Comparison between transoral laser surgery and radiotherapy in the treatment of early glottic cancer: A systematic review and meta-analysis

Spectro-acoustic voice parameters in transoral laser microsurgery vs exclusive radiotherapy for early-stage glottic carcinoma: A systematic review and meta-analysis

PURPOSE

In early glottic squamous cell carcinoma, similar results have been described in terms of disease control between transoral laser microsurgery (TLM) and radiation therapy (RT). During the past two decades, several studies compared subjective vocal outcomes of exclusive RT with those of TLM, showing a trend towards improving results for TLM over time. However, the objective differences in terms of spectro-acoustic voice parameters between exclusive RT and TLM have been less frequently investigated. The aim of this systematic review with meta-analysis was to evaluate voice quality after TLM and RT treatment for early glottic carcinoma, based on acoustic analysis parameters including jitter, shimmer, noise to harmonic ratio, fundamental frequency and maximum phonation time.

MATERIAL AND METHODS

A search of the English published literature was conducted on the Pubmed, Scopus and Cochrane databases following PRISMA guidelines.

RESULTS

A total of 441 titles were retrieved from the search. After full-text screening and application of inclusion/exclusion criteria, 12 articles were included. We found no significant differences between TLM and RT treatment in the considered acoustic analysis parameters, except for Shimmer, with more favorable values reported in the RT group.

CONCLUSIONS

Considering the spread of the disease and expecting an improvement in long-term survival over time, well-designed and multicentric studies involving larger populations with a long-term follow up are mandatory to better assess objective voice outcomes in terms of spectro-acoustic voice parameters.

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Awake endoscopic laser surgery for early glottic carcinoma

The objective of this study was to demonstrate the oncologic efficacy of awake endoscopic laryngeal surgery in the treatment of T1-T2 glottic carcinoma. This is a retrospective study. Seventy-one patients with early glottic carcinoma (T1a- 26, T1b- 18, T2- 27) who underwent awake flexible endoscopic laryngeal surgery under local anesthesia and mild intravenous sedation were included in the study. In 64 cases (90.1%) only endoscopic tumor ablation by Nd:YAG laser (in 32.4% of cases being preceded by diathermy snare excision) was performed, and in 7 T2 cases postoperative radiotherapy was also offered. There were no complications during or after the endoscopic surgery. Ultimate control of disease, including salvage treatment, was obtained in 67 patients (94.4%). Cure without recurrence was achieved in 60 cases (84.5%). Local control without salvage radiotherapy or/and open surgery was achieved in 64 (90.1%) patients. Larynx preservation was obtained in 66 (93.0%) cases. At 5 years from the beginning of endoscopic treatment, 74.6% of the patients were alive and free of disease. The best results were obtained in the T1a group of treated patients, all the patients being free of disease with the preserved larynx. Awake endoscopic laryngeal surgery is a safe and oncologically efficient method of treatment of early glottic carcinoma that can be considered as an alternative to the traditional approach, primarily, for patients with risks/contraindications for radiotherapy, general anesthesia, and transoral microsurgery, and also for the patients who prefer to avoid general anesthesia with its related risks and would rather choose office-based laryngeal surgery.

Minimal invasive LASER-resection vs. radiotherapy as primary treatment of early glottic cancer. A population-based study with, up to 16 years follow up of survival, rate of laryngectomy and voice function

BACKGROUND

Early glottic cancer can be treated with laser resection or radiotherapy. In an earlier study, we found that voice function after laser resection was inferior to that after radiotherapy.

OBJECTIVES

This study was designed to determine if reduced margins at laser resection improved voice function without impairing oncologic results.

METHOD

A total of 268 patients with previously untreated T1-T2 glottic carcinoma were studied. They were primarily treated with either radiotherapy (n = 119) or laser resection (n = 149). Survival, need for additional treatment (radiotherapy and/or total layngectomi) and voice function was compared.

RESULT

Median follow up time was 7 years with range 0.5-16.6. There was no difference in the overall survival (p = .065) or disease-specific survival. (p = .126). After radiotherapy 32/119 patients and after laser resection 57/149 patients had recurrence. Total rate of laryngectomy was 24% in the radiotherapy group, and 8% in the laser resection group (p = .001). Voice analysis (T1A) showed more roughness in the radiotherapy group, otherwise no difference.

CONCLUSIONS

By reducing the surgical margins, we have achieved a better voice function (T1A) but more patients have needed repeated laser excisions and some have also needed supplementary radiotherapy. The risk of laryngectomy and survival were apparently not affected.

Individualized Dynamic Prediction Model for Patient-Reported Voice Quality in Early-Stage Glottic Cancer

OBJECTIVE

Early-stage glottic cancer (ESGC) is a malignancy of the head and neck. Besides disease control, preservation and improvement of voice quality are essential. To enable expectation management and well-informed decision-making, patients should be sufficiently counseled with individualized information on expected voice quality. This study aims to develop an individualized dynamic prediction model for patient-reported voice quality. This model should be able to provide individualized predictions at every time point from intake to the end of follow-up.

STUDY DESIGN

Longitudinal cohort study.

SETTING

Tertiary cancer center.

METHODS

Patients treated for ESGC were included in this study (N = 294). The Voice Handicap Index was obtained prospectively. The framework of mixed and joint models was used. The prognostic factors used are treatment, age, gender, comorbidity, performance score, smoking, T-stage, and involvement of the anterior commissure. The overall performance of these models was assessed during an internal cross-validation procedure and presentation of absolute errors using box plots.

RESULTS

The mean age in this cohort was 67 years and 81.3% are male. Patients were treated with transoral CO2 laser microsurgery (57.8%), single vocal cord irradiation up to (24.5), or local radiotherapy (17.5%). The mean follow-up was 43.4 months (SD 21.5). Including more measurements during prediction improves predictive performance. Including more clinical and demographic variables did not provide better predictions. Little differences in predictive performance between models were found.

CONCLUSION

We developed a dynamic individualized prediction model for patient-reported voice quality. This model has the potential to empower patients and professionals in making well-informed decisions and enables tailor-made counseling.

Outcomes of hypofractionation for early-stage glottic carcinoma

BACKGROUND

Our goal is to evaluate hypofractionation in early-stage glottic carcinoma of a single center in line with randomized trials.

MATERIALS AND METHODS

Between June 2016 and January 2021, 33 early glottic carcinoma patients treated with IMRT (intensity-modulated radiotherapy) in the Radiation Oncology Department were analyzed. Descriptive statistics and survival analysis were applied. Survival analysis and curves were done via the Kaplan-Meier method. Survival curves were analyzed due to the T stage. Log-rank test was used for the analysis of T stage survival curves.

RESULTS

Twenty (60.1%) patients were T1 whereas six (18.2%) and seven (21.2%) were Tis. 56.25 Gy, 63 Gy, and 65.25 Gy were delivered to the patients with Tis, T1, and T2, respectively. All groups were treated with 2.25 Gy per fraction. T2 stage had lesser DFS (disease-free survival) compared to Tis and T1 stage and it was statistically significant (P = 0.035).

CONCLUSION

Hypofractionation with 2.25 Gy per fraction may be standard for early glottic carcinoma with similar results compared to microsurgery and conventional fractionation radiotherapy.

