Quality of life, functional outcome, and costs of early glottic cancer

Distance Traveled by Patients Globally to Access Radiation Therapy: A Systematic Review

PURPOSE

This study aimed to systematically review the literature on the travel patterns of patients seeking radiation therapy globally. It examined the distance patients travel for radiation therapy as well as secondary outcomes, including travel time.

METHODS AND MATERIALS

A comprehensive search of 4 databases was conducted from June 2022 to August 2022. Studies were included in the review if they were observational, retrospective, randomized/nonrandomized, published between June 2000 and June 2022, and if they reported on the global distance traveled for radiation therapy in the treatment of malignant or benign disease. Studies were excluded if they did not report travel distance or were not written in English.

RESULTS

Of the 168 studies, most were conducted in North America (76.3%), with 90.7% based in the United States. Radiation therapy studies for treating patients with breast cancer were the most common (26.6%), while external beam radiation therapy was the most prevalent treatment modality (16.6%). Forty-six studies reported the mean distance traveled for radiation therapy, with the shortest being 4.8 miles in the United States and the longest being 276.5 miles in Iran. It was observed that patients outside of the United States traveled greater distances than those living within the United States. Geographic location, urban versus rural residence, and patient population characteristics affected the distance patients traveled for radiation therapy.

CONCLUSIONS

This systematic review provides the most extensive summary to date of the travel patterns of patients seeking radiation therapy globally. The results suggest that various factors may contribute to the variability in travel distance patterns, including treatment center location, patient residence, and treatment modality. Overall, the study highlights the need for more research to explore these factors and to develop effective strategies for improving radiation therapy access and reducing travel burden.

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.

Early-Stage Glottic Carcinoma in the United States: Demographics and Treatment Choice

OBJECTIVE

Limited investigation of factors potentially contributing to treatment choice in early-stage glottic carcinoma (EGC) has been performed with large-scale data. The National Cancer Database (NCDB) represents >72% of all new cancer cases in the United States. We hypothesized that NCDB variables may lend insight into treatment decisions between surgery and radiation for EGC.

METHODS

The NCDB was queried for all cases of T_1-2  N₀  M₀ glottic carcinoma from 2004 to 2016. We used multivariable logistic regression analysis to examine factors associated with first-line treatment modality: radiation therapy (RT) versus surgery. All reported odds ratios (OR) were adjusted for age, gender, race, insurance, residence in a metropolitan area, region, and facility volume.

RESULTS

34,991 EGC patients received treatment: 6,687 (19%) surgery; 20,289 (58%) RT; and 8,015 (23%) surgery and RT. OR for receiving RT (vs. surgery alone) were >2 for: more advanced T stage cancers (OR 2.5 [95%CI: 2.3, 2.7]), treatment at non-academic facilities (OR 2.8, [95%CI: 2.6, 3.0]), and shorter travel distances to treatment centers (OR 2.2, [95%CI: 2.0, 2.4]). Surgery was more likely with treatment in the western US, higher income, private insurance, living in a metropolitan (vs. non-metropolitan) area, female gender, older age, and low facility volume. Hispanic ethnicity, education level, and race were not associated with treatment type in the multivariable model.

CONCLUSION

Most patients in the NCDB receive first-line treatment with radiation for EGC, and this decision is associated with various tumor, patient, and treatment facility characteristics.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:901-907, 2023.

Understanding Financial Toxicity in Patients with Head and Neck Cancer: A Systematic Review

Background

Cancer treatment often results in financial burdens for patients including healthcare costs as well as treatment-induced disability leading to "financial toxicity" (FT) and decreased quality of life. The purpose of this review is to describe FT related to head and neck cancer (HNC) treatment, including quantifications of direct and indirect costs and descriptions of measurement tools.

Methods

PubMed, Embase, Cochrane Library, and Web of Science databases were searched to identify articles published before April 2022. Full-text published studies were included if they assessed direct or indirect costs of HNC treatment; studies were excluded if they did not focus on HNC or financial burden. The risk of bias was assessed, and the results of the studies were synthesized.

Results

Database searches yielded 530 unique studies, and 33 studies met the criteria for inclusion. Medical expenses for patients with HNC were higher than for patients with other cancers or controls in several studies. Major surgical procedures, neck dissection, free-flap reconstruction, and intensive care unit admission increased hospital costs. Trimodal therapy with surgery plus chemoradiation represented the most expensive treatment, and chemoradiation increased complication-related health care costs. In several studies, >50% of patients treated for HNC were disabled and did not return to work. One of the greatest contributors to the indirect cost of HNC treatment is the loss of lifetime wages. Patients with HNC are at risk for depression, anxiety, and social isolation, which are linked to a decreased quality of life and treatment non-adherence. The only tools used to assess FT in patients with HNC are the Comprehensive Score for financial Toxicity (COST) and the Financial Index of Toxicity (FIT).

Conclusion

Financial toxicity is highly prevalent among patients with HNC. Further research is needed to validate the assessment tools for quantifying FT in HNC patients.

Quality of life and financial toxicity after (chemo)radiation therapy in head and neck cancer: are there any sex- or gender-related differences?

The purpose of this article is to discuss the published evidence related to quality of life (QoL) and financial toxicity (FT) differences between female and male head and neck cancer patients treated with (chemo)radiotherapy. There is a need of promoting methods for assessing QoL difference between female and male patients in order to set up early rehabilitation, psychosocial care, and lifestyle interventions, as well as setting up specific interventions for minimizing financial stress.

