Radiotherapy of Early-Stage Glottic Cancer: Analysis of Factors Affecting Prognosis

Transoral laser microsurgery for T1 glottic cancer with anterior commissure: Identifying clinical and radiological variables that predict oncological outcome

PURPOSE

The involvement of the anterior commissure (AC) is regarded to be a risk factor for poor results after transoral laser microsurgery (TLM) for early glottic cancer. The objective of this study was to determine how AC-related clinical and radiological factors affected oncological outcomes in a cohort of patients with T1 stage early glottic carcinoma involving the anterior commissure who were treated with TLM with negative surgical margins.

METHODS

Retrospective analysis was performed on clinical, radiological, and follow-up data of patients consecutively treated with TLM at a tertiary academic center between November 2011 and August 2021 for T1 glottic squamous cell carcinoma involving the anterior commissure. Recurrence-free survival (RFS), local control with laser alone (LCL), laryngeal preservation (LP), and overall survival (OS) rates (Kaplan-Meier) were the primary outcome metrics.

RESULTS

In our series, 5-year OS probability was 75.1%, RFS was 64.8%, LCL was 73.8%, and LP was 83.4%. OS and RFS were higher in patients with early stages of AC pattern than in patients with advanced stage (p = 0.004, p = 0.034, respectively). Vertical extension ratio was found to be associated with OS and RFS (p = 0.023, p = 0.001, respectively), and thyroid cartilage interlaminar angle with LCL by multiple Cox regression analysis (p = 0.041).

CONCLUSION

TLM remains a valuable treatment option for AC involvement. AC3 type involvement and elevated vertical extension ratio were associated with negative prognosis. There have been signs that thyroid cartilage with a narrow angle increases recurrence. Alternative modalities should be kept in mind in the treatment decision of these cases.

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.

Oncological and Functional Outcomes for Horizontal Glottectomy: A Systematic Review

Horizontal glottectomy (HG) is a particular type of partial laryngectomy indicated for exclusive glottic tumor with anterior commissure involvement. The purpose of this study is to systematically review the literature about functional and oncological outcome of HG. This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analysis) 2009 guidelines. Articles mentioning patients undergoing HG for laryngeal squamous cell carcinoma were included. A total of 14 articles were selected and reviewed from 19 identified. The whole study population consisted of 420 patients who underwent HG. Three hundred and thirty-nine patients out of 359 were staged as T1. The range of post-operative follow-up was 5 months to 10 years. Fifty-five recurrences were experienced, being local, regional and distant in 35, 12 and 8 patients, respectively. Laryngeal preservation rate was 93.6%. Nasogastrict tube was removed on average after 10.1 days. The tracheostomy was maintained for 11.3 days. Mean hospitalization lasted for 11.7 days. According to the results of this systematic review, HG is an oncologically safe surgical option for T1a–T1b glottic tumors with oncological outcomes comparable to other treatment. HG could be a good therapeutical choice whenever poor laryngeal exposure and/or patient’s refusal of radiotherapy are encountered, or when patient’s medical history represents a contraindication for radiation therapy.

Transoral Robotic Surgery for Early-T Stage Glottic Cancer Involving the Anterior Commissure—News and Update

Background

About 20% of all glottic carcinomas involve the anterior commissure (AC), and AC involvement was deemed to be a risk factor of local recurrence and poor prognosis. Transoral robotic surgery (TORS) has been developed for a panoramic view of the AC and en-bloc resection of the tumor by multidirectional dissection with endo-wristed instruments. With satisfactory preliminary results, we would like to update the data with a bigger cohort and present the news on using TORS for salvage treatment of recurrence from irradiation failure.

Methods

From July 2010 to December 2019, 22 patients with early T1 and 2 stage primary (n = 11) or recurrent (n = 11) glottic cancer with AC involvement received TORS without adjuvant therapy. TORS exposure was found to be better than TLM by conventional laryngoscopy in diagnostic biopsy. Seven of the 22 patients had recurrent cancer from irradiation failure. The perioperative factors that may be associated with survival were retrospectively analyzed, and the 5-year overall survival (OS)/disease-specific survival (DSS)/recurrence-free survival (RFS)/and organ preservation survival (OPS) rate were estimated by the Kaplan–Meier Method. Their voice and swallowing functions were evaluated by questionnaires of Voice Handicap Index-10 (VHI-10) and Functional Outcome Swallowing Scale (FOSS).