Is CO2 laser microsurgery better than radiotherapy in early glottic cancer: a meta-analysis

The choice between radiotherapy (RT) and CO2 laser surgery (CO2-LS) for early glottic cancer remains controversial. We systematically examined electronic databases in order to identify prospective trials comparing patients who had undergone CO2-LS or RT to treat early glottic cancer. Eleven studies involving 1053 patients were included. In the selected literature, the parameter setting of CO2 laser equipment can be summarized as wavelength 10.6 µm, superpulsed mode, continuous setting, power tailored on target structures (1-3 W for subtle resections and 4-15 W for cutting a larger tumor), and approximately 2080-3900 W/cm2 of laser energy. Using RevMan 5.3, we estimated pooled odds ratios (ORs) for dichotomous variables and pooled mean differences (MDs) for continuous variables, along with associated 95% confidence intervals (CIs). The heterogeneity in the treatment variables was measured using Higgins' inconsistency test and expressed as I2 values. The continuous variables were then depicted as histograms developed using PlotDigitizer 2.6.8. Compared to patients treated with CO2-LS, those treated with RT had better jitter (MD 1.27%, 95% CI 1.21 ~ 1.32, P < 0.001), and high scores on the "Grade (MD 6.54, 95% CI 5.31 ~ 7.76, P < 0.001), Breathiness (MD 9.08, 95% CI 4.02 ~ 14.13, P < 0.001), Asthenia (MD 2.13, 95% CI 0.29 ~ 3.98, P = 0.02), and Strain (MD 3.32, 95% CI 0.57 ~ 6.07, P = 0.02)" scale. Patients treated with CO2-LS had worse local control rates (OR 3.14, 95% CI 1.52 ~ 6.48, P = 0.002) while lower incidence of second primary tumor (OR 0.30, 95% CI 0.15 ~ 0.61, P < 0.001). It is hoped that retrospective analysis can provide suggestions for early glottis patients to choose personalized treatment.

Overview of glottic laryngeal cancer treatment recommendation changes in the NCCN guidelines from 2011 to 2022

BACKGROUND

The treatment of glottic cancer remains challenging, especially with regard to morbidity reduction and larynx preservation rates. The National Comprehensive Cancer Network (NCCN) has published guidelines to aid decision-making about this treatment according to the tumor site, clinical stage, and patient medical status.

AIM

The present review was conducted to identify changes in the NCCN guidelines for glottic cancer treatment made between 2011 and 2022 and to describe the published evidence concerning glottic cancer treatment and oncological outcomes in the same time period.

METHODS AND RESULTS

Clinical practice guidelines for head and neck cancer published from 2011 up to 2022 were obtained from the NCCN website (www.NCCN.org). Data on glottic cancer treatment recommendations were extracted, and descriptive analysis was performed. In addition, a review of literature registered in the PubMed database was performed to obtain data on glottic cancer management protocols and treatment outcomes from randomized controlled trials, systematic reviews, and meta-analyses published from 2011 to 2022. In total, 24 NCCN guidelines and updates and 68 relevant studies included in the PubMed database were identified. The main guideline changes made pertained to surgical and systemic therapies, the consideration of adverse features, and new options for the treatment of metastatic disease at initial presentation. Early-stage glottic cancer received the most research attention, with transoral endoscopic laser surgery and radiotherapy assessed and compared as the main treatment modalities. Reported associations between treatment types and survival rates for this stage of glottic cancer appear to be similar, but functional outcomes can be highly compromised.

CONCLUSION

NCCN panel members provide updated recommendations based on currently accepted treatment approaches for glottic cancer, constantly reviewing new surgical and non-surgical techniques. The guidelines support decision-making about glottic cancer treatment that should be individualized and prioritize patients' quality of life, functionality, and preferences.

The use of artificial intelligence models to predict survival in patients with laryngeal squamous cell carcinoma

Most recent survival prediction has been based on TNM staging, which does not provide individualized information. However, clinical factors including performance status, age, sex, and smoking might influence survival. Therefore, we used artificial intelligence (AI) to analyze various clinical factors to precisely predict the survival of patients with larynx squamous cell carcinoma (LSCC). We included patients with LSCC (N = 1026) who received definitive treatment from 2002 to 2020. Age, sex, smoking, alcohol consumption, Eastern Cooperative Oncology Group (ECOG) performance status, location of tumor, TNM stage, and treatment methods were analyzed using deep neural network (DNN) with multi-classification and regression, random survival forest (RSF), and Cox proportional hazards (COX-PH) model for prediction of overall survival. Each model was confirmed with five-fold cross validation, and performance was evaluated using linear slope, y-intercept, and C-index. The DNN with multi-classification model demonstrated the highest prediction power (1.000 ± 0.047, 0.126 ± 0.762, and 0.859 ± 0.018 for slope, y-intercept, and C-index, respectively), and the prediction survival curve showed the strongest agreement with the validation survival curve, followed by DNN with regression (0.731 ± 0.048, 9.659 ± 0.964, and 0.893 ± 0.017, respectively). The DNN model produced with only T/N staging showed the poorest survival prediction. When predicting the survival of LSCC patients, various clinical factors should be considered. In the present study, DNN with multi-class was shown to be an appropriate method for survival prediction. AI analysis may predict survival more accurately and improve oncologic outcomes.

Treatment of Early Glottic cancer with Transoral Laser Microsurgery: An Australian Experience

Introduction

Early laryngeal carcinomas may be treated by transoral laser microsurgery (TLM) or external beam radiotherapy. We review our experience of surgical treatment of laryngeal pre-malignant and malignant lesions over the past 15 years in a high-volume head neck unit.

Methods

A review of a prospective patient database of patients with laryngeal SCC, who were treated with CO2 TLM between 2004 and 2019 was carried out.

Results

83 patients with a mean age of 67.7 (SD: 10.6) years underwent primary curative TLM for T1a/b SCC. 5-year overall survival was 93.2% (95%CI 86.9-100%), disease free survival was 86.0% (95%CI 78.1-94.6%), locoregional control was 91.2% (95%CI: 85.1-97.7%) and larynx preservation rate of 95.1% at 5 years.

Conclusion

TLM is an excellent treatment modality for T1 early glottic SCC, with excellent locoregional control and disease-free survival. It is minimally invasive, outpatient-based, and cost-effective procedure preserving upper aerodigestive tract dysfunction for all activities of daily living.

Pathologically Negative Excision for Biopsy-Proven Early Glottic Carcinoma

In certain instances, patients who underwent endoscopic laser excision (ELE) for biopsy-proven early glottic carcinoma do not show any evidence of carcinomatous cells on histopathologic analysis. Our study aims to determine the incidence of this phenomenon. A retrospective analysis of patients with biopsy-proven early glottic squamous cell carcinoma who underwent ELE was conducted. 121 patients with a mean age of 68.2 ± 10.7 were included in this study. Initial biopsy showed carcinoma in situ in 38 patients, (31.4%), T1a in 41 patients (33.9%), and T1b in 42 patients (34.7%). Following ELE, a pathologically negative excision was seen in 26 patients (21.5%). Disease recurrence occurred in 3 patients who had a pathologically negative excision (11.5%). Following repeat ELE, all patients remained disease free. A significant number of early glottic carcinoma present with small volume disease which may be eradicated with diagnostic biopsy alone.

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.

Longitudinal Patient-Reported Voice Quality in Early-Stage Glottic Cancer

OBJECTIVE

Patient-reported voice quality is an important outcome during counseling in early-stage glottic cancer. However, there is a paucity of adequate longitudinal studies concerning voice outcomes. This study aimed to investigate longitudinal trajectories for patient-reported voice quality and associated risk factors for treatment modalities such as transoral CO₂ laser microsurgery, single vocal cord irradiation, and local radiotherapy.

STUDY DESIGN

A longitudinal observational cohort study.

SETTING

Tertiary cancer center.

METHODS

Patients treated for Tcis-T1b, N0M0 glottic cancer were included in this study (N = 294). The Voice Handicap Index was obtained at baseline and during follow-up (N = 1944). Mixed-effects models were used for investigating the different trajectories for patient-reported voice quality.