Management of Laryngeal Dysplasia and Early Invasive Cancer

OPINION STATEMENT

Dysplasia and early laryngeal cancer lie on a spectrum of cellular changes. These start with early changes to the cells including epithelial hyperplasia and expand to dysplasia, squamous cell carcinoma in situ and finally developing in to invasive cancer. Dysplasia can range from low to high grade, with each being treated in a different manner. Treatment options are typically determined by where the dysplasia/invasive cancer lie on this spectrum along with the site within the larynx. Hyperkeratosis, mild dysplasia and moderate dysplasia typically involve primary endoscopic excision. Severe dysplasia and squamous cell carcinoma in situ involve primary endoscopic resection with the addition of possible laser resection and/or ablation. At this stage, surgery will be followed by close surveillance. Finally, early laryngeal cancer such as T1 and T2 lesions is typically more involved. Treatment depends on the site and degree of involvement of the structures, along with spread to surrounding structures. Typical treatment options of more involved early laryngeal cancer can range from radiation therapy, endoscopic transoral laser resection, endoscopic transoral robotic resection to open resection. Often times, my choice of treatment will be aimed at voice preservation but patient preference will also play a role in the decision making between treatment modalities. Chemotherapy and immunotherapy are typically not used in early stage laryngeal cancer.

Financial Toxicity in Head and Neck Cancer Patients Treated With Proton Therapy

Cancer-related financial toxicity impacts head and neck cancer patients and survivors. With increasing use of proton therapy as a curative treatment for head and neck cancer, the multifaceted financial and economic implications of proton therapy-dimensions of "financial toxicity"-need to be addressed. Herein, we identify knowledge gaps and potential solutions related to the problem of financial toxicity. To date, while cost-effectiveness analysis has been used to assess the value of proton therapy for head and neck cancer, it may not fully incorporate empiric comparisons of patients' and survivors' lost productivity and disability after treatment. A cost-of-illness framework for evaluation could address this gap, thereby more comprehensively identifying the value of proton therapy and distinctly incorporating a measurable aspect of financial toxicity in evaluation. Overall, financial toxicity burdens remain understudied in head and neck cancer patients from a patient-centered perspective. Systematic, validated, and accurate measurement of financial toxicity in patients receiving proton therapy is needed, especially relative to conventional photon-based strategies. This will enrich the evidence base for optimal selection and rationale for payer coverage of available treatment options for head and neck cancer patients. In the setting of cancer care delivery, a combination of conducting proactive screening for financial toxicity in patients selected for proton therapy, initiating early financial navigation in vulnerable patients, engaging stakeholders, improving oncology provider team cost communication, expanding policies to promote price transparency, and expanding insurance coverage for proton therapy are critical practices to mitigate financial toxicity in head and neck cancer patients.

Work Outcomes after Intensity-Modulated Proton Therapy (IMPT) versus Intensity-Modulated Photon Therapy (IMRT) for Oropharyngeal Cancer

Purpose

We compared work outcomes in patients with oropharyngeal cancer (OPC), randomized to intensity-modulated proton (IMPT) versus intensity-modulated photon therapy (IMRT) for chemoradiation therapy (CRT).

Patients and Methods

In 147 patients with stage II-IVB squamous cell OPC participating in patient-reported outcomes assessments, a prespecified secondary aim of a randomized phase II/III trial of IMPT (n = 69) versus IMRT (n = 78), we compared absenteeism, presenteeism (i.e., the extent to which an employee is not fully functional at work), and work productivity losses. We used the work productivity and activity impairment questionnaire at baseline (pre-CRT), at the end of CRT, and at 6 months, 1 year, and 2 years. A one-sided Cochran-Armitage test was used to analyze within-arm temporal trends, and a χ² test was used to compare between-arm differences. Among working patients, at each follow-up point, a 1-sided Wilcoxon rank-sum test was used to compare work-productivity scores.

Results

Patient characteristics in IMPT versus IMRT arms were similar. In the IMPT arm, within-arm analysis demonstrated that an increasing proportion of patients resumed working after IMPT, from 60% (40 of 67) pre-CRT and 71% (30 of 42) at 1 year to 78% (18 of 23) at 2 years (P = 0.025). In the IMRT arm, the proportion remained stable, with 57% (43 of 76) pre-CRT, 54% (21 of 39) at 1 year, and 52% (13 of 25) working at 2 years (P = 0.47). By 2 years after CRT, the between-arm difference between patients who had IMPT and those who had IMRT trended toward significance (P = 0.06). Regardless of treatment arm, among working patients, the most severe work impairments occurred from treatment initiation to the end of CRT, with significant recovery from absenteeism, presenteeism, and productivity impairments by the 2-year follow-up (P < 0.001 for all). Higher magnitudes of recovery from absenteeism (at 1 year, P = 0.05; and at 2 years, P = 0.04) and composite work impairment scores (at 1 year, P = 0.04; and at 2 years, P = 0.04) were seen in patients treated with IMPT versus those treated with IMRT.

Conclusion

In patients with OPC receiving curative CRT, patients randomized to IMPT demonstrated increasing work and productivity recovery trends. Studies are needed to identify mechanisms underlying head and neck CRT treatment causing work disability and impairment.

[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.

Laser Microsurgery Versus Radiotherapy Versus Open Partial Laryngectomy for T2 Laryngeal Carcinoma: A Systematic Review of Oncological Outcomes

INTRODUCTION

The aim of the current systematic review is to update the pooled survival outcome of patients with T2 glottic carcinoma treated with either laser surgery (CO₂ transoral laser microsurgery [CO₂ TOLMS]), radiotherapy (RT), or open partial laryngectomy (OPL).

METHODS

A systematic search was performed using the MEDLINE database, Scopus, and Google scholar. The inclusion criteria were studies of patients with T2N0 glottic tumor, treated with either primary CO₂ TOLMS, definitive curative RT, or primary OPL, and with reported oncological outcome at 5 years calculated with a Kaplan-Meier or Cox regression method.

RESULTS

The results of the current review show that local control (LC) is higher with OPL 94.4%, while there are no differences in LC at 5-year posttreatment for patients treated with RT, compared to those treated with CO₂ TOLMS (respectively, 75.6% and 75.4%). Primary treatment with OPL and CO₂ TOLMS results in higher laryngeal preservation than primary treatment with RT (respectively 95.8%, 86.9%, and 82.4%).

