Transoral CO2 laser microsurgery for Tis-T3 supraglottic squamous cell carcinomas

Survival, Surgical, and functional outcomes of transoral laser microsurgery for cT1-T3 supraglottic laryngeal Cancers: A systematic review

BACKGROUND

This review aimed to investigate the surgical, functional, and oncological outcomes of transoral laser microsurgery supraglottic laryngectomy (TOLM-SGL) for cT1-T3 laryngeal cancers.

METHODS

PubMed, Scopus, and Cochrane Library were searched by two independent investigators for studies investigating the surgical, functional, and oncological outcomes of TOLM-SGL using the PRISMA statements. A bias analysis was carried out with MINORS.

RESULTS

Twenty-four studies were included (937 patients), including 206 (25.9 %) cT1, 467 (58.7 %) cT2, and 123 (15.4 %) cT3 cases. Most patients were cN0 (63.9 %). The mean hospital stay of TOLM was 10.1 days. Aspiration (5.5 %), and bleeding (5.3 %) were the most prevalent complications. The laryngeal preservation rate was 93.7 %. Temporary tracheotomy was performed in 18.0 % of patients, with a mean time of decannulation of 6.8 days. A feeding tube was placed in 59.9 % of patients. The oral diet restarted after 6.4 days. Definitive gastrostomy was necessary in 2.4 % of cases. The 5-year OS and DFS were 70.1 % and 82.0 %, respectively. Distant metastasis, local, and regional recurrence occurred in 4.6 %, 11.6 %, and 5.1 % of patients. There was an important heterogeneity between studies for inclusion criteria, patient profiles, TOLM indications, and details of surgical, functional, and oncological outcomes.

CONCLUSION

TOLM supraglottic laryngectomy is a safe, and effective procedure associated with adequate functional, surgical, and oncological outcomes. Future studies are needed to define the place of TOLM in advanced LSCC; the role and timing of concomitant bilateral neck dissection, the indications of tracheotomy and feeding tube.

Survival Outcomes of Transoral Microsurgery in T3/T4a Laryngeal Tumors: Systematic Review and Meta-Analysis

OBJECTIVE

To critically evaluate oncological and functional outcomes following transoral laser microsurgery (TLM) in patients with T3/T4a glottic and supraglottic squamous cell carcinoma (SCC).

DATA SOURCES

A comprehensive search of five major databases-PubMed, Embase, Scopus, ScienceDirect, and Web of Science-was conducted using a combination of relevant keywords and MeSH terms.

REVIEW METHODS

Systematic review and meta-analysis of odds ratio (OR), hazards ratio (HR), and proportion, focusing on oncological and functional outcomes of TLM in advanced T3/T4a glottic and supraglottic tumors. A random-effects meta-analysis model was employed.

RESULTS

The review incorporated 29 cohort studies, representing a total of 1,897 patients undergoing TLM for T3/T4a glottic and supraglottic SCC. The cumulative 5-year disease-free survival (DFS) rate for T3 glottic and supraglottic tumors was 44.4% (95% CI: 47-66%) and 62.8% (95% CI: 63-81%), while the 5-year DFS for T4 glottic and supraglottic tumors was 41.1% (95% CI: 33.4-49.2%) and 32.9% (95% CI: 19.3-50.1%), respectively. T3 glottic tumors exhibited a 2.5-fold significantly higher odds of local recurrence post-TLM compared to their T3 supraglottic tumors (95% CI: 1.6-3.9, p < 0.0001). Laryngeal preservation rates for T3glottic and supraglottic tumors were 68.9% (95% CI: 48.7-83.8%) and 88.4% (95% CI: 79.4-93.8%), respectively. Both groups showed comparable rates of tracheostomy (p = 0.48) and gastrostomy performed (p = 0.17).

CONCLUSIONS

This meta-analysis suggests that TLM is a viable larynx preservation approach in select patients with T3/T4a glottic and supraglottic tumors. However, glottic tumors may have less favorable outcomes after TLM compared to those with advanced supraglottic tumors.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2024 Laryngoscope, 2024.

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).

Surgery for Supraglottic Laryngeal Cancer

Although total laryngectomy continues to be important treatment of supraglottic laryngeal cancer, the management of early-stage disease has evolved from primary radiation/chemoradiation to consideration of partial laryngectomy surgery. Surgeon experience and careful patient selection can lead to excellent oncologic and functional outcomes for these techniques. However, advanced stage tumors and salvage situations are challenging and the ability to eradicate disease and preserve function should be carefully considered. Contraindications to supraglottic laryngectomy depend on surgical approach, as do complications. With adequate patient selection, high rates of cure and function can be achieved with both open and transoral supraglottic laryngectomy procedures.

A novel 3D-printed laryngoscope with integrated working channels for laryngeal surgery

Background

For the surgical treatment of early-stage laryngeal cancer, the use of transoral laser microsurgery (TLM) has emerged as the gold standard. However, this procedure requires a straight line of sight to the operating field. Therefore, the patient's neck needs to be brought into a hyperextended position. In a considerable number of patients, this is not possible due to anomalies in the cervical spine anatomy or soft tissue scarring, e.g., after radiation. In these cases, adequate visualization of relevant laryngeal structures cannot be ensured using a conventional rigid operating laryngoscope, which may negatively affect the outcome of these patients.