RESULTS

The mean follow-up duration was 43.4 (SD 21.5) months. Patients received transoral CO₂ laser microsurgery (57.8%), single vocal cord irradiation (24.5%), or local radiotherapy (17.5%). A steeper improvement during the first year after treatment for single vocal cord irradiation (-15.7) and local radiotherapy (-12.4) was seen, compared with a more stable trajectory for laser surgery (-6.1). All treatment modalities showed equivalent outcomes during long-term follow-up. Associated risk factors for different longitudinal trajectories were age, tumor stage, and comorbidity.

CONCLUSION

Longitudinal patient-reported voice quality after treatment for early-stage glottic cancer is heterogeneous and nonlinear. Most improvement is seen during the first year of follow-up and differs between treatment modalities. No clinically significant differences in long-term trajectories were found. Insight into longitudinal trajectories can enhance individual patient counseling and provide the foundation for an individualized dynamic prediction model.

Preoperative Prediction and Identification of Extracapsular Extension in Head and Neck Cancer Patients: Progress and Potential

Background This study aimed to demonstrate both the potential and development progress in the identification of extracapsular nodal extension in head and neck cancer patients prior to surgery. Methodology A deep learning model has been developed utilizing multilayer gradient mapping-guided explainable network architecture involving a volume extractor. In addition, the gradient-weighted class activation mapping approach has been appropriated to generate a heatmap of anatomic regions indicating why the algorithm predicted extension or not. Results The prediction model shows excellent performance on the testing dataset with high values of accuracy, the area under the curve, sensitivity, and specificity of 0.926, 0.945, 0.924, and 0.930, respectively. The heatmap results show potential usefulness for some select patients but indicate the need for further training as the results may be misleading for other patients. Conclusions This work demonstrates continued progress in the identification of extracapsular nodal extension in diagnostic computed tomography prior to surgery. Continued progress stands to see the obvious potential realized where not only can unnecessary multimodality therapy be avoided but necessary therapy can be guided on a patient-specific level with information that currently is not available until postoperative pathology is complete.

Treating Head and Neck Cancer in the Age of Immunotherapy: A 2023 Update

Most patients diagnosed with head and neck squamous cell carcinoma (HNSCC) will present with locally advanced disease, requiring multimodality therapy. While this approach has a curative intent, a significant subset of these patients will develop locoregional failure and/or distant metastases. The prognosis of these patients is poor, and therapeutic options other than palliative chemotherapy are urgently needed. Epidermal growth factor receptor (EGFR) overexpression is an important factor in the pathogenesis of HNSCC, and a decade ago, the EGFR targeting monoclonal antibody cetuximab was approved for the treatment of late-stage HNSCC in different settings. In 2016, the anti-programmed death-1 (PD-1) immune checkpoint inhibitors nivolumab and pembrolizumab were both approved for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy, and in 2019, pembrolizumab was approved for first-line treatment (either as monotherapy in PD-L1 expressing tumors, or in combination with chemotherapy). Currently, trials are ongoing to include immune checkpoint inhibition in the (neo)adjuvant treatment of HNSCC as well as in novel combinations with other drugs in the recurrent/metastatic setting to improve response rates and survival and help overcome resistance mechanisms to immune checkpoint blockade. This article provides a comprehensive review of the management of head and neck cancers in the current era of immunotherapy.

Intensity modulated proton therapy for early-stage glottic cancer: high-precision approach to laryngeal function preservation with exceptional treatment tolerability

BACKGROUND

Due to the increasing expertise in transoral laser surgery and image-guided radiation therapy, treatment outcomes have recently improved in patients with early-stage glottic cancer. The objective of the current study was to evaluate intensity-modulated proton therapy (IMPT) as novel treatment option.

METHODS

A total of 15 patients with T1-2N0 glottic squamous cell carcinoma, treated between 2017 and 2020, were evaluated. Toxicity was recorded according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.03.

RESULTS

The majority were T1a/b tumors (66.7%) and no patient had lymph node or distant metastases. The median total dose was 70 Gy relative biological effectiveness (RBE) (range 66-70 Gy RBE). The one- and two-year OS and metastases-free survival were 100%. One patient developed local failure and received salvage laryngectomy. No higher-grade acute or late toxicity was reported. The mean number of CTCAE grade I and II overall toxicity events per patient was 4.1 (95%-[confidence interval] CI 3.1-5.3) and 1.0 (95%-CI 0.5-1.5).

CONCLUSION

High-precision proton therapy of T1-2N0 glottic cancer resulted in exceptional treatment tolerability with high rates of laryngeal function preservation and promising oncological outcome. IMPT has the potential to become a standard treatment option for patients with early-stage laryngeal cancer.

Revisiting the Concept of Non- and Minimally Invasive Interventions in Early Glottic Cancer – Part II: Single Therapy Should be Favored over the Combination of Transoral Laser Microsurgery and Radiotherapy, Regarding the Postinterventional Voice Quality

Introduction  Early glottic cancer (EGC) is associated with a high cure rate. Hence, patients and physicians also focus on the impact of the proposed treatment on the speaking function of the preserved larynx.

Objectives  The present study assessed the impact of single-modality treatment (transoral laser microsurgery [TLM], or radiotherapy) or combination therapy for EGC on postinterventional voicing and explored factors which might explain the related perceptions.

Methods  A total of 108 patients filled in the voice handicap index 10 questionnaire, 1 and 2 years postinterventionally. Non-parametric tests were used for the respective statistical analyses.

Results  Sixty-four patients were treated with TLM, 15 with radiotherapy, and 29 with both modalities. Transoral microsurgery and radiotherapy were associated with postinterventional dysphonia, which attenuated between the first and second postintervention year ( p  = 0.000). No association between sociodemographic parameters and the attenuation of postinterventional dysphonia was identified for either treatment modality. Transoral microsurgery and radiotherapy resulted in comparable postinterventional voicing, in the first ( p  = 0.940) and second ( p  = 0.196) postintervention years. The addition of TLM to radiotherapy resulted in worse voice quality in the second, compared with the first postintervention year ( p  = 0.000), demonstrating a detrimental effect on speech intelligibility in noise ( p  = 0.000).

Conclusion  Single therapy should be favored over the combination of TLM and radiotherapy for EGC in terms of retaining better postinterventional voice quality. Postinterventional dysphonia should be taken into account, during preinterventional counseling, as it may exert leverage on the quality of patients' lives. Patients and physicians should acknowledge the optimal time of voice function return, which seems to be extending up to two years posttreatment.

Comparison of Survival Outcomes of Different Treatment Options for cT1-2, N0 Glottic Carcinoma: A Propensity Score–Weighted Analysis

Background

Treatments for cT1-2, N0 glottic squamous cell carcinoma (GLSCC) include endoscopic resection, open surgery, and radiotherapy. The purpose of this study was to compare the outcomes of three treatment modalities and provide reference data for treatment selection.

Methods

In all, 4274 patients with cT1-2, N0 GLSCC underwent these three treatment modalities from 2004 to 2015 were identified from the Surveillance, Epidemiology, and End Results-18 database. Overall survival (OS) and disease-specific survival (DSS) of patients treated with the three modalities were compared.

Results

In the entire cohort, there were no significant differences in 5-year OS and 5-year DSS among the three treatment groups. In subgroup analyses based on stage and age, endoscopic resection provided significantly better 5-year survival than radiotherapy for cT1, N0 patients aged &lt;65 years, with an OS rate of 89.0% vs. 82.3% (p = 0.009) and a DSS rate of 95.6% vs. 88.2% (p = 0.021). For 5-year DSS, open surgery also had better outcomes than patients who received radiotherapy (5-year DSS: 98.5% vs. 88.2%, respectively; p = 0.046).

Conclusions

To summarize, for cT1, N0 GLSCC patients younger than 65 years, surgical treatment (either endoscopic or open) appears to be superior to the radiotherapy, and endoscopic resection should probably be the first consideration.

