Endoscopic Supraglottic Laryngectomy with Postoperative Irradiation

An Observational Cohort Study on 194 Supraglottic Cancer Patients: Implications for Laser Surgery and Adjuvant Treatment

Supraglottic laryngeal cancer is characterized by poor prognosis. In contrast, excellent outcomes have been published in early-stage supraglottic cancers after laser surgery in single-institutional series in centers of excellence. Are these results reproducible in the normal clinical practice of less specialized facilities? As part of an observational cohort study, the outcomes of 194 supraglottic cancer patients were assessed after treatment by larynx-preserving surgery (transoral laser microsurgery [TLM] or open partial laryngectomy [OPL]) or total laryngectomy (TL), with each having risk-adopted adjuvant treatment, or primary (chemo-)radiotherapy (pCRT or pRT). In early-stage supraglottic cancers, TLM achieved a 5-year overall survival (5-year OS) of 62.0%. No significant survival difference could be discerned between patients with and without adjuvant treatment (HR 1.47; 95% CI: 0.80 2.69). The comparison between pCRT and pRT patients suggests that CRT is more effective in supraglottic cancer. The 5-year OS rate achieved in our multiinstitutional setting is comparable to that reached in laser surgery centers of excellence (59.4-76.0%). According to our data and supported by the literature, adjuvant RT (aRT) is not sufficiently effective in supraglottic cancers. In case adjuvant therapy is indicated, adjuvant chemoradiation (aCRT) could be recommended.

The Treatment of Laryngeal Cancer

Successful management of laryngeal cancer depends on careful pretreatment evaluation of patient and disease factors to arrive at accurate staging, leading to appropriate treatment selection for patients with this highly impacting disease. Surgical modalities, including transoral laser microsurgery, open partial laryngectomy, and total laryngectomy, offer options, alone or in combination with radiation and chemotherapy. Treatment strategy for laryngeal cancer should strive for cure while maintaining the best quality of life possible for the patient. Achieving the goals of initial and salvage treatment for laryngeal cancer depends on executing a plan of care determined by the expertise of the multidisciplinary team.

Functional outcomes in early (T1/T2) supraglottic cancer: a systematic review

OBJECTIVES

Organ preserving surgery (OPS) and radiotherapy (RT) are both accepted treatment options for early stage supraglottic cancer (SGC). Radiation has supplanted surgery in most cases, because of the perception that surgery results in poorer functional outcomes. However, evidence suggests that OPS with a neck dissection may be associated with improved survival. Our objective was to conduct a systematic review of the literature to compare functional outcomes of OPS and RT for early SGC.

METHODS

We searched Medline, EMBASE and Cochrane Central Register of Controlled Trials to identify studies. Studies were included if they reported functional outcomes on 10 or more patients with early stage SGC treated with radiation or OPS, including open partial laryngectomy, transoral laser microsurgery (TLM) or transoral robotic surgery (TORS). Two reviewers independently screened articles for relevance using pre-determined criteria.

RESULTS

From 7720 references, we included 10 articles (n = 640 patients). 50% (n = 320) of patients were treated with surgery. Three head-to-head RT versus OPS papers were included, however different outcome measures were used for each group. Intractable aspiration management (including total laryngectomy or permanent tracheostomy) following OPS was reported in five papers representing 186 patients; the definitive intractable aspiration management rate was 2.6% (95% CI 1.0-6.8%). Four papers reported permanent G-tube rate for the surgical group (n = 198), calculating a rate of 5.3% (95% CI 2.6-10.5%), this was not reported for the RT group in any papers. One study reported quality of life. Two studies reported objective voice measures.

CONCLUSIONS

This systematic review revealed a paucity of objective measures and significant data heterogeneity, rendering the comparison of functional outcomes following OPS versus RT for early SGC limited. Future research should include objective measures of functional outcomes including laryngectomy rate, g-tube rate, tracheostomy dependence, quality of life, and voice quality measures.

