTIVES

This study aims to evaluate the diagnostic accuracy of preoperative computed tomography (CT) and intraoperative endoscopic tumor staging with regard to histopathologic staging in patients with early laryngeal cancer.

STUDY DESIGN

A retrospective nonrandomized single-institution comparative cohort study including 109 patients.

SETTING

A tertiary surgical center.

METHODS

Patients were treated for T1a, T1b, and T2a laryngeal squamous cell carcinoma by endoscopic laser surgery. The outcome measures were the presence of under- or overstaging in endoscopic and CT findings and positive postoperative margins.

RESULTS

Endoscopic overstaging as compared with histopathologic T category correlated with rising tumor category (P = .001; odds ratio [OR], 69.1) and CT findings showing anterior commissure involvement (P = .002; OR, 9.54), while endoscopic understaging correlated with rising tumor histologic grade (P = .039; OR, 4.28) and smaller tumor size (P = .011; OR, 6.39). CT overstaging vs histopathologic T category correlated with CT findings showing anterior commissure involvement (P = .001; OR, 21.76), supraglottic involvement (P = .001; OR, 59.98), subglottic involvement (P = .001; OR, 39.94), rising clinical T category (P = .01; OR, 9.11), and rising tumor histologic grade (P = .004; OR, 10.95). CT understaging as compared with histopathologic T category correlated with smaller clinical T categories (P = .002; OR, 12.72) and smaller tumor histologic grade (P = .030; OR, 7.02). Rising age, rising tumor size, anterior commissure involvement on CT, and tumor extension into the supraglottis were risk factors for positive margins.

CONCLUSION

Our results indicate that CT adds little valuable information in differentiating small superficial lesions in the glottis, while systematically overstaging cases of early laryngeal cancer. In T1a and T1b glottic tumors, endoscopy should be the preferred diagnostic method.

Radiological Findings in Laryngeal Anterior Commissure Invasion: CT Scan Highlights

OBJECTIVES

Preoperative anterior commissure (AC) evaluation in glottic cancer is crucial for therapeutic decisions. Endoscopy is often inadequate to precisely detect the presence of cancer in the AC; thus, computed tomography (CT) scan could help. We investigated the relation between AC thickness on CT scan (in mm), AC involvement by cancer at histology, and radiologic signs of anterior paraglottic space (PGS) infiltration.

STUDY DESIGN

Retrospective observational study.

METHODS

An experienced radiologist retrospectively measured AC thickness and identified signs of anterior PGS infiltration on pretreatment contrast-enhanced CT scans of 80 patients with primary glottic cancer. The gold standard to define the presence of cancer in the AC was histology. The receiver operating characteristic (ROC) curves were used to determine the potential cut-off values of AC thickness (Youden index method) able to maximize both sensitivity and specificity in identifying the presence of cancer in the AC at histology and PGS infiltration on CT scan.

RESULTS

AC was significantly thicker in patients with cancer in the AC at histology (P < .001) and in patients with PGS infiltration on CT scan (P < .001). The cut-off values to discriminate the presence of cancer at histology and PGS infiltration on CT scan were 3.62 and 2.6 mm, respectively. We found a substantial agreement between anterior PGS infiltration on CT scan and the presence of cancer in the AC at histology (Cohen Kappa: P = .70).

CONCLUSION

AC thickness and radiologic signs of PGS infiltration on pretreatment CT scan could represent a method to predict the presence of cancer in the AC at histology.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2427-2433, 2022.

Transoral Robotic Surgery for Early-T Stage Glottic Cancer Involving the Anterior Commissure—News and Update

Background

About 20% of all glottic carcinomas involve the anterior commissure (AC), and AC involvement was deemed to be a risk factor of local recurrence and poor prognosis. Transoral robotic surgery (TORS) has been developed for a panoramic view of the AC and en-bloc resection of the tumor by multidirectional dissection with endo-wristed instruments. With satisfactory preliminary results, we would like to update the data with a bigger cohort and present the news on using TORS for salvage treatment of recurrence from irradiation failure.

Methods

From July 2010 to December 2019, 22 patients with early T1 and 2 stage primary (n = 11) or recurrent (n = 11) glottic cancer with AC involvement received TORS without adjuvant therapy. TORS exposure was found to be better than TLM by conventional laryngoscopy in diagnostic biopsy. Seven of the 22 patients had recurrent cancer from irradiation failure. The perioperative factors that may be associated with survival were retrospectively analyzed, and the 5-year overall survival (OS)/disease-specific survival (DSS)/recurrence-free survival (RFS)/and organ preservation survival (OPS) rate were estimated by the Kaplan–Meier Method. Their voice and swallowing functions were evaluated by questionnaires of Voice Handicap Index-10 (VHI-10) and Functional Outcome Swallowing Scale (FOSS).

