Definitive Radiation Management for Carcinoma of the Glottic Larynx

Salvage carbon dioxide transoral laser microsurgery for laryngeal cancer after (chemo)radiotherapy: a European Laryngological Society consensus statement

Purpose

To provide expert opinion and consensus on salvage carbon dioxide transoral laser microsurgery (CO₂ TOLMS) for recurrent laryngeal squamous cell carcinoma (LSCC) after (chemo)radiotherapy [(C)RT].

Methods

Expert members of the European Laryngological Society (ELS) Cancer and Dysplasia Committee were selected to create a dedicated panel on salvage CO₂ TOLMS for LSCC. A series of statements regarding the critical aspects of decision-making were drafted, circulated, and modified or excluded in accordance with the Delphi process.

Results

The expert panel reached full consensus on 19 statements through a total of three sequential evaluation rounds. These statements were focused on different aspects of salvage CO₂ TOLMS, with particular attention on preoperative diagnostic work-up, treatment indications, postoperative management, complications, functional outcomes, and follow-up.

Conclusion

Management of recurrent LSCC after (C)RT is challenging and is based on the need to find a balance between oncologic and functional outcomes. Salvage CO₂ TOLMS is a minimally invasive approach that can be applied to selected patients with strict and careful indications. Herein, a series of statements based on an ELS expert consensus aimed at guiding the main aspects of CO₂ TOLMS for LSCC in the salvage setting is presented.

Objective and self-evaluation voice analysis after transoral laser cordectomy and radiotherapy in T1a-T1b glottic cancer

Voice quality outcome becomes an important factor in the choice of the therapeutic option. The differences between radiotherapy and laser cordectomy have been extensively debated in the literature. We analyzed the vocal outcomes after carbon dioxide (CO₂) laser cordectomy and radiotherapy treatment for T1a-b early glottic cancer by means of objective and subjective voice evaluation. A retrospective study was performed on 56 cancer patients, 30 treated with cordectomy and 26 with radiotherapy. All patients underwent laser cordectomy which was performed under general anesthesia using a surgical microscope in laryngeal suspension. The laser we used was an Ultrapulse one, 10.6-μm wavelength, and a power setting of 2 to 4 W in an Ultrapulse mode was selected. Two different sets of data were recorded: (a) voice acoustic analysis (jitter, shimmer, fundamental frequency and noise/harmonic ratio) and (b) voice handicap index (VHI). Data collected were statistically analyzed using SPSS 20.0 for Windows. Jitter, shimmer, and signal-to-noise ratio were significantly altered in both glottic cancer patient groups as compared to the control group. On the contrary, no statistically significant alteration of the fundamental frequency was found in both treatment groups. Interestingly, jitter and shimmer values were significantly more compromised in transoral laser surgery patients as compared with radiotherapy-treated patients. The VHI was also significantly altered in both cancer patient groups as compared to the control group. More importantly, however, the self-evaluation voice analysis was not significantly different between the two treatment groups, contrary to what we observed for two of the four parameters measured in the objective voice analysis. Given the importance of the self-perception of the voice quality, no treatment can be considered superior from the patients' point of view. Therefore, we suggest that priority should be given to the endoscopic surgery, due to lower costs, lower morbidity, and shorter hospitalization.

Intensity-modulated radiotherapy for early-stage glottic cancer

BACKGROUND

The purpose of this study was to report on treatment outcome of intensity-modulated radiotherapy (IMRT) for early-stage (cT1-2 cN0 M0) squamous cell carcinoma of the glottis, as compared with patients treated with conventional radiotherapy.

METHODS

Between November 2007 and December 2011, 40 consecutive patients were treated with IMRT with daily cone-beam CT position verification. The median prescription to the planning target volume (PTV) was 63 Gy/28 fractions and 67.5 Gy/30 fractions for T1 and T2 tumors, respectively. The historical control comprised 81 consecutive patients treated with conventional radiotherapy to total doses of 66 Gy/33 fractions (66 patients) and 70 Gy/35 fractions (15 patients) for T1 and T2 tumors, respectively.