Methods

We present a system based on a 3D-printed prototype of a curved laryngoscope with three integrated working channels (sMAC). The curved profile of the sMAC-laryngoscope is specifically adapted to the nonlinear anatomy of the upper airway structures. The central working channel provides access for flexible video endoscope imaging of the operating field while the two remaining channels provide access for flexible instrumentation. In a user study (n = 11), visualization and reachability of relevant laryngeal landmarks as well as the feasibility of basic surgical procedures with the proposed system were examined in a patient simulator. In a second setup, the system was evaluated for its applicability in a human body donor.

Results

All participants of the user study were able to visualize, reach and manipulate the relevant laryngeal landmarks. Reaching those took significantly less time in the second attempt compared to the first one (27.5 s ± 5.2 s vs. 39.7 s ± 16.5 s, p = 0.008) indicating a significant learning curve for handling the system. Instrument changes were performed quickly and reliably by all participants (10.9 s ± 1.7 s). All participants were able to bring the bimanual instruments into position for a vocal fold incision. Relevant laryngeal landmarks could be visualized and reached in the human body donor setup.

Conclusion

Possibly, the proposed system may develop into an alternative treatment option for patients with early-stage laryngeal cancer and restricted mobility of the cervical spine in the future. Further improvements of the system could include finer end effectors and a flexible instrument with a laser cutting tool.

Magnetic resonance diagnosis of laryngeal chondritis after transoral laser microsurgery for laryngeal cancer

Objective

Laryngeal chondritis (LC) is a rare complication of carbon dioxide transoral laser microsurgery (CO₂ TOLMS) for laryngeal tumours and can pose a diagnostic challenge. Its magnetic resonance (MR) features have not been previously described. This study aims to characterise a cohort of patients who developed LC after CO₂ TOLMS and describe its clinical and MR findings.

Methods

Clinical records and MR images of all patients presenting with LC after CO₂ TOLMS between 2008 and 2022 were reviewed.

Results

Seven patients were analysed. Timing of LC diagnosis ranged from 1 to 8 months after CO₂ TOLMS. Four patients were symptomatic. Abnormal endoscopic findings included suspected tumour recurrence in 4 patients. MR documented focal or extensive signal changes involving the thyroid lamina and para-laryngeal space with T2 hyperintensity, T1 hypointensity and intense contrast enhancement (n = 7), and minimally reduced mean apparent diffusion coefficient (ADC) values (1.0-1.5 x 10^-3 mm²/s) (n = 6). A favourable clinical outcome was achieved in all patients.

Conclusions

LC after CO₂ TOLMS has a distinctive MR pattern. When tumour recurrence cannot be confidently excluded based on imaging, antibiotic therapy, close clinical and radiological follow-up and/or biopsy are recommended.

Presentation and outcomes of patients with clinically T1-2, N0 supraglottic squamous cell carcinoma: The role of definitive radiotherapy compared to primary partial laryngectomy

BACKGROUND

Early-stage supraglottic squamous cell carcinoma (SCC) is usually treated with a single modality. The aim of this study is to examine the role of radiotherapy (RT) versus partial laryngectomy (open, robotic-assisted, or endoscopic) with elective neck dissection (PL + END).

METHODS

A retrospective analysis of the National Cancer Database, 2010-2016. The study population included adult patients with clinically T1-2, N0 supraglottic SCC.

RESULTS

3301 patients were included. RT was performed in 93.52%, open PL + END in 2.64%, robotic-assisted PL + END in 1.33%, and endoscopic surgical resection in 2.51%. In the surgery group, T was upstaged in 23.36% and N was upstage in 16.36%. Five-year survival in the primary surgery group compared to RT group was 61.89% versus 77.46% (HR: 0.56, 95%CI: 0.43, 0.72).

CONCLUSIONS

T was upstaged in 23% of surgical patients. This accurate staging is likely missed in patients who undergo RT and possibly contributes to lower overall survival of this treatment group.

The Thermal Damage of Canine Vocal Fold by CO2 Laser Under Different Laser Emission Mode

OBJECTIVE

The purpose of this study is to review the differences between continuous wave (CW) and UltraPulse (UP) on thermal damage of the laser with different power.

METHODS

Four adult beagle dogs underwent transoral laser microsurgery (TLM) using CO₂ laser. The laser emission mode and power was CW (3 W, 5 W, and 8 W) and UP (3 W and 5 W), respectively. The tissue from 4 animals was evaluated histologically on postoperative days 1 and 3. The thermal damage of the laser was measured using slide scan system via SlideViewer version 1.5.5.2 software.

RESULTS

All dogs underwent TLM uneventfully. Under microscope examined, the laser damage area was composed of 2 parts: the vaporized zone (VPZ) and thermal damage area. The thermal damage area can be divided into thermal coagulative necrosis area (TCN) and hydropic degeneration area. The width of VPZ and TCN in UP mode was less than that in CW mode (P < .01). The data indicate that lower laser power created less thermal damage (P < .01). In addition, the width of VPZ on postoperative day 3 was less than that on postoperative day 1 (P < .01).

CONCLUSION

CO₂ laser with UP and lower power could decrease the laser thermal damage and may offer more prompt wound healing.