Voice Outcome After Carbon Dioxide Transoral Laser Microsurgery for Glottic Cancer According to the European Laryngological Society Classification of Cordectomy Types - A Systematic Review

BACKGROUND

Voice outcome after carbon dioxide transoral laser microsurgery (CO2TOLMS) for glottic cancer is of prime importance. However, a comprehensive overview according to the European Laryngological Society (ELS) classification of cordectomies is still lacking. The aim of this systematic review is to summarize data on voice outcome associated with individual types of ELS glottic cordectomy after CO2TOLMS.

MATERIALS AND METHODS

A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The initial search identified 936 records of which 25 publications were then included. Voice outcome data (Voice Handicap Index [VHI] version 30, grade of dysphonia [G] and maximum phonation time [MPT]) were extracted per resection type. Weighted averages were calculated.

RESULTS

Data show a gradual increase in the VHI scores although they were still similar for all cordectomy types (range 14.2 to 21.5). The grade of dysphonia showed a gradual increase with increasing resection depth (range 1.0 to 1.9). There was a gradual decrease in the MPT (range 15.2 to 7.2).

CONCLUSION

Voice outcome is related to cordectomy type with mild dysphonia characterizing ELS type I, II and III cordectomies, while more extended cordectomies (ELS type IV, V and VI) result in moderate dysphonia and shortness of breath during phonation. The voice handicap experienced by patients is limited even in the more extended cordectomies.

Effect of treatment modality on the long-term survival of patients with early glottic squamous cancer: a retrospective cohort study based on the SEER database

Background

The optimal treatment strategy for patients with early glottic (T1-2N0M0) squamous cancer remains unclear.

Methods

A retrospective population-based analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was used to balance treatment arms, and Cox regression analysis was used to determine prognostic factors for survival. Kaplan-Meier analysis, log-rank tests, and competing risk analysis were used to compare survival outcomes between treatment modalities (surgery vs. radiotherapy).

Results

Among the 3,994 eligible patients in this study, surgery was associated with improved cancer-specific survival (CSS) and overall survival (OS) compared with radiotherapy (log-rank test, P<0.05). This survival trend favoring surgery was consistent in the T1a, well/moderately differentiated grade, male, and all age subgroups. However, after the baseline characteristics were balanced with PSM, the survival outcomes (CSS and OS) did not differ significantly between the surgery and radiotherapy groups. Interestingly, surgery was associated with a 39% reduced risk of cancer-related death compared with radiotherapy in patients aged ≥70 years (hazard ratio 0.61; 95% CI: 0.43-0.87; P=0.006). However, this survival trend favoring surgery was not observed in younger patients (age <70 years), T stage subgroups, male or female subgroups, or in any of the pathological grade subgroups.

Conclusions

In patients with early glottic squamous cell carcinoma undergoing surgery or radiotherapy, there is no sufficient evidence favoring one method over another in terms of survival. However, surgery is recommended in patients aged ≥70 years because, in this group, it was associated with improved survival outcomes compared with radiotherapy.

Injection laryngoplasty during transoral laser microsurgery for early glottic cancer: a randomized controlled trial

BACKGROUND

Transoral laser microsurgery is widely used for treating T1/T2 glottic cancers. Hyaluronic acid (HA) is commonly used in vocal cord augmentation. We investigated the impact of intra-operative injection laryngoplasty on voice outcomes in early glottic cancer.

METHODS

Twenty patients were randomized to the treatment group receiving HA injection to the vocal cord contralateral to the lesion; or the control group, receiving no injection. Patients had a Voice Handicap Index-10 (VHI-10) questionnaire and a Maximum Phonation Time (MPT) measurement preoperatively and at 3, 12 and 24 months post-operatively. Mean change in VHI-10 and MPT, compared to baseline and between time points, were compared. Survival estimates were calculated.

RESULTS

Mean VHI-10 scores improved over time amongst all patients. There were no changes in mean VHI-10 from pre-operative values to 3, 12 or 24 months post-operatively. There were no significant differences when comparing various timepoints between groups. There were no significant changes in MPT amongst the groups, or the time-points compared. Two-year overall survival was 91.7%; disease free survival was 80.9%; no difference in recurrence free survival was seen between the groups.

CONCLUSION

Subjective voice scores improved over time in both groups; there were no improvements in VHI-10 or MPT scores in the injection group, over control, at any time points. We saw no significant impact for intra-operative HA injection laryngoplasty on subjective or objective voice outcomes following surgery for early glottic cancers.

Prognostic and Treatment Differences Between T1a and T1b Glottic Cancer

OBJECTIVES

This study was designed to evaluate significant differences in treatment and survival outcomes between patients with T1a and T1b glottic cancer.

METHODS

Patients within the SEER Research Plus, 18 Registries dataset who were diagnosed with Stage I T1a or T1b cancer of the glottis between 2004 and 2015 were included in this study. Data prior to 2004 could not be included, as the SEER database did not distinguish between T1a and T1b glottic cancer until that year.

RESULTS

The 5-year disease-specific survival for T1a patients was significantly better than that of patients diagnosed with T1b glottic cancer. Age and year of diagnosis were also independent factors that impacted mortality. More patients who were diagnosed with T1b glottic cancer underwent external beam radiation than those diagnosed with T1a glottic cancer.

CONCLUSION

Our data shows that there are several independent factors effecting mortality including T classification, age at time of diagnosis, and year of diagnosis. T1a glottic cancers also show a significantly better prognosis compared with T1b. T1b glottic cancers are much more likely to be treated with primary radiotherapy compared with surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Oncological and functional outcomes following treatment of T1a glottic squamous cell carcinoma with transoral laser microsurgery

Background

Laryngeal cancers of glottic origin comprise a large proportion of head and neck malignancies. Transoral laser microsurgery (TLM) and radiation therapy are mainstays in the treatment of early stage glottic cancer, but debate persists as to which modality is functionally superior. Furthermore, there is a paucity of North American data related to functional and oncological outcomes in T1a glottic cancer. Here, we assessed oncological and functional outcomes of T1a glottic squamous cell carcinoma (SCC) with TLM to supplement evidence from jurisdictions outside North America.

Methods

This study is a retrospective cohort study performed from a prospectively collected tertiary center institutional TLM database. Patients who were diagnosed with T1a glottic SCC and underwent TLM as their primary treatment were included. Functional outcomes were analyzed using the Voice Handicap Index-10 (VHI-10) questionnaire. Ultimate control with TLM only was considered to be those patients with locoregional control with repeat TLM procedures, but without addition of other modalities. Student’s t-test was used to test significance and Kaplan–Meier survival analysis was used to assess oncological outcomes.

Results

48 patients met study criteria. The mean follow-up time was 74 months. The 5-year locoregional, ultimate control with TLM only and laryngeal preservation rates were 83.2%, 90.4% and 100%, respectively. The overall survival and disease-specific survival were 87.2% and 100%, respectively. VHI-10 scores were available for 13/48 patients and mean scores improved non-significantly from pre-op (mean: 11.23; range: 2 to 30; median: 10) and post op (mean: 7.92; range: 0 to 18; median: 8) scoring (p-value = 0.15). Sub-stratification of voice data revealed a significant improvement between pre and post-operative scores (mean difference − 10.6, 95% CI: − 0.99 to − 20.21, p-value = 0.035) for patients with abnormal pre-operative scores (VHI > 11).

Conclusion

To our knowledge, the current work represents one of the first North American studies to report both functional and oncologic outcomes for TLM treatment of T1a glottic SCC. The oncologic and functional outcomes presented here add to existing evidence in favor of TLM as a safe and effective primary treatment option for early staged T1a glottic cancer.

