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, 2024.

Management of positive resection margins following transoral laser microsurgery for glottic cancer

Objectives

The current literature provides limited guidance on the management of positive margins (PMs) following transoral laser microsurgery (TLM) for glottic squamous cell carcinoma (SCC). Long-term data exploring the treatment of PMs with both initial observation and re-resection are limited. Our objective was to determine the optimal treatment for PM patients following TLM for glottic SCC.

Methods

Clinical information on glottic SCC patients with PMs following treatment with TLM was prospectively collected at our institution from 2007 to 2018. We use a laryngeal template during the initial TLM where the area of resection is outlined for future reference. Data were compared with univariate analysis and survival plots were generated using the Kaplan-Meier method.

Results

A total of 29 patients with PMs were treated with either re-resection (19 patients), close observation (6 patients), or adjuvant radiation alone (4 patients). Re-resection patients had SCC or severe dysplasia on initial margin pathology and 23% with early-stage disease had recurrence (T1-T2). Five (83%) patients who underwent close observation required re-resection based on clinical suspicion of recurrence (confirmed on final pathology), which was significantly different from the re-resection patients (p < .05). Close observation was therefore discontinued as a management of PMs. Four patients (21%) had no residual malignancy on re-resection specimens. Deep margins only accounted for 17% of all PMs. Disease-specific survival for all PM patients at 5 years was 82.4% (SE 9.6%, CI 53.4%-91.6%).

Conclusions

Our long-term experience with treating early-stage glottic SCC with TLM supports re-resection as an appropriate management for cases of PMs.

Level of Evidence

4.

Narrow-Band Imaging in Transoral Laser Surgery for Early Glottic Cancer: A Randomized Controlled Trial

OBJECTIVE

Assessing whether the additional use of narrow-band imaging (NBI) in transoral laser surgery (TOLS) for early laryngeal cancer improves clinical outcomes.

STUDY DESIGN

Randomized controlled trial, performed between September 2015 and November 2022.

SETTING

A tertiary referral hospital in The Netherlands.

METHODS

TOLS was carried out in 113 patients. The procedure was performed with white light imaging (WLI, n = 56) alone, or combined with NBI (n = 57). Patients received frequent follow-up laryngoscopy. Resection margin status, recurrence rate, and recurrence-free survival at 12 months, 18 months, and after study termination (maximum 86 months) were analyzed.

RESULTS

Thirty-one cases in the WLI group had a positive resection margin, versus 16 in the NBI group (p = .002). After 12 months, the recurrence-free survival was 92%: 87% for WLI versus 96% for NBI, p = .07. The recurrence rate was 7/56 (13%) for WLI, versus 2/57 (4%) for NBI, p = .09. After 18 months, the recurrence-free survival was 84% for WLI versus 96% for NBI, p = .02. The recurrence rate was 9/56 (16%) for WLI, versus 2/57 (4%) for NBI, p = .02. After study termination, the recurrence-free survival was 71% for WLI versus 83% for the NBI group (p = .08). The recurrence rate was 16/56 for WLI, versus 10/57 for NBI (p = .16).

CONCLUSION

The additional use of NBI during TOLS significantly decreased the number of positive resection margins. Although not statistically significant at all time points, patients treated with NBI-supported TOLS showed a lower recurrence rate and better recurrence-free survival. Further studies in larger patient groups are needed to confirm these results.

Management and Oncologic Outcomes of Close and Positive Margins after Transoral CO2 Laser Microsurgery for Early Glottic Carcinoma

BACKGROUND

The present study analyzed the impact of margin status on local control and survival, and the management of close/positive margins after transoral CO₂ laser microsurgery for early glottic carcinoma.

METHODS

351 patients (328 males, 23 females, mean age 65.6 years) underwent surgery. We identified the following margin statuses: negative, close superficial (CS), close deep (CD), positive single superficial (SS), positive multiple superficial (MS), and positive deep (DEEP).

RESULTS

A total of 286 patients (81.5%) had negative margins, 23 (6.5%) had close margins (8 CS, 15 CD) and 42 (12%) had positive margins (16 SS, 9 MS, 17 DEEP). Among the 65 patients with close/positive margins, 44 patients underwent enlargement, 6 radiotherapy and 15 follow-up. Twenty-two patients (6.3%) recurred. Patients with DEEP or CD margins showed a higher risk of recurrence (hazard ratios of 2.863 and 2.537, respectively), compared to patients with negative margins. Local control with laser alone, overall laryngeal preservation and disease-specific survival decreased significantly in patients with DEEP margins (57.5%, 86.9% and 92.9%, p < 0.05).

CONCLUSIONS

Patients with CS or SS margins could be safely submitted to follow-up. In the case of CD and MS margins, any additional treatment should be discussed with the patient. In the case of DEEP margin, additional treatment is always recommended.