Results

All 22 TORSs were completed smoothly. After a mean follow-up of 49 ± 35.9 months, the Kaplan–Meier method estimated 5-year OS/DSS/RFS/OPS was 93.8%, 93.8%, 74.6%, and 86.3%, respectively. Our 11 patients with fresh cancer had 100% recurrence-free survival. Although the recurrent rate was higher in patients with history of RT, they could be rescued by further open laryngectomy without compromising the OS and DSS. Only one patient expired. The other 21 patients had satisfactory swallowing function with FOSS of 0.33 ± 0.66. Five patients depended on tracheostomy, but the rest 17 patients had serviceable voice with VHI-10 of 18.41 ± 11.29.

Conclusions

TORS could be used in the primary or salvage management of glottic cancer with AC involvement while TORS was confirmed to have better exposure to TLM. The RFS was good for patients with primary cancer. In patients having irradiation failure, TORS could also be a minimally invasive transoral approach before trying open surgery to preserve the organ.

Prognostic value of the maximum standardized uptake value for the locoregional control in early glottic cancer

Purpose

To evaluate the prognostic value of the pretreatment maximum standardized uptake value (SUVmax) for locoregional control (LRC) of early glottic cancer treated with primary radiotherapy.

Materials and Methods

We retrospectively reviewed the medical records of 101 patients with T1-T2N0 glottic cancer treated with helical tomotherapy between 2013 and 2016. The clinical T-stages were T1 in 87 (86.1%) and T2 in 14 (13.9%) patients. The median total dose was 63 Gy (63–67.5 Gy) in 2.25 Gy per fraction. The survival outcomes were plotted using Kaplan-Meier curves. Receiver operating characteristic curves were used to assess the optimal SUVmax cut-off value for predicting locoregional recurrence.

Results

The median follow-up period was 58 months (range, 11 to 90 months). The 5-year overall survival (OS) and locoregional recurrence-free survival rates were 96.8% and 85.4%, respectively. The median pretreatment SUVmax of the primary tumor for all 101 patients was 2.3 (range, 1.1 to 9.1). The best cut-off value for SUVmax for predicting LRC was 3.3, with a sensitivity of 78.6% and specificity of 73.6%. Univariate analysis showed that T-stage, overall treatment time (≥43 days), and high SUVmax (≥3.3) were significant predictors of LRC. Multivariate analysis showed that LRC was independently affected by a high SUVmax (≥3.3) (hazard ratio = 5.505, p = 0.020).

Conclusion

High pretreatment SUVmax (≥3.3) is a negative prognostic factor for LRC in early glottic cancer patients treated with primary radiotherapy.

Radiotherapy versus partial laryngectomy in the management of early glottic cancer with anterior commissure involvement: A propensity score matched study with 256 patients

OBJECTIVES

The study was intended to compare the outcomes for T1-T2N0M0 glottic squamous cell carcinoma with anterior commissure involvement who had undergone partial laryngectomy (PL) or radiotherapy (RT).

MATERIALS AND METHODS

We retrospectively analyzed 256 patients who were treated by RT (n = 70) or PL (n = 186). Patients received prophylactic irradiation of the neck in RT group whereas PL was not associated with lymphadenectomy. Propensity score matching (PSM) was used to eliminate the baseline variations.

RESULTS

The average age of the RT group (67 years) was significantly higher than that of the PL (59 years). Local recurrence was noted in 14 patients of the RT group and 22 of the PL. While regional recurrence was noted in only 1 patient of the RT group and 23 of the PL. After PSM, the 5-year overall survival (82.8% vs. 83.9%, p = 0.302), 5-year cancer-specific survival (88.3% vs. 89.7%, p = 0.793), 5-year local relapse-free survival (79.3% vs. 84.5%, p = 0.127) were not significantly different between two groups. However, 5-year regional relapse-free survival in the RT group was significantly better than that in the PL (100% vs. 87.1%, p = 0.014). In the PL group, infection, granuloma, laryngeal stenosis, chylous leakage, and pharyngeal fistula were reported in six, 11, 12, one, and two patients, respectively.

CONCLUSIONS

RT resulted in comparable rates of survival, local control, and larynx preservation compared to PL. However, RT was associated with higher regional control rate. The complication rates were extremely low in RT group.

Application of a thyroid cartilage window technique for transoral resection of early glottic cancer involving the anterior commissure

BACKGROUND

Management of early stage glottic carcinoma involving the anterior commissure is challenging.