Graphical abstract

Comparative ex vivo Investigations on the Cutting Quality of the CO2 Laser and the Diode Pumped Er:YAG Laser

Objectives: A sufficient histological evaluation is a key pillar in oncological treatment, especially in situations of cancer of unknown primary. CO2 laser technology is used in clinical routine of soft tissue surgery because of its cutting quality and availability. Diode pumped solid state Er(bium):YAG laser systems promise a higher cutting efficiency and minor thermal damages. The aim of this study was to compare both laser systems with respect to their suitability for cutting soft tissue. Methods: A setup was realized which enables comparable experiments with the clinical CO2 laser (AcuPulse 40ST DUO, Lumenis) and the Er:YAG laser system (DPM 40, Pantec Biosolutions AG). Fresh mucosal samples of porcine tongues were used to determine the influence of laser power and sample velocity on cutting depth and thermal damage width for both lasers. In addition, for the Er:YAG laser, the influence of the pulse repetition rate was examined additionally. For analysis, images of histological sections were taken. Results: In all experiments, the Er:YAG laser shows a significantly higher cutting depth (P < 0.0001) and less thermal damage width (P < 0.0001) than the CO2 laser. For example, at an average power of 7.7 W and a sample velocity of 5 mm/s the Er:YAG laser shows a mean cutting depth of 1.1 mm compared to the CO2 laser with 500 μm. While the Er:YAG laser shows a mean thermal damage width of 70 μm compared to 120 μm. Furthermore, the Er:YAG enables the adjustment of the cutting depth and thermal damage width by varying the irradiation parameters. A decrease of the repetition rate leads to a reduction of thermal damage. For example, a repetition rate of 100 Hz results in a thermal damage width of 46 μm compared to 87 μm at 800 Hz at an average power of 7.7 W and a cutting velocity = 5 mm/s while a homogenous cutting quality can be achieved. Conclusions: In conclusion, the results of these ex vivo experiments demonstrate significant advantages of the diode pumped Er:YAG laser system for soft tissue ablation compared to the CO2 laser, in particular regarding cutting efficiency and thermal damage width.

Deep Convolution Neural Network for Laryngeal Cancer Classification on Contact Endoscopy-Narrow Band Imaging

(1) Background: Contact Endoscopy (CE) and Narrow Band Imaging (NBI) are optical imaging modalities that can provide enhanced and magnified visualization of the superficial vascular networks in the laryngeal mucosa. The similarity of vascular structures between benign and malignant lesions causes a challenge in the visual assessment of CE-NBI images. The main objective of this study is to use Deep Convolutional Neural Networks (DCNN) for the automatic classification of CE-NBI images into benign and malignant groups with minimal human intervention. (2) Methods: A pretrained Res-Net50 model combined with the cut-off-layer technique was selected as the DCNN architecture. A dataset of 8181 CE-NBI images was used during the fine-tuning process in three experiments where several models were generated and validated. The accuracy, sensitivity, and specificity were calculated as the performance metrics in each validation and testing scenario. (3) Results: Out of a total of 72 trained and tested models in all experiments, Model 5 showed high performance. This model is considerably smaller than the full ResNet50 architecture and achieved the testing accuracy of 0.835 on the unseen data during the last experiment. (4) Conclusion: The proposed fine-tuned ResNet50 model showed a high performance to classify CE-NBI images into the benign and malignant groups and has the potential to be part of an assisted system for automatic laryngeal cancer detection.

Early-Stage Glottic Squamous Cell Carcinoma in the Era of Image-Guided Radiotherapy

Early-stage squamous cell cancer (SCC) of the glottis has a good prognosis. Therefore, patients have long survival outcomes and may potentially suffer from late toxicities of radiotherapy. Radiotherapy with a conventional parallel-opposed-pair or anterior-oblique beam arrangements for stage 1 and 2 glottic SCC have field borders that traditionally cover the entire larynx, exposing organs-at-risk (e.g. carotid arteries, contralateral vocal cord, contralateral arytenoid and inferior pharyngeal constrictor muscles) to high radiation doses. The potential long-term risk of cerebrovascular events has attracted much attention to the dose that carotid arteries receive. Swallow and respiratory motion of laryngeal structures has been an important factor that previously limited reduction of the radiation treatment volume. Motion has been evaluated using multiple imaging modalities and this information has been used to calculate PTV margins for generation of more limited target volumes. This review discusses the current literature surrounding dose-effect relationships for various organs-at-risk and the late toxicities that are associated with them. This article also reviews the currently available data and effects of laryngeal motions on dosimetry to the primary target. We also review the current limitations and benefits of a more targeted approach of radiotherapy for early-stage glottic SCCs and the evolution of CT-based IGRT and MR-guided radiotherapy techniques that may facilitate a shift away from a conventional 3D-conformal radiotherapy approach.

Organ preservation and oncological outcomes in early laryngeal cancer: a propensity score-based study

Background

The rates of laryngeal preservation according to therapeutic modality in patients with initial laryngeal squamous cell carcinoma (LSCC) are still controversial. This study evaluated the rates of laryngeal preservation in patients who underwent treatment with surgery or radiotherapy.

Methods

This retrospective cohort study evaluated 151 patients with stage I or II LSCC. Ninety-six patients were matched using a propensity-score and outcomes were compared within this group.

Results

Regarding overall, cancer-specific survival and larynx preservation, no differences were observed according to the therapeutic modalities, but patients who underwent radiotherapy had a higher rate of local recurrence than those who underwent surgery. Patients classified as ASA 3 or 4 and treated with radiotherapy showed a tendency of higher risk of larynx loss.

Conclusions

Patients with stage I or II laryngeal tumours can be submitted to surgery or radiotherapy with similar rates of laryngeal preservation.

Flexible endoscopic laser surgery for early glottic carcinoma

OBJECTIVE

Flexible endoscopic laser surgery (FELS) is able to overcome some limitations of traditional transoral CO2 laser surgery. The objective of this study was to assess the efficacy of FELS in the treatment of T1-T2 glottic carcinoma.

METHODS

We applied FELS for 120 patients with T1-T2 glottic carcinoma. Tumour ablation was performed with Nd:YAG laser. In 76 (63.3%) cases the intervention was performed under local anesthesia. Twenty nine (24.2%) patients (T1b - 2, T2-27) underwent postoperative radiation therapy (RT).

RESULTS

Successful treatment, with local control and larynx preservation, was obtained in 106 cases (88.3%), with mean follow-up of 6.4 years. More than 50% of the patients were followed-up over 5 years.

CONCLUSIONS

FELS can be proposed as an alternative treatment method for patients with early glottic carcinoma. The advantages of the method include: possibility of applying treatment under local anesthesia, that allows avoiding of general anesthesia and its related risks; applicability to patients with contraindications to general anesthesia and patients with anatomic particularities, that make transoral microsurgery impossible, allowing avoidance of the laryngofissure and tracheotomy.

Functional and Oncologic Outcomes of Octogenarians Undergoing Transoral Laser Microsurgery for Laryngeal Cancer

OBJECTIVE

To evaluate the oncologic and functional outcomes of transoral laser microsurgery (TLM) for glottic cancers in patients ≥80 years.

STUDY DESIGN

Prospectively collected case series.

SETTING

QEII Health Sciences Centre, Halifax, Canada.

METHODS

This case series used a prospectively collected glottic cancer database to examine consecutive elderly patients (≥80 years old) undergoing TLM. Kaplan-Meier analysis was used to evaluate rates of disease-free, disease-specific, and overall survival as the primary end points of oncologic control. Secondary functional outcomes included voice function, length of hospital stay, and time to readmission.

