Supraglottic laryngectomy: analysis of 267 cases

Addressing the Neck: An NCDB Study of Clinically Node-Negative Supraglottic Squamous Cell Carcinoma

OBJECTIVE

Identify the proportion of patients undergoing elective neck dissection (END) in surgically managed supraglottic squamous cell carcinoma (SCCa), assess associations between patient, tumor, and treatment factors with END, and assess associations between neck management and overall survival (OS).

STUDY DESIGN

Retrospective study.

SETTING

National Cancer Database (NCDB) 2019 Participant User File.

METHODS

Patients with previously untreated, clinically node-negative (cN0) supraglottic SCCa treated with partial laryngectomy were queried from NCDB. Patients without known neck management and who underwent total laryngectomy were excluded. Patient and tumor factors associated with END were evaluated by logistic regression analysis. Univariable Cox proportional hazard analysis was used to examine associations between patient factors and OS, and factors with P < .05 were included on multivariable analysis.

RESULTS

A total of 1352 patients met eligibility criteria. Eight hundred eleven (60%) patients had END performed with occult nodal metastasis identified in 177 (22%) patients. END was more likely to be performed at academic centers than nonacademic centers (odds ratio: [1.66], 95% confidence interval [CI]: 1.32-2.09, P < .001). On multivariable analysis, patients who underwent adjuvant radiation had worse OS (hazard ratio [HR]: 1.45, 95% CI: 1.13-3.29, P = .017). END was associated with improved OS overall on univariable analysis (HR: 0.83, 95% CI: 0.69-0.98, P = .026), but not on multivariable analysis.

CONCLUSION

In this NCDB study, 22% of cN0 supraglottic SCCa patients had occult nodal metastatic disease. Despite this, 40% of patients do not receive END at the time of primary resection. Patients who receive END for supraglottic SCCa are more likely to avoid adjuvant radiation without impacting OS.

Multicenter clinical trial on functional evaluation of transoral laser microsurgery for supraglottic laryngeal carcinomas

BACKGROUND

Transoral laser microsurgery (TLM) is an accepted and effective treatment strategy for supraglottic carcinomas. Data on oncologic and to a lesser extent functional outcomes have been published by mainly European specialized single institutions. TLM for supraglottic carcinomas has never been tested in a multicenter trial on its applicability as surgical standard at every hospital.

OBJECTIVES

To test the efficacy of TLM supraglottic laryngectomy (TLM-SGL) in terms of swallowing function, oncologic outcome parameters, morbidity, complications of treatment, and quality of life in a multicenter setting.

METHODS

The study is designed as a multicenter (approximately 25 centers), non-randomized, single-arm study with a targeted number of 200 previously untreated patients with squamous cell carcinomas (SCC) of the supraglottic larynx T2/T3 N0-3 M0; UICC stage II-IVa. The surgical treatment consists of TLM-SGL and elective or therapeutic uni- or bilateral selective neck dissection (SND). After pathologic risk stratification adjuvant radio- (RT) or radiochemotherapy (RCT) is indicated. Patients are followed-up for 2 years post surgically. Swallowing function is assessed by fibreoptic endoscopic evaluation of swallowing (FEES). The primary endpoint is aspiration-free swallowing at 12 months as established using FEES and defined as grade < 6 of penetration-aspiration scale (PAS). Secondary endpoints include local control, larynx preservation, overall and disease-free survival, complications and side effects of treatment, prevalence of tracheostomy and percutaneous endoscopic gastrostomy (PEG)-tube-feeding, and dysphagia-specific quality of life (QoL) assessed by the MD Anderson Dysphagia Inventory (MDADI) as well as voice-related QoL assessed by the Voice Handicap Index (VHI).

Transoral Laser Microsurgery for Supraglottic Cancer

INTRODUCTION

Transoral laser microsurgery (TLM) is an accepted and effective treatment strategy for supraglottic carcinomas. Early supraglottic carcinoma has excellent outcomes independently of the treatment approach. The role of TLM for the treatment of locally advanced tumors is debated. Particularly, the functional outcomes after TLM have to be proven by functional assessment of large cohorts of patients. This study analyzes the oncologic and functional outcomes after TLM for supraglottic carcinomas.

PATIENTS AND METHODS

Ninety-one patients with pT1-pT4a supraglottic carcinomas treated between January 2002 and December 2012 were analyzed. Distribution of tumors (UICC 2010) was 11 patients with pT1, 31 patients with pT2, 36 patients with pT3, and 13 patients with pT4a tumors. Node status was positive in 40 (43.6%) patients; 61 (67.1%) patients had stage III or IVa disease. Local control and survival were estimated using the Kaplan-Meier method. For the assessment of functional outcomes, the MD Anderson Dysphagia Inventory (MDADI), the Voice Handicap Index-10 (VHI-10), and the performance status scale for head and neck cancer [Performance Status Scale for Head and Neck (PSS-HN)] were used.