AIMS/OBJECTIVES

This study aimed to evaluate the efficacy of a thyroid cartilage window (TCW) technique for transoral laser resection of early glottic cancer with involvement of the anterior commissure.

MATERIAL AND METHODS

Twenty-one patient who underwent a TCW technique for transoral resection early glottic carcinoma involving the anterior commissure, were retrospectively analyzed. The technical nuances, organ preservation rate and voice outcomes, local and regional recurrence, and perioperative comorbidities, were assessed.

RESULTS

All 21 patients underwent a TCW technique for resection, both the organ preservation rate and negative margin achieved 100%. The local control rate achieved 100%, and the 5 years recurrence free survival was 90.5%. For two patients with subglottic involvement (9.5%), regional recurrence with confirmation of a positive pre-laryngeal lymph node was observed. Postoperative granuloma was detected in all 21 patients, 13 of whom spontaneously disappeared (61.9%); whereas the remaining 8 patients (38.1%) demonstrated a consistent presence of granuloma more than 12 weeks, and they accepted surgical extirpation of granuloma under surface anesthesia. The laryngeal web developed in all 21 patients, while no dyspnea and local recurrence were present. By comparison with preoperative baseline, postoperative self-assessment voice demonstrated a significant improvement (p = .01), while objective voice indices were not significantly altered (p > .05).

CONCLUSIONS AND SIGNIFICANCE

TCW technique is a valuable means for transoral resection of early glottic laryngeal cancer involving the anterior commissure, with acceptable voice quality and seemingly low comorbidities.

Outcomes of frontolateral vertical partial laryngectomy in T1b glottic carcinomas

BACKGROUND

The treatment of T1b glottic carcinomas with invasion of the anterior commissure (AC) is still a challenge in larynx oncology. The diversity in treatment protocols is due to the difficulty in achieving safety margins of resection, especially in the AC.

OBJECTIVE

The treatment success rate of frontolateral vertical partial laryngectomy (FVPL) for the treatment of stage T1b squamous cell carcinoma of the glottic larynx infiltrating the AC.

MATERIAL AND METHODS

Clinical data of patients, who were diagnosed with stage T1b squamous cell carcinoma of the glottic larynx and who underwent a FVPL from 01/2003 to 12/2016 in our ENT clinic were retrospectively evaluated. Clinical and oncological outcomes were analyzed.

RESULTS

39 patients were included in this study. The mean follow-up duration was 79.95 ± 20.59 months. Intraoperative R0 resection was achieved in all patients. In 33.3% patients, documented complications were tissue granulation and synechia formation in the glottic area. The 5-year recurrence-free survival was 82.1%, the 5-year overall survival rate 97.4%, and the 5-year laryngeal preservation rate 94.8%.

CONCLUSION

Our clinical data demonstrate that T1b glottic carcinomas with invasion of the AC can be effectively treated with FVPL. The outcome is similar to other methods such as transoral laser microsurgery, supracricoidal partial laryngectomy, and radiotherapy.

Early glottic tumours with anterior commissure involvement. Literature review and consensus document. Head and Neck and Skull Base Commission, SEORL-CCC

The choice of the most appropriate treatment in early-stage glottic cancer with anterior commissure involvement remains controversial. Its therapeutic management is complex because it is a significant prognostic indicator of local control with 37% recurrence, due to the difficulty in establishing tumour extension with understaging of up to 40%, and due to the comparison of results in series on tumours that behave variably as they progress, such as T1a, T1b and T2a with commissure involvement. Furthermore, the complexity of the surgical approach using transoral CO2 laser microsurgery requires surgical skill, appropriate equipment and experience. Aspects to be reviewed in this document are: an updated anatomical definition of the anterior commissure, tumour progression based on histopathological studies, usefulness of videostroboscopy and NBI in diagnostic accuracy, validity of imaging tests, oncological results published in series reviews, systematic reviews and meta-analyses, tumour margin treatment and voice evaluation.Finally, by way of a summary, the document includes a series of recommendations for the treatment of these tumours.

T1 Glottic Cancer: Does Anterior Commissure Involvement Worsen Prognosis?