Surgical and Functional Outcome After Endoscopic Resection Via Transthyrohyoid for Early Glottic Cancer

Transthyrohyoid access to the larynx for endoscopic resection (TTER) for early-stage glottic cancer in patients with difficult laryngeal exposure (DLE) has recently been developed. However, little is known about the postoperative conditions of patients. Twelve early-stage glottic cancer patients with DLE who received TTER were retrospectively reviewed. Clinical information was collected during the perioperative period. Functional outcome was evaluated using Voice Handicap Index-10 (VHI-10) and Eating Assessment Tool-10 (EAT-10) preoperatively and 12 months after surgery. None of the patients experienced serious complications after TTER. The tracheotomy tube was removed in all patients. The 3-year local control rate was 91.6%. The VHI-10 score decreased from 18.92 to 11.75 (p < .001), and the EAT-10 scores of the 3 patients changed slightly. Thus, TTER may be a good option for early-stage glottic cancer patients with DLE.

Long-Term Voice Outcomes After Type I, Type II, or Type V Cordectomy

INTRODUCTION

We compare long-term voice outcomes in patients treated with European Laryngeal Society (ELS) classification Type I, Type II, or Type V cordectomy. The aim is to understand the impact of Type V cordectomy on voice outcomes in relation to Type I and Type II cordectomy.

METHODS

A retrospective review of patients treated with Type I, Type II, or Type V cordectomy by a single surgeon over a 20-year period was performed. Voice Handicap Index-10 (VHI-10) scores, Cepstral Spectral Index of Dysphonia (CSID) measures from CAPE-V sentences, and two-rater GRBAS scores were analyzed.

RESULTS

Sixty-two patients were identified with a mean follow-up of 52 months. Of these, there were 43 Type I and 19 Type II cordectomies, including 8 in each group with Type V resections. Significant differences in all parameters were noted between the Type I (VHI 5.7, CSID 20.6, Grade 1.3) and the Type II cohorts (VHI 12.6, CSID 36.3, Grade 1.8) who did not undergo Type V cordectomy. Patients undergoing Type V cordectomy demonstrated voice outcomes (VHI 9.4, CSID 35.6, Grade 1.7) which fell between those of Type I and Type II cordectomies.

CONCLUSIONS

Better long-term subjective, objective, and computer-analyzed voice outcomes are noted for patients undergoing Type I rather than Type II cordectomy. When Type V cordectomy is performed, voice outcomes are comparable to those of both Type I and Type II cordectomy, a surprising finding given the expectation of worsened dysphonia in longer resections. Further work is needed to explain this finding and define voice outcomes after Type V cordectomy.

Change in Voice Quality after Radiotherapy for Early Glottic Cancer

Our aim was to track the changes in voice quality for two years after radiotherapy (RT) for early glottic cancer. A videoendostroboscopy, subjective patient and phoniatrician voice assessments, a Voice Handicap Index questionnaire, and objective acoustic measurements (F0, jitter, shimmer, maximal phonation time) were performed on 50 patients with T1 glottic carcinomas at 3, 12, and 24 months post-RT. The results were compared between the subsequent assessments, and between the assessments at 3 months and 24 months post-RT. The stroboscopy showed a gradual progression of fibrosis of the vocal folds with a significant difference apparent when the assessments at 3 months and 24 months were compared (p < 0.001). Almost all of the subjective assessments of voice quality showed an improvement during the first 2 years, but significant differences were noted at 24 months. Jitter and shimmer deteriorated in the first year after RT with a significant deterioration noticed between the sixth and twelfth months (p = 0.048 and p = 0.002, respectively). Two years after RT, only 8/50 (16%) patients had normal voices. The main reasons for a decreased voice quality after RT for early glottic cancer were post-RT changes in the larynx. Despite a significant improvement in the voice after RT shown in a few of the evaluation methods, only a minority of the patients had a normal voice two years post-RT.

Radiomics of dual-energy computed tomography for predicting progression-free survival in patients with early glottic cancer

Aim: This study aimed to predict progression-free survival (PFS) in patients with early glottic cancer using radiomic features on dual-energy computed tomography iodine maps. Methods: Radiomic features were extracted from arterial and venous phase iodine maps, and radiomic risk scores were determined by univariate Cox proportional hazards regression analysis and least absolute shrinkage and selection operator regression with tenfold cross-validation. The Kaplan-Meier method was used to evaluate the association between radiomic risk scores and PFS. Results: Patients were stratified into low-risk and high-risk groups using radiomics, the PFS corresponding rates with statistical significance between the two groups. The high-risk group showed better survival, benefiting from laryngectomy. Conclusion: Radiomics could provide a promising biomarker for predicting the PFS of early glottic cancer patients.

Age as Indicator in the Selection of Surgery Modalities in Early Glottic Cancer

Purpose

Local failure after endoscopic laryngeal surgery (ELS) for early glottic cancer mounts a challenge to researchers to investigate risk factors of recurrence. The present study was therefore designed to explore the prognostic factors in patients who underwent ELS for early glottic cancer.