RESULTS

From 2005 to 2017, 17 octogenarian patients underwent TLM for glottic cancer. Median follow-up was 4.19 years (interquartile range, 0.71-6.95). Kaplan-Meier estimates of 5-year survival were 78.4% (disease free), 92.9% (disease specific), and 81.9% (overall). The median length of hospital stay was 1 day (range, 0-8). There was only 1 readmission within 30 days of surgery. No patients in this study developed significant surgical or postoperative complications requiring unplanned readmissions. Patient-perceived voice function improved to normal after treatment in 62.5% of patients.

CONCLUSION

The results of this study suggest that TLM is a safe and effective treatment modality for glottic cancer in patients aged ≥80 years, providing good oncologic control and satisfactory functional outcomes.

Voice Outcomes after Radiotherapy for Laryngeal Cancer

Objective The study was aimed to assess changes in voice outcomes after radiotherapy in laryngeal cancer patients.

Materials and Methods The study included 60 laryngeal cancer patients treated with definitive radiotherapy or chemoradiotherapy between 2005 and 2012. The primary endpoint of this study was to assess abnormalities of the patients’ voices after the treatment. The Thai version of the Voice Handicap Index (VHI) and xerostomia questionnaire were conducted by telephone. Videostroboscopic examination was done to objectively assess voice outcomes.

Results The median age of patients was 63 years. Most patients had glottic cancer (84.1%) and T1–2 disease (84.1%). The median time from treatment to the study was 46 months. In terms of the total VHI score, most patients were in the normal and slight handicap groups (22% and 71.4%, respectively). Only 4.8% and 1.6% of the patients were in moderate and severe handicap group, respectively. Twenty-eight patients had significant xerostomia. Videostroboscopy examination was done in 23 patients and most common findings were telangiectasia (95.7%), abnormal mucosal wave (47.8%), and abnormal glottic closure configuration (34.8%). Regarding total VHI score, lower radiation dose, conventional radiation dose per fraction, longer period after treatment, and significant xerostomia status were significantly correlated with worse voice outcomes. There were no statistically significant correlations between the videostroboscopic findings and VHI scores.

Conclusion Voice outcomes in most of laryngeal cancer patients treated with radiotherapy had a normal or mild handicap at more than 1 year of follow-up. Only 4.8% and 1.6% of the patients had moderate and severe voice outcome handicap, respectively.

[Radiotherapy for patients with early-stage glottic squamous cell carcinoma of the larynx: Interest of hypofractionation?]

Hypofractionated radiotherapy of early-stage squamous cell carcinoma of the glottic larynx is a promising treatment option. This can be divided into radiotherapy with moderate hypofractionation (up to 2.5Gy per fraction), more intense hypofractionation (between 2.5 and 4.5Gy per fraction) and stereotactic radiotherapy (above 4.5Gy per fraction). Most studies evaluating moderate hypofractionation show a local control rate between 85 and 95%. Acute laryngeal toxicity is superior to conventional treatment, but only for grades 1 and 2, with no significant difference reported for severe toxicity. Stereotactic radiotherapy in this pathology is also an emerging entity, but some authors have reported significant toxicity. There are currently no standardized guidelines for treatment and management regimen. We conducted a systemic review of published prospective and retrospective trials to evaluate efficacy, toxicity, and discuss future directions.

Could Primary Chemoradiotherapy in T2 Glottic Cancers Yield Results Comparable to Primary Radiotherapy in T1? Considerations from 531 German Early Stage Patients

T1 glottic cancer is a highly treatable disease with local control (LC) rates over 90% by either primary radiotherapy (pRT) or transoral laser microsurgery (TLM). LC of T2 glottic cancers is 15 percent points poorer on average. However, salvage after pRT entails more than 50% total laryngectomy. Therefore, there is a need for enhanced LC. Altered fractionation regimens improved LC in T1 but not in T2. For this reason, for T2, alternative strategies must be considered. In a large observational cohort study including 531 early-stage laryngeal cancers, a small number of patients were treated with primary chemoradiotherapy (pCRT). In multivariable analysis, factors associated with significantly poorer outcomes included age, comorbidities, supraglottic localization, and T category. While there was a significant difference between pRT and surgery (HR 1.79; 95%-CI: 1.15-2.79), there was none between pCRT and surgery (HR 0.70; 95%-CI: 0.33-1.51). There is evidence from the literature that pCRT in early glottic cancers could yield results that surpass the limits so far experienced in radiotherapy alone with acceptable toxicity. Thus, prospective randomized studies with larger numbers of patients are warranted.

Long-term Oncologic Outcomes of 1188 Tis-T2 Glottic Cancers Treated by Transoral Laser Microsurgery

OBJECTIVE

To evaluate long-term disease-specific survival (DSS) and organ preservation (OP) rates in patients affected by Tis-T2 glottic squamous cell carcinoma (SCC) treated by carbon dioxide transoral laser microsurgery (CO₂ TOLMS).

STUDY DESIGN

Single-center retrospective cohort study.

SETTING

Tertiary academic hospital.

METHODS

The study included patients treated by CO₂ TOLMS for Tis-T2 glottic SCC at the Department of Otorhinolaryngology-Head and Neck Surgery of the University of Brescia, Italy, from 1988 to 2018. The male:female ratio was 11.2:1, and the mean age was 64 years (range, 31-95). T categories were distributed as follows: 124 (10%) Tis, 646 (54%) T1a, 172 (15%) T1b, and 246 (21%) T2.

RESULTS

Ten- and 20-year DSS rates were 97.6% and 96.3%, respectively, and 10- and 20-year OP rates were 94.7% and 93%. During the follow-up, 91% of patients were treated by CO₂ TOLMS alone, while the remaining needed adjunctive treatments. Assessing the impact of multiple sessions of CO₂ TOLMS, DSS showed no significant difference in terms of patients treated by 1, 2, or >2 procedures. Conversely, patients treated by >2 sessions of CO₂ TOLMS showed a significantly worse OP rate.

CONCLUSIONS

Our series validates CO₂ TOLMS as a long-term treatment strategy for early glottic SCC. Salvage CO₂ TOLMS provided optimal results in terms of DSS and OP in patients with recurrence after previous transoral surgery.

Radiotherapy versus laser microsurgery in the treatment of early glottic cancer

BACKGROUND

Glottic squamous cell carcinoma (SCC) in stages I or II can be treated by transoral CO₂ laser microsurgery (TLM) or exclusive radiotherapy (RT).

OBJECTIVES

To compare the oncological results of patients treated with TLM, to those treated with RT, in a tertiary hospital.

MATERIAL AND METHODS

Data from patients diagnosed with glottic SCC in stages I and II between 2004 and 2018 were analyzed. Response to treatment was studied in terms of recurrence, local control and laryngeal preservation.

RESULTS

Of 164 patients, 63.41% received treatment with TLM and 36.58% with RT. 26.21% presented a recurrence or progression of the tumor. Both treatments obtained good local control rates (84.15% in the case of TLM and 89.6% in the case of RT) and no significant association was found between tumor recurrence and type of treatment, nor with the involvement of the anterior commissure. However, treatment with RT obtained worse laryngeal preservation rate compared to TLM (81.6% and 100% respectively) (p < .001LR). Conclusions and significance: Both treatments obtained good oncological results. There were no significant differences regarding local control. However, TLM obtained a better laryngeal preservation rate. The involvement of the anterior commissure was not a poor prognosis factor for tumor recurrence.

Radiotherapy Versus Surgery-Which Is Better for Patients With T1-2N0M0 Glottic Laryngeal Squamous Cell Carcinoma? Individualized Survival Prediction Based on Web-Based Nomograms

Background

Both radiotherapy and surgery are now recommended for early stage glottic laryngeal squamous cell carcinoma (LSCC), and both have their own advantages in patients with different characteristics. For each patient, it is hard to determine whether radiotherapy or surgery is more appropriate.

