Treatment Preferences in Patients With Early Glottic Cancer

Use of the 445-nm Blue Laser for Management of Early Glottic Carcinoma: Preliminary 1-Year Results

OBJECTIVE

To analyze oncological efficacy and voice outcomes of the 445-nm blue laser (BL) in the treatment of early glottic carcinoma and compare results with the 532-nm potassium-titanyl-phosphate (KTP) laser.

STUDY DESIGN

Single institution, retrospective chart review.

METHODS

All patients who underwent microlaryngoscopic KTP or BL laser excision of early glottic carcinoma from 2018 to the present day with at least 1-year follow-up were included. Primary and recurrent disease, including radiation and surgical failures, were included. Demographic data, voice outcomes and oncologic outcomes were compared between the two laser groups.

RESULTS

Forty-nine patients met the inclusion criteria for the BL group and 88 for the KTP group, with average follow-up of 635 and 1236 days, respectively. Oncologic outcomes were not significantly different, with disease-specific survival rates of 95.9% for BL and 100% for KTP (p = 0.13), organ preservation rates of 98.0% for BL and 95.6% for KTP (p = 0.39), and local control rates of 93.9% for BL and 92.1% for KTP (p = 0.81). Both BL and KTP groups showed significant improvement in CAPE-V (p = 0.04, 0.006 respectively) and VHI-10 scores (p = 0.003, <0.00001) following surgery.

CONCLUSIONS

Photoangiolytic removal of early glottic carcinoma with BL appears to be equally safe and effective as with KTP laser at minimum one-year follow-up, and with excellent voice outcomes. Additional study will be warranted over time to assess long-term outcomes in BL patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:4656-4660, 2024.

Patterns of Care for T1 Glottic Squamous Cell Carcinomas from 2004-2020

OBJECTIVE(S)

Describe recent national trends in overall treatment modalities for T1 glottic squamous cell carcinomas (SCC), and identify factors associated with treatment regimens.

METHODS

National Cancer Database from 2004-2020 was queried for all patients with glottic cT1N0M0 SCC. Treatment patterns over time were analyzed using the Cochran-Armitage test for trend. Multivariable logistic regressions were used to determine the factors associated with treatment regimens.

RESULTS

Of the 22,414 patients identified, most patients received RT only (57%), 21% received surgery only, and 22% received dual-modality treatment ("over-treatment"). Over the time period, there was a decreasing trend in rates of over-treatment for T1 glottic SCC (p < 0.001) and an increasing trend in surgery only (p < 0.001). Treatment in 2016-2018 (OR: 1.168 [1.004 to 1.359]), 2013-2015 (OR: 1.419 [1.221 to 1.648]), 2010-2012 (OR: 1.611 [1.388 to 1.871]), 2007-2009 (OR: 1.682 [1.450 to 1.951]), or 2004-2006 (OR: 1.795 [1.548 to 2.081]) versus 2019-2020 was associated with greater likelihood of over-treatment. T1b tumors were less likely to be over-treated (OR: 0.795 [0.707 to 0.894]) versus T1a tumors, and less likely to receive surgery first (OR: 0.536 [0.485 to 0.592]) versus T1a tumors.

CONCLUSION

Over-treatment for T1 glottic SCC has been declining, with increasing rates of surgery only. Year of treatment was significantly associated with the receipt of dual-modality treatment. Finally, patients with T1b disease were more likely to receive RT as the first and only treatment.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3633-3644, 2024.

Factors Impacting Provider Treatment Decision-Making in Early Glottic Cancer

OBJECTIVES

Transoral laser microsurgery (TLMS) and radiotherapy (XRT) are mainstays of treatment for early glottic carcinoma (EGC). Here, we investigated case-dependent provider treatment preferences and identify factors which impact decision-making in EGC.

