[Modern aspects of organ-preserving surgery for laryngeal cancer]

A review of the literature on modern aspects of organ-preserving surgery for laryngeal cancer - endolaryngeal and open resections - is presented. The indications for these operations are determined depending on the location and extent of the tumor, as well as on the anatomical features. The advantages and disadvantages of each method, complications, functional and oncological results are shown.

Insurance Status Effect on Laryngeal Cancer Survival: A Population Based Study

OBJECTIVE

To analyze insurance status effect on overall survival (OS) and disease-specific survival (DSS) in laryngeal cancer.

STUDY DESIGN

Cross-sectional population analysis.

SETTING

Surveillance, Epidemiology, and End Results (SEER) database.

PARTICIPANTS

Laryngeal cancer patients from 2007 to 2016.

MAIN OUTCOME MEASURES

Kaplan-Meier method with log-rank statistic analyzed OS and DSS by insurance status. Multivariable cox proportional hazard modeling generated survival prognostic factors.

RESULTS

Of 19 667 laryngeal cancer cases, initial disease presentation was stage I: 7770 patients (39.5%), stage II: 3337 patients (17.0%), stage III: 3289 patients (16.7%), and stage IV: 5226 patients (26.6%). Patients had non-Medicaid insurance (15 523, 78.9%), had Medicaid (3306, 16.8%), or were uninsured (891, 4.5%). Mean and median OS for insured, Medicaid, and uninsured patients were 60.5, 49.6, and 56.6 and 74.0, 40.0, and 65.0 months, respectively. Following multivariable analysis, OS for insured, Medicaid, and uninsured patients was stage I: 87.9, 82.8, and 88.4 (P < .001), stage II: 79.1, 75.1, and 78.3 (P = .12), stage III: 68.7, 66.1, and 72.1 (P = .11), and stage IV: 57.1, 51.7, and 50.3 (P < .001) months. DSS mean survival times were 77.0, 65.8, and 67.7 months (P < .001) for insured, Medicaid, and uninsured patients. Age (HR: 1.02/year, P < .001) and black (HR: 1.15, P = .001) compared to white race predicted worse survival. Compared to insured status, Medicaid insurance carried a death hazard ratio of 1.40 (P < .001) and uninsured status had a death hazard ratio of 1.40 (P < .001).

CONCLUSION

Insured laryngeal cancer patients had prolonged OS and DSS compared to Medicaid and uninsured patients. Medicaid patients had equivalent survival outcomes to uninsured patients.

LEVEL OF EVIDENCE

2c.

Predictors of hospital expenses and hospital stay among patients undergoing total laryngectomy: Cost effectiveness analysis

Objective

To determine the predictive factors of postoperative hospital stay and total hospital medical cost among patients who underwent total laryngectomy.

Methods

A total of 213 patients who underwent total laryngectomy in a tertiary referral center for tumor ablation were enrolled retrospectively between January 2009 and May 2018. Statistical analyses including Pearson's chi-squared test were used to determine whether there was a significant difference between each selected clinical factors and outcomes. The outcomes of interest including postoperative length of hospital stay and inpatient total medical cost. Logistic regression analyses were performed to reveal the relationship between clinical factors and postoperative length of hospital stay or total inpatient medical cost.

Results

Preoperative radiotherapy (p = 0.007), method of wound closure (p < 0.001), postoperative serum albumin level (p = 0.025), and postoperative serum hemoglobin level (p = 0.04) were significantly associated with postoperative hospital stay in univariate analysis. Postoperative hypoalbuminemia (odds ratio [OR]: 2.477; 95% confidence interval [CI]: 1.189–5.163; p = 0.015) and previous radiotherapy history (OR 2.194; 95% CI: 1.228–3.917; p = 0.008) are independent predictors of a longer postoperative hospital stay in multiple regression analysis. With respect to total inpatient medical cost, method of wound closure (p < 0.001), preoperative serum albumin level (p = 0.04), postoperative serum albumin level (p < 0.001), and history of liver cirrhosis (p = 0.037) were significantly associated with total inpatient medical cost in univariate analysis. Postoperative hypoalbuminemia (OR: 6.671; 95% CI: 1.927–23.093; p = 0.003) and microvascular free flap reconstruction (OR: 5.011; 95% CI: 1.657–15.156; p = 0.004) were independent predictors of a higher total inpatient medical cost in multiple regression analysis.