Methods

Patients with T1-2N0M0 glottic LSCC who received radiotherapy or surgery in the 2004–2016 SEER database were reviewed, then randomly divided into training and validation cohorts. Propensity score matching was used to eliminate the baseline variations, and competing risk analyses helped to exclude the effects of other causes of death. Based on univariate and multivariate analyses, we built two nomograms to visually predict the survival of each patient with different characteristics who received radiotherapy or surgery, then validated the accuracy in both training and validation cohorts. Using nomogramEx, we quantified the algorithms of the nomograms and put the nomograms on the websites.

Results

A total of 6538 patients in the SEER database were included. We found that therapy (p = 0.004), T stage (p < 0.001), age (p < 0.001), race (p < 0.044), grade (p = 0.001), and marital status (p < 0.001) were independent prognostic factors. Two nomograms were built to calculate the survival for each patient who received radiotherapy (C-index = 0.668 ± 0.050 in the training cohort and 0.578 ± 0.028 in the validation cohort) or underwent surgery (C-index = 0.772 ± 0.045 in the training cohort and 0.658 ± 0.090 in the validation cohort). Calibration plots showed the accuracy of the nomograms. Using the nomograms, we found that 3872 patients (59.22%) had no difference between the two therapies, 706 patients (10.80%) who received radiotherapy had better survival outcomes, and 1960 patients (29.98%) who underwent surgery had better survival outcome.

Conclusion

Nomograms were used to comprehensively calculate independent factors to determine which treatment (radiotherapy or surgery) is better for each patient. A website was used to offer guidance regarding surgery or radiation for patients and physicians.

Surgery versus radiotherapy: Long term outcomes of T1 glottic cancer

Aim

The aim of this study was to compare the outcomes, patterns of failure and laryngeal preservation rates in patients with T1N0 glottic cancer treated with surgery or radiotherapy.

Materials/methods

Retrospective study of T1N0 glottic cancer patients treated in our institution between January 2007 and December 2017. Histologically proven squamous cell carcinoma patients, treated with upfront cordectomy/partial laryngectomy (S group) or radiotherapy (RT group) were included. Elective treatment of the neck was not permitted. Local failure (LF), disease-free survival (DFS), ultimate disease-free survival (UDFS), laryngectomy-free survival (LFS), disease-specific mortality (DSM) and overall survival (OS) were evaluated.

Results

Two hundred and one patients were eligible (172 S group, 29 RT group), with a median follow-up of 38.8 months. Overall, 33 (16%) patients had a recurrence, 30 (17%) in the S group and 3 (10%) in the RT group. Local failure was the predominant site of failure (28 S, 2 RT). Overall, of all those that were salvaged, 17 (8%) underwent total laryngectomy (15 S, 2 RT). There was no significant difference in the 5-year cumulative incidence of LF (20.8% S, 8.1% RT, p = 0.138), 5-y LFS (85.0% vs. 91.7%, p = 0.809), 5-y DFS (67.5% vs. 82.1%, p = 0.343), 5-y UDFS (82.5% vs. 90.3%, p = 0.647) and 5-y OS (84.5% vs. 90.3%, p = 0.892). Multivariate analysis showed no correlation between initial treatment and the analyzed outcomes.

Conclusion

Primary surgery or radiotherapy were similar first line options, since they do not differ in all outcomes. Patients' and physician's preferences must be considered when choosing first treatment.

Analysis of prognostic factors for Tis-2N0M0 early glottic cancer with different treatment methods

INTRODUCTION

In many regions, laryngeal carcinoma is a common upper respiratory tract cancer, most commonly involving the glottic region. The treatment of early glottic cancer includes radiotherapy, open surgery and laryngeal laser microsurgery. However, the preferred treatment for early glottic cancer is still controversial.

OBJECTIVES

To study the factors affecting the 5-year survival rate of T_is-2N₀M₀ early glottis cancer and to demonstrate the oncological safety of different treatments.

METHODS

144 patients with early glottic cancer were analyzed retrospectively. All patients were clinically node negative. 53 patients underwent open surgery, transoral CO₂ laser microsurgery in 46 cases and radiotherapy in 45 cases. The patients were followed up for 26 - 84 months, with an average follow-up period of 62.9 months.

RESULTS

The 5-year overall survival was 82.6%. The 5 year survival rates of open surgery, laser microsurgery and radiotherapy were 83.0%, 82.6% and 82.2%, respectively. There was no significant difference in 5-year survival rate among the three treatments (p =  0.987). In multivariate analysis, age, T-stage, pathological grading, and anterior commissure involvement were important prognostic factors for early glottic cancer.

CONCLUSIONS

There was no significant difference in 5 year survival rate among patients treated by either radiotherapy, laser microsurgery or open surgery for early glottic cancer. We urge more attention to the age, T-stage, pathological grade, and anterior commissure involvement of the patients.

Survival results of 3786 patients with stage I or II laryngeal squamous cell carcinoma: a study based on a propensity score

Introduction

Laryngeal squamous cell carcinoma is the second most prevalent malignancy among head and neck tumors, and the treatment of patients with stage I or II disease can be performed with surgery or radiation therapy. National population studies describing therapeutic results comparing these modalities are unusual, but they can be very important to direct treatment guidelines.

Objective

To evaluate the survival results of patients with laryngeal squamous cell carcinoma at clinical stages I or II, according to the main therapeutic modalities used.

Methods

Cross-sectional, population-based study using the database of Fundação Oncocentro de São Paulo from January 2000 to March 2019. Inclusion criteria were patients with laryngeal squamous cell carcinoma in clinical stages cT1-2N0. To compensate for the non-random allocation of patients and the imbalance between confounding variables between groups, we used the propensity score methodology.

Results

A total of 3786 patients met the inclusion criteria. Regarding the cT stage, there were 2171 patients (57.3%) with cT1 tumors. Patients in the public health system had a longer time between diagnosis and treatment (p < 0.001). The analysis by propensity score showed that patients treated with surgery had a tendency towards better disease-specific survival (p  = 0.012). Comparing radiotherapy alone versus its combination with radiochemotherapy, radiotherapy alone showed a tendency towards a better survival rate (p < 0.001).

Conclusion

Analysis by propensity score identified better results for disease-specific survival in patients with laryngeal squamous cell carcinoma at clinical stages I and II treated by surgery when compared to radiotherapy.

Early glottic tumours with anterior commissure involvement. Literature review and consensus document. Head and Neck and Skull Base Commission, SEORL-CCC

The choice of the most appropriate treatment in early-stage glottic cancer with anterior commissure involvement remains controversial. Its therapeutic management is complex because it is a significant prognostic indicator of local control with 37% recurrence, due to the difficulty in establishing tumour extension with understaging of up to 40%, and due to the comparison of results in series on tumours that behave variably as they progress, such as T1a, T1b and T2a with commissure involvement. Furthermore, the complexity of the surgical approach using transoral CO2 laser microsurgery requires surgical skill, appropriate equipment and experience. Aspects to be reviewed in this document are: an updated anatomical definition of the anterior commissure, tumour progression based on histopathological studies, usefulness of videostroboscopy and NBI in diagnostic accuracy, validity of imaging tests, oncological results published in series reviews, systematic reviews and meta-analyses, tumour margin treatment and voice evaluation.Finally, by way of a summary, the document includes a series of recommendations for the treatment of these tumours.

Current role of primary surgical treatment in patients with head and neck squamous cell carcinoma

PURPOSE OF REVIEW

The objective of this review article is to discuss the current role of surgery as the primary treatment modality in patients with head and neck squamous cell carcinoma (HNSCC).