RESULTS

The median age was 62 years (range, 33-88 years). Fourteen (15.4%) patients developed a local or locoregional recurrence. The 5-year local control rate and 5-year ultimate local control rate were 72 and 92%, respectively. The 5-year overall survival rate was 63%. Twelve (13.2%) patients needed temporary tracheostomy. Sixty-eight (74.0%) patients had a nasogastric feeding tube post-operatively. At 1-year post-operative follow-up, only three patients were PEG dependent. The median VHI-10 score was 35, the median MDADI composite score was 80, and the median score of the domain "normalcy of diet" in the PSS-HN was 91.

CONCLUSION

The oncologic outcomes are comparable to the results of open surgery for early and advanced supraglottic carcinomas. Functional swallowing outcome is superior to open surgery and to concomitant chemoradiation. Patients treated with TLM perceive low levels of voice- and swallowing-related quality of life impairment.

Functional outcomes of supraglottic squamous cell carcinoma treated by transoral laser microsurgery compared with horizontal supraglottic laryngectomy in patients younger and older than 65 years

The treatment of supraglottic carcinoma remains a controversial issue. Five accepted surgical and non-surgical oncological treatments have been currently established: standard horizontal supraglottic laryngectomy (HSL), supraglottic CO2 laser microsurgery (TLM), transoral robotic surgery, radiotherapy alone and radiotherapy in combination with chemotherapy. Some studies have shown that complications of head and neck surgeries increase significantly in patients over 65 years compared to younger patients. We designed a retrospective analysis to assess the rate of complications and functional outcomes of patients treated by TLM and HSL in cases of T1-T3 supraglottic squamous cell carcinomas (SCC) in a tertiary University Hospital. Results were compared between patients younger and older than 65 years. We found significant differences in the rate of aspiration pneumonia (p = 0.026), mean time to decannulation (p = 0.001) and mean hospital stay (p = 0.007) in patients treated by TLM, which was higher and longer in the group of patients over 65 years of age. Regarding HPL, we only found significant differences in the mean time to decannulation (p = 0.001), which was longer in the group of patients younger than 65 years. According to our results, TLM or HPL can both be a safe surgical option for patients older than 65 years, but previous evaluation of lung function before surgery is mandatory because of an increased risk of aspiration pneumonia in patients with lung problems, especially when treated by TLM. Concerning functional outcomes in patients older than 65 years, TLM reduces the postoperative rate of tracheostomy, mean time required for decannulation and mean hospital stay compared with HPL. However, no significant difference in the occurrence of aspiration pneumonia, dysphagia or in the mean length of NGT feeding was found.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

Evaluation of voice quality after supraglottic laryngectomy

OBJECTIVE

Supraglottic laryngectomy is a surgical procedure that preserves laryngeal functions. This technique allows extensions including removal of tongue base or 1 arytenoid. We aimed to compare vocal results of supraglottic laryngectomy and extended procedures.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary care hospital.

SUBJECTS AND METHODS

Thirty-three males who underwent supraglottic laryngectomy were included in the study. Fifteen patients (45.5%) were applied standard supraglottic laryngectomy (standard supraglottic laryngectomy group). In 11 patients (33.3%), unilateral arytenoid cartilage was totally resected by separation at the cricoarytenoid joint (laterally extended group), and the tongue base was removed in 7 patients (anteriorly extended group) (21.2%). Twenty male smokers constituted control group. Acoustic and aerodynamic voice analyses were performed for the assessment of objective results. Grade, roughness, breathiness, asthenia, and strain scale (GRBAS) scores were analyzed for perceptual assessment. Voice Handicap Index-30 was used to evaluate subjective results.

RESULTS

The comparison of supraglottic laryngectomy group with the control group revealed that the mean maximum phonation time and fundamental frequency were significantly lower in the supraglottic laryngectomy group (P < .001), and the mean jitter, shimmer, and noise-to-harmonics ratio were significantly higher in the supraglottic laryngectomy group (P < .001). Maximum phonation time and fundamental frequency were higher in the standard supraglottic laryngectomy group in comparison to extended groups. Jitter value was also lower in the standard supraglottic laryngectomy group compared to extended groups. Perceptual and subjective analyses revealed no difference among standard supraglottic laryngectomy and extended groups.

CONCLUSION

The results of this study indicate that supraglottic laryngectomy patients have acceptable voice quality, as determined by perceptual and subjective assessment.