European Laryngological Society position paper on laryngeal dysplasia Part II: diagnosis, treatment, and follow-up

PURPOSE OF REVIEW

To give an overview of the current knowledge regarding the diagnosis, treatment, and follow-up of laryngeal dysplasia (LD) and to highlight the contributions of recent literature. The diagnosis of LD largely relies on endoscopic procedures and on histopathology. Diagnostic efficiency of endoscopy may be improved using videolaryngostroboscopy (VLS) and bioendoscopic tools such as Narrow Band Imaging (NBI) or Storz Professional Image Enhancement System (SPIES). Current histological classifications are not powerful enough to clearly predict the risk to carcinoma evolution and technical issues such as sampling error, variation in epithelial thickness and inflammation hamper pathological examination. Almost all dysplasia grading systems are effective in different ways. The 2017 World Health Organization (WHO) system should prove to be an improvement as it is slightly more reproducible and easier for the non-specialist pathologist to apply. To optimize treatment decisions, surgeons should know how their pathologist grades samples and preferably audit their transformation rates locally. Whether carcinoma in situ should be used as part of such classification remains contentious and pathologists should agree with their clinicians whether they find this additional grade useful in treatment decisions. Recently, different studies have defined the possible utility of different biomarkers in risk classification. The main treatment modality for LD is represented by transoral laser microsurgery. Radiotherapy may be indicated in specific circumstances such as multiple recurrence or wide-field lesions. Medical treatment currently does not have a significant role in the management of LD. Follow-up for patients treated with LD is a fundamental part of their care and investigations may be supported by the same techniques used during diagnosis (VLS and NBI/SPIES).

Surgical, Oncological, and Functional Outcomes of Transoral Robotic Supraglottic Laryngectomy

OBJECTIVES/HYPOTHESIS

To investigate the surgical, oncological, and functional outcomes of transoral robotic surgery (TORS) for the treatment of supraglottic squamous cell carcinoma.

STUDY DESIGN

Retrospective chart review.

METHODS

The charts of patients treated by TORS supraglottic laryngectomy (SGL) in an academic medical center were reviewed. The following outcomes were studied according to the tumor location: average robotic setup and operative times, mean estimated blood loss, postoperative complications, need of tracheotomy, refeeding characteristics, mean hospital stay, need of neck dissection and adjuvant therapy, 5-year local and regional controls, overall survival (OS), and disease-free survival (DFS).

RESULTS

Seventy-five patients underwent TORS SGL. Tumors were classified as cT1 (32%), cT2 (52%), and cT3 (16%). Average robotic setup and operative times and the mean estimated blood loss were 15 minutes, 55 minutes, and 20 mL, respectively. The mean follow-up period ranged from 2 to 5 years. The 5-year OS and DFS were 80.2% and 94.3%, respectively. Overall, 34.6% of patients received adjuvant radiotherapy. The majority of patients (92%) restarted an oral diet within 24 to 48 hours postsurgery. Transient tracheotomy was performed in 8% of patients. Postoperative hemorrhages occurred in 12 patients (16.0%), lengthening the hospital stay (mean = 6.8 days). There were no outcome differences regarding the tumor location.

CONCLUSIONS

TORS is an effective and safe therapeutic approach for early- and intermediate-stages cancers. Oncological outcomes may be quite similar to other surgical approaches, including transoral laser and open surgeries. Future randomized controlled studies are needed for comparing TORS SGL with other surgical procedures.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1060-1065, 2021.

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.

CO2 Transoral Laser Microsurgery in Benign, Premalignant and Malignant (Tis, T1, T2) Lesion of the Glottis. A Literature Review

Carbon Dioxide transoral laser microsurgery represents a reliable option for the treatment of early glottic carcinoma (Tis–T2), with good functional and oncological outcomes, nowadays representing one of the main options in larynx preservation protocols. The development and improvement of laser devices means surgeons are able to use more precise instruments compared with classic cold dissection in laser-assisted phonosurgery. Secondary effects on voice, swallowing, or quality of life as well as complications have been well documented. Also, with the introduction of a new proposal for staging systems following the principle of the three-dimensional map of isoprognostic zones, the use of narrow-band imaging in clinical evaluation and intraoperative, and the implementation of diffusion-weighted magnetic resonance during preoperative evaluation, the development of new tools to improve surgical quality and preliminary reports regarding the use of carbon dioxide laser in transoral robotic surgery suggests an exciting future for this technique.

Meta-analytic comparison of robotic and transoral laser surgical procedures in supraglottic carcinoma

Objective

To assess published reports of oncological surgical success rates in patients who underwent transoral laser supraglottic surgery and robotic surgery for supraglottic cancer.

Methods

A systematic review of the literature was conducted and a meta-analysis of published data was performed. PubMed, Sage, Medline and Cochrane data sources were investigated. Overall survival rates, disease-specific survival rates, additional treatments and recurrence rates were investigated to determine the success of the surgical procedures.

Results

The meta-analysis included 24 studies; 1617 studies were excluded. There were no statistically significant differences between the transoral laser supraglottic surgery and transoral robotic supraglottic surgery groups in terms of overall survival (77.0 per cent and 82.4 per cent respectively) and disease-specific survival (75.8 per cent and 87.0 per cent respectively). There was recurrence in 164 out of 832 patients (19.7 per cent) in the transoral laser supraglottic surgery group and in only 6 out of 66 patients (9 per cent) in the transoral robotic supraglottic surgery group.