Radiotherapy (RT) and transoral laser microsurgery (TLM) represent the main treatment modalities for early glottic carcinoma. Local failure is notoriously more frequent in T1b glottic cancer in comparison to T1a and T2 tumors. In this scenario, the role of anterior commissure (AC) involvement is still controversial. The aim of the present study was therefore to determine its potential prognostic power in worsening patients’ survival and outcomes. We categorized different tumor glottic fold locations with respect to the involvement of one (T1a) or both vocal cords, with or without AC involvement. We analyzed a retrospective cohort of 74 patients affected by Stage I glottic cancer, treated between 2011 and 2018 by TLM or RT at a single academic institution. There were 22 T1a (30%) and 52 T1b (70%) cases. The median follow-up period was 30 months (mean, 32.09 ± 18.738 months; range, 12–79). Three-year overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and laryngectomy-free survival (LFS) were compared according to tumor location, extension, and cT category. According to both uni- and multivariate analyses, an increased risk for recurrence in T1b with AC involvement and T1a tumors was 7.31 and 9.45 times, respectively (p-values of 0.054 and 0.030, respectively). Among the 17 recurrences, T1b with AC involvement experienced 15 tumor relapses (88.2%), thus significantly affecting both the RFS and LFS in comparison to the other two tumor subcategories (T1a, p = 0.028 and T1b without AC involvement, p = 0.043). The deteriorating prognosis in the presence of AC involvement likely reflects the need to power the hazard consistency and discrimination of the T1b category when associated with such a risk factor, thus deserving an independent T category.

The prognostic value of anterior commissure involvement in T1 glottic cancer: A systematic review and meta-analysis

OBJECTIVE

The anterior commissure is considered a laryngeal subsite, but it is not taken into account in the current T-staging system. The impact of anterior commissure involvement (ACI) on the oncologic outcomes of T1 glottic tumors has not been well defined and remains controversial. The aim of this study was to assess the influence of ACI in the prognosis of T1 glottic tumors.

METHODS

A systematic review and meta-analysis of observational studies was performed by including studies published up to July 2019. Studies were selected if they had investigated the local control rate (LCR) at 5 years of clinical stage I (T1 and N0) glottic squamous cell carcinoma with and without ACI. The difference in LCR at 5 years between T1 glottic tumors without and with ACI was evaluated.

RESULTS

The meta-analysis showed that the difference in LCR at 5 years between T1 glottic tumors without and with ACI is 12% (95% confidence interval: 8%-16%, p < 0,0001, I² = 34.81%).

CONCLUSIONS

Our study pointed out that the anterior commissure involvement is a negative prognostic factor in LCR at 5 years for T1 glottic tumors. Our results suggest the need to consider ACI in the T staging of glottic tumors. Laryngoscope, 130:1932-1940, 2020.

Surgical Treatment for Early Stage Glottic Carcinoma with Involvement of the Anterior Commissure

Objective

Assessment of the value of transoral laser microsurgery (TLM) compared with open surgery (OS) for early stage squamous cell carcinoma of the glottic larynx with special regard to involvement of the anterior commissure (AC).

Study Design

Case series with chart review.

Setting

Tertiary care otolaryngology clinic.

Subjects and Methods

Review of clinicopathological data of all patients with previously untreated T1a, T1b, and T2 glottic squamous cell carcinoma of the larynx who were consecutively enrolled over a 10-year period (January 1, 1992, to December 31, 2002).

Results

Local recurrence rate was 20.4% (10 of 49) for TLM and 10.7% (3 of 28) for OS. Comparison of the TLM and OS groups regarding local recurrence rates revealed a significant difference only for tumors invading the AC ( P = .046). Within the TLM group, tumors with involvement of the AC showed a significantly higher recurrence rate (38.1%; 8 of 21) compared with tumors without involvement of the AC (7.1%; 2 of 28; P = .008). In the OS group, involvement of the AC revealed no significant difference ( P = .45). The overall survival in both groups was comparable in both groups (TLM, 93.9%; OS, 89.3%; P = .47).

Conclusion

TLM and OS are equally effective surgical treatments for early stage glottic cancer without involvement of the AC, with selection of treatment based on pretreatment endoscopy. However, TLM is associated with less morbidity. In case of invasion of the AC, OS yields lower recurrence rates.

Risk factors for radiation failure in early-stage glottic carcinoma: A systematic review and meta-analysis

BACKGROUND

Radiotherapy is one of the main treatment modalities for early-stage glottic carcinoma. Unfortunately, local failure may occur in a group of cases with T1-T2 glottic carcinoma. This meta-analysis sought to determine risk factors for radiation failure in patients with early-stage glottic carcinoma.

METHODS

A systematic and comprehensive search was performed for related studies published between 1995 and 2014. The primary end-point was 5-year local control. Data extraction and analysis were performed using the software STATA/SE 13.1 for Windows.