METHODS

This cross-sectional survey of laryngologists, head-and-neck surgeons, and radiation oncologists presented five diagrammatic cases of progressively advanced EGC (T1/2, N0). Respondents indicated preference for TLMS or XRT and ranked factors which influenced their recommendation for each case. Analysis utilized descriptive statistics, Fischer's exact tests, and Kruskal-Wallis tests for nonparametric data.

RESULTS

A total of 141 complete responses (69.5% laryngologists) were received. Most respondents practiced in academic settings (93.5%) and within multidisciplinary teams (94.0%). Anterior commissure involvement was the most important a priori tumor factor for case-independent treatment recommendation (Likert Scale: 4.22/5), followed by Laterality (Likert Scale: 4.02/5). Across all specialties, TLMS was recommended for unilateral T1a lesions. Laryngologists continued recommending TLMS in T2 lesions (41.0%) more than head-and-neck surgeons (5.0%) and radiation oncologists (0.0%). Across all cases, survival and voice outcomes were the most important clinical factors impacting treatment decisions. Radiation oncologists weighed voice more heavily than laryngologists in more complex presentations of EGC (rank: 1.6 vs. 2.7, Kruskall-Wallis: p < 0.05).

CONCLUSIONS

In more complex clinical presentations of EGC, preference for TLMS compared to XRT differed across specialists, despite similar rankings of factors driving these treatment recommendations. This may be driven by differing experiences and viewpoints on case-dependent voice outcomes following TLMS versus XRT, suggesting a need for increased understanding of how tumor location and depth impact voice outcomes.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:3686-3694, 2024.

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

OBJECTIVE

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

STUDY DESIGN

Longitudinal cohort study.

SETTING

Tertiary cancer center.

METHODS

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

RESULTS

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

CONCLUSION

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

CO2 laser combined with low-temperature plasma radiofrequency ablation promotes recovery of swallowing function in elderly patients with early glottic carcinoma

OBJECTIVE

This study was designed to determine the effect of CO2 laser combined with low-temperature plasma radiofrequency ablation (LPRA) on swallowing function and prognosis in elderly patients with early glottic laryngeal cancer (GLC).

METHODS

The clinical data of 115 elderly patients with early GLC treated in General Hospital of Daqing Oil Field from May 2013 to September 2015 were retrospectively analyzed. These patients were assigned to a research group or control group according to different therapeutic regimen. Totally 56 cases treated with CO2 laser resection were assigned to the control group, and 59 cases treated with CO2 laser combined with LPRA were assigned to the research group. The hospital stay, postoperative pain, mucosal recovery score, postoperative complications, swallowing function, vocal function, and 5-year recurrence rate were compared between the two groups. Independent risk factors for 5-year recurrence in patients were analyzed by multivariate logistic regression.

RESULTS

The research group was significantly superior to the control group in terms of hospital stay, postoperative pain, and mucosal recovery score (P<0.05), and the postoperative complication rate was not significantly different between the two groups (P>0.05). After treatment, the research group showed better swallowing function and vocal function than the control group, and the 5-year recurrence rate of the two groups was similar (P=0.288). Multivariate logistic regression analysis identified higher age, lower differentiation, and presence of a cumulative anterior commissure as independent risk factors for recurrence.

CONCLUSION

CO2 laser combined with LPRA can provide relatively high clinical efficacy for early GLC in the elderly, after which patients' swallowing function and vocal function recover quickly, but the long-term benefit of adding LPRA is not evident.

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.

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

OBJECTIVE

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

STUDY DESIGN

A longitudinal observational cohort study.

SETTING

Tertiary cancer center.

METHODS

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

RESULTS

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

CONCLUSION

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

Healing after transoral carbon dioxide laser surgery for early glottic cancer

OBJECTIVE

This study aimed to evaluate the clinical significance of granulation tissue after endoscopic carbon dioxide laser surgery for glottic cancer.