Results

All 22 TORSs were completed smoothly. After a mean follow-up of 49 ± 35.9 months, the Kaplan–Meier method estimated 5-year OS/DSS/RFS/OPS was 93.8%, 93.8%, 74.6%, and 86.3%, respectively. Our 11 patients with fresh cancer had 100% recurrence-free survival. Although the recurrent rate was higher in patients with history of RT, they could be rescued by further open laryngectomy without compromising the OS and DSS. Only one patient expired. The other 21 patients had satisfactory swallowing function with FOSS of 0.33 ± 0.66. Five patients depended on tracheostomy, but the rest 17 patients had serviceable voice with VHI-10 of 18.41 ± 11.29.

Conclusions

TORS could be used in the primary or salvage management of glottic cancer with AC involvement while TORS was confirmed to have better exposure to TLM. The RFS was good for patients with primary cancer. In patients having irradiation failure, TORS could also be a minimally invasive transoral approach before trying open surgery to preserve the organ.

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.

The nonsurgical management of early stage (T1/2 N0 M0) laryngeal cancer: A population analysis

BACKGROUND

The purpose of this study was to evaluate the patterns of care and survival in the nonsurgical management of early-stage (T1/2 N0 M0) laryngeal cancer.

STUDY DESIGN

This was a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) database during the period 2004 to 2015. Patients diagnosed with T1/2 N0 M0 laryngeal SCC definitively treated without surgery were included. Study predictors were age, gender, race, marital status, histologic grade, stage, and management strategy defined as radiotherapy (RT), chemotherapy, chemoradiotherapy (CRT), or no treatment. Study outcomes were overall survival (OS) and disease-specific survival (DSS).

RESULTS

In total, 3221 patients comprised the final sample. Over half of the lesions were stage I (63.8%); 74.0%, 24.8%, and 1.2% were located in the glottis, supraglottis, and subglottis, respectively. RT (77.6%) was the preferred nonsurgical treatment modality, followed by CRT (12.7%). A greater proportion of patients with stage II disease (25.1%) received CRT compared with those with stage I (5.6%). Similarly, patients receiving CRT were significantly younger and more likely to present with higher-grade lesions located in the supraglottis and subglottis. In the multivariate model, the risks of both disease-specific and overall death were increased by age, male gender, supraglottic and subglottic location, stage II disease, CRT, and no treatment.

CONCLUSIONS

Definitive RT was the preferred treatment modality regardless of tumor characteristics. CRT was more often selectively reserved for younger patients with higher grade, stage II tumors located in the supraglottis and subglottis. This approach may be driven by the poorer rates of survival associated with these particular characteristics. CRT did not appear to improve survival in comparison with RT after controlling for subsite and disease severity; however, future clinical studies are required to validate this finding.

The prognostic value of anterior commissure involvement in T1 glottic cancer: A systematic review and meta-analysis

OBJECTIVE

The anterior commissure is considered a laryngeal subsite, but it is not taken into account in the current T-staging system. The impact of anterior commissure involvement (ACI) on the oncologic outcomes of T1 glottic tumors has not been well defined and remains controversial. The aim of this study was to assess the influence of ACI in the prognosis of T1 glottic tumors.

METHODS

A systematic review and meta-analysis of observational studies was performed by including studies published up to July 2019. Studies were selected if they had investigated the local control rate (LCR) at 5 years of clinical stage I (T1 and N0) glottic squamous cell carcinoma with and without ACI. The difference in LCR at 5 years between T1 glottic tumors without and with ACI was evaluated.

RESULTS

The meta-analysis showed that the difference in LCR at 5 years between T1 glottic tumors without and with ACI is 12% (95% confidence interval: 8%-16%, p < 0,0001, I² = 34.81%).