CONCLUSION

First-line treatment with OPL and CO₂ TOLMS should be encouraged in selected T2 patients, because it results in higher laryngeal preservation and similar LC compared to primary treatment with RT. The involvement of the anterior commissure in the craniocaudal plane and T2b impaired vocal cord mobility have a poorer prognosis and LC compared to patients with T2a tumors for both CO₂ TOLMS and RT.

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study

Objectives

To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins.

Study Design

Retrospective review of the National Cancer Database.

Setting

Population based.

Subjects/Methods

Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors.

Results

A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], P = .001), academic status (vs nonacademic; academic: 0.70 [0.54-0.90], P = .008), T-stage (vs T1; T2: 2.74 [2.05-3.65], T3: 5.53 [3.55-8.63], TIS: 0.59 [0.38-0.92], P < .001), and N-stage (vs N0; N1: 3.42 [1.79-6.54], N2: 2.01 [1.09-3.69], P < .001). Tumor subsite was not associated with margin status.

Conclusion

The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections.

The Prognostic Value of Adding Narrow-Band Imaging in Transoral Laser Microsurgery for Early Glottic Cancer: A Review

BACKGROUND AND OBJECTIVES

Transoral laser microsurgery (TLM) is a universally recognized safe and minimally invasive approach for early glottic cancer. Narrow band imaging (NBI) is an optical technique working with a filtered light that reveals superficial mucosal abnormalities through the neoangiogenic pattern. The aim of this systematic review is to demonstrate the role of intraoperative NBI during TLM for early glottic cancer to better evaluate tumor extension and for more precise margin resection.

STUDY DESIGN/MATERIALS AND METHODS

A systematic review of the literature following the PRISMA guidelines was performed. A literature search was performed using the following keywords: TLM, NBI, and early glottic cancer. Two independent authors evaluated the extracted data. Data regarding status of surgical margins after TLM, local recurrence, recurrence-free survival, and need of additional samples following NBI were collected.

RESULTS

Five articles met inclusion criteria with a total of 577 patients undergoing TLM with intraoperative NBI. A significant reduction of positive superficial margins was found in patients treated with (52%) and without (28.6%) intraoperative use of NBI (P < 0.05) CONCLUSIONS: Routine use of intraoperative NBI increases the accuracy of neoplastic superficial spreading evaluation and accuracy of mass resection during TLM for early glottic cancer. The significant reduction of superficial positive margins dramatically decreases the number of patients at risk and improves clinical outcomes. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Low expression of pRB predicts disease relapse in early glottic cancer treated with transoral laser microsurgery

OBJECTIVES/HYPOTHESIS

To elucidate the associations among the immunohistochemical expression of tumor markers, clinicopathological variables, and disease-free survival (DFS) in patients with early-stage glottic squamous cell carcinoma (SCC) who underwent transoral laser microsurgery (TLM) as the primary treatment.

STUDY DESIGN

Retrospective chart review.

METHODS

The records of consecutive patients with Tis-T2N0 glottic SCC who underwent TLM between August 1, 2012 and October 31, 2015 were reviewed. Expression of Bcl-2, pRB, p16^INK4A , p53, c-Myc, E-cadherin, and EGFR was examined using tissue microarrays containing tumor specimens through immunohistochemistry. Three-year DFS rates were calculated.

RESULTS

A total of 65 consecutive patients were identified, of which 28 were excluded due to insufficient tissue (n = 22) and low biomarker quality (n = 6). Therefore, 37 patients with complete records were included. The included patients were significantly older and had a more advanced type of cordectomy than did the excluded patients (P = .015 and .009, respectively). According to the findings of univariate analysis, age, betel quid chewing, type of cordectomy, BCL-2 expression, and pRB expression significantly predicted 3-year DFS. According to the findings of multivariate analysis, age (adjusted hazard ratio: 0.94, 95% CI: 0.88-1.00), betel quid chewing (adjusted hazard ratio: 5.07, 95% CI: 1.32-19.44), and pRB expression (adjusted hazard ratio: 0.02, 95% CI: 0.00-0.28) were independent predictors of 3-year DFS.

CONCLUSIONS

Low pRB expression is a potential biomarker for predicting disease relapse after primary TLM for early-stage glottic SCC and may help to identify high-risk patients who can subsequently undergo intensive management.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:E220-E226, 2019.

A comparison of phonatory outcome between trans-oral CO2 Laser cordectomy and radiotherapy in T1 glottic cancer

PURPOSE

This study aimed at comparing phonatory outcomes between Trans-oral Laser Surgery and Radiotherapy in T1 glottic cancer.

INTRODUCTION

Early glottic carcinoma, i.e. T1 stage, can be treated using trans-oral surgery, radiotherapy, or partial open surgery. Trans-oral laser (TOL) surgical techniques and Radiotherapy (RT) have undergone significant advancement in the past few years leading to a decrease in open procedures. Various studies have been published comparing voice quality after TOL surgery and RT. There are few works which consider patients' opinions, i.e. subjective parameters regarding functional voice quality post treatment. This study uses both subjective and objective parameters to evaluate phonatory outcome of both treatment options.

METHODS

Phonatory outcomes were measured in patients who underwent RT and CO₂ Laser excision for early laryngeal cancer. VHI, GRBAS and MDVP were used to measure the vocal outcome of treatment modality after 1 year of cancer-free survival. A comparison was then made between the outcomes in the two groups.

RESULTS

Superior vocal outcomes in G, R and S criteria of the GRBAS scale, a better VHI index, and better jitter, shimmer and NHR were found in patients who underwent CO₂ laser excision as compared to patients who underwent RT. Other parameters were comparable between the two groups.

CONCLUSIONS

TOL surgery provides excellent vocal outcome as compared to RT in management of early glottic cancer and should be considered as the first line of management for the same.

Is There a Change in the Treatment of T1 Glottic Cancer After CO2 Laser? A Comparative Study with Cold Steel

Objective

Carbon dioxide (CO₂) laser provides high local control and disease-specific survival rates with minor morbidity and good quality of life in transoral cordectomy. We aimed to compare the oncological outcome and survival between cold steel and CO₂ laser in the treatment of early glottic cancer.

