Transoral laser microsurgery for T1b glottic cancer: review of 51 cases

Prognostic value of preoperative inflammatory ratios in early glottic cancer treated with transoral laser surgery

BACKGROUND

There is growing evidence regarding the prognostic utility of ratios such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammatory index (SIII) in head and neck squamous cell carcinoma (HNSCC). However, most studies to date include heterogeneous series with different treatments or tumor subsites.

METHODS

We collected data from 201 patients with stage I-II glottic squamous cell carcinoma treated with transoral laser surgery. NLR, PLR, and SIII were calculated from preoperative cell blood count, cut-off points were obtained by ROC curve analysis, and survival rates were calculated.

RESULTS

High NLR (p = 0.012) and SIII (p = 0.037), but not PLR (p = 0.48), were associated with worse disease-specific survival (DSS). A similar trend was observed with overall survival (OS), although it did not reach statistical significance. On multivariable analyses, both high NLR (HR = 3.8, 95% CI = 1.5-9.9, p = 0.006) and high SIII (HR = 2.77, 95% CI = 1.1-6.9, p = 0.03) were significantly associated with shortened DSS.

CONCLUSIONS

Preoperative NLR and SIII emerge as independent prognostic biomarkers for early-stage surgically treated glottic tumors and could guide individualized follow-up.

Radiofrequency Coblation-Assisted Transoral Surgery for the Treatment of Oropharyngeal Squamous Cell Carcinoma: A Comparative Study with Open Surgery

Objective

Radiofrequency coblation (RFC) is a relatively new method that has opened up new perspectives in treating oropharyngeal squamous cell carcinoma (OPSCC). Our study was designed to explore the feasibility and effectiveness of RFC-assisted transoral surgery (RFC-TOS) for primary OPSCC.

Methods

Sixty-nine cases of OPSCC from February 2005 to November 2020 were retrospectively analyzed, including 31 in the RFC-TOS group and 38 in the open surgery group. No difference was observed in demographic and oncological characteristics.

Results

The significance between the RFC-TOS group and the open surgery group was proved in intraoperative bleeding volume (34.10 ± 10.10 ml vs. 193.68 ± 21.00 ml, P < 0.001), durations of surgery (79.58 ± 8.45 min vs. 217.87 ± 17.65 min, P < 0.001), time to resume oral feeding (1.64 ± 0.41 d vs. 11.58 ± 1.41 d, P < 0.001), duration of hospitalization (7.84 ± 0.66 d vs. 15.66 ± 1.62 d, P < 0.001), and the total costs (22846.22 ± 1821.55¥ vs. 41792.24 ± 4150.86¥, P < 0.001). The rates of 5-year overall survival (OS), 5-yeardisease-specific survival (DSS), and 5-year local control rate (LC) were 69.1%, 71.7%, and 75.7%, respectively, in the RFC-TOS group and 71.0%, 73.4%, and 73.7% in the open surgery group (P > 0.05).

Conclusions

RFC-TOS is a feasible alternative transoral approach for OPSCC. The reported perioperative and oncologic outcomes are satisfactory.

To what extent has the last two decades seen significant progress in the management of older patients with head and neck cancer?

INTRODUCTION

Life expectancy is rising and consequently also the number of older patients with head and neck cancer. Different treatment regimens are often applied for older patients. The aim of this study is to investigate how treatment patterns and survival rates have changed over the past 20 years in older patients with head and neck squamous cell carcinoma (HNSCC).

MATERIALS

Patient and tumour characteristics, treatment and 5-year survival data from the Netherlands Cancer Registry of patients aged ≥60 years diagnosed with HNSCC in 1990-1995 and 2010-2015 were compared using chi-square test and relative survival analysis.

RESULTS

Data of 14,114 patients were analyzed. Oral cavity cancer treatment did not change over time, while survival improved from 54% to 58% (p = 0.03). Oropharyngeal and hypopharyngeal cancer treatment shifted towards non-surgical, with survival improving from 31% to 51% (p < 0.01) and 26% to 34% (p < 0.01), respectively. Laryngeal cancer treatment changed towards surgery in stage I and non-surgical treatment in stage III and IV disease. Survival in laryngeal cancer stage I remained stable and favorable at a relative survival rate of around 90%. Survival non-significantly changed from 54% to 49% for stage III disease and from 37% to 33% for disease.

CONCLUSION

Relative survival increased for all head and neck cancer sites in older patients, except for laryngeal cancer. For oropharyngeal, hypopharyngeal and advanced laryngeal cancer, a shift towards non-surgical treatment modalities was observed.