METHOD

This was a retrospective review of 36 patients who underwent endoscopic carbon dioxide laser surgery for T₁ and T₂ glottic cancer. Post-operative, endoscopic examinations were rated by three blinded otolaryngologists for time to heal and presence of granulation. Patient and surgical factors were compared with time to heal and granulation.

RESULTS

A total of 16 of 36 wounds (44 per cent) developed granulation tissue, and 24 wounds (67 per cent) healed without requiring surgical intervention. A total of 7 of 8 wounds biopsied more than 3.5 months after surgery had persistent cancer versus 1 of 4 wounds biopsied at equal to or less than 3.5 months (85.7 per cent vs 25 per cent; p = 0.03). Biopsy at more than 3.5 months was associated with 28-fold increased odds of cancer in biopsy compared with biopsy at equal to or less than 3.5 months (odds ratio, 28.0; 95 per cent confidence interval, 1.088-373.3).

CONCLUSION

After carbon dioxide laser surgery for glottic cancer, development of granulation tissue is common. Granulation that persists for more than 3.5 months necessitates biopsy because of increased risk of persistent cancer.

Laryngeal Cancer Surgery: History and Current Indications of Transoral Laser Microsurgery and Transoral Robotic Surgery

The development of transoral laser microsurgery (TLM) was an important step in the history of conservative laryngeal surgery. TLM reported comparable oncological outcomes and better functional postoperative and rehabilitation outcomes than open partial laryngectomy. TLM is currently considered as the standard surgical approach for early-stage laryngeal carcinoma. However, TLM has many limitations, including the limited view of the surgical field through the laryngoscope, exposure difficulties for some tumor locations, and a long learning curve. The development of transoral robotic surgery (TORS) appears to be an important issue to overcome these limitations. The current robotic technologies used in surgery benefited from the research of the U.S. Military and National Aeronautics and Space Administration (NASA) in the 1970s and 1980s. The first application in humans started in the 2000s with the first robotic-assisted cholecystectomy in the US, performed by a surgeon located in France. The use of robots in otolaryngology occurred after the development of the Da Vinci system in digestive surgery, urology, and gynecology, and mainly concerns cT1-T2 and some selected cT3 oropharyngeal and supraglottic carcinomas. With the development of a new robotic system with smaller arms and instruments, TORS indications will probably evolve in the next few years, leading to better outcomes for laryngeal or hypopharyngeal carcinomas.

Comparison of Oncologic Outcomes Between Radiation Therapy and Transoral Laser Microsurgery for Early Glottic and Supraglottic Squamous Cell Carcinoma; a Retrospective Cohort Study with Literature Review

Background: Laryngeal cancer is known as the second most common airway cancer. These tumors are usually diagnosed early; thus, it is important to choose the optimal treatment modality. Several studies are comparing transoral laser microsurgery (TLM) and radiotherapy in early-stage laryngeal cancer. Due to a paucity of high-quality research and the lack of conclusive randomized prospective studies, standard care for early glottic cancer is still a matter of controversy. Methods: In this retrospective cohort study, T1-T2N0M0 laryngeal cancer patients who underwent TLM or radiotherapy were compared with statistical methods in terms of Recurrence Rate, Organ (Larynx) Preservation Rate, Mortality Rate, and Overall Survival. Results: A total of 123 patients were evaluated in this study, 65 of whom underwent TLM and 58 underwent radiotherapy. There was no significant difference in demographic and medical characteristics of patients. The rate of recurrence was 27.3% in the TLM group and 43.6% in the radiotherapy group. There was no significant difference between the two groups (P = 0.114). Overall mortality rate (5.4% vs 39.6%, P = 0.001), Disease-specific mortality rate (5.5% vs 39.9%, P = 0.001), and aorgan preservation rate (98.5%vs 89.7%, P = 0.035) were all in favor of TLM. Conclusions: TLM appears to be the treatment of choice in patients with early laryngeal cancer due to a better overall survival rate, lower disease-specific mortality rate, and better organ preservation rate than definitive radiotherapy.

