Decisional Conflict in Patients with Advanced Laryngeal Carcinoma: A Multicenter Study

OBJECTIVES

Decision-making for patients with a locally advanced laryngeal carcinoma (T3 and T4) is challenging due to the treatment choice between organ preservation and laryngectomy, both with different and high impact on function and quality of life (QoL). The complexity of these treatment decisions and their possible consequences might lead to decisional conflict (DC). This study aimed to explore the level of DC in locally advanced laryngeal carcinoma patients facing curative decision-making, and to identify possible associated factors.

METHODS

In this multicenter prospective cohort study, participants completed questionnaires on DC, level of shared decision-making (SDM), and a knowledge test directly after counseling and 6 months after treatment. Descriptive statistics and Spearman correlation tests were used to analyze the data.

RESULTS

Directly after counseling, almost all participants (44/45; 98%) experienced Clinically Significant DC score (CSDC >25, scale 0-100). On average, patients scored 47% (SD 20%) correct on the knowledge test. Questions related to radiotherapy were answered best (69%, SD 29%), whilst only 35% (SD 29%) of the questions related to laryngectomy were answered correctly. Patients' perceived level of SDM (scale 0-100) was 70 (mean, SD 16.2), and for physicians this was 70 (SD 1.7).

CONCLUSION

Most patients with advanced larynx cancer experience high levels of DC. Low knowledge levels regarding treatment aspects indicate a need for better patient counseling.

LEVEL OF EVIDENCE

Level IV Laryngoscope, 2024.

Predictors of multiple dilations and functional outcomes after total laryngectomy and laryngopharyngectomy

BACKGROUND

Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown.

METHODS

Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022.

RESULTS

A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group.

CONCLUSIONS

Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

Reduced expression of secretogranin VGF in laryngeal squamous cell carcinoma

Laryngeal cancer accounts for one-third of all head and neck tumors, with squamous cell carcinoma (SCC) being the most predominant type, followed by neuroendocrine tumors. Chromogranins, are commonly used as biomarkers for neuroendocrine tumors, including laryngeal cancer. It has been reported that secretogranin VGF, a member of the chromogranin family, can be also used as a significant biomarker for neuroendocrine tumors. However, the expression and role of VGF in laryngeal carcinomas have not been previously investigated. Therefore, the present study aimed to determine the expression levels of VGF in laryngeal SCC (LSCC). The present study collected tumor tissues, as well as serum samples, from a cohort of 15 patients with LSCC. The results of reverse transcription-quantitative PCR, western blot analysis and immunofluorescence assays showed that the selective VGF precursor was downregulated in patients with LSCC. Notably, in tumor tissue, the immunoreactivity for VGF was found in vimentin-positive cells, probably corresponding to T lymphocytes. The current preliminary study suggested that the reduced expression levels of VGF observed in tumor tissue and at the systemic level could sustain LSCC phenotype. Overall, VGF could be a potential biomarker for detecting neoplastic lesions with a higher risk of tumor invasiveness, even in non-neuroendocrine tumors.

Cancer-Related Fatigue in Head and Neck Cancer Survivors: Longitudinal Findings from the Head and Neck 5000 Prospective Clinical Cohort

Cancer-related fatigue (CRF) is a common side-effect of cancer and its treatments. For head and neck cancer (HNC), CRF may exacerbate the symptom burden and poor quality-of-life. Using data from the Head and Neck 5000 prospective clinical cohort, we investigated clinically important CRF over a year post-diagnosis, assessing temporal trends, CRF by HNC site and treatment received, and subgroups at higher risk of CRF. Recruitment was undertaken in 2011-2014. Socio-demographic and clinical data, and patient-reported CRF (EORTC QLQ-C30 fatigue subscale score ≥39 of a possible 100) were collected at baseline (pre-treatment) and 4- and 12- months post-baseline. Mixed-effects logistic multivariable regression was used to investigate time trends, compare cancer sites and treatment groups, and identify associations between clinical, socio-demographic and lifestyle variables and CRF. At baseline, 27.8% of 2847 patients scored in the range for clinically important CRF. This was 44.7% at 4 months and 29.6% at 12 months. In the multivariable model, after adjusting for time-point, the odds of having CRF over 12 months were significantly increased in females and current smokers; those with stage 3/4 disease, comorbidities and multimodal treatment; and those who had depression at baseline. The high prevalence of clinically important CRF indicates the need for additional interventions and supports for affected HNC patients. These findings also identified patient subgroups towards whom such interventions could be targeted.

Squamous Cell Carcinoma of the Oral Cavity, Oropharynx, and Larynx: A Scoping Review of Treatment Guidelines Worldwide

Head and neck cancer (HNC) treatments have been based on single or multimodal therapies with surgery, radiotherapy (RT), chemotherapy, and immunotherapy. However, treatment recommendations among countries may differ due to technological/human resources and usual local practices. This scoping review aims to identify, compare, and map the clinical practice guidelines (CPGs) for treating squamous cell carcinoma (SCC) of the oral cavity, oropharynx, and larynx worldwide. A search strategy on global CPGs for HNC was performed by using five electronic databases and grey literature. CPGs were selected for inclusion using EndNote-20 and Rayyan online software. No language or publication date restrictions were applied. The results were analyzed descriptively considering the most updated CPG version. In total, 25 CPGs covering the head and neck region (10), the larynx (7), the oral cavity (5), and the oropharynx (3), were found in 13 geographical regions, and 19 were developed by medical societies from 1996 to 2023. Surgery and RT remain the main modalities for early-stage HNC, with surgery preferred in low-resource countries, and RT in selected cases, especially in the larynx/oropharynx aiming to achieve a cure with organ preservation. Human papillomavirus infection for oropharyngeal SCC is not tested in some Asian countries and there is still no consensus to treat p16-positive cases differently from p16-negative. Recommendations for larynx preservation vary according to facilities in each country, however, individualized choice is emphasized. Inequality across countries/continents is evident, with a similar pattern of recommendations among developed as well as developing ones. No CPGs were found in Latin America as well as Oceania countries, where the incidence of HNC is high and limitations of access to treatment may be encountered.

Nodal metastasis in surgically treated laryngeal squamous cell carcinoma

BACKGROUND

Management of the neck in laryngeal squamous cell carcinoma (LSCC) is essential to oncologic control and survival. We aim to describe patterns and rates of clinical/pathologic lymph node disease, elective neck dissection (END), and occult lymph node metastasis (LNM) in patients with surgically-managed LSCC.

METHODS

Retrospective cohort study of patients in the National Cancer Database (NCDB) diagnosed with LSCC between January 2004 and December 2016 who underwent primary surgery.

RESULTS

Seven thousand eight hundred and seventy-six patients met inclusion criteria. For cN0 patients, the rates of END and occult LNM both increased with tumor stage and were highest for supraglottic tumors. Predictors of occult LNM included supraglottic site, pathologic T3 and T4 stage, positive margins, and presence of lymphovascular invasion (p < 0.05).

CONCLUSIONS

The propensity for cervical LNM in surgically-managed LSCC varies based on primary tumor site and stage, and a variety of disease factors increase risk of occult LNM.

Updates on Larynx Cancer: Risk Factors and Oncogenesis

Laryngeal cancer is a very common tumor in the upper aero-digestive tract. Understanding its biological mechanisms has garnered significant interest in recent years. The development of laryngeal squamous cell carcinoma (LSCC) follows a multistep process starting from precursor lesions in the epithelium. Various risk factors have been associated with laryngeal tumors, including smoking, alcohol consumption, opium use, as well as infections with HPV and EBV viruses, among others. Cancer development involves multiple steps, and genetic alterations play a crucial role. Tumor suppressor genes can be inactivated, and proto-oncogenes may become activated through mechanisms like deletions, point mutations, promoter methylation, and gene amplification. Epigenetic modifications, driven by miRNAs, have been proven to contribute to LSCC development. Despite advances in molecular medicine, there are still aspects of laryngeal cancer that remain poorly understood, and the underlying biological mechanisms have not been fully elucidated. In this narrative review, we examined the literature to analyze and summarize the main steps of carcinogenesis and the risk factors associated with laryngeal cancer.

Trend and projection of larynx cancer incidence and mortality in China from 1990 to 2044: A Bayesian age-period-cohort modeling study

BACKGROUND

Larynx cancer is one of the most common cancers in head and neck, and imposes heavy burden on individual and societies. A comprehensive understanding of the burden of larynx cancer is necessary to improve prevention and control strategies. However, the secular trend of larynx cancer incidence and mortality in China remains unclear.