Methods

In this retrospective study, the participants were divided into two groups. The first group comprised patients who were operated upon between 2001 and 2007 using cold steel (group 1, n=38), and the second group comprised patients who were operated upon between 2008 and 2016 using CO₂ laser (group 2, n=88). Both groups were compared regarding age, gender, pathological grade, T stage, type of cordectomy, margin status, anterior commissure involvement, follow-up, locoregional recurrence, and disease-free survival (DFS).

Results

The overall survival rate and DFS were similar between the two groups (94.7% vs. 98.9% and 100% vs. 98.9%, respectively), and no association was found between surgical margin positivity and local recurrence. However, a significant association between the presence of anterior commissure involvement and recurrence was found in all 126 patients (p=0.016). Local recurrence was significantly higher in the group 2 (p=0.024), but it did not affect overall survival and DFS in these patients (100% vs. 94.1%).

Conclusion

Although CO₂ laser excision is considered to be superior to cold steel regarding surgical time and bleeding control, the local recurrence rates were found to be higher with the laser than the cold steel. Thus, we argue that cases should be selected more carefully concerning the anterior commissure, depth of tumor invasion lateral to vocal muscle, difficulty at endoscopic exposure for lesions with anterior commissure involvement, and reliability of surgical margins at frozen sections.

Vocal activity profile and dysphonia coping strategies in subjects with laryngeal cancer treated with radiotherapy

ABSTRACT Purpose: to verify the vocal activity participation and the dysphonia coping strategies of subjects with laryngeal cancer treated with radiotherapy. Methods: a cross-sectional trial involving 17 individuals with laryngeal cancer treated only by radiotherapy with vocal complaints after radiotherapy management. A sociodemographic questionnaire, the Brazilian versions of Voice Activity and Participation Profile and Voice Disability Coping Questionnaire protocols were applied. Results: there was a prevalence of male participants (n=16) and the mean age was 62 years. All were former smokers and 15 were former drinkers. Voice Activity and Participation Profile in mean scores was: overall,141.2, self-perception of vocal problem, 6.2, effect at work, 19.1, effects on daily communication, 60.5, effects on media, 20.1, and effects on their emotional, 36.7. In Voice Disability Coping Questionnaire mean scores were: overall,71.7, focusing on problem, 33, and focusing on emotion, 38.9. Conclusion: the participants had high Voice Activity and Participation Profile scores as compared to the literature scores considered for dysphonic individuals in general, and activity with effects on daily communication was the most affected. Voice Disability Coping Questionnaire demonstrates that these patients adopt dysphonia coping strategies with greater focus on emotion.

Quality of life during the first year after partial laryngectomy: Longitudinal study

BACKGROUND

This prospective study was conducted to assess changes in quality of life (QOL) of patients who undergo a partial laryngectomy.

METHODS

The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires Core and Head and Neck (EORTC-QLQ-C30, QLQ-H&N35) were used preprocedure (n = 218), 1 week (n = 159), 3 months (n = 122), and 1 year after partial laryngectomy (n = 88). Changes over time were analyzed with the Wilcoxon signed rank test and the Holm-Bonferroni method, and interpreted regarding clinical relevance.

RESULTS

Most subscales worsened 1 week postprocedure, but many recovered to baseline level after 1 year. Dyspnea and cognitive functioning deteriorated over time, with worst scores recorded after 1 year. Financial difficulties and fatigue increased after surgery and maintained that level throughout the follow-up period; sticky saliva remained worse than at baseline, despite some improvements over time.

CONCLUSION

The discovered limitations of QOL should be observed more closely during follow-up treatment, and patients should be informed about these potential effects before partial laryngectomy.

AHNS Series: Do you know your guidelines? Review of current knowledge on laryngeal cancer

The following article is part of a series in an initiative by the American Head and Neck Society's Education Committee and will review clinical practice guidelines for head and neck oncology. The primary goal is to increase awareness of current best practices pertaining to head and neck surgery and oncology. This manuscript is a review of current knowledge in laryngeal cancer with a focus on anatomy, epidemiology, diagnosis, evaluation, and treatment.

Life quality improvement in hoarse patients with early glottic cancer after transoral laser microsurgery

BACKGROUND

The purpose of this study was to evaluate the recovery kinetics of voice and quality of life (QOL) over time in patients with early glottic cancer who underwent transoral laser microsurgery (TLM).

METHODS

A prospective cohort study was conducted in which acoustic and aerodynamic voice assessments and QOL analyses were done using health-related questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30-questions [EORTC-QLQ-C30] and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35-questions [EORTC-QLQ-H&N35]) were administered at designated times.

RESULTS

Most voice laboratory parameters worsened during the first month, then recovered to baseline after 6 months. The QLQ-H&N35 speech subscale was significantly improved. Among the voice laboratory parameters, pretreatment harmonics-to-noise ratio was an independent predictor (P = .041) for improvement on the speech subscale at the endpoint.

CONCLUSION

Despite an initial deterioration of voice and QOL in the first month, patients who underwent TLM recovered to a plateau since the sixth month and then to better than preoperative status afterward. A greater improvement in QOL was seen in patients with poorer baseline voice quality.

Endoscopie Laser Resection of Laryngeal Cancer: Is it Oncologically Safe?

The purpose of this report is to summarize the salient points made during a panel discussion at the 88th Annual Meeting of the American Broncho-Esophagological Association about the efficacy and oncological safety of endoscopic laser treatment of laryngeal cancer. Guidelines for endoscopic laser management of early glottic and supraglottic cancer, including contraindications for this treatment modality, are presented. On the basis of all currently available data, the panel, which critically considered the question of oncological safety, is of the opinion that endoscopic laser resections are oncologically safe when applied judiciously and by a skilled oncological surgeon. Relative contraindications for endoscopic laser resection of laryngeal cancer include instances in which the whole tumor cannot be visualized; large tumors that require removing too much of the functional laryngeal unit, severely decreasing airway protection and leading to aspiration; and cartilage invasion. Specific contraindications for supraglottic cancer include bilateral arytenoid involvement and direct extension into the neck.