Patients and Methods

We reviewed 328 patients with T1-2N0 glottic cancer who were treated with either ELS or open surgery between 2007 and 2018 at our institution. Survival, univariate and multivariate analyses were performed in different groups (ELS vs open surgery; < 65 vs ≥ 65 years).

Results

Age was discovered to be the independent prognostic factor of DFS for patients treated with ELS (HR = 3.673, p = 0.003), but not for patients who underwent open surgery. Survival analysis performed on young patients (< 65 years) showed that survival outcomes between different surgery modalities were significantly different (ELS vs open surgery: five-year DFS: 72.5 vs 84.7%, p = 0.034). Univariate and multivariate analyses further confirmed the finding, whereas these results did not appear in old patients (≥ 65 years).

Conclusion

Young patients (< 65 years) treated with ELS had less favorable oncologic outcomes than those treated with open surgery. Young patients (< 65 years) are advised to consider open surgery over ELS.

Salvage Following Transoral Laser Microsurgery for Early Glottic Cancer in National Veteran Database

OBJECTIVES

Transoral laser microsurgery (TLM) is commonly utilized for early glottic cancer and offers favorable oncologic and functional outcomes. However, the survival implications of salvage therapy for recurrent or persistent disease have not been definitively characterized.

STUDY DESIGN

Retrospective, national database cohort study.

METHODS

Data were extracted from Veterans Health Affairs (VHA) Informatics and Computing Infrastructure (VINCI) concerning the TLM-based management of T1-T2 glottic squamous cell carcinoma patients between 2000 and 2017. Patients were characterized as either requiring TLM-only, or in cases of persistent or recurrent local disease, TLM plus change in treatment modality (radiotherapy, chemoradiotherapy, or open surgery). Predictors of overall survival (OS), cancer-specific survival (CSS), and salvage-free survival were evaluated via Cox and Fine-Gray models.

RESULTS

About 553 patients (70.9% T1a, 13.4% T1b, 15.7% T2) were included, with a median follow-up time of 74.5 months. The need for non-TLM salvage increased along with more advanced disease (11.7% T1a, 29.7% T1b, 32.2% T2). Compared to patients with T1a disease, those with T1b and T2 tumors initially treated with TLM had a significantly higher probability of receiving non-TLM salvage (T1b: HR 2.70, 95% CI: 1.61-4.54; T2: HR 3.02, 95% CI: 1.88-4.84). In a multivariable model, receipt of non-TLM salvage was not a significant predictor of either OS (HR = 0.91, 95% CI: 0.62-1.33, P = .624) or CSS (HR 1.21 95% CI 0.51-2.86, P = .667).

CONCLUSION

The majority of patients with early glottic cancer that are managed with TLM do not require additional salvage therapy. When non-TLM salvage was required, there was no decrement in OS or CSS.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

T1b Glottic Tumor and Anterior Commissure Involvement: Is the Transoral CO2 Laser Microsurgery a Safe Option?

OBJECTIVES

Transoral CO₂ laser therapy represents the treatment of choice for early-stage laryngeal tumors. The anterior commissure involvement (ACI) is related to a worse local control and a lower rates of organ preservation. The objective of this study is to analyze the differences in survival, local control, and organ preservation in T1b glottic patients according to the presence of ACI.

METHODS

Observational prospective study in pT1b treated with transoral CO₂ laser between 2009 and 2014.

RESULTS

Forty patients (37 male and 3 female) with a mean age of 66.43 ± 8.16 years were recruited. Anterior commissure involvement was present in 70% of the patients. The 5-year specific cause survival was 91.66%, with 32.50% of local recurrences. Laryngeal preservation was 80%, being lower in the group with local recurrence (P < .000). The involvement of the anterior commissure does not influence the organ preservation (P = .548), the appearance of local recurrences (P = .391), or the survival (P = .33).

CONCLUSIONS

Transoral CO₂ laser therapy is an effective and reproducible treatment for early-stage laryngeal tumors. The results obtained are similar to previous studies, although they present discrepancies in relation to the role of the ACI. Prospective randomized trials are required focusing also on the patients' quality of life and functional outcome in order to clarify the role of the ACI and the need to implement changes in its evaluation, staging, and evolution.

Early Glottic Cancer Treated by Transoral Laser Surgery Using Toluidine Blue for the Definition of the Surgical Margins: A Pilot Study