RESULTS

Twenty-seven studies were eligible. A higher risk of radiation failure was demonstrated in male patients [relative risk (RR): 0.927, p<0.001] and those with low hemoglobin level (RR: 0.891, p<0.001) with a high agreement between studies (I-squared=0.0%). Moreover, T2 tumors (RR: 0.795, p<0.001), tumors with anterior commissure involvement (RR: 0.904, p<0.001), tobacco use during/after therapy (RR: 0.824, p<0.001), and "bulky" tumors (RR: 1.270, p<0.001] or tumors bigger in size (RR: 1.332, p<0.001]. Poorly differentiated tumors had a questionable risk of local failure, although a moderate to high interstudy heterogeneity was determined. A statistically significant contribution was not detected for age, presence of comorbidity, alcohol use or subglottic extension.

CONCLUSION

This is the first meta-analysis which assessed the potential risk factors for radiation failure in patients with early-stage glottic carcinoma. Gender and pretreatment hemoglobin level are major influential factors associated with radiation failure in patients with early-stage glottic carcinoma. However, prospective, randomized clinical trials may permit better stratification of their relative contributions, and those who may benefit more from upfront surgery.

Long-term quality of life after transoral laser microsurgery for laryngeal carcinoma

BACKGROUND AND OBJECTIVES

Previous studies showed good short-term Quality of life (QOL) after Transoral Laser Microsurgery (TLM) for laryngeal cancer. Here, we aimed to evaluate QOL after TLM in the long-term.

METHODS

Prospective longitudinal study. Sixty-two consecutive disease-free patients were evaluated using UW-QOL v4 and SF-12 questionnaires, 1 and 5 years after TLM. Changes over time were assessed according to age, location, and tumor size. Long-term VHI-10 was also evaluated.

RESULTS

The mean follow-up time was 5.41 ± 2.02 years. No differences in the global UW-QOL score were observed between 1 and 5 years after TLM (1135.00 vs. 1127.20; P = 0.4). Activity worsened slightly in the long-term (93.03 vs. 87.70; P = 0.02). Forty-two and 58% of the patients reported that their health 1 and 5 years after treatment was much better than prior to diagnosis. Initially, 3.3% considered their health much worse, which was reduced to 1.7% at 5 years. SF-12 scores remained unchanged for both physical and mental aspects (P > 0.05). The VHI-10 was 3.81 ± 5.7 for supraglottic and 7.2 ± 9.6 for glottic tumors.

CONCLUSION

Patients treated with TLM present a very good long-term QOL. Only activity deteriorates over time, while voice and swallowing remain satisfactory in the majority of patients. J. Surg. Oncol. 2016;114:789-795. © 2016 2016 Wiley Periodicals, Inc.

Transoral robotic surgery for early glottic carcinoma involving anterior commissure: Preliminary reports

BACKGROUND

Transoral robotic surgery (TORS) for early glottic cancer has been reported, but the issue of anterior commissure involvement has seldom been addressed. Therefore, the purpose of this study was to preliminarily report the treatment results of TORS in this disease entity.

METHODS

Eight patients with T1 and T2 glottic carcinoma with anterior commissure involvement were selected to receive TORS. The clinical parameters, including rates of adjuvant radiotherapy (RT), survivals, as well as organ and function preservation, were retrospectively analyzed.

RESULTS

TORS was successfully performed in all patients without temporary tracheostomy. There were no major complications and no patient received adjuvant RT to the larynx after surgery. With a mean follow-up of 40 months, all patients survived with their larynx preserved and no local recurrence, tracheostomy, or tube feeding dependence.

CONCLUSION

TORS is a feasible approach for selected patients with early T classification glottic carcinoma with anterior commissure involvement. The preliminary oncologic and functional outcomes are satisfactory. © 2015 Wiley Periodicals, Inc. Head Neck 38: 913-918, 2016.

Tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers: a critical appraisal

Objective:

The tumour–node–metastasis staging system has a dynamic structure that is continuously being updated as scientific data develops. This review discusses some suggested revisions on tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers.

Methods:

The seventh edition of The American Joint Committee on Cancer Staging Manual was reviewed and important issues that could be considered for revision were identified and discussed.

Results:

According to our assessment of the oncological outcomes of previous studies, the following factors should be considered for revision: anterior commissure involvement and subglottic extension in laryngeal cancers; underlying bone involvement in hard palate and upper alveolar ridge cancers; tumour thickness in oral cancers; and extracapsular spread and carotid artery involvement in neck metastases.

Conclusion:

Sufficient data on the prognostic importance of these issues have been reported. Suggested revisions in line with current knowledge on the clinical behaviour of upper aerodigestive tract cancers would improve the relevancy of staging.