Transoral Laser Microsurgery in Early Glottic Lesions

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

SBRT for early-stage glottic larynx cancer-Initial clinical outcomes from a phase I clinical trial

Purpose

To confirm safety and feasibility of hypofractionated SBRT for early-stage glottic laryngeal cancer.

Methods

Twenty consecutive patients with cTis-T2N0M0 carcinoma of glottic larynx were enrolled. Patients entered dose-fractionation cohorts of incrementally shorter bio-equivalent schedules starting with 50 Gy in 15 fractions (fx), followed by 45 Gy/10 fx and, finally, 42.5 Gy/5 fx. Maximum combined CTV-PTV expansion was limited to 5 mm. Patients were treated on a Model G5 Cyberknife (Accuray, Sunnyvale, CA).

Results

Median follow-up is 13.4 months (range: 5.6–24.6 months), with 12 patients followed for at least one year. Maximum acute toxicity consisted of grade 2 hoarseness and dysphagia. Maximum chronic toxicity was seen in one patient treated with 45 Gy/10 fx who continued to smoke >1 pack/day and ultimately required protective tracheostomy. At 1-year follow-up, estimated local disease free survival for the full cohort was 82%. Overall survival is 100% at last follow-up.

Conclusions

We were able to reduce equipotent total fractions of SBRT from 15 to 5 without exceeding protocol-defined acute/subacute toxicity limits. With limited follow-up, disease control appears comparable to standard treatment. We continue to enroll to the 42.5 Gy/5 fx cohort and follow patients for late toxicity.

Trial registration

ClinicalTrials.gov NCT01984502

Comparison of survival between radiation therapy and trans-oral laser microsurgery for early glottic cancer patients; a retrospective cohort study

BACKGROUND

The literature reports various treatment methodologies, such as trans-oral laser microsurgery, radiation therapy, total/partial laryngectomies, and concurrent radiation chemotherapy for patients with early larynx cancer. However, at the forefront of early glottis treatment is trans-oral laser microsurgery and radiation therapy, likely due to better functional and survival outcomes. Here we conduct the largest Canadian head-to-head comparison of consecutive patients treated with either radiation therapy or trans-oral laser microsurgery. Additionally, we compare these two treatments and their 5-year survival rates post treatment to add to the existing literature.

METHODS

Charts of patients who were diagnosed with early glottic cancer between 2006 and 2013 were reviewed. Seventy-five patients were identified, and split into 2 groups based on their primary treatment, trans-oral laser microsurgery and radiation therapy. Kaplan-Meier survival curves, life-tables, and the log-rank statistic were reported to determine if there was a difference between the two treatment groups and their disease-specific survival, disease-free survival, and total laryngectomy-free survival. Additionally, each different survival analysis was stratified by potential confounding variables, to help conclude which treatment is more efficacious in this population.

RESULTS

The 5-year disease-specific survival rate is 93.3 % σ = 0.063 and 90.8 % σ = 0.056 for patients treated with trans-oral laser microsurgery and radiation therapy, respectively (χ (2) < 0.001, p = 0.983). The disease free survival rate is 60.0 % (σ =0.121) for patients treated with trans-oral laser microsurgery, and 67.2 % (σ = 0.074) for those who received RT (χ (2) = 0.19, p = 0.663). Additionally, the total laryngectomy-free survival rate is 84.1 % (σ = 0.1) and 79.1 % (σ = 0.072) for patients' early glottic cancer treated by trans-oral laser microsurgery and radiation therapy, respectively (χ (2) = 0.235, p = 0.628). Chi-square analysis of age-group versus treatment group (χ (2) = 6.455, p = 0.04) and T-stage versus treatment group (χ (2) = 11.3, p = 0.001) revealed a statistically significant relationship, suggesting survival analysis should be stratified by these variables. However, after stratification, there was no statistically significant difference between the trans-oral laser microsurgery and radiation therapy groups in any of the survival analyses.

CONCLUSION

No difference was demonstrated in the 5-year disease-specific survival, disease-free survival, and total laryngectomy-free survival, between the RT and TLM treatment groups. Additionally, both groups showed similar 5-year survival after stratifying by confounding variables.

Retrospective analysis of factors influencing oncologic outcome in 590 patients with early-intermediate glottic cancer treated by transoral laser microsurgery

BACKGROUND

The purpose of this study was to identify the factors influencing oncologic outcomes for patients with early-intermediate glottic cancer treated by transoral laser microsurgery (TLM).

METHODS

This was a retrospective mono-institutional study. A total of 590 patients with cTis-cT3 glottic cancer underwent TLM with curative intent.

RESULTS

TLM alone was performed in 538 patients (91.2%) and TLM followed by adjuvant radiotherapy (RT) was done in 52 (8.8%). Five-year recurrence-free survival (RFS) and 10-year overall survival (OS) were 85.3% and 74.7%, respectively. The larynx-preservation ratio was 95.9%. In particular, from our data, we found that occult metastases were rare (1.2%); preventive tracheotomy was not necessary; the local recurrence rate of Tis was similar to that in the T2 and T3 group; and no major or lethal complications were observed.

CONCLUSION

Age (>60 vs ≤60), type of cordectomy (≥IV vs ≤III), status of margins, fixed arytenoid, and pathologic T classification, were the variables associated with RFS, OS, and organ-preservation rate. © 2016 Wiley Periodicals, Head Neck 39: 71-81, 2017.

Comparison of quality of life outcomes in laryngeal cancer patients following chemoradiation vs. total laryngectomy

OBJECTIVE: To evaluate quality of life issues in patients with laryngeal cancer after treatment with either chemoradiation or total laryngectomy and radiation therapy.