METHODS

The incidence and deaths rates of larynx cancer from 1990 to 2019 were collected from the Global Burden of Disease Study 2019 database. The temporal trend of larynx cancer was analyzed using a joinpoint regression model. The age-period-cohort model was used to explore the age, period, and cohort effects on larynx cancer and predict future trends up to 2044.

RESULTS

From 1990 to 2019, the age-standardized incidence rate of larynx cancer in China increased by 1.3% (95% CI 1.1 to 1.5) in males, but decreased by 0.5% (95% CI -0.1 to 0) in females. The age-standardized mortality rate of larynx cancer in China decreased by 0.9% (95% CI -1.1 to -0.6) and 2.2% (95% CI -2.8 to -1.7) in males and females, respectively. Among the four risk factors, smoking and alcohol use contributed to a heavier burden compared to occupational exposure to asbestos and sulfuric acid with respect to mortality. Age effects showed that the incidence and deaths of larynx cancer were concentrated in people older than 50 years old. Period effects exerted the most significant effect on larynx cancer incidence for males. In terms of cohort effects, people born in the earlier cohorts presented a higher risk of larynx cancer compared with the later cohorts. From 2020 to 2044, the age-standardized incidence rates of larynx cancer continued to increase in males, whereas the age-standardized mortality rates continued to decrease in both males and females.

CONCLUSION

The burden of larynx cancer in China has a significant gender difference. The age-standardized incidence rates will continue to increase in males up to 2044. The disease pattern and risk factors of larynx cancer should be comprehensively studied to promote the development of timely intervention measures and relieve the burden effectively.

Early-Stage Glottic Carcinoma in the United States: Demographics and Treatment Choice

OBJECTIVE

Limited investigation of factors potentially contributing to treatment choice in early-stage glottic carcinoma (EGC) has been performed with large-scale data. The National Cancer Database (NCDB) represents >72% of all new cancer cases in the United States. We hypothesized that NCDB variables may lend insight into treatment decisions between surgery and radiation for EGC.

METHODS

The NCDB was queried for all cases of T_1-2  N₀  M₀ glottic carcinoma from 2004 to 2016. We used multivariable logistic regression analysis to examine factors associated with first-line treatment modality: radiation therapy (RT) versus surgery. All reported odds ratios (OR) were adjusted for age, gender, race, insurance, residence in a metropolitan area, region, and facility volume.

RESULTS

34,991 EGC patients received treatment: 6,687 (19%) surgery; 20,289 (58%) RT; and 8,015 (23%) surgery and RT. OR for receiving RT (vs. surgery alone) were >2 for: more advanced T stage cancers (OR 2.5 [95%CI: 2.3, 2.7]), treatment at non-academic facilities (OR 2.8, [95%CI: 2.6, 3.0]), and shorter travel distances to treatment centers (OR 2.2, [95%CI: 2.0, 2.4]). Surgery was more likely with treatment in the western US, higher income, private insurance, living in a metropolitan (vs. non-metropolitan) area, female gender, older age, and low facility volume. Hispanic ethnicity, education level, and race were not associated with treatment type in the multivariable model.

CONCLUSION

Most patients in the NCDB receive first-line treatment with radiation for EGC, and this decision is associated with various tumor, patient, and treatment facility characteristics.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:901-907, 2023.

Surgeon Volume and Laryngectomy Outcomes

OBJECTIVE

To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy.

DATA SOURCES

The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables.

METHODS

Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression.

RESULTS

Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity.

CONCLUSION

There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.

Defining targets to improve care delivery for T4 larynx squamous cell carcinoma

Objective

United States oncology trends consistently demonstrate that nearly half of T4a larynx carcinoma patients are treated with larynx preservation, despite national guidelines favoring laryngectomy. This study identifies clinical decision-making drivers and defines patient subsets that should become targets for care improvement.

Methods

Retrospective analysis of patients with cT4 squamous cell carcinoma of the larynx from US National Cancer Database 2005-2016. Demographic data and survival rates between clinical pathways were compared. Survival was estimated by Kaplan-Meier method with statistical comparisons assessed by log-rank test.

Results

Of 11,556 patients with cT4 disease, laryngectomy (TL) was the initial treatment for 4627 (40%) patients. Larynx preservation via chemoradiation (CRT) occurred for 4307 patients. TL and CRT patients had similar Charlson-Deyo comorbidity indices and insurance status. TL patients had higher total tumor size, lower N3 rates and were more often seen at academic institutions (p < .0001). N0 surgery patients with adjuvant treatment demonstrated superior median survival (MS) compared to CRT (surgery + radiation MS: 69 months, surgery + chemoradiation MS: 66, CRT MS: 37.7), p < .0001. MS for N1/N2 disease patients was 56.5 months for surgery + radiation and 35.5 months for surgery + CRT, superior to CRT, MS 30.8 months, p < .0001. Tri-modality N3 patients with up front surgery had similar MS compared to CRT (surgery + chemoradiation 21.3 months vs. CRT 16.1), p = .95.

Conclusion

National quality improvement initiatives are needed to promote guideline adherence and improve survival in advanced larynx cancer. Targets for such initiatives should be patients with limited or no nodal disease burden, that meet clear T4a imaging criteria.

Level of Evidence

Level IV, non-randomized controlled cohort.

Videomics of the Upper Aero-Digestive Tract Cancer: Deep Learning Applied to White Light and Narrow Band Imaging for Automatic Segmentation of Endoscopic Images

Introduction

Narrow Band Imaging (NBI) is an endoscopic visualization technique useful for upper aero-digestive tract (UADT) cancer detection and margins evaluation. However, NBI analysis is strongly operator-dependent and requires high expertise, thus limiting its wider implementation. Recently, artificial intelligence (AI) has demonstrated potential for applications in UADT videoendoscopy. Among AI methods, deep learning algorithms, and especially convolutional neural networks (CNNs), are particularly suitable for delineating cancers on videoendoscopy. This study is aimed to develop a CNN for automatic semantic segmentation of UADT cancer on endoscopic images.

Materials and Methods

A dataset of white light and NBI videoframes of laryngeal squamous cell carcinoma (LSCC) was collected and manually annotated. A novel DL segmentation model (SegMENT) was designed. SegMENT relies on DeepLabV3+ CNN architecture, modified using Xception as a backbone and incorporating ensemble features from other CNNs. The performance of SegMENT was compared to state-of-the-art CNNs (UNet, ResUNet, and DeepLabv3). SegMENT was then validated on two external datasets of NBI images of oropharyngeal (OPSCC) and oral cavity SCC (OSCC) obtained from a previously published study. The impact of in-domain transfer learning through an ensemble technique was evaluated on the external datasets.

Results

219 LSCC patients were retrospectively included in the study. A total of 683 videoframes composed the LSCC dataset, while the external validation cohorts of OPSCC and OCSCC contained 116 and 102 images. On the LSCC dataset, SegMENT outperformed the other DL models, obtaining the following median values: 0.68 intersection over union (IoU), 0.81 dice similarity coefficient (DSC), 0.95 recall, 0.78 precision, 0.97 accuracy. For the OCSCC and OPSCC datasets, results were superior compared to previously published data: the median performance metrics were, respectively, improved as follows: DSC=10.3% and 11.9%, recall=15.0% and 5.1%, precision=17.0% and 14.7%, accuracy=4.1% and 10.3%.

Conclusion

SegMENT achieved promising performances, showing that automatic tumor segmentation in endoscopic images is feasible even within the highly heterogeneous and complex UADT environment. SegMENT outperformed the previously published results on the external validation cohorts. The model demonstrated potential for improved detection of early tumors, more precise biopsies, and better selection of resection margins.

G870A Polymorphic Variants of CCND1 Gene and Cyclin D1 Protein Expression as Prognostic Markers in Laryngeal Lesions

CCND1 gene encodes Cyclin D1 protein, the alternations and overexpression of which are commonly observed in human cancers. Cyclin D1 controls G1-S transition in the cell cycle. The aim of the study was to assess utility of the genotyping and protein expression in predicting the susceptibility of transformation from normal tissue to precancerous laryngeal lesions (PLLs) and finally to laryngeal cancer (LC). Four hundred and thirty-five patients (101 with LC, 100 with PLLs and 234 healthy volunteers) were enrolled in the study. Cyclin D1 expression was examined by immunohistochemistry and G870A polymorphism of gene CCND1 by PCR-RFLP technique. We confirmed association between the A allele and risk of developing LC from healthy mucosa (p = 0.006). Significantly higher expression of Cyclin D1 was observed in LC compering with PLLs (p < 0.0001) and we found that it could be a predictive marker of shorter survival time. To sum up, in the study population CCND1 gene polymorphism A870G and Cyclin D1 expression have a significant impact on the risk of developing PLLs and LC, and, therefore, Cyclin D1 could be a useful marker for the prediction of survival time in LC, whereas CCND1 gene polymorphism does not have a direct impact on patients’ outcome.