CONCLUSIONS

Our study pointed out that the anterior commissure involvement is a negative prognostic factor in LCR at 5 years for T1 glottic tumors. Our results suggest the need to consider ACI in the T staging of glottic tumors. Laryngoscope, 130:1932-1940, 2020.

Survival and Prognostic Factors for Outcome after Radiotherapy for T2 Glottic Carcinoma

Background: Local recurrence after radiotherapy for T2 glottic carcinoma remains an issue and identifying patients at risk for relapse is, therefore, important. This study aimed to assess the oncological outcomes and prognostic factors in a consecutive series of patients treated with radiotherapy for T2N0 glottic carcinoma. Methods: Patients with T2N0 glottic carcinoma treated with radiotherapy were included in this retrospective study. Five- and ten-year local control (LC), overall survival (OS), disease-specific survival (DSS), and laryngeal preservation (LP) rates were calculated with the Kaplan–Meier method. The impact of prognostic variables was evaluated with the log-rank test. Results: Ninety-four patients were included for analysis. LC, OS, DSS, and LP rates were 70.5, 63.7, 86.0, and 74.7%, respectively at five years and 65.8, 41.0, 75.6, and 72.4% at 10 years. In total, 46 scans were included in the analyses. Vertical involvement of the anterior commissure on imaging showed a significant impact on LC. Conclusions: In accordance with previously described surgical risk factors, we identified vertical involvement of the anterior commissure on imaging as a prognostic factor for radiation failure.

Involvement of the Anterior Commissure in Early Glottic Cancer (Tis-T2): A Review of the Literature

Background: The impact of the anterior commissure (AC) involvement on prognosis in laryngeal cancer remains a topic of discussion with inconsistent results in the literature. This review examines AC involvement as a prognostic factor in patients with early glottic cancer (Tis-T2) treated with radiotherapy or transoral laser microsurgery (TLM). Methods: A systematic literature search was performed. Due to the heterogeneity of the data, no meta-analysis was implemented. Weighted averages were calculated if the appropriate data were extractable. Results: Thirty-four studies on radiotherapy and 23 on TLM fit the inclusion criteria. The majority of studies for both radiotherapy (67.7%) and TLM (75.0%) did not report a significant impact on oncological outcomes. Weighted averages were slightly lower in patients with AC involvement. The two studies that applied a more detailed classification showed a significant impact on the amount of AC involvement. Conclusions: Binary variables (yes/no) for AC involvement lead to inconsistent results. Studies that use more detailed classifications of the AC show that there is a significant impact on the outcome. To further elucidate the role of the AC, detailed stratification of tumors involving the AC need to be investigated in further studies for both treatment modalities.

Prognostic factors in patients with T1 glottic cancer treated with radiotherapy

PURPOSE

Presentation of long-term results of radiation treatment in patients with T1 glottic cancer and evaluation of prognostic factors.

METHODS

We performed a retrospective analysis in a group of 569 patients with T1 squamous cell glottic carcinoma treated with radiotherapy at the Center of Oncology in Cracow between 1977 and 2007. In all, 503 (88%) patients presented with T1a stage disease and 66 (12%) with T1b. Anterior commissure infiltration was present in 179 (31%) patients. Average hemoglobin level prior to therapy was 13.9 g/dl. Using the body mass index (BMI), 114 (20%) patients were underweight, and 91 (16%) were overweight. Median time between collecting tumor specimen and beginning of radiotherapy was 56 days (range 14-145 days). Treatment regimen was normofractionated with single fraction ≤2 Gy in 102 (18%) and hypofractionated in 467 (82%) patients.

RESULTS

The 5‑ and 10-year overall survival (OS), disease-specific survival (DSS) and local control (LC) rates were 85 and 68%, 88 and 86%, 89 and 87%, respectively. Multivariate analysis showed that tobacco smoking, low hemoglobin level (<13 g/dl), anterior commissure infiltration, fraction dose ≤2 Gy and time from collecting specimen to beginning of therapy longer than 30 days had negative impact on LC and DSS. Patients' age over 60 years, worse performance status and malnutrition (BMI <18.5) had negative impacts on OS.