Conclusion

Transoral laser surgery and robotic surgery appear to have comparable and acceptable oncological success rates.

Functional outcomes in early (T1/T2) supraglottic cancer: a systematic review

OBJECTIVES

Organ preserving surgery (OPS) and radiotherapy (RT) are both accepted treatment options for early stage supraglottic cancer (SGC). Radiation has supplanted surgery in most cases, because of the perception that surgery results in poorer functional outcomes. However, evidence suggests that OPS with a neck dissection may be associated with improved survival. Our objective was to conduct a systematic review of the literature to compare functional outcomes of OPS and RT for early SGC.

METHODS

We searched Medline, EMBASE and Cochrane Central Register of Controlled Trials to identify studies. Studies were included if they reported functional outcomes on 10 or more patients with early stage SGC treated with radiation or OPS, including open partial laryngectomy, transoral laser microsurgery (TLM) or transoral robotic surgery (TORS). Two reviewers independently screened articles for relevance using pre-determined criteria.

RESULTS

From 7720 references, we included 10 articles (n = 640 patients). 50% (n = 320) of patients were treated with surgery. Three head-to-head RT versus OPS papers were included, however different outcome measures were used for each group. Intractable aspiration management (including total laryngectomy or permanent tracheostomy) following OPS was reported in five papers representing 186 patients; the definitive intractable aspiration management rate was 2.6% (95% CI 1.0-6.8%). Four papers reported permanent G-tube rate for the surgical group (n = 198), calculating a rate of 5.3% (95% CI 2.6-10.5%), this was not reported for the RT group in any papers. One study reported quality of life. Two studies reported objective voice measures.

CONCLUSIONS

This systematic review revealed a paucity of objective measures and significant data heterogeneity, rendering the comparison of functional outcomes following OPS versus RT for early SGC limited. Future research should include objective measures of functional outcomes including laryngectomy rate, g-tube rate, tracheostomy dependence, quality of life, and voice quality measures.

Treatment of early-stage laryngeal cancer: A comparison of treatment options

Over the course of the last several decades, the treatment options for early laryngeal cancers (T1 and T2) have evolved; however, simultaneously the mortality rate has increased. As larynx preservation approaches have become the standard of care, the selection of the proper treatment modality has become paramount. Radiation therapy or transoral laser microsurgery are the most common options for treatment of these early lesions. Oncologic and functional outcomes are considered equivalent between the two modalities for early glottic cancers; however, no direct comparisons exist for robust analysis. In terms of larynx preservation, there also is not compelling data favoring one treatment option or another. For early stage lesions, the goal for any larynx-sparing technique, either radiation or surgery, should be the intent to cure with single modality treatment and minimal short- and long-term toxicity. This article is designed to create a frame of reference for managing early stage disease with respect to lesions of the glottis and supraglottis while weighing treatment implications from an oncologic, functional, and cost perspective.

Oncologic and functional outcomes of patients treated with transoral CO2 laser microsurgery or radiotherapy for T2 glottic carcinoma: a systematic review of the literature

PURPOSE OF REVIEW

To give an overview of the laryngeal preservation and functional outcomes of patients treated with transoral CO2 laser microsurgery (TLM) or radiotherapy for T2 glottic carcinoma. This information supports physicians and patients in treatment counselling and choices.

RECENT FINDINGS

A recent systematic review showed that local control rates at 5-year did not differ between radiotherapy and TLM for T2 glottic tumours. However, there is a lack of comparative data on laryngeal preservation as well as functional outcomes in T2 glottic carcinoma.

SUMMARY

Laryngeal preservation for T2 tumours in this review is higher for patients treated primarily with TLM (88.8 vs. 79.0%). It is important to differentiate between tumours with normal and impaired mobility (T2a and T2b) because the latter showed poorer prognosis for both TLM and radiotherapy. Involvement of the anterior commissure does not result in significantly lower oncological results, if adequately staged and treated. More studies are needed to support these data and to compare the functional outcomes between TLM and radiotherapy for T2 glottic carcinoma.