Treatment of early stage Supraglottic squamous cell carcinoma: meta-analysis comparing primary surgery versus primary radiotherapy

Objectives

For early stage supraglottic squamous cell carcinoma (SCC), single modality treatment either in the form of primary organ preservation surgery alone or radiation alone is recommended. Thus, a definite treatment strategy for early stage supraglottic SCC remains undefined. The primary objective of this study was to conduct a systematic review and meta-analysis comparing the oncologic outcomes of surgery and radiotherapy in early stage (Stage I and II) T1 N0 and T2 N0 supraglottic SCC.

Methods

Systematic methods were used to identify published and unpublished data. Two reviewers independently screened all titles, abstracts and articles for relevance using predefined criteria. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Five studies met the inclusion criteria for disease specific mortality with a total of 2864 pooled patients. 5-year disease specific mortality was lower in the surgery group (ORs 0.43, 95% CI 0.31–0.60). Four studies met the inclusion criteria for 5-year overall mortality with a total of 2790 pooled patients. Five-year overall mortality was lower in surgery group (ORs 0.40, 95% CI 0.29–0.55).

Conclusions

This is the first study to examine the management of early stage supraglottic SCC using meta-analytic methodology. Our results suggest that primary surgery may result in decreased disease specific and overall mortality compared to primary radiotherapy.

What is the price of functional surgical organ preservation in local-regionally advanced supraglottic cancer? Long-term outcome for partial laryngectomy followed by radiotherapy in 32 patients

Aims and background

To achieve the goal of organ preservation, both a chemoradiotherapy and a conservative surgical approach can be proposed. The aim of the study was to review all patients treated in our Institute with conservative surgery and postoperative radiotherapy for locally advanced supraglottic tumor.

Methods and study design

A retrospective analysis of 32 patients treated between 2000 and 2010 was performed. Overall survival, disease-free survival and late laryngeal toxicity were evaluated. The impact of surgical procedures, radiotherapy characteristics and addition of chemotherapy on late laryngeal toxicity was studied.

Results

The median follow-up was 38 months. Overall survival and disease-free survival at 5 years were 73% and 66%, respectively. Three (9%) patients experienced local recurrence (after 22, 25 and 40 months, respectively) and were treated with total laryngectomy. The larynx preservation rate was 93%. Severe treatment-related late laryngeal toxicity (grade 3 and 4 laryngeal edema, laryngeal stenosis, presence of tracheotomy at last follow-up because of treatment-related toxicity, and the need for enteral nutrition) was experienced by 34% of patients. The functional larynx preservation rate was 81%. The statistically significant risk factors for severe late toxicity were: female gender, extension of the surgical procedure, removal of one arytenoid and association with concomitant chemotherapy.

Conclusions

We confirmed literature data on the feasibility and efficacy of a surgical organ preservation strategy. However, the high incidence of severe late toxicity requires further studies to improve patient selection and to reduce side effects.

Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Purpose To update the guideline recommendations on the use of larynx-preservation strategies in the treatment of laryngeal cancer. Methods An Expert Panel updated the systematic review of the literature for the period from January 2005 to May 2017. Results The panel confirmed that the use of a larynx-preservation approach for appropriately selected patients does not compromise survival. No larynx-preservation approach offered a survival advantage compared with total laryngectomy and adjuvant therapy as indicated. Changes were supported for the use of endoscopic surgical resection in patients with limited disease (T1, T2) and for initial total laryngectomy in patients with T4a disease or with severe pretreatment laryngeal dysfunction. New recommendations for positron emission tomography imaging for the evaluation of regional nodes after treatment and best measures for evaluating voice and swallowing function were added. Recommendations Patients with T1, T2 laryngeal cancer should be treated initially with intent to preserve the larynx by using endoscopic resection or radiation therapy, with either leading to similar outcomes. For patients with locally advanced (T3, T4) disease, organ-preservation surgery, combined chemotherapy and radiation, or radiation alone offer the potential for larynx preservation without compromising overall survival. For selected patients with extensive T3 or large T4a lesions and/or poor pretreatment laryngeal function, better survival rates and quality of life may be achieved with total laryngectomy. Patients with clinically involved regional cervical nodes (N+) who have a complete clinical and radiologic imaging response after chemoradiation do not require elective neck dissection. All patients should undergo a pretreatment baseline assessment of voice and swallowing function and receive counseling with regard to the potential impact of treatment options on voice, swallowing, and quality of life. Additional information is available at www.asco.org/head-neck-cancer-guidelines and www.asco.org/guidelineswiki .