RESULTS

The median follow-up of living patients was 3.8 years (range, 1.0-5.0 years) in the IMRT group and 9.0 years, (range, 5.2-12.7 years) in the conventional group. Five-year actuarial local control was equal compared to the conventional group: 83% versus 74% (p = .64). Five-year actuarial ultimate local control was 100% in the IMRT group and 95% in the conventional group (p = .17). Five-year actuarial overall and disease-specific survival was 85% after IMRT versus 65% after conventional radiotherapy (p = .15) and 97% versus 89% (p = .31), respectively. Incidence and severity of acute dermatitis was significantly less during IMRT than in the control group (p < .001). Two patients receiving IMRT had late grade 3 hoarseness.

CONCLUSION

IMRT is as efficient as conventional radiotherapy in terms of disease control and overall survival. It has the potential to reduce toxicity as compared to conventional radiotherapy. © 2015 Wiley Periodicals, Inc. Head Neck 38: E179-E184, 2016.

Pathologic evaluation of primary laryngeal anterior commissure carcinoma both in patients who have undergone open surgery as initial treatment and in those who have undergone salvage surgery after irradiation failure

Laryngeal anterior commissure (AC) cancer has been the subject of much controversy. Our study was aimed at pathologically evaluating the tendency of AC cancer to invade the thyroid cartilage and analyzing the role of thyroid cartilage invasion by tumor cells at the AC as an anatomic cause for irradiation failure. Our study included 36 patients with glottic cancer involving AC. Patients with recurrent or persistent disease after radiotherapy underwent salvage surgery. Surgical specimens from 22 patients who had open surgery, either as primary or salvage surgery, were available for pathologic examination to identify the presence of cartilage invasion. We found microscopic invasion of the thyroid cartilage in 40.9% of the studied tumors. Only 21.4% of patients who had open salvage surgery showed evidence of cartilage invasion at the AC. We concluded that laryngeal AC cancers are more likely to invade the cartilage, and that anatomic risk factors are not the main cause of irradiation failure.

Salvage Surgery following Radiation Failure for Laryngeal Cancer in Elderly Patients

Objective. To find the survival rate of patients ≥80 years old who undergo salvage surgery for squamous cell carcinoma of the larynx.

Study Design. National data registry analysis.

Setting. Seventeen population-based registries comprising the National Cancer Institute’s Surveillance, Epidemiology, and End Results database.

Subjects and Methods. Overall, cancer-specific, and relative survival rates were calculated from 1418 patients, stratified into 3 age cohorts, who underwent surgery following radiation therapy for treatment of laryngeal cancer.

Results. The 1-year overall survival of patients ≥80 years old (n = 57) was 76.1%. The cancer-specific survival at 1 year was 86.4%. These survival rates were significantly less than those of patients <65 years old (n = 869), who had a 1-year overall survival of 88.1% ( P = .006) and cancer-specific survival of 90.5% ( P = .029). Patients aged between 65 and 79 years old (n = 492) displayed 1-year overall survival of 80.7% ( P = .426) and cancer-specific survival of 85.1% ( P = .711), which were not significantly different from the ≥80 year cohort. When comparing relative survival at 5 years, the ≥80-year-old cohort’s survival trended the highest (≥80 years, 62.8%; 65-79 years, 51.3%; 20-64 years, 56.2%).

Conclusion. While patients ≥80 years old have a less favorable prognosis than patients <65 years old, the survival rates of patients ≥80 years old are not significantly different from the 65- to 79-year-old cohort. After controlling for non-cancer-related death, patients ≥80 years old appear to have similar 5-year survival outcomes compared with other patients.

FDG PET with contrast-enhanced CT: a critical imaging tool for laryngeal carcinoma

Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has evolved to be an essential imaging modality in the evaluation of laryngeal carcinoma. Although the modality has limited utility in assessing the extent of the primary tumor, FDG PET has proved to be superior to anatomic modalities in the detection of lymph node and distant metastases. The role of FDG PET in the evaluation of patients with laryngeal tumors that are clinically classified as N0 has not shown consistent usefulness because of the innate resolution limitations of the camera. In the posttherapy setting, however, FDG PET has consistently demonstrated a high negative predictive value in the identification of recurrent disease, both during the course of therapy and during long-term follow-up. In addition, contrast material-enhanced computed tomography (CT) in conjunction with FDG PET has demonstrated a complementary role by allowing for superior anatomic coregistration and therefore more definitive diagnosis. There is sufficient evidence that with further advances in PET technology, this modality will likely become more useful in the detection of small lesions and occult nodal disease, as well as in guiding the management of laryngeal carcinoma.