CO2 Transoral Microsurgery for Supraglottic Squamous Cell Carcinoma

The present study analyzed the results of the endoscopic approach to T1, T2 and selected T3 supraglottic carcinoma with the aim of reviewing functional and oncologic outcomes after different types of endoscopic supraglottic laryngectomies. This is a retrospective clinical study of 42 consecutive patients (mean age of 61.8 years, 33 males, 9 females) treated by the senior author for supraglottic squamous cell carcinoma with a transoral CO₂ laser approach and reviewed from November 2010 to September 2017. Surgical procedures were classified according to the European Laryngological Society. In addition to the standardized transoral supraglottic laryngectomies, we introduced a modified type IVb by sparing the inferior third of the arytenoid if not directly involved in the tumor. Swallowing was evaluated with the Swallowing Performance Status Scale reported by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. Survival probabilities were estimated using Kaplan-Meier curves. Two type I, 2 type IIa, 2 type IIb, 3 type IIIa, 12 type IIIb, 13 type IVa, 3 type modified IVb, and 5 type IVb supraglottic laryngectomies were performed. Twenty-one patients (50%) underwent primary neck dissection. The pathologic TNM classification according to the 8th edition of the American Joint Committee on Cancer system was as follows: 9 pT1cN0, 2 pT1N0, 1 pT1N1, 7 pT2cN0, 1 rypT2cN0, 9 pT2N0, 4 pT2N1, 2 ypT2N1, 2 pT3cN0, 2 rypT3cN0, 1 pT3N1, and 2 pT3N2b. Mean follow-up was 3.4 years (range of 9 months to 6 years). According to the Kaplan-Meier analysis, 5-year disease-specific survival, local-relapse-free survival, nodal-relapse-free survival, overall laryngeal preservation and overall survival of patients without previous head and neck radiotherapy/open surgery were 100%, 95.2%, 87.8%, 100%, and 64.6%, respectively. Patients who underwent type I, IIa, and IIb resections (n = 6) started oral feeding the day after surgery, patients who underwent type III-IVb modified resections (n = 31) started oral feeding 3-4 days after surgery, and patients who underwent standard type 4b resections (n = 5) started oral feeding 7 days after surgery. Three months after surgery, patients without a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed significantly better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing in 8 and 66.7% of cases, respectively (p = 0.006072); patients with a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed not statistically significant better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing at 3 months in 16.7% and 50% of cases, respectively (p = 0.23568). Transoral CO₂ laser supraglottic laryngectomy is an oncologic sound alternative to traditional open neck surgery and chemo-radiotherapy. Recovery of swallowing is significantly worsened after total resection of the arytenoid. Modified type IVb procedure leaving intact, when possible, the inferior third of the arytenoid and consequently the glottic competence, improves functional outcome.

Evaluation of surgical margin status in patients with early glottic cancer (Tis-T2) treated with transoral CO2 laser microsurgery, on local control

Purpose

To assess the impact of surgical margins status on local control in patients with primary early glottic (Tis-T2) squamous cell carcinoma after treatment with transoral CO₂ laser microsurgery (TLM) and to assess the significance of additional wound bed biopsies.

Methods

Patients with Tis-T2 tumours treated with TLM type I–III resections according to the European Laryngological Society classification between 2009 and 2013 were included in retrospective analysis. Recurrence rate was determined in patients with free versus non-free specimen margins and wound biopsies. Five-year survival rates were determined using the Kaplan–Meier method. Prognostic impact of pT-category, resection margin status, tumour differentiation, wound bed biopsy status, and number of biopsies on local control (LC) were tested with the log-rank test.

Results

Eighty-four patients were included in the analysis. Positive margins were seen in 68 patients (81.0%). Margin status after TLM did not significantly influence LC (p = 0.489), however, additional wound bed biopsies were significantly associated with lower LC (p = 0.009). Five-year LC, disease-specific survival, overall survival and laryngeal preservation were 78.6, 78.0, 98.6 and 100%, respectively.

Conclusions

Additional wound bed biopsies can help predict local recurrence in patients treated with TLM for early glottic carcinoma. We propose that there is enough evidence to support a wait-and-see policy in patients with positive specimen margins and negative wound bed biopsies. For patients with positive wound bed biopsies, further treatment is warranted.

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.

Treatment of early stage Supraglottic squamous cell carcinoma: meta-analysis comparing primary surgery versus primary radiotherapy

Objectives

For early stage supraglottic squamous cell carcinoma (SCC), single modality treatment either in the form of primary organ preservation surgery alone or radiation alone is recommended. Thus, a definite treatment strategy for early stage supraglottic SCC remains undefined. The primary objective of this study was to conduct a systematic review and meta-analysis comparing the oncologic outcomes of surgery and radiotherapy in early stage (Stage I and II) T1 N0 and T2 N0 supraglottic SCC.

Methods

Systematic methods were used to identify published and unpublished data. Two reviewers independently screened all titles, abstracts and articles for relevance using predefined criteria. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Five studies met the inclusion criteria for disease specific mortality with a total of 2864 pooled patients. 5-year disease specific mortality was lower in the surgery group (ORs 0.43, 95% CI 0.31–0.60). Four studies met the inclusion criteria for 5-year overall mortality with a total of 2790 pooled patients. Five-year overall mortality was lower in surgery group (ORs 0.40, 95% CI 0.29–0.55).

Conclusions

This is the first study to examine the management of early stage supraglottic SCC using meta-analytic methodology. Our results suggest that primary surgery may result in decreased disease specific and overall mortality compared to primary radiotherapy.

The role of intraoperative narrow-band imaging in transoral laser microsurgery for early and moderately advanced glottic cancer

Introduction

Trans-oral laser microsurgery is an established technique for the treatment of early and moderately advanced laryngeal cancer.

Objective

The authors intend to test the usefulness of narrow-band imaging in the intraoperative assessment of the larynx mucosa in terms of specifying surgical margins.

Methods

Forty-four consecutive T1–T2 glottic cancers treated with trans-oral laser microsurgery Type I–VI cordectomy were presented. Suspected areas (90 samples/44 patients) were biopsied under the guidance of narrow-band imaging and white light and sent for frozen section.