CONCLUSIONS

Radiotherapy is a highly effective treatment method in patients with T1N0M0 glottic cancer. LC and DSS may be improved following hypofractionation, smoking cessation, and shortening of waiting-time until start of treatment. OS was mainly influenced by nutritional and performance status.

Oncologic and functional outcomes of patients treated with transoral CO2 laser microsurgery or radiotherapy for T2 glottic carcinoma: a systematic review of the literature

PURPOSE OF REVIEW

To give an overview of the laryngeal preservation and functional outcomes of patients treated with transoral CO2 laser microsurgery (TLM) or radiotherapy for T2 glottic carcinoma. This information supports physicians and patients in treatment counselling and choices.

RECENT FINDINGS

A recent systematic review showed that local control rates at 5-year did not differ between radiotherapy and TLM for T2 glottic tumours. However, there is a lack of comparative data on laryngeal preservation as well as functional outcomes in T2 glottic carcinoma.

SUMMARY

Laryngeal preservation for T2 tumours in this review is higher for patients treated primarily with TLM (88.8 vs. 79.0%). It is important to differentiate between tumours with normal and impaired mobility (T2a and T2b) because the latter showed poorer prognosis for both TLM and radiotherapy. Involvement of the anterior commissure does not result in significantly lower oncological results, if adequately staged and treated. More studies are needed to support these data and to compare the functional outcomes between TLM and radiotherapy for T2 glottic carcinoma.

Supracricoid partial laryngectomy with crico-hyoido-epiglottopexy for glottic carcinoma with anterior commissure involvement

Glottic cancers discovered at an early stage (T1-T2) can be treated with either radiotherapy or surgery. The aim of our study is to analyse survival and functional results of supra-cricoid partial laryngectomy (SCPL) with crico-hyoido-epiglottopexy (CHEP) as surgical treatment for glottic carcinoma with anterior commissure involvement. We performed a retrospective study (1996-2013) which included patients who underwent SCPL-CHEP for glottic squamous cell carcinoma with involvement of the anterior commissure. Before surgery, all patients underwent staging including head, neck and chest CT-scan with contrast injection as well as suspension laryngoscopy under general anaesthesia. A total of 53 patients were included. The median follow-up period was 124 months. Tumour resection was complete in 96.2% of cases. The overall, specific and recurrence-free survival rates at 5 years were, respectively, 93.7%, 95.6% and 87.7%. The average period of hospitalisation was 18 days. The average time elapsed before decannulation and before restoration of oral feeding were 15 and 18 days, respectively. SCPL-CHEP is an important option for laryngeal surgical preservation. It allows adequate disease control as well as good functional results as long as the indications are well respected and the surgical techniques are mastered.

Transoral laser microsurgery versus radiotherapy for T2 glottic squamous cell carcinoma: a systematic review of local control outcomes

BACKGROUND

Systematic reviews comparing treatment of early glottic cancer with transoral surgery or radiotherapy demonstrate similar oncological outcomes. Most studies of 'early-stage' laryngeal cancer include Tis, T1a, T1b and T2 cases. The data are dominated by patients with T1 and Tis tumours, although extrapolating these results and applying them for T2 cases may be inappropriate. No previous systematic reviews have focused on T2 cancers as a separate group.

OBJECTIVE OF REVIEW

This review compares local control outcomes for T2 glottic squamous cell carcinoma, treated with transoral microsurgery or external beam radiotherapy.

TYPE OF REVIEW

This is a systematic review of case series and comparison studies, focusing on oncological outcomes.

SEARCH STRATEGY

Independent searches of MEDLINE, EMBASE and the Cochrane Database were conducted by two authors, using the search terms: laryngeal/glottic/vocal cord combined with carcinoma/cancer/tumour and laser/microsurgery or radiotherapy. Studies of adult patients treated for primary T2N0 glottic squamous cell carcinoma (SCC) with laser surgery or curative radiotherapy were included.

EVALUATION METHOD

Full text of studies satisfying the inclusion criteria were reviewed with extraction of local control and survival data and laryngeal preservation rates. The primary endpoint is local control at 5 years.