Tumor-Infiltrating Lymphocytes in Patients With Advanced Laryngeal Cancer Undergoing Bioselection

OBJECTIVE

Bioselection to assess tumor response after induction chemotherapy has been introduced as an alternative treatment strategy to total laryngectomy for patients with advanced larynx squamous cell carcinoma (LSCC). Tumor-infiltrating lymphocytes (TILs) have proven to serve as prognostic biomarkers in head and neck cancer but have not been evaluated as a way to select patients for treatment paradigms. The aim of this study is to evaluate the role of pretreatment TILs in patients with advanced LSCC undergoing the bioselection paradigm.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care hospital.

METHODS

Patients with advanced LSCC treated with bioselection and available tissue were included (N = 76). Patients were stratified into CD8-low and CD8-high cohorts by using the median TIL count. Kaplan-Meier survival analysis and multivariate cox regression were performed with SPSS version 26 (IBM).

RESULTS

After controlling for tobacco use, tumor site, and stage, a high CD8 TIL count was an independent predictor of improved 5-year disease-specific survival (hazard ratio, 0.17 [95% CI, 0.03-0.84]; P = .03). CD8 TIL counts did not predict response to induction chemotherapy; however, subgroup analysis of patients treated with chemoradiation therapy revealed that CD8 TIL count was significantly associated with degree of response (P = .012).

CONCLUSION

These findings support prior data published by our group showing that TILs are predictive of disease-specific survival in patients with head and neck cancer. CD8 TIL counts were significantly associated with degree of clinical response after induction chemotherapy. These results suggest that pretreatment assessment of tumor-infiltrating CD8 cells could be useful in selecting patients.

Early-Stage Glottic Squamous Cell Carcinoma in the Era of Image-Guided Radiotherapy

Early-stage squamous cell cancer (SCC) of the glottis has a good prognosis. Therefore, patients have long survival outcomes and may potentially suffer from late toxicities of radiotherapy. Radiotherapy with a conventional parallel-opposed-pair or anterior-oblique beam arrangements for stage 1 and 2 glottic SCC have field borders that traditionally cover the entire larynx, exposing organs-at-risk (e.g. carotid arteries, contralateral vocal cord, contralateral arytenoid and inferior pharyngeal constrictor muscles) to high radiation doses. The potential long-term risk of cerebrovascular events has attracted much attention to the dose that carotid arteries receive. Swallow and respiratory motion of laryngeal structures has been an important factor that previously limited reduction of the radiation treatment volume. Motion has been evaluated using multiple imaging modalities and this information has been used to calculate PTV margins for generation of more limited target volumes. This review discusses the current literature surrounding dose-effect relationships for various organs-at-risk and the late toxicities that are associated with them. This article also reviews the currently available data and effects of laryngeal motions on dosimetry to the primary target. We also review the current limitations and benefits of a more targeted approach of radiotherapy for early-stage glottic SCCs and the evolution of CT-based IGRT and MR-guided radiotherapy techniques that may facilitate a shift away from a conventional 3D-conformal radiotherapy approach.

Outcomes between intensity-modulated radiation therapy versus 3D-conformal in early stage glottic cancer

BACKGROUND

The purpose of this study is to evaluate practice patterns and outcomes between intensity-modulated radiation therapy (IMRT) and 3D-conformal radiation (3D-CRT) in early stage glottic cancer.

METHODS

The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify and compare patient and disease profiles, mortality, and toxicity in patients with T1-2 larynx cancer undergoing definitive radiation (RT).

RESULTS

A total of 1520 patients underwent definitive radiation with 3D-CRT (n = 1309) or IMRT (n = 211). Non-white race, those with a Charlson Comorbidity Index ≥2, T2 disease, and those treated at community practices were more likely to undergo IMRT. Rates of IMRT increased from 2006 to 2015, while relative rates of 3D-CRT decreased. Two-year CSS was superior with 3D-CRT (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.22-0.65; p < 0.001). There was no difference in OS between 3D-CRT and IMRT (p = 0.119).

CONCLUSIONS

Patients receiving 3D-CRT had improved CSS compared to IMRT with no difference in OS.

Statistical harmonization can improve the development of a multicenter CT-based radiomic model predictive of nonresponse to induction chemotherapy in laryngeal cancers

PURPOSE

To develop a radiomic model predicting nonresponse to induction chemotherapy in laryngeal cancers, from multicenter pretherapeutic contrast-enhanced computed tomography (CE-CT) and evaluate the benefit of feature harmonization in such a context.

METHODS

Patients (n = 104) eligible for laryngeal preservation chemotherapy were included in five centers. Primary tumor was manually delineated on the CE-CT images. The following radiomic features were extracted with an in-house software (MIRAS v1.1, LaTIM UMR 1101): intensity, shape, and textural features derived from Gray-Level Co-occurrence Matrix (GLCM), Neighborhood Gray Tone Difference Matrix (NGTDM), Gray-Level Run Length Matrix (GLRLM), and Gray-Level Size Zone Matrix (GLSZM). Harmonization was performed using ComBat after unsupervised hierarchical clustering, used to determine labels automatically, given the high heterogeneity of imaging characteristics across and within centers. Patients with similar feature distributions were grouped with unsupervised clustering into an optimal number of clusters (2) determined with "silhouette scoring." Statistical harmonization was then carried out with ComBat on these 2 identified clusters. The cohort was split into training/validation (n = 66) and testing (n = 32) sets. Area under the receiver operating characteristics curves (AUC) were used to evaluate the ability of radiomic features (before and after harmonization) to predict nonresponse to chemotherapy, and specificity (Sp) and sensitivity (Se) were used to quantify their performance in the testing set.

RESULTS

Without harmonization, none of the features identified as predictive in the training set remained significant in the testing set. After ComBat, one textural feature identified in the training set keeps a predictive trend in the testing set-Zone Percentage, derived from the GLSZM, was predictive of nonresponse in the training set (AUC = 0.62, Se = 70%, Sp = 64%, P = 0.04) and obtained a satisfactory performance in the testing set (Se = 80%, Sp = 67%, P = 0.03), although significance was limited by the size of the testing set. These results are consistent with previously published findings in head and neck cancers.

CONCLUSIONS

Radiomic features from CE-CT could help in the selection of patients for induction chemotherapy in laryngeal cancers, with relatively good sensitivity and specificity in predicting lack of response. Statistical harmonization with ComBat and unsupervised clustering seems to improve the predictive value of features extracted in such a heterogeneous multicenter setting.

Functional and Oncologic Outcomes of Octogenarians Undergoing Transoral Laser Microsurgery for Laryngeal Cancer

OBJECTIVE

To evaluate the oncologic and functional outcomes of transoral laser microsurgery (TLM) for glottic cancers in patients ≥80 years.

STUDY DESIGN

Prospectively collected case series.

SETTING

QEII Health Sciences Centre, Halifax, Canada.

METHODS

This case series used a prospectively collected glottic cancer database to examine consecutive elderly patients (≥80 years old) undergoing TLM. Kaplan-Meier analysis was used to evaluate rates of disease-free, disease-specific, and overall survival as the primary end points of oncologic control. Secondary functional outcomes included voice function, length of hospital stay, and time to readmission.

RESULTS

From 2005 to 2017, 17 octogenarian patients underwent TLM for glottic cancer. Median follow-up was 4.19 years (interquartile range, 0.71-6.95). Kaplan-Meier estimates of 5-year survival were 78.4% (disease free), 92.9% (disease specific), and 81.9% (overall). The median length of hospital stay was 1 day (range, 0-8). There was only 1 readmission within 30 days of surgery. No patients in this study developed significant surgical or postoperative complications requiring unplanned readmissions. Patient-perceived voice function improved to normal after treatment in 62.5% of patients.

CONCLUSION

The results of this study suggest that TLM is a safe and effective treatment modality for glottic cancer in patients aged ≥80 years, providing good oncologic control and satisfactory functional outcomes.

Assessing the Applicability of the TALK Score: A Modification for Concurrent Tobacco Use During Treatment

OBJECTIVE

The previously described TALK score (T-stage, Albumin, Liquor, Karnofsky Performance Status) has been proposed as a method to predict laryngectomy-free survival (LFS) in patients undergoing definitive chemoradiation (CRT). This study assesses its use as well as a modification to include continued tobacco use.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic institution from 2004 to 2020.