METHODS: Forty-nine patients with a history of stage II-IV laryngeal squamous cell carcinoma treated primarily with either chemoradiation or by total laryngectomy with postoperative radiation completed the University of Washington Quality of Life instrument, version 4. Patients were identified on a volunteer basis in an academic university head and neck clinic setting. Each patient completed the above instrument, and statistical analysis was performed by Wilcoxon and X 2 , tests.

RESULTS: Instruments were completed by all 49 patients: 15 patients who underwent primary chemoradiation and 34 patients who underwent a total laryngectomy followed by radiation. Domains reported in both treatment groups without significant differences were appearance, activity, recreation, moods, taste, saliva, anxiety, and general questions. However, there were significant differences between the 2 groups in the domains of pain, swallowing, chewing, speech, and shoulder function. The laryngectomy patients reported greater impairment of speech ( P = 0.001), and shoulder function ( P = 0.018), whereas the chemoradiation patients suffered from greater pain, difficulty swallowing ( P = 0.061), and problems chewing ( P = 0.027).

CONCLUSIONS: Most patients with laryngeal cancer, whether treated primarily with chemoradiation or total laryngectomy, reported excellent functional outcomes and health-related quality of life. Pain, swallowing, chewing, saliva, and shoulder function were recorded as significant factors affecting their daily quality of life.

Carbon Dioxide Laser Microsurgery for Early Glottic Carcinoma

OBJECTIVES: To define the oncologic efficacy of transoral endoscopic CO2 laser surgery in early glottic carcinoma.

METHODS: A retrospective study of 103 patients with glottic carcinoma (14 Tis, 68 pT1a, 14 pT1b, and 7 pT2) treated from October 1993 to June 2001. Surgical treatment included endoscopic CO2 laser cordectomies according to the classification of the European Laryngological Society.

RESULTS: According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery alone was 100% for the Tis, 96.05% for the T1, and 100% for the T2. Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03%. The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100%. Laryngeal preservation was achieved in 100% of the cases.

CONCLUSIONS: According to the present series, endoscopic CO2 laser surgery is an effective treatment for early glottic cancer.

Acoustic Characteristics of Voice Before and After Endoscopic Partial Laryngectomy in Early Glottic Cancer

OBJECTIVES

To evaluate the voice changes after narrow-margin endoscopic partial laryngectomy in subjects with T1N0M0 glottic cancer.

STUDY DESIGN

Uncontrolled retrospective comparison of preoperative and postoperative mean phonation time; fundamental frequency, jitter, shimmer, and noise-to-harmonic ratio; and voice-related quality of life (V-RQOL) survey scores.

METHODS

Seventeen adults diagnosed with T1N0M0 glottic cancer who underwent narrow-margin endoscopic partial laryngectomy were included. All subjects had preoperative and postoperative acoustic evaluation and V-RQOL scores. Subjects were separated into three groups based on age and depth of resection. Group A (mean age, 52 years) consisted of seven subjects who underwent superficial resection (superficial layer of lamina propria) and were younger than 60 years. Group B (mean age, 76 years) consisted of six subjects who were older than 60 years and underwent superficial resection (superficial layer of lamina propria). The four subjects in group C were older than 60 years and underwent deep resection (into the vocal ligament and/or into the thyroarytenoid muscle).

RESULTS

There was a statistically significant improvement in V-RQOL in group A. The acoustic measures did not change after surgery (no P<0.05).

CONCLUSION

For early-stage cancer, patients younger than 60 years and superficial resection of cancer are predictive for better voice.

Post-surgical and oncologic outcomes of frontal anterior laryngectomy with epiglottic reconstruction: a review of 68 cases

OBJECTIVE

To report post-surgical and oncological outcomes of 68 patients treated with frontal anterior laryngectomy with epiglottic reconstruction.

STUDY DESIGN

Demographic data and all information regarding histopathological grade, initial tumor stage and neck status, follow up time, postoperative complications, nasogastric tube removal time, decannulation time and recurrences were collected from the database and follow-up forms.

SETTING

All patients between 1994 and 2014 who were treated with frontal anterior laryngectomy with epiglottic reconstruction for early glottic carcinoma at Ege University Otolaryngology Clinic were included in the study.

SUBJECTS AND METHODS

Sixty-six of the patients were male and 2 were female with a median age of 57.5 years (IQR 53-63.75, range 44-75). Four patients had a tumor stage of T1a, 43 had T1b and 21 had T2. Median nasogastric tube removal time, decannulation time, overall and disease free survival rates were calculated.

RESULTS

Median nasogastric tube removal time was 10 days. Median decannulation time was 12 days. Median N/G tube removal and decannulation times were higher in T2 patients but this did not reach statistical significance (p>0.05). Median follow-up time was 68.5 months (6-222 months). Five year disease free survival was 93.5%. There were 6 oncologic failures which were salvaged with total laryngectomy, neck dissection and adjuvant radiotherapy.

CONCLUSION

According to our results, which is one of the largest reported FAL with epiglottic reconstruction series in the English literature, this procedure's local control and survival rates are high with good functional results.

[Internal and external chordectomy via laryngofissure with the use of CO2 laser]

INTRODUCTION

The aim of this work was to evaluate the therapy results of patients with glottic carcinoma in the T1NoMo advanced clinical stage on internal or external chordectomy via the thyroid cartilage with the use of CO2 laser.

MATERIAL AND METHODS

The study was conducted in 110 patients, including 7 women aged 52-68 and 103 men aged 52-73, who were treated in the Department of Otolaryngology and Laryngological Oncology, Military Medical Academy Teaching Hospital in Lodz, during the years 2010-2012, due to laryngeal carcinoma (T1N0M0).