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.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

Oncological and survival outcomes following transoral robotic surgery versus transoral laser microsurgery for the treatment of oropharyngeal squamous cell carcinoma: a systematic review protocol

OBJECTIVE/REVIEW QUESTIONS

The objective of this systematic review is to synthesize the best available evidence regarding the oncological and survival outcomes (as measured by disease control, disease-free survival, disease-specific survival and overall survival) of transoral robotic surgery (TORS) versus transoral laser microsurgery (TLM) in the treatment of oropharyngeal squamous cell carcinoma in adults (aged 18 years or older). Specifically the review questions are:1 Is there a difference in oncological outcomes between a traditional "Halstedian" en bloc tumor resection technique used in TORS versus a modern segmental tumor dissection technique used in TLM?2 Does one surgical approach confer better oncological outcomes with respect to a particular patient subgroup, such as patients with a positive human papilloma virus status or patient's with different tumor T-stages?

Comparison of Functional Outcomes after Endoscopic versus Open-Neck Supraglottic Laryngectomies

Objectives:

Endoscopic supraglottic laryngectomy (ESL) by carbon dioxide laser for selected T1-T3 supraglottic squamous cell carcinomas is a sound procedure with oncological results comparable to those obtained by open-neck supraglottic laryngectomy (ONSL). The aim of this study was to retrospectively evaluate functional outcomes after ESL in comparison with ONSL.

Methods:

We performed perceptual voice evaluation by GRBAS (grade, roughness, breathiness, asthenicity, strain), subjective analysis by Voice Handicap Index, objective analysis with the Multidimensional Voice Program, swallowing evaluation with the M. D. Anderson Dysphagia Inventory, video nasal endoscopic examination of swallowing, videofluoroscopy, and analysis of hospitalization time, need for and duration of feeding tube and tracheotomy, and complication and aspiration pneumonia rates in a group of 14 patients treated with ESL. These results were compared to those obtained in a historical group of 14 patients matched for T category who were treated with ONSL at the same institution. Statistical analysis was performed with the Mann-Whitney U and Pearson χ2 tests.

Results:

Comparison of comprehensive voice analysis, M. D. Anderson Dysphagia Inventory, and complication and aspiration rates showed no statistically significant differences between the Two groups. However, significant differences were found for video nasal endoscopic examination of swallowing (p = .03), videofluoroscopy (p = .03), hospitalization (p = .0001), feeding tube duration (p = .0001), and tracheotomy duration (p = .0001).

Conclusions:

Endoscopic supraglottic laryngectomy had a significantly lower functional impact on swallowing than ONSL, even though it was not subjectively perceived by patients, and was associated with less morbidity and a shorter hospitalization time.

Transoral laser microsurgery for carcinoma of the supraglottic larynx

Objectives

The study goal was to report the oncologic outcomes of transoral laser microsurgery (TLM) in the treatment of squamous cell carcinoma of the supraglottic larynx.

Study Design and Setting

A two-center prospective case series analysis.

Results

Thirty-eight patients underwent TLM for previously untreated carcinoma of the supraglottic larynx between 1997 and 2005. Pathological T stages were T1 in 8 (21%), T2 in 14 (37%), T3 in 8 (21%), and T4 in 8 (21%). Twenty-six patients (68%) had neck dissections. Thirteen patients (34%) received adjuvant radiotherapy. The mean follow-up for all patients was 31 months. The 2-year Kaplan-Meier estimates for local control were 97%; locore-gional control, 94%; disease-specific survival, 80%; and overall survival, 85%. The overall functional laryngeal preservation rate was 79% (19 of 24).