Results

Our study revealed that 75 of 90 (83.3%) white light and narrow-band imaging-guided samples were histopathologically positive: 30 (40%) were confirmed as carcinoma in situ or invasive carcinoma and 45 (60%) as moderate to severe dysplasia. In 6 patients mucosa was suspected only in narrow-band imaging, with no suspicion under white light. Thus, in these 6 patients 18/90 (20%) samples were taken. In 5/6 patients 16/18 (88.8%) samples were positive in frozen section: in 6/18 (33.3%) carcinoma (2 patients), 10/18 (66.6%) severe dysplasia was confirmed (3 patients). In 1 patient 2/18 (11.1%) samples were negative in frozen section. Presented analysis showed, that sensitivity, specificity and accuracy of white light was 79.5%, 20% and 71.1% respectively, while narrow-band imaging was 100%, 0.0% and 85.7%, respectively.

Conclusion

The intraoperative use of narrow-band imaging proved to be valuable in the visualization of suspect areas of the mucosa. Narrow-band imaging confirms the suspicions undertaken in white light and importantly, it showed microlesions beyond the scope of white light.

What is the price of functional surgical organ preservation in local-regionally advanced supraglottic cancer? Long-term outcome for partial laryngectomy followed by radiotherapy in 32 patients

Aims and background

To achieve the goal of organ preservation, both a chemoradiotherapy and a conservative surgical approach can be proposed. The aim of the study was to review all patients treated in our Institute with conservative surgery and postoperative radiotherapy for locally advanced supraglottic tumor.

Methods and study design

A retrospective analysis of 32 patients treated between 2000 and 2010 was performed. Overall survival, disease-free survival and late laryngeal toxicity were evaluated. The impact of surgical procedures, radiotherapy characteristics and addition of chemotherapy on late laryngeal toxicity was studied.

Results

The median follow-up was 38 months. Overall survival and disease-free survival at 5 years were 73% and 66%, respectively. Three (9%) patients experienced local recurrence (after 22, 25 and 40 months, respectively) and were treated with total laryngectomy. The larynx preservation rate was 93%. Severe treatment-related late laryngeal toxicity (grade 3 and 4 laryngeal edema, laryngeal stenosis, presence of tracheotomy at last follow-up because of treatment-related toxicity, and the need for enteral nutrition) was experienced by 34% of patients. The functional larynx preservation rate was 81%. The statistically significant risk factors for severe late toxicity were: female gender, extension of the surgical procedure, removal of one arytenoid and association with concomitant chemotherapy.

Conclusions

We confirmed literature data on the feasibility and efficacy of a surgical organ preservation strategy. However, the high incidence of severe late toxicity requires further studies to improve patient selection and to reduce side effects.

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 .

Conservative treatment for advanced T3-T4 laryngeal cancer: meta-analysis of key oncological outcomes

GOAL

Controversies exist regarding the treatment of advanced laryngeal carcinomas. The purpose of this systematic review was to evaluate the oncologic outcomes of both transoral laser and open partial laryngectomies for advanced (T3-T4) squamous cell laryngeal cancers management.

INTRODUCTION

A systematic review of literature was led searching for articles mentioning the following terms: advanced (T3-T4) laryngeal cancer AND laser; AND open partial laryngectomy; AND transoral laser microsurgery; AND cordectomy; AND conservative surgery; AND tracheohyoidopexy or tracheohyoidoepiglottopexy; AND supratracheal partial laryngectomy; AND supracricoid partial laryngectomy; AND cricohyoidopexy or cricohyoidoepiglottopexy. Then a quantitative analysis was carried on papers published after 1980.

DISCUSSION

The search identified 110 publications, and a total of 21 articles satisfied inclusion criteria and were selected for quantitative synthesis. 10 out of 21 studies had a good quality score, 10 were fair and only one rated a poor score. The pooled disease-free survival (DFS) was 79% (95% CI 74-85), and pooled overall survival (OS) was 71% (95% CI 64-78) at 5 years from all 1921 patients included in the study, with significant heterogeneity (I ² = 89.7% and I ² = 90.4%), respectively. Significant heterogeneity value (p = 0.118) was seen by comparing transoral laser and open partial laryngectomies in terms of DFS.

CONCLUSION

The two surgical techniques are both valid conservative surgical options for advanced laryngeal cancer treatment.

Transoral Laser Microsurgery in Early Glottic Lesions

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

ELMO3 predicts poor outcome in T1 laryngeal cancer

OBJECTIVES

Despite the excellent overall survival of 92%-97% in early glottic cancer, recurrence rates of 13%-20% have not improved in the last decades. The engulfment and cell motility protein 3 (ELMO3) have been described as prognostic marker in patients with lung cancer. The aim of this study was to investigate the expression of ELMO3 in early laryngeal cancer patients treated with TLM and to evaluate its prognostic significance on clinical outcome.

DESIGN, SETTING AND PARTICIPANT

Forty-eight patients with glottic carcinoma (T1N0M0) that underwent primary treatment with TLM between 1994 and 2012 were analysed. ELMO3 expression of the tumour was assessed using immunohistochemistry and correlated with clinical data.

MAIN OUTCOME MEASURE

Overall survival, disease-specific survival (DSS) and disease-free survival (DFS) rates RESULTS: Positive ELMO3 expression was found in 23% of the patients and was correlated with poor DSS and DFS (P<.05).

CONCLUSION

This is the first study to show a prognostic effect of positive ELMO3 expression in early glottic carcinoma patients.

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.