Outcomes of frontolateral vertical partial laryngectomy in T1b glottic carcinomas

BACKGROUND

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of Postoperative Radiation Following Laser Resection in Early-Stage Glottic Cancer

OBJECTIVE

Guideline recommendations for the treatment of early-stage glottic cancer are limited to single-modality therapy with surgery or radiation alone. We sought to investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) following laser excision for patients with T1-T2N0 glottic squamous cell carcinoma (SCC).

STUDY DESIGN

Retrospective observational study of the National Cancer Database.

SETTING

National Cancer Database review from 2004 to 2014.

PATIENTS AND METHODS

A total of 1338 patients with primary cT1-T2N0M0 glottic SCC undergoing primary laser excision were included. Hospitals were divided into quartiles based on yearly volume of laryngeal laser cases performed. Multivariate logistic regression was performed to identify independent predictors of PORT.

RESULTS

The overall rate of PORT was 30.0%. Predictors of PORT included treatment at lower-volume hospitals (adjusted odds ratio [aOR] for quartiles 2-4, 1.32-4.84), positive margins (aOR, 3.83 [95% CI, 2.54-5.78]), and T2 tumors (aOR, 3.58 [95% CI, 2.24-5.74]). PORT utilization demonstrated a strong inverse correlation with hospital volume. Among top-quartile hospitals, the rate of PORT was 11.2%, while rates of PORT at second-, third-, and fourth-quartile institutions were 19.2%, 32.2%, and 37.4%, respectively.

CONCLUSIONS

Predictors of PORT in multivariable analysis included treatment at lower-volume facilities, positive margins, and T2 disease. This study highlights the importance of treating early-stage glottic carcinoma at high-volume institutions. In addition, there is a need to reevaluate the use of PORT and reduce the rate of dual-modality therapy for patients with early-stage glottic SCC.

T1b Glottic Tumor and Anterior Commissure Involvement: Is the Transoral CO2 Laser Microsurgery a Safe Option?

OBJECTIVES

Transoral CO₂ laser therapy represents the treatment of choice for early-stage laryngeal tumors. The anterior commissure involvement (ACI) is related to a worse local control and a lower rates of organ preservation. The objective of this study is to analyze the differences in survival, local control, and organ preservation in T1b glottic patients according to the presence of ACI.

METHODS

Observational prospective study in pT1b treated with transoral CO₂ laser between 2009 and 2014.

RESULTS

Forty patients (37 male and 3 female) with a mean age of 66.43 ± 8.16 years were recruited. Anterior commissure involvement was present in 70% of the patients. The 5-year specific cause survival was 91.66%, with 32.50% of local recurrences. Laryngeal preservation was 80%, being lower in the group with local recurrence (P < .000). The involvement of the anterior commissure does not influence the organ preservation (P = .548), the appearance of local recurrences (P = .391), or the survival (P = .33).

CONCLUSIONS

Transoral CO₂ laser therapy is an effective and reproducible treatment for early-stage laryngeal tumors. The results obtained are similar to previous studies, although they present discrepancies in relation to the role of the ACI. Prospective randomized trials are required focusing also on the patients' quality of life and functional outcome in order to clarify the role of the ACI and the need to implement changes in its evaluation, staging, and evolution.

A prospective clinical trial of the second-look procedure for transoral surgery in patients with T1 and T2 laryngeal, oropharyngeal, and hypopharyngeal cancer

Background

Transoral surgery (TOS) has been widely applied for early T‐stage head and neck cancer (HNC). The resection is performed with a minimum safety margin for function preservation under a limited surgical field; therefore, it is difficult to have a strong conviction about the complete resection. This study aims to evaluate the completeness of the initial TOS procedure; possibility of primary control by TOS alone; and predictive factors in patients with early T‐stage laryngeal, oropharyngeal, and hypopharyngeal cancer.

Methods

Patients were treated by TOS at the primary site with or without neck dissection. The patients were divided into two groups based on the pathological evaluation of their surgical specimens: the control (observation) group, in that the resection was considered complete and the intervention (second‐look procedure) group, in that incomplete tumor resection was suspected. The predictive factors for the possibility and/or limitations of complete resection by TOS were then analyzed.

Results

The study enrolled 26 and 25 patients in the control and intervention group, respectively. The success rate for single resection was 66% and the predictive factor was tumor depth obtained by enhanced computed tomography (CT) examination (odds ratio, 7.870, P = .0243). The success rate for definitive therapy by TOS alone was 83% and the predictive factor was poor differentiation observed on pathological examination (odds ratio, 6.800, P = .0248).