Conclusions

TLM is a safe and effective treatment for cancer of the supraglottic larynx

Significance

TLM is an emerging strategy in the management of laryngeal cancer. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Transoral Endoscopic Head and Neck Surgery: The Contemporary Treatment of Head and Neck Cancer

Traditional open surgical approaches are indicated for treatment of select tumor subsites of head and neck cancer, but can also result in major cosmetic and functional morbidity. Transoral surgical approaches have been used for head and neck cancer since the 1960s, with their application continuing to evolve with the changing landscape of this disease and recent innovations in surgical instrumentation. The potential to further reduce treatment morbidity with transoral surgery, while optimizing oncologic outcomes, continues to be investigated. This review examines current literature evaluating oncologic and quality-of-life outcomes achieved through transoral head and neck surgery.

Laryngeal cancer

PURPOSE OF REVIEW

Treatment of laryngeal carcinoma continues to evolve, and whereas there was a transition from total laryngectomy to chemoradiation in response to the Veterans Affairs study and Radiation Therapy Oncology Group (RTOG) 91-11, recent data suggest the role of partial laryngectomy must be revisited.

RECENT FINDINGS

Recent data have shown that laryngeal preservation does not equate with laryngeal function. Data are accumulating in support of operative management of advanced laryngeal carcinoma away from chemoradiation for select patients. In particular, supracricoid laryngectomy may be a viable option for intermediate and selected advanced laryngeal carcinoma while maintaining laryngeal function.

SUMMARY

The evolution of treatment for advanced laryngeal carcinoma is focusing treatment on maintaining locoregional control while also maintaining a functional larynx.

Management of advanced laryngeal cancer

Squamous cell carcinoma of the larynx continues to be the commonest head and neck cancer in many Western countries. The larynx plays a key role for many essential functions, including breathing, voice production, airway protection, and swallowing. The goals of laryngeal cancer treatment are thus to provide best possible oncologic control, while optimizing functional outcomes. In recent decades, the treatment paradigm for advanced laryngeal cancer has shifted from one of primary surgery (total laryngectomy) as gold standard, toward non-surgical organ-preserving treatment using radiotherapy or chemoradiotherapy. However, concerns have emerged regarding functional outcomes after chemoradiotherapy, as well as possible decreased overall survival in patients with laryngeal cancer. The purpose of the present review is to review surgical and non-surgical options for treatment of advanced laryngeal cancer, as well as the evidence supporting each of these.

Results of transoral laser microsurgery for supraglottic carcinoma in 277 patients

The objective of the study was to evaluate the oncological and functional results of transoral laser microsurgery (TLM) in patients with supraglottic laryngeal squamous cell carcinoma. Between June 1980 and December 2006, 277 patients with squamous cell supraglottic carcinoma of all stages were treated by primary carbon dioxide laser microsurgery. All treatments were performed with curative intention. The goal was the complete tumor removal with preservation of functionally important structures of the larynx. The administered treatment was exclusively TLM with or without selective or modified radical neck dissection in 215 cases (78 %); TLM with postoperative radiotherapy was performed in 62 cases (22 %). Data were analyzed using the Kaplan–Meier method. The median follow-up was 65 months. We achieved a 5-year local control rate of 85 % for pT1/pT2, 82 % for pT3, and 76 % for pT4. The 5-year overall, recurrence-free and disease-specific survival rates for stages I and II were 76, 81, and 92 %, for stages III and IVa 59, 65, and 81 %, respectively. With respect to local control and survival, these results are comparable with the results achieved by conventional partial and total resection of the larynx, while being superior to primary (chemo)radiotherapy. Transoral laser microsurgery results in a low morbidity, rapid recovery, and superior function compared with standard therapy.

Outcomes following transoral robotic surgery: supraglottic laryngectomy

OBJECTIVES/HYPOTHESIS

To describe a single center outcomes following transoral robotic surgery for supraglottic laryngectomy (TORS-SL).

STUDY DESIGN

Prospective data collection.

METHODS

Patient records receiving TORS-SL for squamous cell carcinoma (SCCA) with at least 12 months follow-up fit inclusion for this study. Two patients with previous SCCA were excluded.