Complications in CO2 Laser Transoral Microsurgery for Larynx Carcinomas

Introduction Transoral laser microsurgery (TLM) has established itself as an effective option in the management of malignant tumors of the glottis, supraglottis, and hypopharynx. Nonetheless, TLM is not a harmless technique. Complications such as bleeding, dyspnea, or ignition of the air may appear in this type of surgery. Objective The aim of this study is to describe the complications that occurred in a group of patients treated for glottic and supraglottic carcinomas in all stages by TLM. Methods This study is a retrospective analysis of patients diagnosed with squamous cell carcinoma of the glottis and supraglottis for all stages (T1, T2, T3, T4), N -/ + , M -/+ treated with TLM between January 2009 and March 2012 in a tertiary hospital. Results Ninety-eight patients met the inclusion criteria, which had undergone a total of 131 interventions. Ninety-four (95.9%) patients were male and 4 (4.1%) were female. The mean age was 64.2 years (± 10.7 years = min 45; max 88). The presence of intraoperative complications was low, affecting only 2% of patients. Immediate postoperative complications occurred in 6.1%, whereas delayed complications affected 13.2% of patients, without any of them being fatal. Conclusion TLM has shown good oncologic results and low complication rate compared with traditional open surgery during intervention, in the immediate and delayed postoperative period and in the long-term with respect to radiotherapy.

Organ Preservation for Advanced Larynx Cancer: Issues and Outcomes

PURPOSE

To provide a review of the clinical data, controversies, and limitations that underpin current recommendations for approaches to larynx preservation for locally advanced larynx cancer requiring total laryngectomy.

METHODS

The key findings from pivotal randomized controlled trials are discussed, including quality of life, late effects, and function assessments. Trials investigating taxane inclusion in induction chemotherapy and trials of epidermal growth factor receptor inhibition for radiosensitization are put into perspective for larynx cancer. Controversies in the management of T4 primaries and the opportunities for conservation laryngeal surgery are reviewed.

RESULTS

There are data from clinical trials to support induction chemotherapy, followed by radiotherapy (preferred approach in Europe) and concomitant cisplatin plus radiotherapy (preferred in North America) for nonsurgical preservation of the larynx. Treatment intensification by a sequential approach of induction, followed by concomitant treatment, is investigational. Transoral laryngeal microsurgery and transoral robotic partial laryngectomy have application in selected patients.

CONCLUSION

The management of locally advanced larynx cancer is challenging and requires an experienced multidisciplinary team for initial evaluation, response assessment, and support during and after treatment to achieve optimal function, quality of life, and overall survival. Patient expectations, in addition to tumor extent, pretreatment laryngeal function, and coexisting chronic disease, are critical factors in selecting surgical or nonsurgical primary treatment.

The effect of midline crossing of lateral supraglottic cancer on contralateral cervical lymph node metastasis

CONCLUSION

The degree of midline crossing of lateral supraglottic cancer does not significantly change its rate of contralateral cervical metastasis. The rate of occult metastasis is too high to take the risk of contralateral regional recurrence. We support routine bilateral neck dissection even in lateral supraglottic cancers with no or minimal midline crossing.

OBJECTIVES

Data on the rate of contralateral cervical metastasis of laterally located supraglottic cancer, the effect of its degree of midline crossing on contralateral cervical metastasis, and its treatment are still controversial.

METHODS

This was a retrospective cohort, chart review involving 305 surgically treated patients with T1-3 squamous cell carcinoma of the supraglottic larynx. In all, 184 patients had bilateral neck dissection; 86 N0 contralateral necks were followed up. Thirty-five patients who needed postoperative radiation therapy because of the primary tumor or ipsilateral neck dissection specimen also received radiation therapy to the contralateral neck. The degree of midline crossing at the epiglottis was measured on a laryngectomy specimen with a ruler and expressed as 'no,' '<5 mm' or '≥5 mm.'

RESULTS

The rates of occult and overall contralateral metastasis in our series were 16% and 28%, respectively. There was no statistically significant difference between contralateral neck metastasis and recurrence rates in the neck dissection, follow-up, and irradiation groups according to the degree of midline crossing.

Laryngeal cancer in Finland: A 5-year follow-up study of 366 patients

BACKGROUND

The purpose of this study was to acquire nationwide data on the management and outcome of laryngeal squamous cell carcinoma (SCC) in Finnish university hospitals over a 5-year posttreatment follow-up.

METHODS

All records of patients diagnosed and treated for primary laryngeal SCC during 2001 to 2005 were reviewed.

RESULTS

Three hundred sixty-six patients with laryngeal cancer were identified, 360 of whom had laryngeal SCC. Three hundred forty-two patients with laryngeal SCC (95%) were treated with curative intent. Five-year disease-specific survival (DSS) for T1a, T1b, T2, T3, and T4 glottic SCC was 100%, 95%, 78%, 79%, and 53%, respectively. The corresponding figures for T1 to T4 supraglottic SCC were 68%, 54%, 72%, and 59%.

CONCLUSION

Results of this nationwide study give a general overview of the outcome of unselected patients treated with unified guidelines. Patients with T2 tumors, usually treated with radiotherapy (RT), had a worse prognosis than expected. This patient group warrants further investigation and possibly treatment intensification.

Magnetic resonance for laryngeal cancer

PURPOSE OF REVIEW

This review summarizes the most recent experiences on the integration of magnetic resonance in assessing the local extent of laryngeal cancer and detecting submucosal recurrences.