Conclusions

Postoperative albumin status is a significant factor in predicting prolonged postoperative hospital stay and higher inpatient medical cost among patients who undergo total laryngectomy. In this cohort, the inpatient medical cost was 48% higher and length of stay after surgery was 35% longer among hypoalbuminemia patients.

A Multidisciplinary Team Guided Approach to the Management of cT3 Laryngeal Cancer: A Retrospective Analysis of 104 Cases

The optimal treatment for T3 laryngeal carcinoma (LC) is still a matter of debate. Different therapeutic options are available: Transoral laser microsurgery (TLM), open partial horizontal laryngectomies (OPHLs), total laryngectomy (TL), and organ preservation protocols (radiation therapy (RT) or chemo-radiation (CRT)). This study aimed to retrospectively evaluate oncologic outcomes of 104 T3 LCs treated by surgery or non-surgical approaches from January 2011 to December 2016 at a single academic tertiary referral center. Each case was evaluated by a multidisciplinary team (MDT) devoted to the management of head and neck cancers. We divided the cohort into two subgroups: Group A, surgical treatment (TLM, OPHLs, TL) and Group B, non-surgical treatment (RT, CRT). For the entire cohort, two- and five-year overall survival (OS) rates were 83% and 56%, respectively. The two- and five-year disease-free survival (DFS) rates were 75% and 65%, and disease-specific survival rates were 93% and 70%, respectively. The N category was a significant independent prognosticator for OS (p = 0.02), whereas Group B was significantly and independently associated with DFS (HR 4.10, p = 0.006). Analyzing laryngo-esophageal dysfunction-free survival as an outcome, it was found that this was significantly lower in higher N categories (p = 0.04) and in cases that underwent non-surgical treatments (p = 0.002). Optimization of oncologic outcomes in T3 LCs may be obtained only by a comprehensive MDT approach, considering that different treatment options have heterogenous toxicity profiles and indications.

Three-Dimensional Map of Isoprognostic Zones in Glottic Cancer Treated by Transoral Laser Microsurgery as a Unimodal Treatment Strategy

Introduction

The Union for International Cancer Control–American Joint Committee on Cancer TNM staging system for glottic squamous cell carcinoma (SCC) includes different types of lesions defined by the involvement of specific subsites in each T category. Our study aims to identify different subcategories according to tumor local extension and determine oncologic outcomes after treatment by transoral laser microsurgery (TLM) alone.

Methods

We retrospectively evaluated 410 patients affected by previously untreated pT1-pT3 glottic SCC treated by TLM alone from January 2005 to December 2015 at the Departments of Otorhinolaryngology—Head and Neck Surgery, Universities of Genoa and Brescia, Italy. All patients had at least 2 years of follow-up. Clinical, radiological, surgical, and histopathological data were reviewed and tumors divided into six subcategories: I, pT1a not involving the anterior commissure (AC); II, pT1b involving the AC; III, pT2 extending superficially to the supraglottis or the subglottis; IV, pT2 infiltrating the vocal muscle; V, pT3 involving the anterior paraglottic space; VI, pT2 or pT3 with vertical extension across the AC with/without involvement of the pre-epiglottic space. Recurrence-free survival (RFS), local control with laser alone (LCL), and organ preservation (OP) were defined as the primary oncologic outcomes.

Results

The 2, 5, and 10-year RFS for the entire series were 85.7, 80.3, and 73.8%, LCL rates 93.8, 92.1, and 89.6%, and OP rates 96.8, 95.9, and 93.5%, respectively. However, when comparing the rates of RFS, LCL, and OP for each subcategory, important differences emerged. In particular, subcategories V and VI showed a significantly increased risk of local recurrence [hazard ratio (HR) = 9.2 and 13.3, respectively]. These subcategories also had a significantly reduced probability to achieve LCL (HR: 73.6 and 93.5, respectively) and OP (HR: 6.4 and 8.1, respectively).

Conclusion

The present classification in subcategories allows introducing the concept of a three-dimensional map of isoprognostic zones in glottic SCC treated by TLM alone as a useful tool in its management by a multidisciplinary tumor board.