Background and objectives: Transoral laser microsurgery (TLM) is widely accepted for its advantages, which consist of a brief hospital stay, rapid functional recovery, low management costs and the fact that it can be easily repeated in cases of recurrence. However, a high incidence of positive or narrow surgical margins has been reported in the literature, even if controversy still exists on the prognostic significance of positive resection margins. The aim of the study was to evaluate the utility of toluidine blue staining in defining the resection margins of early glottic cancer (T1a–T2) treated with TLM. Materials and Methods: This retrospective study was conducted on patients with early glottic cancer (T1a–T2) managed by TLM. A group of patients treated between 2010 and 2014 underwent toluidine blue staining (TB group) of the lesions before starting the cordectomy by TLM, and a group of patients treated by TLM between 2006 and 2009 was considered the control group. Results: A total of 44 subjects were included in this study: 41 were men, and 3 were women. The mean age was 58 ± 9.0 years (median 59.0, range 41–77). Twenty-three of the 44 patients were included in the TB group and 21 in the case control group. In the TB group, only the positivity of the deep margin was a predictor of local recurrence (p = 0.037), while in the control group, positive or close margins and the type of cordectomy were predictive factors of local recurrence (p = 0.049). Considering the TB group and control cases, the 5-year local recurrence-free survival was 95.6% and 80.9%, respectively (p = 0.14). Conclusions: From this first study, toluidine blue staining seems to be a useful modality to improve the rate of the negative resection margins of early glottic cancer (T1a–T2) treated by TLM.

T1 Glottic Cancer: Does Anterior Commissure Involvement Worsen Prognosis?

Radiotherapy (RT) and transoral laser microsurgery (TLM) represent the main treatment modalities for early glottic carcinoma. Local failure is notoriously more frequent in T1b glottic cancer in comparison to T1a and T2 tumors. In this scenario, the role of anterior commissure (AC) involvement is still controversial. The aim of the present study was therefore to determine its potential prognostic power in worsening patients’ survival and outcomes. We categorized different tumor glottic fold locations with respect to the involvement of one (T1a) or both vocal cords, with or without AC involvement. We analyzed a retrospective cohort of 74 patients affected by Stage I glottic cancer, treated between 2011 and 2018 by TLM or RT at a single academic institution. There were 22 T1a (30%) and 52 T1b (70%) cases. The median follow-up period was 30 months (mean, 32.09 ± 18.738 months; range, 12–79). Three-year overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and laryngectomy-free survival (LFS) were compared according to tumor location, extension, and cT category. According to both uni- and multivariate analyses, an increased risk for recurrence in T1b with AC involvement and T1a tumors was 7.31 and 9.45 times, respectively (p-values of 0.054 and 0.030, respectively). Among the 17 recurrences, T1b with AC involvement experienced 15 tumor relapses (88.2%), thus significantly affecting both the RFS and LFS in comparison to the other two tumor subcategories (T1a, p = 0.028 and T1b without AC involvement, p = 0.043). The deteriorating prognosis in the presence of AC involvement likely reflects the need to power the hazard consistency and discrimination of the T1b category when associated with such a risk factor, thus deserving an independent T category.

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.

Multifactorial analysis of local control and survival in patients with early glottic cancer

OBJECTIVES

The purpose of this study is to determine the effects of various prognostic factors for early glottic cancer patients who underwent radiotherapy.

METHODS

We retrospectively reviewed the all patients who were treated at our hospital for early glottic squamous cell carcinoma from 2004 to 2016. Data included patient's age, sex, T classification, tumor size, pathological grade, anterior commissure involvement, subglottic extension, laryngeal ventricle involvement, and restriction of vocal cord movement.

RESULTS

There were 74 patients with T1 tumors and 31 with T2 tumors. Recurrence was found in four patients with T1 and eight patients with T2. There were 99 males and six females enrolled, and the mean age was 67.5 ± 9.2 years for T1a, 67.3 ± 11.2 years for T1b, and 67.4 ± 7.9 years for T2. One patient with recurrence after 1 month was thought to have a residual tumor. The 5-year overall survival (OS) rate and the 5-year disease-specific survival (DSS) rate for T1-T2 patients were both 100%. The rate of larynx preservation was 94.6% for T1 and 74.2% for T2. A univariate analysis showed that the effective factors were age, T, size, SE. A multivariate logistic regression analysis showed that age influenced the recurrence status. Size is also suspected to be a prognostic factor.

CONCLUSIONS

This study revealed that the effective factors were age, T, size, and SE.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1701-1706, 2020.

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

BACKGROUND AND OBJECTIVES

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

STUDY DESIGN/MATERIALS AND METHODS

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

RESULTS

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

Local inflammatory reaction to benign, pre-malignant and malignant glottic lesions: A matched case-control study

OBJECTIVES

To study the inflammatory infiltrates associated with the different stages of laryngeal carcinogenesis.

DESIGN

Observational, matched case-control study of histopathologic specimens.

SETTING

An academic referral centre.

PARTICIPANTS

A total of 45 patients who underwent removal of glottic lesions between 2008 and 2015. Patients were enrolled and categorised into three matched groups according to lesions' histopathologic diagnoses, 15 patients in each group: benign, pre-malignant and squamous cell carcinoma (SCC). Matching was based on age, gender and pack-years.

MAIN OUTCOME MEASURES

Immunohistochemistry staining using monoclonal antibodies against CD4, CD8, CD68, CD20 and S100 representing T-helper cells, cytotoxic T cells, macrophages, B cells and dendritic cells, respectively. Cell counts and distributions were measured and compared between groups. Correlations between the different cells were examined.