Transoral laser microsurgery for recurrence after primary radiotherapy of early glottic cancer

OBJECTIVE

To analyze oncological results of transoral laser microsurgery (TLM) on recurrent early glottic cancer after primary radiotherapy.

METHODS

The records of 53 patients treated by TLM for early (rTis-rT2) and advanced (rT3, rT4) recurrence after curative radiotherapy were retrospectively analyzed. Data on loco-regional control, overall survival, and disease specific survival were calculated by the Kaplan-Meier method. The larynx preservation rates were given absolutely.

RESULTS

Mean post-therapeutic follow-up time after TLM for patients alive was 87.9 months. Twenty-two patients (42%) were cured by the first TLM procedure, but one of them underwent total laryngectomy after TLM due to chondronecrosis without evidence of residual tumor. Thirty-one patients (58%) developed another recurrence after TLM. Ten of them were cured by further laser procedures alone. Therefore, in 31 patients (58%), local recurrences were successfully treated by TLM alone. In 20 patients, recurrences could not be controlled by TLM: 14 patients underwent salvage laryngectomy and six palliative treatment. Three- and five-year loco-regional control rates for all patients were 46.1 and 38.8%. Three- and five-year overall survival rates were 67.5 and 53.3%. The corresponding 3- and 5-year disease specific survival rates were 68.6%, each. There was no statistically significant difference in loco-regional control or survival between patients presenting initially with early and advanced recurrence. Further recurrence after the first TLM procedure was associated with a statistically significant decrease in 3- and 5-year overall (56.6% vs. 81.8% and 40.2% vs. 70.5%; p=0.03) and disease specific (48.9% vs. 100%, each; p=0.001) survival. Ultimate local control rate including repeated TLM and salvage laryngectomy was 77.4%.

CONCLUSIONS

Many patients with recurrent glottic carcinoma after primary radiotherapy can be cured by single or repeated TLM as an organ-preserving procedure. However, in case of failure after TLM for the first recurrence, salvage laryngectomy should be considered early as local control by further laser surgery is unfavorable.

Concurrent hyperfractionated radiotherapy and carboplatin with transoral debulking microsurgery for T2N0 glottic cancer

BACKGROUND

Our aim was to evaluate the efficacy and toxicity of chemoradiotherapy (CRT) with transoral debulking microsurgery for T2N0 glottic cancer.

METHODS

Thirty patients with T2N0 glottic cancer treated with concurrent hyperfractionated radiotherapy (RT) and carboplatin were retrospectively analyzed. Median total dose of RT was 72 Gy. Nineteen of 30 patients also received transoral debulking microsurgery during or before CRT. The remaining 11 patients who demonstrated complete response or good partial response at 36 to 45.6 Gy were not treated with transoral debulking microsurgery.

RESULTS

Local recurrence developed in 5 patients; 4 of these patients did not undergo transoral debulking microsurgery. The 3-year local control rate was significantly better for CRT with transoral debulking microsurgery (95%) than for CRT alone (61%) (p = .02).

CONCLUSION

CRT with transoral debulking microsurgery may have a positive impact on the local control of T2N0 glottic cancer, which justifies further evaluation to confirm its definite benefit.

Salvage with supracricoid partial laryngectomy after radiation failure

BACKGROUND

Supracricoid partial laryngectomy (SCPL) is an alternative to total laryngectomy (TL) for selected glottic and supraglottic carcinomas but its role in the setting of radiation failure is unclear. The aim of the present study was to present a series of patients with laryngeal cancer undergoing salvage surgery for local recurrence and examine the morbidity associated with this intervention.

METHODS

A retrospective review of 111 patients presenting with laryngeal cancer between 1997 and 2002 was performed. A total of 21 patients with recurrent disease following radiation therapy were identified, of which salvage surgery was performed in 18 patients. Minimum follow up of survivors was 22 months.

RESULTS

The 5-year cumulative local control and disease-specific survival was 76% and 85%, respectively. Surgical salvage consisted of TL in 12 patients and SCPL in six. The mortality and major morbidity rates for TL were 0% and 33%, and for SCPL they were 33% and 50%, respectively. Median length of hospital stay was similar in both groups (21 and 19 days). No patient undergoing SCPL developed recurrent disease at a median follow up of 19 months.