RESULTS

Initial searches identified 3252 studies. Following full-text review of 183 papers, 59 studies met the inclusion criteria, all level IV evidence. A total of 48 studies specified 5-year local control for 1156 patients treated with transoral laser surgery and 3191 patients treated with radiotherapy. Weighted averages of local control at 5 years demonstrated similar results: 75.81% for radiotherapy versus 77.26% for transoral laser surgery.

CONCLUSIONS

The results of this review indicate no difference in 5-year local control between radiotherapy and transoral surgery for T2 glottic SCC. The data demonstrated higher rates of local failure for T2b compared with T2a cases, although outcomes were similar between laser excision and radiotherapy for each substage. Further research focusing upon functional outcomes for T2 glottic tumours is imperative to guide decision-making, ideally with subgroup analysis of T2a and T2b cases.

Endoscopic Treatment of cT2 Glottic Carcinoma: Prognostic Impact of Different pT Subcategories

Objectives:

The cT2 glottic squamous cell carcinomas are a heterogeneous group of lesions in terms of superficial and deep extension. As a consequence, they differ greatly in treatment indications and prognosis. The aim of the present study was to divide cT2 glottic tumors into subcategories according to radiologic and postoperative histopathologic information, in order to identify risk factors connected with determinate survival, local-regional control, and laryngeal preservation rates.

Methods:

We retrospectively analyzed 55 cT2 glottic lesions treated at a single institution by carbon dioxide laser with at least 2 years of follow-up. Clinical, radiologic, surgical, and histopathologic data were reviewed, and the tumors were accordingly divided into 5 subcategories: I, or pT2 with lateral supraglottic extension (19 patients); II, or pT2 with lateral subglottic extension (6 patients); III, or pT2 with supracommissural and/or subcommissural extension (10 patients); IV, or pT2 with deep vocal muscle infiltration (14 patients); and V, or pT3, for superior and/or inferior paraglottic space invasion lateral to the thyroarytenoid muscle not detected before operation by computed tomographic scan (6 patients).

Results:

The disease-free survival, ultimate local control with laser alone, and laryngeal preservation rates were compared for each subcategory. Statistically significant differences were found only for the pT3 subgroup (2-year rates of 16.7%, 16.7%, and 16.7% for pT3 versus 5-year rates of 80.5%, 84.7%, and 93.3% for the entire pT2 group).

Conclusions:

Endoscopic treatment of cT2 glottic tumors can be considered effective when the pT2 stage has been confirmed. In cT2/pT3 patients, after the first endoscopic resection that allows the correct pT staging, additional treatment should always be considered.

Tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers: a critical appraisal

Objective:

The tumour–node–metastasis staging system has a dynamic structure that is continuously being updated as scientific data develops. This review discusses some suggested revisions on tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers.

Methods:

The seventh edition of The American Joint Committee on Cancer Staging Manual was reviewed and important issues that could be considered for revision were identified and discussed.

Results:

According to our assessment of the oncological outcomes of previous studies, the following factors should be considered for revision: anterior commissure involvement and subglottic extension in laryngeal cancers; underlying bone involvement in hard palate and upper alveolar ridge cancers; tumour thickness in oral cancers; and extracapsular spread and carotid artery involvement in neck metastases.

Conclusion:

Sufficient data on the prognostic importance of these issues have been reported. Suggested revisions in line with current knowledge on the clinical behaviour of upper aerodigestive tract cancers would improve the relevancy of staging.

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

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

Comparison among different available surgical approaches in T1 glottic cancer

OBJECTIVES/HYPOTHESIS

This study aims to assess the oncologic results of open and transoral surgical techniques in T1a and T1b category glottic carcinomas.

STUDY DESIGN

Retrospective clinical study.

METHODS

The files of 438 T1a and T1b glottic cancer cases managed with primary surgery were reviewed. Transoral laser surgery and open surgical procedures used to treat these cases, including cordectomy, vertical partial laryngectomy, and frontolateral partial laryngectomy, were compared for disease specific survival and local control rates. In addition, all techniques were compared for incidence of major complications and related tracheotomies.