METHODS

Patients diagnosed with larynx or hypopharynx cancer undergoing CRT were reviewed. Clinically relevant variables were collected (TALK), which were dichotomized per previously set cutoffs. Concurrent tobacco use was evaluated and also dichotomized as 0 or 1. Multivariate analysis was conducted to determine which factors were most predictive of the key outcomes of survival and LFS.

RESULTS

A total of 2514 patient charts were evaluated. Patients treated for larynx cancer with primary CRT with complete data were included, ultimately totaling 300. Of these, 78 patients required salvage total laryngectomy (TL). Multivariate analysis demonstrated that LFS was best predicted by tobacco use during treatment (odds ratio [OR] 0.3465, 95% confidence interval [CI] 0.1862-0.6300) and Karnofsky Performance Status (OR 0.1646, 95% CI 0.0673-0.3662). Tobacco use during treatment was also strongly predictive of survival. Excluding T4 tumors, the utilization of tobacco in place of T-stage improved the accuracy of the predictive model in this cohort.

CONCLUSION

Given that a T-stage of 4 is typically treated with total laryngectomy, modification of the TALK score to include tobacco use during treatment (tALK) for patients with T < 4 can be used to improve prediction of 3-year LFS and overall survival.

Serum hypoxia-inducible factor-2: A candidate prognostic biomarker for laryngeal cancer

OBJECTIVES

To determine the serum hypoxia-inducible factor-1, -2 and -3 (HIF-1, -2 and -3) levels in patients with laryngeal neoplasm, and to investigate their role in differential diagnosis, prediction of tumour characteristic and extension, and prognosis and survival.

STUDY DESIGN

Prospective, cohort study at a tertiary referral centre.

SETTINGS

The study was conducted in a tertiary medical centre.

PARTICIPANTS

Patients with benign, premalignant and malignant laryngeal neoplasms were included. Sixty-four patients with a laryngeal neoplasm were enrolled.

MAIN OUTCOME MEASURES

Serum HIF-1, -2 and -3 levels were measured from blood samples that were drawn before treatment, using ELISA.

RESULTS

A statistically significant difference between benign (HIF-1, -2, -3:4046,1 pg/mL; 2581,5 pg/mL; 1321,0 pg/mL), premalignant (HIF-1, -2, -3:3630,3 pg/mL; 3229,7 pg/mL; 2549,8 pg/mL) and malignant (HIF-1, -2, -3:3576,7 pg/mL; 2595,8 pg/mL; 1106,3 pg/mL) laryngeal neoplasms was not detected when serum HIF-1, -2 and -3 levels were compared. However, high serum HIF-2 level adversely affected survival and locoregional control and had more than 7-fold increase in hazard ratio. Moreover, serum HIF-2 was an independent prognostic factor for 2-year overall, disease-free, distant metastasis-free survival and locoregional control.

CONCLUSION

This is the first clinical study in which the diagnostic, predictive and prognostic roles of hypoxia-related biomolecules were examined in laryngeal neoplasms. Hypoxia-inducible factor-2 is a prognostic factor in larynx cancer irrespective of treatment modality.

Micronucleus, nucleoplasmic bridge and nuclear bud frequencies in patients with laryngeal carcinoma

The aim of the study is to determine and compare micronucleus (MN), nucleoplasmic bridge (NPB) and nuclear bud (NBUD) frequencies in patients with laryngeal carcinoma and healthy controls. The study was conducted in the School of Medicine of Onsekiz Mart University. A total of 102 volunteers, 51 of whom had laryngeal carcinoma and 51 of whom were healthy control subjects, participated in this study. The Cytokinesis-Block Micronucleus Assay (CBMN) was applied to peripheral blood lymphocytes taken from patients and controls. We evaluated MN, NPBs and NBUDs frequencies in patients with laryngeal carcinoma and compared the results with those in the control group. The frequencies of MN, NPBs and NBUDs of patients with laryngeal carcinoma were found significantly higher than those in the control group (P = 0.01, P = 0.004, P = 0.01, respectively). MN, NPB and NBUD frequencies were also compared in the patients with and without pesticide exposure, and the means of all frequencies was higher in patients with pesticide exposure (P = 0.001, P = 0.02 respectively). The MN, NPBs and NBUDs frequencies of the patients with laryngeal cancer were significantly higher than those of the control group, and pesticide exposure might be a risk factor that increases genomic instability and risk of laryngeal cancer.

Analysis of the TCGA Dataset Reveals that Subsites of Laryngeal Squamous Cell Carcinoma are Molecularly Distinct

Simple Summary

Squamous cell carcinomas from different parts of the larynx have distinct presentations and prognoses, but the molecular basis for this discrepancy has yet to be characterized. We aimed to determine whether different types of mutations at the DNA, mRNA, and protein levels exist to explain the differential prognoses observed. We found that cancers of the supraglottis had higher overall and smoking-associated genome mutations. Further, supraglottic cancers had a significantly poorer prognosis when other clinical variables and mutational status were controlled for. Different protein pathways were enriched in each subsite: muscle-related in the glottis and neural in the supraglottis. Specific cancer-related proteins were also differentially abundant between the supraglottis and glottis. Our findings may partially explain therapeutic response differences, but further study is required for validation.

Abstract

Laryngeal squamous cell carcinoma (LSCC) from different subsites have distinct presentations and prognosis. In this study, we carried out a multiomic comparison of LSCC subsites. The Cancer Genome Atlas (TCGA) LSCC cohort was analyzed in the R statistical environment for differences between supraglottic and glottic cancers in single nucleotide variations (SNVs), copy number alterations (CNAs), mRNA abundance, protein abundance, pathway overrepresentation, tumor microenvironment (TME), hypoxia status, and patient outcome. Supraglottic cancers had significantly higher overall and smoking-associated SNV mutational load. Pathway analysis revealed upregulation of muscle related pathways in glottic cancer and neural pathways in supraglottic cancer. Proteins involved in cancer relevant signaling pathways including PI3K/Akt/mTOR, the cell cycle, and PDL1 were differentially abundant between subsites. Glottic and supraglottic tumors have different molecular profiles, which may partially account for differences in presentation and response to therapy.

Chronic opioid use after laryngeal cancer treatment

BACKGROUND

Survivors of head and neck cancer may be at increased risk for chronic opioid use and questions remain about risk factors.

METHODS

Retrospective study of patients with laryngeal cancer prescribed opioids utilizing the Truven Health Marketscan database. Patients had laryngeal cancer, underwent treatment, filled an opioid prescription, and were enrolled in this private insurance plan 1 year prior to and after treatment.

RESULTS

In this study, 7484 patients were included; 17.2% developed chronic opioid use, defined as consecutive opioid fills at least 90 days after treatment cessation. Early opioid use (OR = 3.607, 95% CI [3.125-4.163]), tobacco use (OR = 1.28, 95% CI [1.117-1.467]), median morphine milligram equivalent (MME; OR = 1.001, 95% CI [1.000-1.0001]), and radiation alone (OR = 1.435, 95% CI [1.199-1.717]) were predictive of chronic opioid use.

CONCLUSIONS

Nearly one in five patients prescribed opioids during treatment developed chronic use. Providers should discuss the risk of chronic opioid use, set expectations for opioid weaning, and consider adjunct pain regimens to develop effective pain management strategies.

The Impact of Narrow-band Imaging on the Pre- and Intra- operative Assessments of Neoplastic and Preneoplastic Laryngeal Lesions. A Systematic Review

Introduction  Narrow-band imaging is an endoscopic diagnostic tool that, focusing on superficial vascular changes, is useful to detect suspicious laryngeal lesions, enabling their complete excision with safe and tailored resection margins.

Objectives  To analyze the applications and benefits of narrow-band imaging in detecting premalignant and malignant laryngeal lesions through a comparison with white-light endoscopy.

Data Synthesis  A literature search was performed in the PubMed, Scopus and Web of Science databases using strict keywords. Then, two authors independently analyzed the articles, read the titles and abstracts, and read completely only the relevant studies according to certain eligibility criteria. In total, 14 articles have been included in the present review; the sensitivity, specificity, positive and negative predictive values, and accuracy of pre- and/or intraoperative narrow-band imaging were analyzed. The analysis showed that narrow-band imaging is better than white-light endoscopy in terms of sensitivity, specificity, positive and negative predictive values, and accuracy regarding the ability to identify cancer and/or precancerous laryngeal lesions. Moreover, the intraoperative performance of narrow-band imaging resulted more effective than the in-office performance.