CONCLUSIONS

Supracricoid partial laryngectomy is an oncologically sound alternative to TL as salvage for radiation failure. The operative morbidity and potential for mortality is high in this setting.

Voice quality after carbon dioxide laser and conventional surgery for T1A glottic carcinoma

The different types of small vocal fold tumor therapy allow the preservation of respiration and deglutition; the quality of phonation is the most important criterion for the patient. The aim of the study is to compare vocal function after treatment of T1a tumors by conventional and laser cordectomy. Fifty-seven male patients were included in the study: 27 underwent conventional cordectomy using an external approach, and 30 underwent an endoscopic microscopic laser cordectomy. Videolaryngoscopy was performed for each subject, and the maximal phonation time was measured. Spectrograms were recorded, and a perturbation analysis was performed if a clear harmonic structure was visible. Voices were perceptually rated by two experienced phoniatricians using the GRBAS scale. Even though a slightly better voice was found after conventional surgery throughout the data, no statistically significant difference was measured in the two groups. The data on voice outcome per se do not indicate the selection of one surgical approach over another.

Partial laryngectomy for recurrent glottic carcinoma after radiotherapy

BACKGROUND

Early laryngeal cancer is treated with surgery or radiotherapy. A partial laryngectomy instead of a total laryngectomy can be used for treating patients with radiation failures.

METHODS

Patients were grouped by the two types of partial laryngectomies we performed: group I, endoscopic laser surgery (n = 42); and group II, frontolateral partial laryngectomy (n = 21).

RESULTS

With CO2 laser treatment, 14 of 24 patients (no involvement of the anterior commissure) and eight of 18 patients (involvement of the anterior commissure) were cured. With the frontolateral partial laryngectomy, we achieved local control in 15 of 21 patients.

CONCLUSIONS

If the surgeon is familiar with the different techniques of, and indications for, partial laryngectomy, this can be a good and satisfying treatment in selected patients with radiation failure for glottic cancer

Curative radiotherapy for anterior commissure laryngeal carcinoma

There is continuing controversy surrounding the most effective treatment of glottic carcinoma involving the anterior commissure (AC). Surgery has been the preferred method of treatment, since studies previously indicated early tumor invasion of the thyroid cartilage at the AC, thereby assuming less curability by radiotherapy (RT). Subsequent laryngeal anatomic studies and refinement of RT techniques have brought into question the ineffectiveness of curative irradiation. A retrospective review of 174 patients with early-stage glottic carcinoma treated with standard fractionation curative RT revealed 34 patients with T1 and T2 lesions involving the AC. Allowing for a follow-up of at least 3 years, we observed only a 12% (4 of 34 patients) local recurrence rate after RT alone, with excellent voice quality and no major complications related to the irradiation. The 4 local recurrences were controlled by total laryngectomy, although 2 patients developed distant metastatic disease. Radiotherapy represents an effective method of treating T1 squamous cell carcinoma of the glottis with AC involvement. The small number of T2 glottic carcinomas in this study prevents a meaningful conclusion concerning treatment of these lesions.

Organ preservation

OBJECTIVES

To review organ preservation in cancer treatment within the context of organ function, treatment-related acute and late toxicities, outcome data, and quality of life.

DATA SOURCES

Published review and research articles, proceedings of conferences, and oncology textbooks.

CONCLUSIONS

The implementation of surgery, with sequential and/or concurrent chemoradiation, has advanced the success of organ preservation in multiple tumor types and organ systems. Integral to the discussion of organ preservation is consideration of quality of life.

IMPLICATIONS FOR NURSING PRACTICE

An understanding of organ preservation in cancer treatment will allow oncology nurses to be more effective patient advocates by providing current information that can be integrated into patient care and education.

Supracricoid laryngectomy: a significant advance in the management of laryngeal cancer

Supracricoid laryngectomy is a new development in the treatment of laryngeal cancer in Australia. It allows the removal of both vocal cords, vestibular folds, and the entire thyroid cartilage including the paraglottic space without the loss of laryngeal function. This technique may offer a significant advance in the treatment of squamous cell carcinoma of the larynx. This paper reviews the surgical management of laryngeal cancer and discusses this new technique with modifications, indications for its use and the advantages of supracricoid laryngectomy. Case reports of seven patients operated on in our institution are included.