RESULTS

The studied material was subjected to external chordectomy via laryngofissure in 51 men (46.4%), and internal chordectomy with the use of CO2 laser in 52 men (47.2%) and 7 women (6.4%). In the patients operated via laryngofissure, the following types of external chordectomy were performed: IV - in 25 cases (49.0%), Vc - in 12 cases (23.6%), and Vb and Vd - in 7 cases each (13.7% each). Internal chordectomy was conducted with the use of the following types: III - in 31 cases (52.5%), IV - in 15 cases (25.4%) and Vd - in 13 cases (22.1%). During the post-operative follow-up of 1-3 years, no recurrence of carcinoma was observed.

CONCLUSIONS

The place and size of carcinoma are often dependent on the type of internal and external chordectomy, which is preceded by tracheotomy and is usually dependent on a patient's consent. Too short post-operative follow-up does not allow for the comparison of effective therapies of the two surgical methods.

[Estimation of quality of voice after removal of neoplasms T1 and T2 of glottis with simultaneous reconstruction of vocal fold with pedunculated sterno-thyroid muscle flap]

INTRODUCTION

In recent years there has been an increasing number of cases of cancer, including cancer of the larynx. The choice of treatment should be primarily dictated by the complete elimination of cancer, but from the point of view of the patient, an important factor to keep in mind, is the quality of the voice that will be created at the end of the therapeutic process.

AIM

The aim of this study was to evaluate the voice quality of patients after partial surgery of the larynx with vocal fold reconstruction pedunculated sterno-thyroid muscle flap.

MATERIALS AND METHODS

The study included 30 men aged 53-72 years who were treated at the Clinic of Otorhinolaryngology Department of Medical-Dental Medical University of Warsaw on account of cancer of the larynx, qualified according to the TNM classification T1 or T2. The radical removal of cancer was associated with resection of one vocal fold, laryngeal pouches and ventricular fold. In 15 patients, included to the group I at the end of phase oncology surgery, a reconstruction of "vocal fold" pedunculated sterno-thyroid muscle flap were performed simultaneously. The group II consisted of 15 patients who underwent surgery that removed only the cancerous lesions. Impact assessments arising after surgery of voice disorders on quality of life were made using the self-test failure of the voice (Voice Handicap Index in the Pruszewicz modification). The nature of the created voice was studied using GRBAS scale. All patients performed the laryngostroboscope examination. With "IRIS" program, prepared by a team at Wrocław University of Technology, the voice was recorded, and then was subjected to acoustic analysis. In addition, noise level and the maximum phonation time was measured.

RESULTS

The results indicate that the patients of group I gained a better voice confirming the values of objective acoustic analysis. The assessment made by the scale GRBAS patients who supplemented the resulting loss after tumour removal, with much less hoarseness of voice, did not have the hyperkinesis and there was no puff character. They had the better flow of voice and phonation time of vowels "a" was much longer. The assessment of quality of life of patients in group I made in a test of the VHI was higher than in group II. The laryngostroboscope examination confirmed a good phonatory occlusion and a nearly regular, healthy vocal fold vibration in patients who had received flap of muscle.

CONCLUSIONS

Evaluation of the quality of voice after removing the tumor multiplicity in the glottis with simultaneous reconstruction "vocal fold" has confirmed that this is a very good surgical technique, which allows radically curing cancer for the simultaneous preservation of a good voice. The operation has limited indications for radiotherapy because of the desire to preserve the phonatory function of the larynx, and thus avoids the negative effects of radiation.

Treatment expectations and quality of life outcomes of patients with laryngeal cancer based on different treatment methods

The treatment expectations of patients with laryngeal carcinoma and their quality of life after treatment were evaluated. We enrolled patients who were receiving treatment for epidermoid carcinoma of the larynx between January 2011 and January 2012. Their expectations from the treatment were evaluated using the visual analog scale (VAS) prior to and at the end of the treatment. Quality of life was assessed using the EORTC QLQ C 30 and EORTC H&N 35 questionnaires 3 months after completion of the treatment. In addition, the Beck Depression Inventory was used for mood assessment of the patients after treatment. As per the VAS scores pre-treatment, no differences were found between treatment expectations of early and advanced-stage tumors groups in pre-treatment expectations, but post-treatment evaluation statistically found difference between two groups in terms of average VAS score. Emotional, cognitive, and social functions of the EORTC QLQ C 30 questionnaire were the most affected items in the advanced-stage tumor group. Sense and speech problems in the symptom scales of the EORTC H&N 35 questionnaire were found to be significantly higher in patients with advanced-stage tumors than in those with early stage tumors. The present study is the first to assess the treatment expectations of patients with laryngeal carcinoma by using the VAS. Although the treatment expectations of the patients with early and advanced-stage tumors did not differ according to VAS scores in pre-treatment evaluation, early stage groups had better score than advanced-stage group. VAS was an easy and a simple applicable method for evaluating treatment expectations.

Transoral laser microsurgery for early and moderately advanced laryngeal cancers: outcomes from a single centralised United Kingdom centre

Transoral laser microsurgery (TLM) represents an important treatment for selected laryngeal cancers. Utilisation of TLM, however, is highly variable between United Kingdom (UK) centres, and published data relating to its use in the UK is scarce. We report outcomes from our tertiary referral centre, and highlight lessons learned. Patients undergoing primary TLM for laryngeal cancer with curative intent (2007-2011) were studied retrospectively. Survival analyses were evaluated using the Kaplan-Meier method and log-rank statistics used to examine the influence of several variables. Overall, 170 cases were included-153 glottic and 17 supraglottic. Median follow-up was 39 months (range 14-79 months). Respective 3-year local control (LC), overall survival (OS), disease-specific survival (DSS), and disease-free survival were 92, 92, 98, and 86 % for glottic carcinomas. Three-year LC and OS were both 88 % for supraglottic carcinomas. For glottic cases, a significant impact of pT stage on DSS was observed, and of age on OS. Median hospital stay was one and 19 days for glottic and supraglottic cases respectively, with respective 3-year laryngeal preservation rates of 97 and 94 %, and tracheostomy rates of 0 and 29 %. One patient in the glottic group and four in the supraglottic group failed to regain swallowing function post-operatively, remaining either PEG dependent or undergoing functional total laryngectomy. Our series confirms the oncological and functional efficacy of TLM, offering a unique large-scale UK perspective. Our experience indicates, however, that treatment of larger supraglottic tumours should be considered carefully, as functional outcomes may be compromised.