Traditional transcutaneous approaches in head and neck surgery

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.

Prognostic factors for supraglottic laryngeal carcinoma: Importance of the unfit patient

BACKGROUND

The purpose of this study was to define prognostic factors for supraglottic laryngeal cancer that may influence management.

METHODS

This ethics-approved study captured information on patients who presented with supraglottic laryngeal cancer between 1967 and 2008. Endpoints were local/ultimate failure and cancer-specific survival (CSS). Analysis was performed using chi-square, Fisher exact test, and logistic regression. Kaplan-Meier and Cox regression analysis were used to describe time-to-event data.

RESULTS

Three hundred sixty-nine patients were analyzed. Two hundred seventeen patients received radiotherapy, 30 were treated with surgery, and 122 were treated with radiotherapy and surgery. The 5-year ultimate local control and CSS rates were 79.5% and 62.8%. Treatment type was a univariate predictor for outcome; however, it was not an independent predictor for ultimate local control or CSS.

CONCLUSIONS

This study highlights the fact that by documenting information it is possible to define prognostic factors. It also shows the importance of adjusting for clinical predictors such as patients being unfit for surgery.

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.

Laser surgery for early to moderately advanced glottic, supraglottic, and hypopharyngeal cancers

Current practice standards for the treatment of early to moderately advanced laryngeal and hypopharyngeal cancer demand both achievement of cure and preservation of laryngeal structure and function to the greatest extent possible. The oncologic and functional results of transoral laser microsurgery (TLM) for early glottic cancer appear to be comparable to those of radiotherapy, with a higher rate of laryngeal preservation and a lower cost. TLM for early and moderately advanced supraglottic and hypopharyngeal cancers offers similar results with regard to survival and local control to those obtained with open surgical approaches. In addition, functional results of TLM are superior to those of open approaches because tracheotomies are usually avoided, rehabilitation of swallowing is faster, and hospital stay is shorter. TLM, when applicable, has become the preferred modality for surgical treatment of most early to moderately advanced cancers of the larynx and selected tumors of the hypopharynx.

[The current role of partial surgery as a strategy for functional preservation in laryngeal carcinoma]

With the current advances and recent organ preservation protocols for intermediate or advanced stage laryngeal cancer, based on chemotherapy, the role of surgery seemed replaced except for surgical rescue of tumours not responding to these treatments, total laryngectomy being the surgical option. This type of non-surgical treatment is offered as a strategy for organ preservation, as opposed to total laryngectomy. However, we believe that there are two organ-preservation strategies, surgical and non-surgical. A wide spectrum of surgical techniques is available and such techniques lead to excellent results, both oncological and functional (speech and swallowing). The aim of this paper is to present options for organ-preserving surgery for laryngeal cancer. A review of surgical techniques available for functional preservation in cancer of the larynx at intermediate or advanced stage is presented. In addition to classic approaches such as vertical partial laryngectomy and horizontal or supraglottic laryngectomy, options for conservative laryngeal surgery have improved significantly over the past two decades. Minimally invasive surgery, transoral laser surgery, and supracricoid partial laryngectomy have become important laryngeal preservation approaches for patients with laryngeal cancer. Surgery must define its role in the multidisciplinary treatment of advanced cancers of the larynx, which at present often favours (chemo)radiotherapy protocols.

[Experience in laryngeal cancer operations from the last 35 years in the Department of Laryngology in Zielona Gora]

INTRODUCTION

For many years, we are operating tumor conditions of the larynx, and periodically we evaluate our work. It is important as it allows us to compare the operational materials and the results of treatments.

MATERIAL AND METHOD

We have conducted almost 1000 surgeries of larynx cancer and we have decided to subject our results from the past 35 years to proper analysis. The purpose of this work--beyond verification of regular epidemiological parameters--is to evaluate the increase in number of patients and changes in therapeutic procedures--with particular attention paid to surgical cases. The results of treatment was the third problem we have analyzed. Additionally, we own 968 records of the patients, who are systematically controlled in the widely accepted formula. The controls take on the nature of laryngological and oncological counsels. Moreover, we periodically conduct surveys, for instance acceptance of the after-treatment life.

RESULTS AND CONCLUSIONS

From the obtained analysis, we have determined, that the number of the sick for the studied time frame--the 1990's--is constant. The number of women grows at a greater rate than that of men. The most significant changes appeared in the way of treatment, for instance, the new methods of oncological treatments, especially growth of operational preservation procedures of the larynx. I consider it to be the outcome of the awareness of the society, the technological step forward, and the care of surgeons of the quality of life after the treatment.