RESULTS

The predominant cell type was CD8+, followed by CD68+ and CD4+. All inflammatory cells increased significantly in number in SCC (P-value < 0.001), with no significant difference between benign and pre-malignant groups. Strong correlations between the different cells were demonstrated only in the malignant group. S100+ cells correlated with both T-cell subsets, CD4+ (rho = 0.769, P-value = 0.001) and CD8+ (rho = 0.697, P-value = 0.0004). Infiltrates exhibited more extensive distribution in SCC compared to pre-malignant and benign; CD8+ and CD68+ cells were demonstrated in both intraepithelial and stromal regions in 93% of SCC lesions (P-value = 0.0001).

CONCLUSIONS

Laryngeal carcinoma demonstrates a unique pattern of inflammatory infiltrates, with significant changes in cell counts and distribution. Leucocyte infiltrates increased significantly in the transition from laryngeal pre-malignant lesion to malignancy while no significant differences were seen between benign and pre-malignant lesions.

Clinical value of (dedicated) 3 Tesla and 7 Tesla MRI for cT1 glottic carcinoma: A feasibility study

Objective

To assess the feasibility of the clinical use of 3 Tesla and 7 Tesla Magnetic Resonance Imaging for early (cT1) glottic carcinoma, including structural assessment of technical image quality and visibility of the tumor; and if feasible, to correlate MRI findings to routine diagnostics.

Methods

Prospective feasibility study. Twenty patients with primary clinical T1 glottic carcinoma underwent both routine clinical staging and CT. In addition, a 3 T and 7 T MRI protocol, developed for small laryngeal lesions, was performed in a 4-point immobilization mask, using dedicated surface coils. Afterwards, routine endoscopic direct suspension laryngoscopy under general anaesthesia was performed.

Results

Only 2 of 7 (29%) of 7 T MRI scans were rated as moderate to good technical image quality. After exclusion of three patients with only mild to moderate dysplasia at the time of MRI, 13 of 17 (76%) of 3 T MRIs were of adequate technical image quality. Tumor visualization was adequate in 8 of 13 (62%) of patients with invasive squamous cell carcinomas. With exclusion of the four MRIs with motion artefacts, the tumor and its boundaries could be adequately seen in 8 of 9 (89%) patients with squamous cell carcinoma versus only one in four (25%) of patients with carcinoma in situ lesions.

Conclusions

7 Tesla MRI was considered not feasible. 3 Tesla MRI, with adequate patient selection, namely clinical exclusion of patients with a history of claustrophobia and inclusion of only histologically proven invasive squamous cell carcinoma, can be feasible. Especially with further improvement of MR image quality.

Level of Evidence

2B, prospective diagnostic study.

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.

Phonosurgical Resection Using Submucosal Infusion Technique for Early Glottic Lesions: Diagnostic and Therapeutic Procedure?

OBJECTIVES:

The aim of this study was to assess the feasibility of the submucosal infusion combined with microflap dissection via laser CO2 as both a diagnostic and therapeutic procedure for superficial glottic lesions. To define a safe surgical procedure in terms of local control, a morphometric study of surgical margins was performed.

METHODS:

From January 2011 to January 2016, we treated 122 patients with early glottic lesions with phonomicrosurgery. Patients with effective hydrodissection underwent a microflap and type I-II diagnostic cordectomy. In the others, a biopsy was carried out, and in the case of a malignant lesion, a type III to VI cordectomy was performed. Disease-free survival (DFS) for all the lesions was also determined according to comparative assessments of surgical margins. The Voice Handicap Index was used to evaluate functional outcomes.

RESULTS:

In 27 cases (32%), hydrodissection was effective; specifically, 24 (88.8%) were premalignant lesions, and 3 (11.2%) had a carcinoma. In 56 patients (68%), hydrodissection was not adequate, and a biopsy was performed: 9 (16%) were premalignant and 47 (84%) malignant lesions. The DFS analysis suggests that margins >0.7 mm resulted in a cutoff that can guarantee a safe procedure in the case of effective hydrodissection ( P < .05).

CONCLUSION:

Phonomicrosurgery may be both a diagnostic and therapeutic option with oncological efficacy for superficial glottic lesions of undetermined nature when surgical margins exceed 0.7 mm. In case of inadequate hydrodissection, the hypothesis of an infiltrative carcinoma warrants a wider cordectomy.