Conclusion  Narrow-band imaging is an effective diagnostic tool to detect premalignant and malignant laryngeal lesions and to define proper resection margins. Moreover, narrow-band imaging is useful in cases of leukoplakia that may cover a possible malignant lesion and that cannot be easily assessed with white-light endoscopy. Finally, a shared, simple and practical classification of laryngeal lesions, such as that of the European Laryngological Society, is required to identify a shared lesion management strategy.

Key Points

Predictors of Stricture and Swallowing Function Following Salvage Laryngectomy

BACKGROUND

Long-term functional outcomes are poorly characterized for salvage laryngectomy. We identified predictors of esophageal stricture and swallowing function after salvage laryngectomy in a large cohort.

METHODS

A retrospective study of 233 patients who underwent salvage total laryngectomy for recurrent/persistent squamous cell carcinoma of the larynx or hypopharynx after radiation (XRT) or chemoradiation (CRT) was performed. Primary outcomes were esophageal dilation within 1 year, time to dilation, and gastrostomy tube dependence. Multivariate logistic and Cox regressions were used for statistical analysis.

RESULTS

Dilation was performed in 29.9% of patients. Dilation was twice as likely in patients with post-operative fistula compared to those without (Hazard Ratio (HR) 2.10, 95% Confidence Interval (CI) 1.06-4.13, P = .03). Every year between XRT/CRT and salvage was associated with 10% increase in dilation (HR 1.09, 95% CI 1.03-1.17, P = .01). No factors were associated with dilation by 1 year. About 10% of patients were at least partially gastrostomy tube-dependent 1 year post-operatively. At last follow-up (median 29 months), this rate was 13%. Patients with supraglottic recurrence had an increased risk of gastrostomy tube dependence at 1 year compared to glottic (OR 16.7, 95% CI 1.73-160, P = .02). For every 10 pack years pre-salvage, the OR of requiring tube feeds at last follow-up was 1.24 (95% CI 1.04-1.48, P = .02).

CONCLUSIONS

Fistula and pre-salvage smoking were associated with stricture post-salvage laryngectomy. No factors were associated with dilation by 1 year. Supraglottic recurrence and smoking were associated with gastrostomy tube dependence. These findings are important for pre-operative counseling prior to salvage laryngectomy.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 131:1229-1234, 2021.

Convolutional Neural Network Classifies Pathological Voice Change in Laryngeal Cancer with High Accuracy

Voice changes may be the earliest signs in laryngeal cancer. We investigated whether automated voice signal analysis can be used to distinguish patients with laryngeal cancer from healthy subjects. We extracted features using the software package for speech analysis in phonetics (PRAAT) and calculated the Mel-frequency cepstral coefficients (MFCCs) from voice samples of a vowel sound of /a:/. The proposed method was tested with six algorithms: support vector machine (SVM), extreme gradient boosting (XGBoost), light gradient boosted machine (LGBM), artificial neural network (ANN), one-dimensional convolutional neural network (1D-CNN) and two-dimensional convolutional neural network (2D-CNN). Their performances were evaluated in terms of accuracy, sensitivity, and specificity. The result was compared with human performance. A total of four volunteers, two of whom were trained laryngologists, rated the same files. The 1D-CNN showed the highest accuracy of 85% and sensitivity and sensitivity and specificity levels of 78% and 93%. The two laryngologists achieved accuracy of 69.9% but sensitivity levels of 44%. Automated analysis of voice signals could differentiate subjects with laryngeal cancer from those of healthy subjects with higher diagnostic properties than those performed by the four volunteers.

Transforming growth factor-β1 gene polymorphism as a potential risk factor in Turkish patients with laryngeal squamous cell carcinoma

Introduction

Laryngeal cancer is the most common head-and-neck malignancies with more than 20% of all cases. The vast majority of tumors are squamous cell carcinoma (SCC). Several genes encoding different cytokines may play crucial roles in host susceptibility to cancer because cytokine production capacity varies among individuals and depends on cytokine gene polymorphisms.

Materials and Methods

The association between cytokine gene polymorphisms with primary laryngeal SCC was investigated. DNA samples were obtained from a Turkish population of eighty patients with primary cancer and fifty healthy controls.

Results

All genotyping (interferon-gamma, transforming growth factor-β1 [TGF-β1], tumor necrosis factor-alpha [TNF-α], interleukin [IL]-6, and IL-10) experiments were performed using polymerase chain reaction sequence-specific primers. When compared to the healthy controls, the frequencies of TGF-β1 codon 25 (rs1800471) GC genotype and 25 C allele were significantly more common in the patient group.

Conclusions

These results suggest that TGF-β1 gene polymorphisms may affect host susceptibility to laryngeal cancer.

Genotype of Null Polymorphisms in Genes GSTM1, GSTT1, CYP1A1, and CYP1A1*2A (rs4646903 T>C)/CYP1A1*2C (rs1048943 A>G) in Patients with Larynx Cancer in Southeast Spain

Simple Summary

Epidemiological studies have shown that individual susceptibility to cancer is mediated by genetic and environmental factors. The aim of the present study is to evaluate the individuals’ metabolic genetic susceptibility to toxic habits (smoking and alcohol consumption) by detecting polymorphisms CYP1A1 rs1048943 T>C and CYPA1A2 rs4646903 A>G, and null polymorphisms in GSTM1 and GSTT1 genotypes, comparing a group of healthy control subjects with a population of larynx cancer patients from southeastern Spain. As results patients with larynx cancer present more gene GSTM1 and GSTT1 null polymorphisms, and CYP1A1 rs4646903 T>C polymorphisms.

Abstract

Background: some types of cancer have been associated with the presence of single nucleotide polymorphisms (SNPs) of some genes that encode enzymes: glutathione-S transferase (GST), whose alteration leads to loss of function and a lower capacity to eliminate toxic GSTM1 and GSTT1 null genotypes; SNPs causing loss of function of CYP1A1 or CYP1A1–2 cytochrome P450 enzymes related with a lower capacity to deactivate hydrocarbons related to smoking, which involves a higher risk of developing some smoking-dependent cancers including larynx cancer. Objective: to compare the presence of null SNPs in genes GSTM1, GSTT1, and CYP1A1 rs 4646903 T>C, and CYP1A1–2 RS1048943 A>G in patients with hypopharyngeal and larynx cancer with a healthy control group. Materials and method: The study included a total of 80 patients with hypopharyngeal and laryngeal cancer and 23 healthy subjects. Genomic DNA was obtained from saliva samples, determining genotype GSTM1 (present +, or null −), GSTT1 (present + or null −). Polymorphisms (SNP) in CYP1A1 T>C (present + CC, or absent − TC/TT), and CYP1A1–2 A>G (present + GG, or absent − AG/AA). Results: the mean age of patients with larynx cancer was 62 years and of control subjects 63 years. Of the total sample, over 95% were men, and over 90% were smokers. The presence of null genotypes for GTM1 was 50% in patients with larynx cancer (p = 0.042), while GSTT1 was 88.75% (p = 0.002). CYP1A1 rs4646903 T>C polymorphisms were detected in 100% of cases of larynx cancer and 17.39% of healthy subjects (p > 0.001). Conclusions: patients with larynx cancer present more gene GSTM1 and GSTT1 null polymorphisms, and CYP1A1 rs4646903 T>C polymorphisms.

A Rare Case of Primary Neuroendocrine Carcinomas in the Ear and Throat and Review of Literatures

The neuroendocrine carcinomas (NECs) of the head and neck are rare. The purpose of this article is to explore the diagnosis and treatment of NECs in the ear and larynx. We report a case of a patient with NECs found in the ear and throat simultaneously, and the relevant literatures are reviewed. It is difficult to identify which is the original site. There is no specific clinical manifestation of NECs in the ear and throat, and carcinoid syndrome is a rare situation. Surgery is still the preferred treatment for this disease. For patients with metastasis, radiotherapy and/or chemotherapy are required.

The Predictive Value of Proportional Evaluation Based on the Metabolic Activity of Cervical Lymph Nodes on PET/CT Imaging in Patients with Larynx Cancer

Objectives

We aimed to evaluate the proportional values of maximum standardized uptake value (SUV_max) for cervical lymph nodes on ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for prediction of the presence of metastasis in patients with larynx squamous cell cancer (LSCC).