Early glottic cancer recurrence: A critical review on its current management

INTRODUCTION

Recurrent early glottic cancer (rEGC) poses several issues in terms of timely diagnosis, correct re-staging, and treatment. We want to critically review the latest evidence about rEGC considering its epidemiology, biology, diagnostic challenges, and treatment strategies.

METHODS

A systematic search of the literature using PubMed from 1990 to October 31, 2020 was performed.

RESULTS

There are many different treatment options available (open surgery, transoral mini-invasive surgery, radiotherapy), and many factors related to the patient's status and previous treatments must be considered when planning the best management strategy for rEGC. While its overall prognosis remains satisfactory, it is of the utmost importance to appreciate all the clinical implications derived from the choice of the initial therapeutic modality, and from a correct primary and recurrent staging.

CONCLUSION

The balance between oncological and voice and swallowing functions represents the fundamental principle underlying rEGC management. Future studies should focus on molecular profiling of rEGC, and on the results of the emerging radiation delivery techniques and mini-invasive procedures.

Shared Decision-making in Head and Neck Surgery: A Review

Importance

Shared decision-making is a partnership between physicians and patients whereby patient values and preferences are incorporated with the best medical evidence. Shared decision-making may reduce decisional conflict, improve value-choice congruence, and increase patient involvement. Despite potential benefit in many key areas of otolaryngology-head and neck surgery, both clinical and research focuses on shared decision-making are scarce. Head and neck surgical oncology is of particular interest owing to the frequency by which preference-sensitive decisions must be made. Information used in this review was obtained between January 1 and February 1, 2020.

Observations

Various conceptual models have been developed in an attempt to define the concept of shared decision-making. More than 40 instruments have endeavored to measure the construct of shared decision-making. However, in head and neck surgery, few studies to date have explicitly done so. Situations of clinical equipoise, such as in the management of indeterminate thyroid nodules and in the treatment of laryngeal cancer, are frequent. In contrast, value-option incongruence may occur when patient values do not align with the most oncologically sound treatment choice, such as when the resection and reconstruction of oral cancer may leave patients with significant sequelae. Several patient decision aids have been developed to improve shared decision-making in specific clinical scenarios, for example, in considering total laryngectomy or primary chemoradiotherapy.

Conclusions and Relevance

Despite its potential benefit, there is a dearth of research and clinical applications of shared decision-making in head and neck surgery. Shared decision-making represents an area of substantial need in this regard, and additional efforts should be put forth.

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

OBJECTIVE

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

STUDY DESIGN

Single-center retrospective cohort study.

SETTING

Tertiary academic hospital.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Value and Quality of Care in Head and Neck Oncology

PURPOSE OF REVIEW

The concept of value-based health care (VBHC) was articulated more than a decade ago. However, its clinical implementation remains an on-going process and a particularly demanding one for the domain of head and neck cancer (HNC). These cancers often present with fast growing tumors in functionally and cosmetically sensitive sites and afflict patients with differing circumstances and comorbidity. Moreover, the various treatment modalities and protocols have different effects on functional outcomes. Hence, the interpretation of what constitutes VBHC in head and neck oncology remains challenging.

RECENT FINDINGS

This monograph reviews developments in specific aspects of VBHC for HNC patients, including establishment of registries and quality indices (such as infrastructure, process, and outcome indicators). It emphasizes the importance of the multidisciplinary team, "time to treatment intervals," and adherence to guidelines. The discussion addresses major indicators including survival, quality of life and functional outcomes, and adverse events. Also, strengths and weaknesses of nomograms, prognostic and decision models, and variation of care warrant attention. Health care professionals, together with patients, must properly define quality and relevant outcomes, both for the individual patient as well as the HNC population. It is essential to capture and organize the relevant data so that they can be analyzed and the results used to improve both outcomes and value.