Conclusions

TOS has the potential for both definitive resection and function preservation with minimal invasiveness. Identification of the risk factors for TOS is advantageous for accurate treatment selection in patients with early T‐stage HNC.

A study of the association between local recurrence and surgical margins in vertical partial laryngectomy for T1 glottic squamous cell carcinoma

Background: The effect of surgical margins on local recurrence in T1 glottic squamous cell carcinoma (GSCC) is unclear. Objectives: To investigate the association between surgical margins and local recurrence of T1 GSCC patients with vertical partial laryngectomy (VPL). Materials and methods: We retrospectively studied 117 T1 GSCC patients. Close and negative margins were estimated as distance <5 mm and ≥5 mm. The effect of surgical margins on local recurrence was evaluated. For patients with invasion not reaching muscular-layer, a threshold margin of 2 mm was detected. Results: About 109 patients were exclusively treated by VPL and 8 patients received postoperative radiotherapy. In 109 cases, the posterolateral margins and shortest margins in recurrence group were both lower than no-recurrence group (p<.01). The ratios of posterolateral margin to average diameter, upper-lower diameter and internal-external diameter in recurrence group were also statistically lower (p<.05). A threshold margin of 2 mm showed statistical difference on recurrence in patients with invasion not reaching muscular-layer. Conclusions and significance: Posterolateral margin is crucial for local recurrence in T1 GSCC patients treated by VPL. A shortest margin of ≥5 mm should be considered. For the patients with invasion not reaching the muscular-layer, a threshold of 2 mm is enough for safe margin.

Nature and role of surgical margins in transoral laser microsurgery for early and intermediate glottic cancer

PURPOSE OF REVIEW

Summarize recent findings regarding the impact of margin status on oncologic outcomes and organ preservation, as well as evaluate possible management policies of close and positive margins after transoral laser microsurgery (TLM) for Tis-T2 glottic carcinomas.

RECENT FINDINGS

Impact of margin status on survival rates remains controversial, whereas some authors found close and positive margins to be independent risk factors for recurrence and poorer survival rates, others did not find any significant variations compared with negative ones. A common trend can be observed in performing a watchful waiting policy or second look TLM in patients with close-superficial and positive single-superficial margins. Further treatment seems preferable in case of deep and positive multiple superficial margins.

SUMMARY

Positive margins are present in up to 50% of patients treated by TLM, even though a high rate of false positivity, reaching 80%, has been described. Close and positive single superficial margins seem to be linked to higher recurrence rates compared with negative margins, even though watchful wait and see policy, especially when performed by adjunctive visual aids like Narrow Band Imaging, maintains good final oncological and organ preservation outcomes. Further treatments are required in case of deep margin positivity.

The Second-Look Procedure for Transoral Videolaryngoscopic Surgery for T1 and T2 Laryngeal, Oropharyngeal, and Hypopharyngeal Cancer Patients: Protocol for a Nonrandomized Clinical Trial

BACKGROUND

Transoral videolaryngoscopic surgery (TOVS) has been widely applied for early T stage head and neck cancer. The resection is performed with a minimum safety margin for function preservation under a limited surgical field of view, making it difficult to be certain of complete resection.

OBJECTIVE

Our aim is the evaluation of the completeness of resection by initial TOVS resection, and the possibility of primary control by TOVS alone, allowing for repeat procedures for function preserving treatment in early T stage laryngeal, oropharyngeal, and hypopharyngeal cancer patients.

METHODS

Patients are treated by TOVS for the primary site with or without neck dissection. Patients are divided in two groups based on the results of the pathological evaluation of the surgical specimen; the control group in which the resection is considered to be complete, and the intervention (second-look procedure) group in which incomplete tumor resection is suspected. The predictive factors for the possibility of complete resection by TOVS will then be analyzed.

RESULTS

Patient enrollment started on January 1, 2014, and closed on March 31, 2016, with 54 patients. The control group consists of 27 patients, the intervention group is 21 patients, and 6 patients were excluded. There were no clinical differences between the control and intervention groups. The observation period will end on December 31, 2018.

CONCLUSIONS

TOVS has potential for both definitive resection and function preservation with minimal invasiveness. Identifying the limitations of TOVS is beneficial to ensure accurate treatment selection in early T stage head and neck cancer patients.

TRIAL REGISTRATION

UMIN Clinical Trials Registry: UMIN000012485; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000014472 (Archived by WebCite at http://www.webcitation.org/6v1b741Iw).