Methods

This retrospective study involved 43 patients with LSCC. All patients underwent resection of the primary tumor and neck dissection within 4 weeks after undergoing ¹⁸F-FDG PET/CT examinations. Receiver operating characteristic (ROC) analysis was performed to evaluate the lymph node SUV_max/primary tumor SUV_max (SUV_maxLN/SUV_maxPT), lymph node SUV_max/aortic SUV_max (SUV_maxLN/SUV_maxA), and lymph node SUV_max/ liver SUV_max (SUV_maxLN/SUV_maxL) ratios for diagnosis of lymph node metastasis.

Results

SUV_maxLN/SUV_maxA, SUV_maxLN/SUV_maxL, and SUV_maxLN/SUV_maxPT rates were significantly higher in metastatic lymph nodes compared to non-metastatic nodes. ROC analysis for metastasis showed that the cut-off thresholds were 3.87 for SUV_maxLN; 1.78 for SUV_maxLN /SUV_maxA; 1.08 for SUV_maxLN/SUV_maxL; and 0.36 for SUV_maxLN/SUV_maxPT. The diagnostic sensitivity, specificity and AUC were 83.7%, 77%, 0.856 for SUV_maxLN; 79.7%, 84%, 1.78 for SUV_maxLN/SUV_maxA; 84.1%, 76%, 0.833 for SUV_maxLN/SUV_maxL; and 53.6%, 76%, 0.666 for SUV_maxLN/SUV_maxPT, respectively.

Conclusion

SUV_maxLN/SUV_maxA, SUV_maxLN/SUV_maxL, and SUV_maxLN/SUV_maxPT ratios can be safely used for diagnosis of cervical lymph node metastasis in patients with LSCC.

Imperatorin as a Promising Chemotherapeutic Agent Against Human Larynx Cancer and Rhabdomyosarcoma Cells

Naturally occurring coumarins are bioactive compounds widely used in Asian traditional medicine. They have been shown to inhibit proliferation, induce apoptosis, and/or enhance the cytotoxicity of currently used drugs against a variety of cancer cell types. The aim of our study was to examine the antiproliferative activity of different linear furanocoumarins on human rhabdomyosarcoma, lung, and larynx cancer cell lines, and dissolve their cellular mechanism of action. The coumarins were isolated from fruits of Angelica archangelica L. or Pastinaca sativa L., and separated using high-performance counter-current chromatography (HPCCC). The identity and purity of isolated compounds were confirmed by HPLC-DAD and NMR analyses. Cell viability and toxicity assessments were performed by means of methylthiazolyldiphenyl-tetrazolium bromide (MTT) and lactate dehydrogenase (LDH) assays, respectively. Induction of apoptosis and cell cycle progression were measured using flow cytometry analysis. qPCR method was applied to detect changes in gene expression. Linear furanocoumarins in a dose-dependent manner inhibited proliferation of cancer cells with diverse activity regarding compounds and cancer cell type specificity. Imperatorin (IMP) exhibited the most potent growth inhibitory effects against human rhabdomyosarcoma and larynx cancer cell lines owing to inhibition of the cell cycle progression connected with specific changes in gene expression, including CDKN1A. As there are no specific chemotherapy treatments dedicated to laryngeal squamous cell carcinoma and rhabdomyosarcoma, and IMP seems to be non-toxic for normal cells, our results could open a new direction in the search for effective anti-cancer agents.

Clinical outcomes for larynx patients with cancer treated with refinement of high-dose radiation treatment volumes

BACKGROUND

To evaluate disease control, toxicities, and dose to dysphagia/aspiration risk structures (DARS) using a direct gross tumor volume (GTV_70Gy ) to planning target volume expansion (dPTV_70Gy ) for patients with squamous cell carcinoma of the larynx (LSCC).

METHODS

A retrospective review was performed on patients with LSCC treated between 2003 and 2018. Clinical outcomes, toxicities, and dosimetric data were analyzed.

RESULTS

Seventy-three patients were identified. Overall survival at 5-years was 57.8%. Five-year local and regional control was 79.8% and 88.2%, respectively. Distant metastatic-only failure was 2.7%. Eighty percent of failures were 95% contained within the dPTV_70Gy . Mean dose and the volume of DARS receiving 70 Gy was significantly lower for dPTV_70Gy compared to a consensus-defined PTV_70Gy .

DISCUSSION

Judicious reduction in high-dose target volumes can preserve high tumor control rates while reducing dose to normal surrounding structures underscoring the potential benefit of this approach in enabling local therapy intensification to improve locoregional control.

Global burden of larynx cancer, 1990-2017: estimates from the global burden of disease 2017 study

Larynx cancer is one of the most common cancers in head and neck. This study aimed to investigate the health burden of larynx cancer at global, regional, and national levels. We collected data of larynx cancer between 1990 and 2017 from the Global Burden of Disease study, including incidence, mortality, and disability adjusted life-years (DALYs). Estimated annual percentage changes (EAPCs) were calculated to assess the changes in age-standardized rate (ASR) of larynx cancer. From 1990 to 2017, LC incident cases increased by 58.67%; however, age-standardized incidence rate (ASIR) decreased, with an EAPC of -0.99. Additionally, the incident cases and ASIR of LC were 6-fold higher for male than those for female in 2017. Over the past 28 years, deaths and DALYs of larynx cancer increased by 33.84% and 25%. Contrarily, age-standardized death and DALY rate showed a downward trend. Incidence, death, and DALYs of larynx cancer were always the highest in people aged 50-69 years. Overall, all the ASRs showed downward trends globally. The majority of larynx cancer burden was observed in men, especially among male aged 50-69 years. South and East Asia carried the heaviest burden of larynx cancer worldwide.

Estimation of Occupational Exposure to Asbestos in Italy by the Linkage of Mesothelioma Registry (ReNaM) and National Insurance Archives. Methodology and Results

The identification and monitoring of occupational cancer is an important aspect of occupational health protection. The Italian law on the protection of workers (D. Leg. 81/2008) includes different cancer monitoring systems for high and low etiologic fraction tumors. Record linkage between cancer registries and administrative data is a convenient procedure for occupational cancer monitoring. We aim to: (i) Create a list of industries with asbestos exposure and (ii) identify cancer cases who worked in these industries. The Italian National Mesothelioma Registry (ReNaM) includes information on occupational asbestos exposure of malignant mesothelioma (MM) cases. We developed using data from seven Italian regions a methodology for listing the industries with potential exposure to asbestos linking ReNaM to Italian National Social Security Institute (INPS) data. The methodology is iterative and adjusts for imprecision and inaccuracy in reporting firm names at interview. The list of asbestos exposing firms was applied to the list of cancer cases (all types associated or possibly associated with asbestos according to International Agency for Research on Cancer (IARC) monograph 100C) in two Italian regions for the indication of possible asbestos exposure. Eighteen percent of the cancer cases showed at least one work period in firms potentially exposing to asbestos, 48% of which in regions different from where the cases lived at diagnosis. The methodology offers support for the preliminary screening of asbestos exposing firms in the occupational history of cancer cases.

Updates on larynx cancer epidemiology

Objective

Laryngeal cancer is an important oncologic entity, whose prognosis depends on establishing appropriate preventive and diagnostic measures, especially in populations at higher risk.

Methods

Epidemiologic information including worldwide incidence, prevalence, burden of health loss (disability-adjusted life year; DALYs) and mortality of larynx cancer was obtained from the Global Health Data Exchange (GHDx) database.

Results

The current incidence, prevalence and mortality of laryngeal cancer are estimated at 2.76 cases/year per 100,000 inhabitants, 14.33 cases/year per 100,000 inhabitants and 1.66 deaths/year per 100,000 inhabitants, respectively, averaging 3.28 million DALYs each year. Incidence and prevalence have increased by 12% and 24%, respectively during the past 3 decades, whilst mortality has declined by around 5%. The epidemiologic burden of this malignancy is approximately 5-fold higher in males and increases in parallel with ageing, peaking after 65 years of age. Both incidence and mortality rates are higher in Europe and lower in Africa, but the ratio between deaths and incidence is the highest in Africa. Incidence has gradually declined in Europe during the past 3 decades, whilst it has increased in South-East Asia and Western Pacific. Cigarette smoking and alcohol abuse contribute for about 90% of overall worldwide mortality for laryngeal cancer.

Conclusions

Laryngeal cancer still poses a high clinical and societal burden, with an escalating temporal trend not expected to reverse soon.

Outcomes of carotid-sparing IMRT for T1 glottic cancer: Comparison with conventional radiation

OBJECTIVES

We aim to report oncologic outcomes after conventional radiotherapy (ConRT) using opposed lateral beams and intensity-modulated radiation therapy (IMRT) for tumor (T)1 nodal (N)0 T1 N0 glottic squamous cell carcinoma.