Optimized treatment strategy of radiotherapy for early glottic squamous cell carcinomas: An initial analysis

The purpose of this study was to evaluate the clinical outcomes of radiotherapy for patients with T1/T2 glottic carcinoma. Patients with T1/T2 glottic carcinoma histopathologically diagnosed with squamous cell carcinoma and treated at our hospital between 2007 and 2015 were analyzed retrospectively. Our strategy for T1/T2 glottic carcinoma was as follows: radiotherapy alone with 2.25 Gy per fraction to a total of 25–28 fractions for patients with non-bulky T1 glottic carcinoma; concurrent chemoradiotherapy with oral S-1 and radiotherapy with 2 Gy per fraction to a total of 30 fractions for patients with T1 bulky/T2 favorable glottic carcinoma; or chemoradiotherapy with high-dose cisplatin and radiotherapy with 2 Gy per fraction to a total of 35 fractions for T2 unfavorable glottic carcinoma. Forty-eight patients were eligible. The median follow-up period among surviving patients was 38 months (range, 11–107). The disease was T1a in 23%, T1b in 13%, and T2 in 65% of patients. The 3-year local control rate in all patients, T1a, T1b, and T2 was 96.7%, 100%, 100%, and 96.0%, respectively. Of the 46 patients, one with T2 glottic carcinoma developed recurrent disease at the primary site, and one with T2 glottic carcinoma had lymph node recurrences in the neck. Acute Grade 3 dermatitis occurred in 8 (17%) patients and late Grade 2 hypothyroidism occurred in 2 (4%) patients. This retrospective study shows that our optimized treatment strategy of radiotherapy depending on the stage of early glottic carcinoma is not only effective but also well-tolerated.

Wound healing after transoral angiolytic laser surgery for early glottic carcinoma

OBJECTIVES/HYPOTHESIS

Wound healing after transoral angiolytic laser surgery for early glottic carcinoma was analyzed to identify factors influencing healing and clinical significance of persistent granulation tissue.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review of 100 consecutive patients undergoing endoscopic angiolytic laser surgery for T1 and T2 glottic carcinoma was performed. Patients with prior radiation or incomplete data were excluded. Postoperative endoscopic images were analyzed for time to healing, size and location of wound, and presence of granulation tissue. Three blinded, independent raters graded wound appearance and presence of granulation tissue.

RESULTS

Seventy-nine patients healed without need for intervention at a median of 3.5 months. Two patients had office-based ablation of granulation without biopsy and healed. The remaining 19 patients had biopsy for granulation tissue. Wounds that underwent biopsy at >3 months were more likely to contain carcinoma (5/6 patients, 83%) than wounds that were biopsied <3 months (2/13 patients, 15%) (P = .004). Presence of granulation significantly correlated with resection involving anterior commissure (P = .01), > 75%vocal fold length (P = .006), and depth into muscle (P = .001). Delayed healing (>3 months) correlated with T2b tumors (P = .02), depth into ligament (P = .002) and anterior commissure involvement (P = .04). T1a carcinomas more commonly healed in <3 months (P = .005).

CONCLUSIONS

Many vocal fold wounds heal completely within 3.5 months after angiolytic laser surgery for early glottic carcinoma. Larger and deeper wounds are more likely to heal with granulation tissue. Granulation can resolve without surgical intervention; however, granulation present > 3 months warrants biopsy due to increased risk of malignancy.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:435-440, 2019.

Impact of Close and Positive Margins in Transoral Laser Microsurgery for Tis-T2 Glottic Cancer

Introduction

Transoral laser microsurgery (TLM) represents one of the most effective treatment strategies for Tis–T2 glottic squamous cell carcinomas (SCC). The prognostic influence of close/positive margins is still debated, and the role of narrow band imaging (NBI) in their intraoperative definition is still to be validated on large cohort of patients. This study analyzed the influence of margin status on recurrence-free survival (RFS) and disease-specific survival (DSS).

Methods

We retrospectively studied 507 cases of pTis–T1b (Group A) and 127 cases of pT2 (Group B) glottic SCC. We identified the following margin status: negative (n = 232), close superficial (n = 79), close deep (CD) (n = 35), positive single superficial (n = 146), positive multiple superficial (n = 94), and positive deep (n = 48) and analyzed their impact on RFS and DSS. Close margins were defined by tumor-margin distance <1 mm. Pre-TLM margins were defined by white light in 323 patients, whereas NBI was employed in 311 patients.

Results

In Group A, DSS and RFS were reduced in positive multiple superficial and positive deep margins (DSS = 96.1 and 97%, both p < 0.05; RFS = 72%, p < 0.001 and 75.8%, p < 0.01). In Group B, DSS was reduced in positive multiple superficial margins (82.4%, p < 0.05). RFS was reduced in positive single superficial, positive multiple superficial, and positive deep margins (62.5, 41.2, and 53.3%, p < 0.01). In the entire population, RFS was reduced in CD margins (77.1%, p < 0.05). Use of NBI led to improvement in RFS and DSS.

Conclusion

The study indicates that close and positive single superficial margins do not affect DSS. By contrast, all types of margin positivity predict the occurrence of relapses, albeit with different likelihood, depending on stage/margin type. CD margins should be considered as a single risk factor. Use of NBI granted better intraoperative margins definition.

Management of primary T1-T4 glottic squamous cell carcinoma by transoral laser microsurgery

OBJECTIVES/HYPOTHESIS

Evaluate the oncologic outcomes of patients with early and select advanced primary glottic squamous cell carcinoma (SCCa) managed by transoral laser microsurgery (TLM).