Study of the Histopathologic Characteristics and Surface Morphologies of Glottic Carcinomas With Anterior Vocal Commissure Involvement

This article explores the features and the role of the anterior vocal commissure (AVC) structure and the surface morphologies of glottic carcinomas with AVC involvement to provide a reference for the selection of transoral carbon dioxide (CO2) laser surgery. A total of 31 cases of glottic carcinomas with AVC involvement from May 2012 to January 2014 were included. All patients underwent electronic laryngoscopic examinations and computed tomography scans to determine the surface morphology. After surgery, the tumor specimens were resected integrally, and axial serial sections parallel to the plane of vocal cords were taken to explore the features and possible invasion paths of the glottic carcinomas with AVC involvement. The rates of involvement of the supraglottis and subglottis were 71.4% and 14.8%, respectively, via the AVC. The involvement of the superficial layer of the unilateral or bilateral vocal cords without involvement of the vocal muscle in the AVC region (IVM) or the cartilage was present in 15 cases (48.4%). The involvement of the superficial layer of the unilateral and bilateral vocal cords occurred in 16 cases (51.6%) with the IVM in 13 cases and the involvement of the intermediate lamina of the thyroid cartilage (ITC) in 8 cases. The involvement of the ITC was associated with the involvement of the vocal muscle of the AVC region (P < 0.05). Among the pushing carcinomas, 15 of 21 (71.4%) presented with well-defined tumor mass, and 8 of 10 (80.0%) infiltrating carcinomas presented with multiple tumor nests that were often surrounded by fibrosis (P < 0.05). The AVC is an important path of invasion of subglottic in glottic carcinomas but less so for suparglottic. The Broyles' ligaments acted as a barrier against the spread of the tumors to the thyroid cartilage, but this role was obviously weaken by the involvement of the vocal muscle of the AVC region. The infiltrating carcinomas presented with multiple tumor nests in fibrous tissue. When CO2 laser microsurgery is considered as a treatment option, these facts should be kept in mind.

Early glottic cancer: role of MRI in the preoperative staging

INTRODUCTION

Clinical staging is the most important time in management of glottic cancer in early stage (I-II). We have conducted a prospective study to evaluate if magnetic resonance imaging (MRI) is more accurate than computed tomography (CT) about tumoral extension, to exactly choose the most appropriate surgical approach, from organ preservation surgery to demolitive surgery. MATERIALS and

METHODS

This prospective study was conducted on 26 male patients, with suspected laryngeal neoplasia of glottic region. The images of MRI and CT were analyzed to define the expansion of glottic lesion to anterior commissure, laryngeal cartilages, subglottic and/or supraglottic site, and paraglottic space. The results of MRI and CT were compared with each other and with the pathology report.

RESULTS

CT accuracy was 70% with low sensitivity but with high specific value. MRI showed a diagnostic accuracy in 80% of cases, with a sensitivity of 100% and high specificity. Statistical analysis showed that MRI has higher correlation than CT with the pathology report.

CONCLUSION

Our study showed that MRI is more sensitive than CT in the preoperative staging of early glottic cancer, to select exactly the eligible patients in conservative surgery of the larynx, as supracricoid laryngectomy and cordectomy by CO2 laser.

Middle frontal horizontal partial laryngectomy (MFHPL): a treatment for stage T1b squamous cell carcinoma of the glottic larynx involving anterior vocal commissure

Objective

The therapeutic effect of middle frontal horizontal partial laryngectomy (MFHPL) in treating stage T1b squamous cell carcinoma of the glottic larynx involving anterior vocal commissure (AVC) was compared with that of the anterior frontolateral vertical partial laryngectomy (AFVPL). The feasibility and practical significance of MFHPL in clinical application was discussed in the present study.

Methods

From January 1996 to January 2010, a total of 65 patients diagnosed with stage T1bN0M0 glottic laryngeal cancer were treated with MFHPL or AFVPL. The postoperative complications, glottic reconstruction, recurrence rate, voice quality and survival rates were evaluated and compared between two treatments.

Results

AFVPL and MFHPL were performed in 34 and 31 patients, respectively. Flexible fiberoptic laryngoscopy revealed that in the MFHPL-treated patients the reconstructed glottis was spacious and symmetric. In contrast, AFVPL treatment resulted in irregular glottic area with poor symmetry and tubular glottis. The incidence of postoperative laryngeal stenosis significantly differed between the MFHPL- and AFVPL-treated groups (P = 0.025). No significant difference was detected in the 3- and 5-year overall- or tumor-free survival rates between two treatments. The Voice Handicap Index (VHI) and maximum phonation time (MPT) after surgery were 51.0±12.99 and 12.42±3.44 sec in the AFVPL-treated group; while in the MFHPL-treated patients they were 31.81±7.48 and 7.65±1.98 sec, respectively. Both differences in VHI (P = 0.012) and MPT (P = 0.024) were significant between two treatments.