STUDY DESIGN

Retrospective case-control study.

METHODS

We retrospectively reviewed demographic, disease, and treatment characteristics for patients treated at our institution during 2000 to 2013.

RESULTS

One hundred fifty-three patients (71%) were treated using ConRT and 62 (29%) using IMRT. The median follow-up for all patients was 68 months. There was no statistically significant difference in 5-year local control between patients with T1a versus T1b disease (94% vs. 89%, respectively, P = 0.5). Three-year locoregional control for patients treated with ConRT was 94% compared to 97% with IMRT (P = 0.4). Three-year overall survival (OS) for patients treated with ConRT was 92.5% compared with 100% with IMRT (P = 0.1). Twelve of 14 patients with local recurrence underwent salvage surgery with 5-year ultimate locoregional control of 98.5% and 97.1% in the ConRT and IMRT cohorts, respectively (P = 0.7). Multivariate analysis showed age < 60 years (P < 0.0001) and pretreatment Eastern Cooperative Oncology Group performance status <2 (P = 0.0022) to be independent correlates of improved OS. Postradiation cerebrovascular events were in four patients in the ConRT cohort (3%), whereas no patients in the IMRT cohort suffered any events.

CONCLUSION

Because the oncologic outcomes for patients treated with IMRT were excellent and IMRT allows for carotid sparing, we have transitioned to IMRT as our standard for most patients with T1 glottic cancer.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:146-153, 2020.

Head and neck neuroendocrine tumors at a single institution over 15 years

Head and neck cancer is a diverse group of rare diseases such as neuroendocrine tumors which can be thought of as extrapulmonary small-cell cancer. Surgery, chemotherapy, and radiation can frequently cure this disease, possibly due to early detection.

Influencing Factors on Radiotherapy Outcome in Stage I-II Glottic Larynx Cancer-A Multicenter Study

Background and Purpose: Larynx cancer represents one of the most frequently diagnosed head and neck malignancies, which is most often confined to the glottic area. The aim of this study was to report the oncological outcome and identify prognostic factors in early-stage glottic squamous cell carcinoma treated with radiotherapy. Material and Methods: Patients (n = 761) diagnosed and treated in 10 centers between 1990 and 2015 were retrospectively analyzed. Probabilities of loco-regional control (LRC) and overall survival (OS) were calculated and possible prognostic factors were analyzed using Cox proportional hazards models. Results: The median follow-up was 63 months (range: 2-243). Three hundred and sixty-four, 148 and 249 patients had cT1a, cT1b, and cT2 stage I-II disease, respectively. Five and 10-years LRC/OS rates in the whole cohort were 83/82% and 80/68%, respectively. Three patients developed distant recurrences. In univariate analysis, male sex (HR: 3.49; 95% CI: 1.47-11.37; p < 0.01), T2 vs. T1a (HR: 1.62; 95% CI: 1.08-2.43; p = 0.02) and anterior commissure involvement (ACI) (HR: 1.66; 95% CI: 1.38-2.45; p < 0.01) were associated with impaired LRC. In multivariate analysis, male sex (HR: 3.42; 95% CI: 1.44-11.17; p < 0.01) and ACI (HR: 1.51; 95% CI: 1.01-2.28; p = 0.047) remained poor prognostic factors. No relation of treatment technique and biologically equivalent dose (BED) to oncological outcome was identified except for higher BED₁₀(L = 25; T = 1) yielding better LRC in T1a tumors (p = 0.04) in univariate analyses. Conclusion: Our results highlight the negative impact of ACI on tumor control. A less-expected finding was the impact of sex on tumor control. Further research is needed to validate its prognostic value and investigate any related biologic or behavioral factors, which may be modified to improve oncologic outcome.

Salvage surgery for recurrent larynx cancer

BACKGROUND

Despite advances in treatment, the recurrence rates for laryngeal cancer range from 16% to 40%.

METHODS

Patients with recurrent laryngeal cancer treated at Memorial Sloan Kettering (MSK) from 1999 to 2016 were reviewed. Survival outcomes were analyzed.

RESULTS

Of 241 patients, 88% were male; the median age was 67 years; 71% had primary glottic tumors. At initial treatment, 72% of patients were seen with early stage disease; primary treatment was radiation (68%), chemoradiation (29%), and surgery (3%). The most common salvage surgery was total laryngectomy (74%). Forty-seven percentage were upstaged at salvage surgery. The 2- and 5-year disease-specific survival (DSS) was 74% and 57%, respectively. Patients with cT4 disease treated with nonsurgical primary management had a 0% 5-year DSS. Independent predictors of DSS were tumor location, perineural invasion, margin, and stage.

CONCLUSIONS

Salvage surgery results in acceptable oncologic outcomes. Stage, disease site, perineural invasion, and margins are associated with inferior DSS.

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.

The investigation of hyaluronic acid and hyaluronidase-1 levels as tumour marker in larynx cancer

OBJECTIVE

The purpose of this study was to investigate the hyaluronic acid (HA) and hyaluronidase-1 (HYAL-1) levels in laryngeal cancer patients.

STUDY DESIGN

Prospective, controlled clinical trial.

SETTING

University Medical Center.

PARTICIPANTS

Fifty laryngeal squamous cell carcinoma patients and 50 volunteers who gave saliva samples investigated prospectively between 2016 and 2017.

METHODS

Hyaluronidase-1 expression was measured by RT-PCR in normal and tumour tissue samples; hyaluronic acid values of saliva and tumour tissues were measured by ELISA method.

RESULTS

HYAL-1 expression increased 2.5-fold in tumour tissues compared to normal tissues, and the difference was statistically significant (P < 0.001).Mean saliva HA levels were 103.93 ± 69.04 ng/mL and 177.29 ± 98.44 ng/mL in the patients and controls' saliva specimens, respectively. The difference was not statistically significant (P = 0.657). HA levels were higher in tumour tissue samples than saliva samples, but there was not statistically significant difference between saliva and tumour tissue HA levels.

CONCLUSION

HYAL-1 expression in laryngeal squamous cell carcinomas is elevated compared to normal tissues of same patients. Targeting this gene and HA catabolism products may use treatment of larynx cancer in the future.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for laryngeal cancer

OBJECTIVES/HYPOTHESIS

To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer.

STUDY DESIGN

Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data.

METHODS

Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume.

RESULTS

Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E <1 (N = 32) treated 284 patients (16.5%), with a mean O/E of 0.77 ± 0.18. Hospitals treating more than six cases with an O/E ≥1 (N = 68) treated 672 patients (39.1%), with a mean O/E of 1.17 ± 0.11. Treatment at hospitals with an O/E ≥1 was associated with improved survival (hazard ratio [HR] = 0.83 [95% confidence interval [CI]: 0.70 to 0.98]) and lower mean incremental treatment-related costs (-$3,009 [-$5,226 to -$791]) compared with hospitals with an O/E <1 (HR = 1.00 [0.80 to 1.24]) and the reference group of low-volume hospitals.

CONCLUSIONS

A hospital-specific O/E for NCCN treatment guideline adherence, combined with a minimum case volume criterion, is associated with survival and treatment-related costs in elderly patients with larynx cancer, and may be a feasible measure of larynx cancer quality of care.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:672-678, 2020.

Biweekly cetuximab in combination with platinum and 5-fluorouracil in metastatic head and neck carcinoma

Background and Aim

The combination of cetuximab with platinum and 5-fluorouracil (5-FU) chemotherapy prolongs survival in patients with metastatic or recurrent squamous-cell carcinoma of the head and neck (SCCHN). Biweekly (once in 2 weeks) administration of cetuximab requires fewer hospital visits and decreases treatment costs; therefore, it is more convenient both for the patients and for the healthcare providers. Here, we assessed the efficacy, safety, and tolerability of an alternative biweekly regimen of cetuximab in combination with platinum and 5-FU chemotherapy as a first-line treatment for these patients.

Methods and Materials

Medical records of patients with metastatic or recurrent non-nasopharyngeal SCCHN who were treated with a biweekly regimen of cetuximab (500 mg/m² on day 1), cisplatin (40 mg/m² on day 1) or carboplatin (target area under the curve 3.5 mg/ml × min on day 1), folinic acid (400 mg/m² on day 1), and 5-FU (400 mg/m² bolus on day 1 followed by continuous infusion of 2,400 mg/m² 5-FU over 46 h) were retrospectively reviewed. Survival estimates were calculated with the Kaplan-Meier method.