STUDY DESIGN

Retrospective cohort study.

METHODS

Ninety cases of TLM-managed primary glottic SCCa were identified retrospectively using a prospectively collected database.

RESULTS

Outcomes of patients with pTis-pT2a disease (n = 65) and pT2b-pT4a disease (n = 25) were, respectively: 5-year local control, 86.2% and 67.5%; 5-year disease-free survival, 64.9% and 44.9%; 5-year disease-specific survival, 96.4% and 59.0%; laryngeal preservation, 96.9% and 80%. Five of nine patients (56%) with supraglottic-glottic-subglottic tumors were local recurrence-free compared to the 70 of 81 (86%) patients with glottic, supraglottic-glottic, and glottic-subglottic tumors. Seven of 13 patients (54%) with positive or indeterminate margins were local recurrence-free compared to 68 of 77 (88%) patients with negative margins.

CONCLUSIONS

Given sample size considerations, this study highlights the satisfactory oncologic outcomes of TLM-treated glottic cancer and the potential importance of margin management and disease extension within the larynx.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:597-604, 2017.

Comparative multidimensional assessment of laryngeal function and quality of life after radiotherapy and laser surgery for early glottic cancer

BACKGROUND

This study was designed to comparatively assess laryngeal function and quality of life (QOL) of patients after laser surgery (LS) or radiotherapy (RT) for early glottic cancer.

METHODS

Sixty-four patients with T1 glottic cancer treated with RT or type II cordectomy underwent both subjective and objective vocal assessments. The LS group was divided into the following: (1) vaporization with defocused mode (laser surgery [LS]-Vap); and (2) excision with focused mode using lower power (LS-Ex).

RESULTS

Auditory-perceptual evaluation and videostroboscopic images in the LS-Ex group worsened shortly after treatment and time-dependent recovery was quicker than in the LS-Vap group. The LS-Ex group showed equivalent posttherapeutic vocal function with the RT group by acoustics, aerodynamics, and self-assessment questionnaire analysis, whereas the LS-Vap group showed statistically significant worse function.

CONCLUSION

The multidimensional assessment showed that early glottic cancer could be successfully treated by either RT or LS-Ex with equivalent posttherapeutic laryngeal function and QOL. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1085-1090, 2016.

Subjective and objective voice outcomes after transoral laser microsurgery for early glottic cancer

OBJECTIVES/HYPOTHESIS

Transoral laser microsurgery (TLM) continues to gain popularity as a treatment modality for early glottic cancer. Oncologic outcomes have been well-defined, but there are little data to date describing functional outcomes accounting for stage of resection.

STUDY DESIGN

Retrospective review.

METHODS

We retrospectively reviewed patient-rated voice handicap and observer-rated vocal quality of patients who underwent TLM for early glottic carcinoma. Patients were grouped by European Laryngological Society (ELS) resection type, and the data were combined for ELS type I-III and compared with advanced resections (ELS IV-VI). The Voice Handicap Index (VHI) was used for patient-rated voice outcomes, and voice recordings were graded by two senior speech-language pathologists. Voice recordings and VHI scores were taken preoperatively and at least 1 month postoperatively.

RESULTS

No major complications were encountered. Six of 49 patients underwent repeat resection for suspicious findings with pathology, demonstrating moderate dysplasia in two cases, carcinoma in situ in two cases, and inflamed mucosa only in two cases. There was no significant difference in preoperative VHI scores or objective voice grades among patients who underwent limited (ELS I-III) and those who required more advanced (ELS IV-VI) resection. There was a significant improvement in VHI scores in patients after ELS type I to III resection, from 38.77 to 22.86 (P = .006). There was no significant difference between mean preoperative and postoperative perceptual evaluation scores in patients who underwent ELS type I, II, or III resections (62.25 and 64.32 respectively, P = .621).

CONCLUSIONS

Patients who undergo limited ELS resections can be assured of having a similar to improved voice after healing. Patients who undergo extended resections have poorer vocal outcomes.

LEVEL OF EVIDENCE

4.

Critical evaluation of a prospective study of concurrent chemoradiotherapy with S-1 for early glottic carcinoma

AIM

To improve the outcomes of radiotherapy alone for T2 glottic carcinoma (GC), we initiated a prospective study of concurrent chemoradiotherapy with S-1 for patients with early GC, primarily T2 cases. We report the efficacy and safety of this protocol.

PATIENTS AND METHODS

Eligible patients had T1b or T2 glottic squamous cell carcinomas. Patients received S-1 (55.3 mg/m(2)/day, once daily) and radiotherapy (2 Gy/day, five days/week, to a total of 30 fractions).

RESULTS

Thirteen patients were eligible. Complete responses were observed in all 13 patients (100%). At a median follow-up duration of 53 months (range=23-68 months), the 3-year local control and overall survival rates were both 100%. Grade 3 dermatitis occurred in only one patient.