RECENT FINDINGS

HNSCC represents one of the cancer locations where the primary treatment modality is the most under discussion. Indeed, the respective roles of primary surgical resection followed, as necessary, by adjuvant radiotherapy or definitive chemoradiotherapy remain controversial. The results of organ preservation trials and the drastic rise in the incidence of human papillomavirus-induced oropharyngeal tumors, which are known to be highly radiosensitive, have led to an increasing use of chemoradiation-based therapies in HNSCC patients. However, no chemoradiation-based protocol has shown better oncologic outcomes than radical primary surgery. Moreover, development of minimally invasive surgical techniques, such as transoral robotic surgery, and advances in head and neck microvascular reconstruction have considerably improved the clinical outcomes of the patients and have led to a reconsideration of the role of primary surgery in HNSCC patients.

SUMMARY

Surgery should be the primary treatment modality for most resectable oral cavity cancers and for T4a laryngeal/hypopharyngeal cancers. Primary surgery could also be the preferred modality of treatment for most early (T1-T2, N0) laryngeal and hypo/oropharyngeal carcinomas when this strategy offers an opportunity to reserve radiotherapy for a potential recurrence or second primary tumor. Primary surgery should also be considered in patients with locally advanced human papillomavirus-negative oropharyngeal carcinoma.

Radioresistant laryngeal cancers upregulate type 1 IGF receptor and exhibit increased cellular dependence on IGF and EGF signalling

OBJECTIVES

Patients failing radiotherapy for laryngeal squamous cell carcinoma (LSCC) often require salvage total laryngectomy which has major functional consequences, highlighting a need for biomarkers of radiotherapy resistance. In other tumour types, radioresistance has been linked to epidermal growth factor receptor (EGFR) and type 1 insulin-like growth factor receptor (IGF-1R). Here, we evaluated IGF-1R and EGFR as predictors and mediators of LSCC radioresistance.

DESIGN

We compared IGF-1R and EGFR immunohistochemical scores in patients with LSCC achieving long-term remission post-radiotherapy (n = 23), patients treated with primary laryngectomy (n = 22) or salvage laryngectomy following radiotherapy recurrence (n = 18). To model radioresistance in vitro, two LSCC cell lines underwent clinically relevant irradiation to 55 Gy in 2.75 Gy fractions.

RESULTS

Type 1 insulin-like growth factor receptor expression was higher in pre-treatment biopsies of radiotherapy failures compared with those in long-term remission and was upregulated post-radiotherapy. Patients undergoing primary laryngectomy had more advanced T/N stage and greater tumour IGF-1R content than those achieving long-term remission. Pre-treatment EGFR did not associate with radiotherapy outcomes but showed a trend to upregulation post-irradiation. In vitro, radiosensitivity was enhanced by inhibition of EGFR but not IGF. Repeated irradiation upregulated IGF-1R in BICR18 and SQ20B cells and EGFR in SQ20B, and enhanced SQ20B radioresistance. Repeatedly irradiated SQ20B_55 cells were not radiosensitised by inhibition of IGF and/or EGFR, but IGF-1R:EGFR co-inhibition suppressed baseline cell survival more effectively than blockade of either pathway alone, and more effectively than in parental cells.

CONCLUSIONS

Radiation upregulates IGF-1R and may enhance IGF/EGFR dependence, suggesting that IGF/EGFR blockade may have activity in LSCCs that recur post-radiotherapy.

Early glottic cancer in a veteran population: Impact of race on management and outcomes

OBJECTIVES

Multiple population studies have shown racial discrepancies in head and neck cancer treatment and outcomes. We sought to characterize the impact of race on clinical outcomes for patients with early glottic squamous cell carcinoma (SCC) in a tertiary institution which provides equivalent access to care.

METHODS

We retrospectively reviewed all early glottic (T1-T2) squamous cell carcinoma at a single institution, the Michael E. DeBakey Veterans' Administration Medical Center (MEDVAMC). Data collected included demographic information, primary and adjuvant treatment modalities, time to diagnosis, time to treatment, recurrences, recurrence treatment modality, secondary malignancies, recurrence-free survival (RFS), and overall survival (OS).

RESULTS

One hundred seventeen patients with a primary diagnosis of T1-T2 glottic squamous cell carcinoma were included. Black and white patients demonstrated equivalent rates of recurrence, RFS, and OS. There was no significant difference in treatment delivery by race for all recorded parameters. T1b tumors were associated with an increased risk of recurrence which did not translate into a statistically significant decrease in RFS or OS. Surgical treatment was associated with increased recurrence but similar RFS and OS compared to radiation-based treatment. Secondary malignancies were common; 12% of patients were diagnosed with a second primary lung cancer during the study period.

CONCLUSION

At our institution, race did not impact survival when access to care, treatment selection, and delivery are equivalent for early glottic SCC. Secondary lung cancer is a critical risk factor for mortality in this patient group and requires long-term surveillance and monitoring.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1733-1739, 2020.

Multifactorial analysis of local control and survival in patients with early glottic cancer

OBJECTIVES

The purpose of this study is to determine the effects of various prognostic factors for early glottic cancer patients who underwent radiotherapy.

METHODS

We retrospectively reviewed the all patients who were treated at our hospital for early glottic squamous cell carcinoma from 2004 to 2016. Data included patient's age, sex, T classification, tumor size, pathological grade, anterior commissure involvement, subglottic extension, laryngeal ventricle involvement, and restriction of vocal cord movement.

RESULTS

There were 74 patients with T1 tumors and 31 with T2 tumors. Recurrence was found in four patients with T1 and eight patients with T2. There were 99 males and six females enrolled, and the mean age was 67.5 ± 9.2 years for T1a, 67.3 ± 11.2 years for T1b, and 67.4 ± 7.9 years for T2. One patient with recurrence after 1 month was thought to have a residual tumor. The 5-year overall survival (OS) rate and the 5-year disease-specific survival (DSS) rate for T1-T2 patients were both 100%. The rate of larynx preservation was 94.6% for T1 and 74.2% for T2. A univariate analysis showed that the effective factors were age, T, size, SE. A multivariate logistic regression analysis showed that age influenced the recurrence status. Size is also suspected to be a prognostic factor.

CONCLUSIONS

This study revealed that the effective factors were age, T, size, and SE.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1701-1706, 2020.

Quality of life and voice outcome of patients treated with transoral CO2 laser microsurgery for early glottic carcinoma (T1-T2): a 2-year follow-up study

Purpose

Longitudinal studies in laryngeal cancer can provide clinicians information about short-term and long-term functional outcomes, like quality of life (QoL) and voice outcome. This information is important when counseling patients or choosing a primary treatment modality. The present study assessed long-term (2 years) QoL and voice outcome in patients with extended T1 and limited T2 glottic carcinoma treated with transoral CO₂ laser microsurgery (TLM) (unilateral type III or bilateral type II resections).

Methods

Three questionnaires were administered: the Voice Handicap Index (VHI), the European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaire (QLQ)-C30, the EORTC QLQ-HN35. A perceptual voice evaluation at six different time points was conducted: preoperatively, and postoperatively at 6 weeks, 3 months, 6 months, 1 year, and 2 years. Fluctuations over time were investigated.

Results

Sixty-one patients were included in the analysis. Patients reported high-level functioning and low symptom scores 2 years postoperatively. Gender significantly affected the VHI scores at 2 years (mean VHI scores: female 8.7 vs. male, 23.9; p = 0.023). The major improvement in VHI scores was observed within the first 6 months. The tumor stage (T1a, T1b, and T2) significantly impacted the grade (mean scores at 2 years: 1.0, 1.9, and 1.7; p = 0.001). These scores stabilized at 6 months.

Conclusions

Patients show good long-term QoL with low symptom scores, a low voice handicap, and mild to moderate dysphonia, 2 years postoperatively. Scores stabilize at 6 months and provide a clear indication of status at 1 and 2 years.

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.