Role of endolaryngeal surgery (with or without laser) versus radiotherapy in the management of early (T1) glottic cancer: a systematic review

BACKGROUND

Treatment options for early glottic cancer include transoral microsurgery or radiotherapy (RT). There is continuing debate about which is the superior treatment.

METHODS

The literature was searched from 1996 to 2011 using MEDLINE, EMBASE, and Cochrane Library. A quality assessment of each included study was conducted and reported.

RESULTS

There is no evidence in favor of 1 treatment modality when considering likelihood of local control or overall survival. There is a suggestion that RT may be associated with less measureable perturbation of voice as compared to surgery, but no significant differences were seen in patient perception. The likelihood of laryngeal preservation may be higher when surgery can be offered as initial treatment.

CONCLUSION

For patients with early (T1) glottic cancer, treatment options include the equally effective endolaryngeal surgery, with or without laser, or radiation therapy. The choice between treatment modalities should be based on patient and clinician preferences and general medical condition.

Transoral robotic surgery for the treatment of T1-T2 carcinoma of the larynx: preliminary study

OBJECTIVES/HYPOTHESIS

To determine the feasibility and the preliminary oncological results of transoral robotic surgery (TORS) for the treatment of early stage laryngeal tumors.

STUDY DESIGN

Retrospective single center study.

METHODS

We reviewed the medical records of 23 patients who underwent TORS for the treatment of T1 or T2 laryngeal squamous cell carcinoma between August 2009 and March 2012.

RESULTS

Laryngeal tumors were involving the glottis (13 cases) and the supraglottis (10 cases). They were classified T1 N0 in 16 cases, T2 N0 in four cases, and T2 N+ in three cases. The median TORS operative time was 60 minutes (ranging from 30 to 118 minutes). The median hospitalization time was 7.5 days. Histopathological examination of the resected tumors confirmed 14 cases in which the margins were clear, four cases in which the surgical margins were close (less than 1 mm), one case in which the margins were microscopically positive, and in four cases margins status were not able to be recorded. A tracheostomy was carried out for three patients, and 11 patients got a nasogastric feeding tube postoperatively. The local recurrence rate was 8.7% (2/ 23 cases), and in both cases the recurrence occurred in the anterior commissure area only. The overall larynx preservation rate was 95,7% (22/ 23 cases).

CONCLUSION

In this preliminary study, we demonstrated that laryngeal TORS is feasible and may result in oncological results comparable with other treatment strategies, including laser CO2 surgery. This innovative approach needs to be evaluated through randomized multi-institutional trial.

LEVEL OF EVIDENCE

4.

Intra-operative application of confocal endomicroscopy using a rigid endoscope

Objective:

To introduce the application of confocal endomicroscopy during microlaryngoscopy, to enable intra-operative evaluation of human laryngeal epithelium.

Methods:

A rigid endoscope was connected to the scanner head of a Heidelberg Retina Tomograph II confocal laser scanning system via an adapter. The endoscope was gently placed on the surface of a vocal fold through a laryngoscope during microlaryngoscopy.

Results:

The application of confocal endomicroscopy using a rigid endoscope enabled technical improvements (i.e. improved image quality, automatic volume scan, and reduced tissue pressure due to the presence of a perforation plate with central hole at the end of the endoscope) which permitted greater sensitivity and improved handling. Confocal endomicroscopy provided good quality, in vivo, en-face images and enabled an assessment of laryngeal epithelium volume.

Conclusion:

This method enables the surgeon to monitor epithelial changes in pre-malignant lesions. The combination of confocal endomicroscopy together with optical coherence tomography (as a complementary technique that provides optical cross-sections) should be further explored in a formal clinicopathological study.

Evaluation of lasersurgery and radiotherapy as treatment modalities in early stage laryngeal carcinoma: tumour outcome and quality of voice

For treatment of early stage (Tis-T2) laryngeal cancer the main choice is between microlaryngoscopy with carbon dioxide laser resection (laser surgery) and radiotherapy. Because both treatments provide excellent tumour control, secondary outcome variables such, as quality of voice may be of importance in treatment preference. In this study tumour outcomes and quality of voice were analysed for a cohort of patients with early stage (Tis-T2) laryngeal (glottic) carcinoma. The "physical subscale" of the voice handicap index questionnaire (VHI) and a validated five-item screening questionnaire were used. Analysis of 89 patients treated with laser surgery and 159 patients treated with radiotherapy revealed a 5-year local control of 75 and 86 % (p = 0.07). Larynx preservation (5-year) was, however, superior in patients treated with laser surgery, 93 vs 83 % (p < 0.05). Tumour outcomes were also analysed per tumour stage and none were of significant difference. Quality of voice was analysed in 142 patients. VHI scores were 12.4 ± 8.9 for laser surgery and 8.3 ± 7.7 for radiotherapy (p < 0.05), with a higher score reflecting a worse outcome. VHI scores per tumour stage for laser surgery and radiotherapy were, respectively, 12.0 ± 9.9 and 7.9 ± 7.5 in T1a (p = 0.06), 16.7 ± 9.0 and 4.9 ± 6.6 in T1b (p < 0.05). Outcomes of the five-item questionnaire showed voice deficiency in 33 % for laser surgery and 23 % for radiotherapy in T1a (p = 0.330) and 75 and 5 % for T1b (p = 0.001). Oncologic outcomes of laser surgery and radiotherapy were comparable. Larynx preservation is, however, preferable in patients initially treated with laser surgery. According to subjective voice analysis, outcomes were comparable in T1a lesions. Depth of laser resection is of influence on voice deficiency displayed by a significantly higher percentage of voice deficiency in patients treated with laser surgery for T1b lesions.