RECENT FINDINGS

Advances in magnetic resonance have been characterized by the development of technical solutions that shorten the acquisition time, thereby reducing motion artifacts, and increase the spatial resolution. Phased-array surface coils, directly applied to the neck, enable the use of parallel-imaging techniques, which greatly reduce the acquisition time, and amplify the signal intensity, being closer to the larynx. One of the most important drawbacks of this technique is the small field-of-view, restricting the imaged area to the larynx. Furthermore, diffusion-weighted imaging (DWI) has increased the set of magnetic resonance sequences. Differently from computed tomography (CT), which has only two variables (precontrast/postcontrast), magnetic resonance is based on a multiparameter analysis (T2-weighting and T1-weighting, DWI, and postcontrast acquisition). This multiparameter approach amplifies the contrast resolution. It has, also, permitted to differentiate scar tissue (after laser resection) from submucosal recurrent disease. In addition, DWI sequences have the potential of a more precise discrimination of peritumoral edema from neoplastic tissue, which may lead to improve the assessment of paraglottic space invasion.

SUMMARY

Magnetic resonance of the larynx is technically challenging. The use of surface coils and motion-reducing techniques is critical to achieve adequate image quality. The intrinsic high-contrast resolution is further increased by the integration of information from different sequences. When CT has not been conclusive, magnetic resonance is indicated in the pretreatment local assessment and in the suspicion of submucosal recurrence.

Transoral robotic surgery vs transoral laser microsurgery for resection of supraglottic cancer: a pilot surgery

BACKGROUND

Transoral laser microsurgery (TLM) is a mature approach to supraglottic cancer, while transoral robotic surgery (TORS) is emerging. The present study compared these approaches.

METHODS

The first 10 patients (2002-2005) given TLM were compared with the first 10 (2007-2011) given TORS for cT1-3 cN0-cN2c supraglottic cancer.

RESULTS

A feeding tube was used in four TLM and seven TORS patients. Margins were more often positive, but operating times shorter, in TORS. All 10 TORS patients are without evidence of disease, but only six TLM patients remain disease-free after much longer follow-up. TORS was considerably less uncomfortable and fatiguing for the surgeon.

CONCLUSIONS

TORS seems as safe and effective as TLM. Shorter TORS operating times are probably attributable to prior experience with TLM. For laryngeal exposure, length of tube placement and margin evaluability, TLM was superior; however, this may change as TORS develops and transoral robotic instruments are optimized.

Oncologic and Functional Outcomes of Partial Laryngeal Surgery for Intermediate-Stage Laryngeal Cancer

Objective

To evaluate the oncologic and functional outcomes of partial laryngeal surgery (PLS) using transoral laser microsurgery (TLM) and supracricoid laryngectomy (SCL) in patients with intermediate-stage laryngeal squamous cell carcinoma (LSCC).

Study Design

Historical cohort study.

Setting

Single tertiary care center.

Subjects and Methods

Retrospective review of oncologic and functional outcomes in intermediate-stage (T2-3/N0-1, stage II and III) LSCC patients who underwent TLM or SCL from 1998 to 2010.

Results

Sixty patients were included, of whom 28 (47%) underwent TLM and 32 (53%) underwent SCL. For the entire cohort, 2- and 5-year probabilities were 86.2% (95% confidence interval [CI], 73.0%-93.2%) and 72.9% (95% CI, 52.4%-85.6%), respectively, for overall survival (OS) and 79.3% (95% CI, 65.6%-88.0%) and 62.4% (95% CI, 41.9%-77.4%), respectively, for recurrence-free survival (RFS). There was no difference between the TLM and SCL cohorts in OS ( P = .542) or RFS ( P = .483). More than 75% of patients avoided adjuvant therapy. Communication Scale and Functional Outcome Swallowing Scale scores at median follow-up of 33 months were 2 or better in 97% and 91% of patients, respectively, reflecting functional voice and swallowing postoperatively. Eighty-eight percent of patients retained a functional larynx.

Conclusion

PLS provides excellent oncologic and functional outcomes for intermediate-stage LSCC and should be considered an alternative to chemoradiation or total laryngectomy in selected patients.

Outcomes following transoral robotic surgery: supraglottic laryngectomy

OBJECTIVES/HYPOTHESIS

To describe a single center outcomes following transoral robotic surgery for supraglottic laryngectomy (TORS-SL).

STUDY DESIGN

Prospective data collection.

METHODS

Patient records receiving TORS-SL for squamous cell carcinoma (SCCA) with at least 12 months follow-up fit inclusion for this study. Two patients with previous SCCA were excluded.

RESULTS

18 patients (14 male, 4 female) were included in the study, having a mean follow-up time of 28.1 months (SD = 12.1). All patients had negative margins confirmed on final pathology. Nine (50%) patients received postoperative chemoradiation therapy for advanced neck disease. No (0%) patients received tracheostomy or gastrostomy tubes. There were no (0%) local recurrences, and three (16.7%) regional recurrences. Five (27.8%) patients experienced temporary postoperative complications. Overall 2-year outcomes reached 83%, 100%, and 89% for locoregional control, disease-specific survival, and overall survival respectively.

CONCLUSIONS

Initial outcomes for TORS-SL are encouraging and are comparable to previously described treatment modalities. Larger studies are encouraged.

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.