Conclusions

MFHPL was comparable to AFVPL with respect to postoperative complications, recurrence rate and survival rates, but possessed advantages over AFVPL in terms of the incidence of laryngeal stenosis and voice quality. Our study indicated that MFHPL has a potential value in clinical practice of treating stage T1b squamous cell carcinoma of the glottic larynx involving AVC.

Transoral treatment strategies for head and neck tumors

The introduction of transoral endoscopic surgery has initiated a fundamental change in the treatment of head and neck cancer. The endoscopic approach minimizes the intraoperative trauma. Due to the lower burden for the patient and the savings potential these methods have gained wide acceptance. These transoral accesses routes allow experienced surgeons to reduce the morbidity of surgical resection with no deterioration of oncologic results. This suggests a further extension of the indication spectrum and a high growth potential for these techniques and equipment in the coming years. For selected patients with selected tumors the minimally invasive transoral surgery offers improved oncological and functional results. In the present paper, different surgical access routes are presented and their indications discussed.

Evidence-based practice: management of glottic cancer

The main issue in the management of glottic squamous cell carcinoma, as for all cancers, is adequate disease control while optimizing functional outcomes and minimizing morbidity. This is true for early-stage disease as for advanced tumors. This article evaluates the current evidence for the diagnostic and pretherapeutic workup for glottic squamous cell carcinoma and the evidence concerning different treatment options for glottic carcinoma, from early-stage to advanced-stage disease.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Transoral laser microsurgery for early glottic cancer

Objectives. To assess the outcome of transoral laser-assisted microsurgery (TLM) with regards to local and distant tumour control, quality of voice and swallowing. Design. Retrospective review of patients with five-year follow-up period. Setting. Royal Derby Hospital Head and Neck Department. Participants. All patients undergoing TLM with a diagnosis of Tis, T1, or T2 glottic tumour following endoscopic biopsy. Main Outcome Measures. Speech, swallowing, cancer-free survival, laryngectomy-free survival, and mortality rate. Results. 22 patients were treated for early glottic carcinoma with TLM. The 5-year local control rate for T1 tumours is 89% and 56% for T2 tumours. The laryngectomy rate was 4.5%. The mortality rate from local and distant disease was 4.5% with an overall mortality rate of 22% from all causes. 40% of patients had normal voices and a further 45% had only mild or moderate voice change. At their last followup, no patients assessed had any difficulty swallowing relating to their treatment for glottic cancer. Conclusion. Transoral Endoscopic CO2 laser microsurgery is a valid technique for treating early glottic tumours.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

Quality of life and functional outcomes in the management of early glottic carcinoma: a systematic review of studies comparing radiotherapy and transoral laser microsurgery

BACKGROUND

Early glottic carcinoma can be managed by radiotherapy and transoral laser microsurgery with similar control and survival rates. The functional and quality of life outcomes of these interventions are therefore important to guide management.

OBJECTIVE OF REVIEW

To compare the different treatment modalities for early glottic carcinoma with respect to quality of life, post-treatment voice character and swallowing outcomes.

TYPE OF REVIEW

A systematic review of the literature with defined search strategy.

SEARCH STRATEGY

Searches of EBM databases, and literature databases using key words: glotti*, laryn*, neoplasm, radiotherapy and laser surgery from 1970 to November 2009. Articles were screened for relevance using pre-determined inclusion and exclusion criteria.

EVALUATION METHOD

Articles reviewed by authors and data compiled in tables for analysis.

RESULTS

No randomised controlled trials were identified. There were 15 studies reporting vocal outcomes, and perception of voice disability was measured in eight studies; numbers were low in all the papers. Cumulatively, results for 880 patients were included, 448 had trans-oral laser microsurgery and 442 had radiotherapy. For vocal outcomes, 12 studies found no significant difference between radiotherapy and laser surgery, three reported superior outcomes for radiotherapy, whereas for the perception of voice disability, five reported no difference between treatment groups, while the remaining three reported conflicting results. Nine studies reported quality of life outcomes; seven of these reported no difference between the treatment groups in overall scores although some report differences in subsets of questions.

CONCLUSIONS

The evidence base to date demonstrates comparable vocal and quality of life outcomes for radiotherapy and transoral laser surgery for early glottic carcinoma. There is a need for consensus on which measures of vocal quality and life satisfaction to be used in research trials to allow comparison between studies.