RESULTS

18 patients (14 male, 4 female) were included in the study, having a mean follow-up time of 28.1 months (SD = 12.1). All patients had negative margins confirmed on final pathology. Nine (50%) patients received postoperative chemoradiation therapy for advanced neck disease. No (0%) patients received tracheostomy or gastrostomy tubes. There were no (0%) local recurrences, and three (16.7%) regional recurrences. Five (27.8%) patients experienced temporary postoperative complications. Overall 2-year outcomes reached 83%, 100%, and 89% for locoregional control, disease-specific survival, and overall survival respectively.

CONCLUSIONS

Initial outcomes for TORS-SL are encouraging and are comparable to previously described treatment modalities. Larger studies are encouraged.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Swing of the pendulum: optimizing functional outcomes in larynx cancer

For years, total laryngectomy was the only treatment option for patients with intermediate to advanced laryngeal cancer. Over the past two decades, great progress has been made in the management of this disease, with multimodality approaches aimed at laryngeal preservation reshaping the treatment landscape. In the era of chemoradiation, greater focus and attention are now directed toward functional laryngeal preservation--not simply "organ preservation." The continued development and integration of new treatment approaches, including organ preservation surgery (eg, transoral minimally invasive surgery of the head and neck, supracricoid partial laryngectomy), intensity-modulated radiotherapy, and targeted molecular therapies, offer the potential to improve clinical outcomes, function, and quality of life. Incorporation of these new approaches advances the concept of personalized medicine, with treatment strategies tailored to the circumstances and future of each patient.

The role of laser microsurgery in the treatment of laryngeal cancer

PURPOSE OF REVIEW

Transoral laser microsurgery has developed in recent years into a surgical method that combines a minimally invasive approach with the surgical precision of laser and microscope. The outcomes of laser microsurgical treatment of laryngeal carcinomas are reviewed and compared with the results of competitive standard procedures.

RECENT FINDINGS

Laser microsurgery is widely acknowledged to have advantages in the treatment of early glottic carcinoma. In the treatment of glottic carcinoma causing impaired mobility or fixation of the vocal cord the role of laser surgery has not yet been definitively assessed. Based on published results, primary laser therapy can achieve local tumor control with a functional residual larynx in approximately 70-80% of cases. In patients with early or moderately advanced supraglottic carcinoma, laser microsurgery is comparable to open supraglottic laryngectomy in terms of local control and survival. With regard to organ preservation, laser microsurgery is comparable to open supraglottic laryngectomy but superior to radiotherapy. Microsurgery can preserve functionally important structures, allowing for early swallowing rehabilitation while avoiding tracheotomy.

SUMMARY

This review elucidates the role of laser microsurgical partial resections of the larynx in comparison with other treatment modalities.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

Purpose

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials.

Methods

A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors.

Results

Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated.

Recommendations

All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Extended and standard supraglottic laryngectomies: a review of 110 patients

The purpose of this study was to compare functional and oncological results of extended and standard supraglottic laryngectomies. One hundred ten patients with supraglottic carcinoma were treated. A standard supraglottic laryngectomy (SSL), a laterally extended supraglottic laryngectomy (LESL) and an anteriorly extended supraglottic laryngectomy (AESL) were performed on 32, 47 and 31 patients, respectively. Indications for postoperative radiotherapy included positive surgical margins (23% of patients) and/or node metastasis (63% of patients). Local recurrence occurred in 13% of SSL, 15% of LESL and 17% of AESL patients. Pulmonary complications due to aspiration were observed in 6% of SSL, 15% of LESL and 19% of AESL. The overall 5-year cure rates were 63% for SSL, 45% for LESL and 47% for the AESL procedures. Extended supraglottic laryngectomies provided as good a local tumor control as SSL. Extension to the hypopharynx (LESL) and to the vallecula (AESL) showed more frequent pulmonary complications and reduced cure rates.

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.

Advanced laryngeal carcinoma: surgical and non-surgical management options

This article discusses the surgical and non-surgical management of advanced laryngeal cancers.