CONCLUSION

This chemoradiotherapy protocol is well -tolerated and effective in patients with early glottic carcinoma. Furthermore, due to its once-daily administration, this protocol is considered to be easier than usual chemoradiotherapy, and makes outpatient-treatment possible.

Comprehensive head and neck radiotherapy dose-volume constraints do not apply to smaller volumes

AIM

To investigate the impact of definitive radiation therapy (RT) in the management of early glottic cancer on clinical RT-induced dysphagia (RID) and carotid vasculopathy (RICV).

PATIENTS AND METHODS

This is a single-institution retrospective study. From January 1997 to 2010, 253 patients, with early glottic cancer, underwent RT with (60)Co or LINAC-6 MV photons. RT fields with wedge pair and daily 5-mm bolus were applied in all patients treated with 6-MV photons to avoid under-dose of the anterior laryngeal structures. The whole larynx (LX), pharyngeal constrictors (PCs), and carotid arteries (CA) were contoured and dose-volume histograms (DVHs) were generated to assess the delivered dose. The median age of patients was 65 years (range; 28-93), Caucasians were 80%, males were 87%, and 23% had T2 lesions.

RESULTS

After a median follow-up of seven years (range; 1.5-12), the median dose and fraction size delivered to the LX were 63 and 2.25 Gy, respectively. The mean doses to the LX, PC, and CA were 57 Gy delivered to 34 cm(3), 54 Gy to 15 cm(3), and 60 Gy to 4 cm(3), respectively. The LX, PC and CA V60 and V65 were (77 and 71), (70 and 52) and (84 and 51), respectively. Patients with acute dysphagia grades 1, 2, and 3 or more were 81, 19%, and zero, respectively; none had clinically RID or RICV.

CONCLUSION

Small-volume RT up to 67.5 Gy at 2.25 Gy per fraction, is not a predictor of RID or RICV. Separate delineation of the aforementioned critical structures, as well as others, may better identify dose tolerances to maintain function and further prioritize the importance of structures in RID and RICV.

Evaluation of acute/late toxicity and local recurrence in T1-T2 glottic carcinoma treated with accelerated hypofractionated 3D-conformal external beam radiotherapy (3D-CRT)

Background

The aim of the study was to evaluate the efficacy, as well as the acute and late toxicity of an accelerated hypofractionated 3DCRT schedule as radical treatment in patients with organ confined glottic cancer cT1-2N0.

Patients and methods.

Between June of 2004 and September 2010, 47 retrospectively selected patients (29 males, 18 females) diagnosed with organ confined T1 or T2 glottic cancer, were treated with external 3DCRT in an accelerated hypofractionation schedule. The median age was 70 years. A dose of 64.4 Gy in 28 daily fractions was prescribed. The primary study endpoints were to assess the acute and late effects of radiation toxicity, according to the EORTC/ RTOG scale, as well as the therapeutic impact of this schedule in terms of local recurrence.

Results

The median follow up was 36 months. At the end of radiotherapy, grade I, II and III acute toxicity was observed in 34, 9 and4 patients, respectively. Late grade I and II toxicity was observed in 25 and in 8 patients respectively. Only two local recurrences were observed, 15 and 24 months post 3DCRT respectively.

Conclusions

Our radiotherapy schedule achieves a high locoregional control rate with the advantage of voice preservation. The proposed hypofractionated schedule can be recommended as a standard radiotherapy treatment, since these results are comparable with those of conventional fractionation schedules.

Modified supracricoid laryngectomy: oncological and functional outcomes in the elderly

BACKGROUND

Supracricoid laryngectomy is an organ preservation surgical technique for early-stage glottic tumors. Modified supracricoid laryngectomy using sternohyoid muscles for neoglottis reconstruction is a new surgical technique. This report evaluates oncological and functional outcomes of this new technique and its feasibility in elderly patients.

METHODS

Clinical records from 21 consecutive patients affected by glottic cancer and treated by modified SCL between 2004 and 2009 were retrospectively reviewed. Postoperative parameters and quality of voice after modified SCL were retrospectively reviewed. Actuarial overall survival, disease-specific survival rates, and recurrence-free survival rates were assessed. The functional and oncological outcomes of patients over 65 years were compared with those of patients younger than 65 years of age.

RESULTS

There were no postoperative complications and all of the patients had complete swallowing rehabilitation. Twenty of the 21 patients had decannulation. Two patients received total laryngectomy for locoregional relapse. Overall survival and disease-specific survival rates were 100%. Recurrence-free survival rates were 90.1% and 90% in patients younger and older than 65 years of age, respectively. The larynx preservation index was lower in patients who were older than 65 years of age. The postoperative courses with regard to functional outcome and voice quality in elderly patients were similar to those of patients younger than 65 years of age.

CONCLUSION

Modified SCL is a new open organ preservation surgical technique that is oncologically safe. The positive functional and oncological outcomes of this surgical procedure allow it to be performed in elderly patients.