Outcome of transoral laser microsurgery for T2-T3 tumors growing in the laryngeal anterior commissure

BACKGROUND

To evaluate the outcomes of transoral laser microsurgery (TLM) in the treatment of T2 to T3 laryngeal carcinomas growing in the laryngeal anterior commissure.

METHODS

This study was a retrospective analysis of 107 patients. Overall survival, disease-specific survival, and laryngectomy-free survival were analyzed. Technical difficulties, postoperative complications, influence of the learning curve, and the number of surgeries were evaluated.

RESULTS

Five-year overall survival, disease-specific survival, and laryngectomy-free survival were 71%, 79.5%, and 71.4%, respectively. The probability of tumor relapse was related to the status of the margins (p = .01) and to surgical experience (p = .02), but not to tumor exposure (p = .78) or pT category (p = .36). Disease-specific survival differed significantly between the group of patients treated in the early period of surgical experience and those treated in the advanced period of surgical experience (71% vs 94%; p = .02)

CONCLUSION

TLM is a useful treatment for T2 to T3 laryngeal carcinomas growing in the laryngeal anterior commissure when it is performed under an advanced learning curve.

CO(2) laser therapy in Tis and T1 glottic cancer: indications and results

BACKGROUND

Laser cordectomy for glottic cancer is still hampered by recurrence, which is more frequent upon anterior commissure (AC) involvement. Analysis of results may be a step to improve the efficacy of this therapy for early glottic cancer.

METHODS

In all, 81 patients who underwent surgery with CO(2) laser for Tis and T1, AC0 to AC2 glottic carcinoma were followed up to 55 months.

RESULTS

The incidence of recurrence increased significantly with T and AC classifications. The disease-free interval decreased with increasing T and AC classifications and with increasing severity of histology, but only the AC classification appeared significant. Recurrences occurred in 5 of 35 patients upon type I and type II cordectomy, in 16 of 24 patients upon type V cordectomy, and never upon type III and IV cordectomy.

CONCLUSIONS

Type I to type IV cordectomy, when indicated, can achieve radical treatment of most T1 glottic cancer. Type V cordectomy requires that any suspicion of cartilage invasion, even microscopic, be excluded.

Radiotherapy or CO(2) laser surgery as treatment of T(1a) glottic carcinoma?

Both radiotherapy and laser surgery give excellent results in the treatment of T(1a) glottic carcinoma. In this study, we compared the outcome of these treatment options. Demographic details and continuous follow-up with exact cause of death have been recorded prospectively for 351 patients with T(1a) glottic carcinoma at a tertiary referral centre in two consecutive decennia 1986-2005. Patients were treated with radiotherapy (163 patients) until 1996 when laser surgery was adopted as primary treatment (188 patients). The minimum follow-up time was 29 months. Neither the estimated 5-year disease-free survival, the disease-specific survival nor the crude survival differ between the two treatment options. The incidence of mainly local recurrences was equal during the first 3 years, followed by an increase in number of recurrences in the laser-operated patients. The odds ratio for a laryngectomy was 13.5 in patients treated with radiotherapy (P = 0.002), but mortality due to recurrence did not differ between the groups. The incidence of second primaries was equal (11%) but death due to second primaries differed significantly, favouring laser-treated patients (P = 0.003). In conclusion, the relative risk for a laryngectomy when a tumour recurs is 12.7 times higher in patients primarily treated with irradiation for T(1a) laryngeal carcinoma, compared with patients treated with laser surgery. Regarding the treatment costs, treatment impact on patients and organ preservation, we consider laser therapy to be the better treatment option for patients with T(1a) glottic cancer as no difference in survival could be observed.

Endoscopic laser surgery of early glottic cancer: involvement of the anterior commissure

BACKGROUND

Early glottic cancer can be cured with transoral laser resection, but in cases with anterior commissure involvement, there is still controversy concerning the best treatment modality.

METHODS

The impact of anterior commissure involvement on local control was analyzed in a retrospective review of 444 patients with early glottic cancer (pT1a-pT2a) treated between 1986 and 2004 with transoral laser microsurgical resection.

RESULTS

The anterior commissure was involved in 153 cases; the 5-year local control rate with and without anterior commissure involvement was 73% versus 89% for T1a and 68% versus 86% for T1b tumors. For T2a lesions, the 5-year local control rate was 76%, irrespective of anterior commissure involvement.

CONCLUSION

In early glottic cancer treated by transoral laser microsurgery, a decrease in local control is evident in case of anterior commissure involvement for T1a and T1b but not for T2a tumors.