RESULTS

No statistically significant differences were noted between laser surgery and open procedures with regard to disease specific survival and local control for both T1a and T1b cases. Laser surgery showed a significantly lower incidence of complications and tracheotomies.

CONCLUSIONS

Laser surgery appears to be a very effective management modality for T1 glottic cancer with comparable results to open procedures and a lower incidence of complications. A transcervical approach should be reserved only for selected cases where individual anatomic factors do not permit complete tumor exposure during diagnostic microlaryngoscopy.

[Risk of distant metastases after postoperative radiation therapy for locally advanced laryngeal cancer]

PURPOSE

To evaluate the prognostic factors for the risk of distant metastases after postoperative radiotherapy for laryngeal cancer.

MATERIAL AND METHODS

Medical records of 267 patients cancer treated between 1997 and 2003 were analyzed. All pts had locally advanced squamous cell laryngeal cancer treated with surgery and postoperative radiotherapy. Metastasis Free Survival was analyzed using Kaplan-Meier method. A multivariate Cox proportional hazard model and logistic regression model was used to evaluated influence of the following variables on MFS and the ultimate risk of metastases: age, sex, localization, TN stage, HGB before and at the end radiotherapy, total radiation dose, dose per fraction, overall treatment time, interval surgery-radiation time, pathological margins and positive nodes in surgical specimen.

RESULTS

The crude incidence of distant metastases was 12% (33/267 pts). One year, 3-year, 5-year actuarial metastases free survival were 95%, 85% and 84% respectively. The lungs and bones were the most common sites of metastases (58% and 33% respectively), whereas metastases to liver (6%) and brain (3%) were rare. Localization of cancer (glottic vs. supraglottic) and number of positive lymph nodes at pathological staging significantly and independently affected MFS.

CONCLUSIONS

Number of positive lymph nodes in pathological specimen and site of primary cancer (glottic vs. supraglottic) significantly and independently predict a risk of distant metastases in combined modality treatment for laryngeal cancer.

[Prospective factors of T1 and T2 glottic carcinoma]

The aim of our study was to estimate the probability of the neoplasm recurrence in patients with T1 and T2 glottic carcinoma operated with CO2 laser microsurgery. We analyzed the material of 171 patients treated in the Otolaryngology Department of the Collegium Medicum Nicolaus Copernicus University between 1991 and 2003. The statistical method of logistic regression was used to estimate factors disposing the local recurrence of laryngeal cancer. We studied: age, sex, extent and location of the lesion, time up to recurrence, carbon granuloma, smoking cigarettes before and after the operation. We confirmed statistically significant correlation between the local recurrence and anterior commissure involvement.

Histologic characteristics and tumor spread of recurrent glottic carcinoma: analysis on whole-organ sections and comparison with tumor spread of primary glottic carcinomas

BACKGROUND

The assessment of the precise tumor extent of recurrent glottic carcinomas is a challenge.

METHODS

The histologic characteristics of 29 recurrent glottic carcinomas after radiation failures, initially classified as T1 and T2, were analyzed on whole-organ slices. The growth patterns of 21 recurrent prT3 and prT4 and 52 primary pT3 and pT4 carcinomas were compared.

RESULTS

Fifteen of 29 (52%) recurrent carcinomas were under-staged by imaging studies and endoscopy. Most recurrent carcinomas presented with multicentric tumor foci, whereas most primary carcinomas with a concentric tumor growth pattern (p < .05). Undifferentiated dissociated tumor cells were observed more often in the vicinity of recurrent tumor foci than of the primary tumor mass (p < .05).

CONCLUSION

Recurrent glottic carcinomas are often under-staged and present with multiple tumor foci dispersed in different regions of the larynx. If voice-preserving salvage surgery is considered as a treatment option, these facts should be kept in mind.