Survival Outcomes and Prognostic Factors of Open Partial Laryngeal Surgery: A Thirty Years' Experience

BACKGROUND

Open partial laryngeal surgery (OPLS) represents a wide array of procedures that can be fitted to treat different types of laryngeal cancer (LC). We would like to present our 30-years' institutional experience, to analyze survival outcomes and to critically discuss prognostic factors.

METHODS

We reviewed all cases of OPLS performed at our Institution from 1982 to 2016 for LC. Survival analysis by Kaplan-Meier estimate was performed and prognostic variables by multivariate analysis were identified.

RESULTS

Mean follow-up time was 68.3 months, 30-day mortality 0.2%, subsequent functional total laryngectomy (TL) was 1.01%. Over 80% of cases were stage I to II. We had 25 local, 62 regional and eight distant recurrences. Local control was 94.9%, overall survival (OS) was 83.4% and disease-specific survival (DSS) was 87.7%. The two major risk factors significantly associated with the risk of death were cT and cN stage. CONCLUSIONS: We have confirmed that OPLS represents an oncologically sound option in the treatment of LC despite the emergence of non-surgical strategies and new transoral mininvasive techniques. Our results highlight that accurate staging, correct selection of the patient and a strong surgical expertise are of paramount importance in this type of surgery.

Prospective validation of an institutional treatment strategy for T1N0M0 glottic carcinoma

INTRODUCTION

The aim of this study was to assess the validity of a treatment strategy for T1N0 glottic squamous cell carcinoma.

METHODS

One hundred and seventeen patients were prospectively treated according to institutional guidelines. using 1) laser microsurgery (L) for exophytic tumor, limited to one vocal cord, without extension to the anterior commissure or the vocal process of the arytenoid cartilage, 2) radiotherapy (RT) for large or infiltrative tumor reaching the anterior commissure or the vocal process of the arytenoid cartilage, poor endoscopic exposure and cT1b or 3) partial laryngectomy (PL) for tumor infiltrating the anterior commissure. Ninety-five patients were treated with RT and 22 with surgery alone (S) [L:19; PL:3].

RESULTS

The 5-year overall survival (OS) and disease-specific survival (DSS) were 81.5% and 97.1% (median follow-up: 73 months), respectively. There was no statistically significant difference in OS or DSS between patients treated with RT or S (logrank test: p = 0.974 and 0.978). The 5-year ultimate local control rate reached 98.3%. The local control rate with larynx preservation was 94.9% with no difference between RT (94.7%) and S (95.5%) (χ²: p = 0.891). Continued smoking after RT was significantly associated with a lower 5-year OS (77.9% versus 87%), [HR 3.458; p = 0.043 (95%CI 1.010-11.837)].

CONCLUSIONS

For patients with T1 glottic carcinoma, and based on our previous studies, these data prospectively confirm the oncologic validity of an institutional treatment strategy. Continued smoking after RT correlated with poor OS.

Voice outcome after unilateral ELS type III or bilateral type II resections for T1-T2 glottic carcinoma: Results after 1 year

Background

Voice outcome was assessed in patients with extended T1 and limited T2 glottic carcinoma, treated with a unilateral type III or a bilateral type II resection according to the European Laryngological Society (ELS) classification.

Methods

Objective evaluation (acoustic and aerodynamic parameters), perceptual evaluation (GRBAS), and patients' self‐assessment (voice handicap index [VHI]) were performed before and 1 year after treatment. Results were evaluated according to ELS resection type and the involvement of the anterior commissure.

Results

The majority of voice parameters in all resection subgroups showed an improvement of the mean score 1 year postoperatively. Grade of dysphonia varied between 1.15 and 1.66 postoperatively and VHI score varied from 23.3 to 24.5.

Conclusion

Voice outcome after ELS unilateral type III or a bilateral type II resection for extended T1 and limited T2 glottic carcinoma is good with mild to very moderate perceptive dysphonia and low self‐reported voice impairment.