Transoral CO2 laser management for selected supraglottic tumors and neck dissection

Investigation of low and high dose rate X-ray effects on histopathological changes and prognostic importance of Ki-67 in laryngeal cancer radiotherapy

The aim of this study is to analyze the effect on histopathological changes and Ki-67 expression levels of Flattening Filter (FF) and Flattening Filter Free (FFF) beams to investigate the radiobiological mechanisms underlying laryngeal cancer (LCa) post-radiotherapy (RT) on mice models. Forty adult NOD SCID gamma (NSG) mice models were randomly divided into four groups; the sham, LCa, FF-RT and FFF-RT groups. The head and neck region of mice in FF-RT and FFF-RT groups (LCa plus RT groups) were irradiated with a single dose of 18 Gy at 400 MU/min and 1400 MU/min. The NSG mice received radiotherapy 30 days after tumor transplantation and sacrificed 2 days after radiotherapy for analysis of histopathology parameters and K-67 expression levels. Comparing the LCa, FF-RT and FFF-RT groups with the sham group, statistically significant differences were observed in histopathological parameters depending on tumor tissue and dose rate (p < 0.05). When the histopathological effects of FF-RT beam on LCa tissue were compared with FFF-RT beam, it was observed that statistically significant differences occurred (p < 0.05). Comparing the LCa group with the sham group, it was observed that the Ki-67 level affected significantly depending on the development of cancer (p < 0.01). It was concluded that FF and FFF beams caused significant changes in the histopathological parameters and Ki-67 expression levels. When the effects of FFF beam on Ki-67 levels, cell nucleus and cytoplasmic findings were compared with FF beam, significant radiobiological differences were observed.

Incidence of Occult Lymph Node Metastasis in Primary Larynx Squamous Cell Carcinoma, by Subsite, T Classification and Neck Level: A Systematic Review

Background: Larynx cancer is a common site for tumors of the upper aerodigestive tract. In cases with a clinically negative neck, the indications for an elective neck treatment are still debated. The objective is to define the prevalence of occult metastasis based on the subsite of the primary tumor, T classification and neck node levels involved. Methods: All studies included provided the rate of occult metastases in cN0 larynx squamous cell carcinoma patients. The main outcome was the incidence of occult metastasis. The pooled incidence was calculated with random effects analysis. Results: 36 studies with 3803 patients fulfilled the criteria. The incidence of lymph node metastases for supraglottic and glottic tumors was 19.9% (95% CI 16.4–23.4) and 8.0% (95% CI 2.7–13.3), respectively. The incidence of occult metastasis for level I, level IV and level V was 2.4% (95% CI 0–6.1%), 2.0% (95% CI 0.9–3.1) and 0.4% (95% CI 0–1.0%), respectively. For all tumors, the incidence for sublevel IIB was 0.5% (95% CI 0–1.3). Conclusions: The incidence of occult lymph node metastasis is higher in supraglottic and T3–4 tumors. Level I and V and sublevel IIB should not be routinely included in the elective neck treatment of cN0 laryngeal cancer and, in addition, level IV should not be routinely included in cases of supraglottic tumors.

Survival differences between definitive radiotherapy and surgery followed by adjuvant radiotherapy in supraglottic and hypopharyngeal carcinoma

Background:

Organ preservation has long been a consideration in the treatment of supraglottic and hypopharyngeal carcinoma to improve the quality of life (QOL). Definitive radiotherapy (DRT) with or without systematic treatment, such as chemotherapy, is always the first choice to achieve improved QOL. This retrospective study focused on the survival differences between DRT and surgery followed by adjuvant radiotherapy (S + RT) in supraglottic and hypopharyngeal carcinoma.

Methods:

This study included adult patients with supraglottic or hypopharyngeal carcinoma undergoing single-modality treatment with either DRT or S + RT between January 2012 and August 2016. A total of 59 patients were identified, of whom 31 were treated with DRT, and 28 were treated with S + RT. In the 31 cases of DRT, 23 cases were treated with concurrent chemoradiotherapy (CRT), one case was treated with DRT plus cetuximab, and seven cases were treated with DRT alone. Of the other 28 cases of S + RT, 15 cases were treated with adjuvant concurrent CRT. Survival analysis was used to compare the overall survival (OS), local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) between DRT and S + RT groups.

Results:

The median follow-up was 20 months (range, 4–67 months). The patients of the two groups were similar with respect to mean age, original sites, and tumor stages. The 1-, 2-, and 5-year OS rates were 80.6%, 53.4%, and 24.7% for the DRT group and 85.7%, 67.1%, and 24.7% for the S + RT group, respectively. There was no significant difference between the two groups (χ² = 3.183, P = 0.074). The 1-, 2-, and 5-year LRFS and DMFS were 90.4%, 61.7%, and 18.0% and 87.4%, 49.2%, and 9.9%, respectively, and no statistical difference was observed between the two groups (LRFS: χ² = 0.028, P = 0.868; DMFS: χ² = 3.347, P = 0.067). No significant difference was found between the two groups in acute radiotoxicity.

Conclusion:

Without loss of laryngeal function, the survival of DRT is comparable to that of S + RT in supraglottic and hypopharyngeal carcinoma.

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.

The Treatment of Laryngeal Cancer

Successful management of laryngeal cancer depends on careful pretreatment evaluation of patient and disease factors to arrive at accurate staging, leading to appropriate treatment selection for patients with this highly impacting disease. Surgical modalities, including transoral laser microsurgery, open partial laryngectomy, and total laryngectomy, offer options, alone or in combination with radiation and chemotherapy. Treatment strategy for laryngeal cancer should strive for cure while maintaining the best quality of life possible for the patient. Achieving the goals of initial and salvage treatment for laryngeal cancer depends on executing a plan of care determined by the expertise of the multidisciplinary team.

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 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.

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 .

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.

Tumor Volumes and Prognosis in Laryngeal Cancer

Tumor staging systems for laryngeal cancer (LC) have been developed to assist in estimating prognosis after treatment and comparing treatment results across institutions. While the laryngeal TNM system has been shown to have prognostic information, varying cure rates in the literature have suggested concern about the accuracy and effectiveness of the T-classification in particular. To test the hypothesis that tumor volumes are more useful than T classification, we conducted a retrospective review of 78 patients with laryngeal cancer treated with radiation therapy at our institution. Using multivariable analysis, we demonstrate the significant prognostic value of anatomic volumes in patients with previously untreated laryngeal cancer. In this cohort, primary tumor volume (GTV_P), composite nodal volumes (GTV_N) and composite total volume (GTV_P + GTV_N = GTV_C) had prognostic value in both univariate and multivariate cox model analysis. Interestingly, when anatomic volumes were measured from CT scans after a single cycle of induction chemotherapy, all significant prognosticating value for measured anatomic volumes was lost. Given the literature findings and the results of this study, the authors advocate the use of tumor anatomic volumes calculated from pretreatment scans to supplement the TNM staging system in subjects with untreated laryngeal cancer. The study found that tumor volume assessment after induction chemotherapy is not of prognostic significance.

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.

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.