Primary treatment of the anterior vocal commissure squamous carcinoma

Squamous cell carcinoma may involve the anterior commissure (AC) area of the laryngeal glottis, and can be grouped morphologically into four groups; (1) tumor confined to the AC, (2) tumor involving one cord and the AC, (3) tumor involving the AC and a portion of both vocal cords, and (4) tumor involving a greater part of one cord and crossing over to involve a variable length of the other cord. Some of these patients when evaluated by imaging, either CT and/or MRI, may demonstrate thyroid cartilage erosion or involvement, thereby upstaging a T1a, T1b into a T3 or a T4 glottic cancer. The majority of patients treated by radiotherapy have only been staged clinically, and hence a failure or recurrence rate of 15%. In patients treated surgically by endoscopic or external surgery, the local recurrence rates are similar at 15%. Therefore, future reporting of patients treated with AC involvement should be staged radiologically, to include CT or MRI, and documentation of the treatment results be reported in subgroups, according to whether there is no cartilage involvement, inner-table cartilage erosion, or through-and-through cartilage invasion. Should endoscopic cordectomy be used, then the type of surgery performed should be based on the classification as suggested by the European Laryngological Society. The use of the above recommendations would allow for more meaningful results to be reported and for cause specific analysis of failure of treatment techniques applied.

The management of early laryngeal cancer: options for patients and therapists

PURPOSE OF REVIEW

To evaluate the optimal treatment of early laryngeal cancer and to highlight new developments.

RECENT FINDINGS

The use of hyperfractionation and acceleration of radiotherapy may result in improved outcomes for patients with respect to cancer cure and preservation of the larynx. Options for surgical treatment include endoscopic resection and open partial laryngectomy. The use of endoscopic vertical partial laryngectomy may overcome the difficulties encountered in exposure with transoral laser resection of anterior commissure tumors. The microdebrider may be a useful alternative to CO(2) laser in endoscopic resection in selected cases. A further treatment option that shows promising results is photodynamic therapy, which has some important advantages over the other treatment modalities. Further larger studies are needed to assess the efficacy of these treatment modalities to ascertain the treatment modality of choice.

SUMMARY

Different treatment modalities are available for early laryngeal cancer. The treatment choice should take into account the likely post-treatment morbidity, quality of life, patient preference, and voice quality. The cost of treatment, not only to the treating institution but also to the patient and those involved in the patient's care at home, is also an important issue. Well-designed randomized multicenter controlled trials are now necessary to influence patients' and clinicians' decision in the choice of the most effective and predictable treatment plan.

Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience

On the basis of an inception cohort of 270 patients with a previously untreated invasive squamous cell carcinoma of the true vocal cord (232 T N0M0, 35 T2N0M0, and 3 T3N0M0) and a minimum of 3 years of follow-up, the authors analyze the oncological and functional outcomes following frontolateral vertical partial laryngectomy without tracheotomy. The 5-year Kaplan-Meier actuarial survival estimate ranged from 83.1% for T1 tumors to 67.2% for T2 tumors (p = .005). On univariate analysis, a significant statistical relationship was noted between reduced survival and the following variables: increased age, increased Charlson comorbidity index score over grade 0, increased tobacco intake, increased alcohol intake, increased T stage, local failure, nodal failure, and development of a metachronous second primary cancer. The hospital mortality rate was 0.4%. A significant postoperative surgical complication was noted in 49 patients (18.1%). The predominant significant surgical complication was wound infection (19 patients; 7%), followed by seroma and major subcutaneous emphysema. No significant statistical relationship was noted in a comparison of each, significant postoperative complication (including postoperative death) with the variables under analysis. The incidence of secondary tracheotomy was 0.4%. The incidence of completion laryngectomy due to functional problems was 0%. The 5-year Kaplan-Meier actuarial local control estimate was 91% for T1 tumors and 68.7% for T2 tumors (p <.0001). Within the T1 tumors, the 5-year Kaplan-Meier actuarial local control estimate ranged from 96.2% for tumors without anterior commissure involvement to 74.7% for tumors with anterior commissure involvement (p = .0002). On univariate analysis, a significant statistical relationship was noted between an increase in local recurrence and the following variables: increased T stage, anterior commissure involvement, and pathological margin involvement. The overall disease control rate and laryngeal preservation rate were 92.9% and 93.3%, respectively.