Results

In total, 60 patients were included. The median age of the patients was 60.5. The objective response rate was 53.3% (95% confidence interval [CI] = 40.7-65.9). The median progression-free survival duration was 6.8 months (95% CI = 5.5-8.1) and the median overall survival duration was 13.3 months (95% CI = 8.4-18.2). The most common grade 3 or 4 adverse events were neutropenia (28.3%) and leucopenia (13.3%). Grade 3 or 4 rash was observed in 3.3% of the patients.

Conclusion

Biweekly administration of cetuximab, cisplatin, and 5-FU is an effective regimen with a favorable toxicity profile for the first-line treatment of metastatic or recurrent SCCHN. These results warrant further evaluation of this regimen in prospective trials.

Improving decision making in larynx cancer by developing a decision aid: A mixed methods approach

OBJECTIVE

Patients diagnosed with advanced larynx cancer face a decisional process in which they can choose between radiotherapy, chemoradiotherapy, or a total laryngectomy with adjuvant radiotherapy. Clinicians do not always agree on the best clinical treatment, making the decisional process for patients a complex problem.

METHODS

Guided by the International Patient Decision Aid (PDA) Standards, we followed three developmental phases for which we held semi-structured in-depth interviews with patients and physicians, thinking-out-loud sessions, and a study-specific questionnaire. Audio-recorded interviews were verbatim transcribed, thematically coded, and analyzed. Phase 1 consisted of an evaluation of the decisional needs and the regular counseling process; phase 2 tested the comprehensibility and usability of the PDA; and phase 3 beta tested the feasibility of the PDA.

RESULTS

Patients and doctors agreed on the need for development of a PDA. Major revisions were conducted after phase 1 to improve the readability and replace the majority of text with video animations. Patients and physicians considered the PDA to be a major improvement to the current counseling process.

CONCLUSION

This study describes the development of a comprehensible and easy-to-use online patient decision aid for advanced larynx cancer, which was found satisfactory by patients and physicians (available on www.treatmentchoice.info). The outcome of the interviews underscores the need for better patient counseling. The feasibility and satisfaction among newly diagnosed patients as well as doctors will need to be proven. To this end, we started a multicenter trial evaluating the PDA in clinical practice (ClinicalTrials.gov Identifier: NCT03292341).

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2733-2739, 2019.

Diagnostics and acknowledgement of occupational diseases - topics and challenges in the Czech Republic

The causes of occupational diseases are changing, thats why a regular update of Czech List of Occupational Diseases is needed. New compensable occupational diseases, such as cancer of the larynx and ovarian cancer due to asbestos, and chronic obstructive pulmonary diseases due to black coal dust were included in the last two updates of the Czech List. The need of an early examination at the Centers of Occupational Diseases is stressed in this article, especially before a surgery or other treatment of epicondylitis and carpal tunnel syndrome. These treatments may suppress the diagnostic hallmarks requested for acknowledgements of these disorders. Extrinsic allergic alveolitis, allergic rhinitis and bronchial asthma are underdiagnosed, and isocyanates belong among the key factors. Only about 10 % patients with mesotheliomas due to asbestos are compensated. The latency in cancers due to asbestos may reach more than 50 years.

Integrative analysis of mRNA and microRNA expression profiles in laryngeal squamous cell carcinoma

Larynx cancer is a therapeutically challenging disease. Rapidly evolving experimentally validated data have significantly improved our understanding of the complex role of numerous RNA, DNA, and proteins that play a role in the development and progression of cancer. Based on the insights from approximately two decades of research, it seems clear that microRNAs (miRNAs) have revolutionized our concepts related to the main role of noncoding RNAs in different cancers' progression, development, and metastasis. Mechanistically, miRNAs have been reported to regulate different RNAs and finally protein-coding genes. The expression profiling of miRNAs and messenger RNA (mRNAs) was conducted for a deeper analysis of the miRNAs and mRNAs which play an essential role in larynx cancer. Downregulation or upregulation over twofolds in the miRNAs was considered to be significant, and that of sixfolds or below was considered to be significant for the mRNAs. In accordance with this approach, the expression levels of 43 miRNAs were increased in this study, whereas the expression levels of 129 were decreased. Accordingly, all the genomic expression studies provided evidence of upregulation of 97 genes, whereas 128 genes were found to be downregulated. Among these miRNAs, hsa-miR-20a-3p and hsa-miR-1972 were noted to be important in the etiology of larynx cancer.

Age-adjusted comorbidity and survival in locally advanced laryngeal cancer

BACKGROUND

The purpose of this study was to quantify the relationship among age, pretreatment comorbidity, and survival outcomes in patients with locally advanced laryngeal cancer.

METHODS

Baseline comorbidity data were collected and age-adjusted Charlson Comorbidity Index (CCI) was calculated for each case. Kaplan-Meier and Cox proportional hazards modeling were used to determine associations with survival.

RESULTS

For 548 patients, with a median age of 59 years (range 31-91 years), 58% were treated with larynx preservation and the rest with total laryngectomy and adjuvant radiotherapy (RT). Two hundred thirty-eight patients (43%) had at least 1 comorbidity each. Cardiovascular diseases were the most common comorbidities (19%). The 5-year overall survival (OS) for patients with CCI ≤3 (n = 442) were superior to CCI >3 (n = 106; 60% vs 41%; P < .0001), although the 5-year disease-specific survival (DSS) rates were not significantly different. The 5-year noncancer CSS was better for age-adjusted CCI ≤3 (88% vs 67%; P < .0001).

CONCLUSION

The age-adjusted CCI is a significant predictor of noncancer CSS and OS for patients with locally advanced laryngeal cancer but is not associated with DSS.

Role of Krüppel-like factor 4 and heat shock protein 27 in cancer of the larynx

Late detection and lack of standard treatment strategies in larynx cancer patients result in high levels of mortality and poor prognosis. Prognostic stratification of larynx cancer patients based on molecular prognostic tumor biomarkers may lead to more efficient clinical management. Krüppel-like factor 4 (KLF4) and Heat Shock Protein 27 (HSP27) have an important role in tumorigenesis and are considered promising candidate biomarkers for various types of cancer. However, their role in larynx carcinoma remains to be elucidated. The present study aimed to determine KLF4 and HSP27 expression profiles in laryngeal tumors. The protein and mRNA expression levels of KLF4 and HSP27 were evaluated by immunohistochemical and reverse transcription-polymerase chain reaction analyses in 44 larynx carcinoma samples and 21 normal tissue samples, and then correlated with clinical characteristics. A differential expression of KLF4 and HSP27 was observed between normal and tumor tissues. The protein and mRNA expression levels of KLF4 were significantly decreased in larynx squamous cell carcinoma (LSCC) compared with normal tissue, whereas HSP27 was significantly overexpressed in tumor tissues compared with normal tissues, at the protein and mRNA levels. KLF4 expression decreased gradually with tumor progression whereas HSP27 expression increased. A significant difference was observed between stages I and IV. KLF4 and HSP27 exhibit opposite functions and roles in the carcinogenic process of LSCC. Their role in laryngeal cancer initiation and progression emphasizes their use as potential future targets for prognosis and treatment. KLF4 and HSP27 expression levels may act as potential biomarkers in patients with cancer of the larynx.

Individualized outcome prognostication for patients with laryngeal cancer

BACKGROUND

Accurate prognostication is essential to the optimal management of laryngeal cancer. Predictive models have been developed to calculate the risk of oncologic outcomes, but extensive external validation of accuracy and reliability is necessary before implementing them into clinical practice.

METHOD

Four published prognostic calculators that predict 5-year overall survival for patients with laryngeal cancer were evaluated using patient information from a prospective epidemiology study cohort (n = 246; median follow-up, 60 months) with previously untreated, stage I through IVb laryngeal squamous cell carcinoma.

RESULTS

Different calculators yielded substantially different predictions for individual patients. The observed 5-year overall survival was significantly higher than the averaged predicted 5-year overall survival of the 4 calculators (71.9%; 95% confidence interval [CI], 65%-78%] vs 47.7%). Statistical analyses demonstrated the calculators' limited capacity to discriminate outcomes for risk-stratified patients. The area under the receiver operating characteristic curve ranged from 0.68 to 0.72. C-index values were similar for each of the 4 models (range, 0.66-0.68). There was a lower than expected hazard of death for patients who received induction (bioselective) chemotherapy (hazard ratio, 0.46; 95% CI, 0.24-0.88; P = .024) or primary surgical intervention (hazard ratio, 0.43; 95 % CI, 0.21-0.90; P = .024) compared with those who received concurrent chemoradiation.

CONCLUSIONS

Suboptimal reliability and accuracy limit the integration of existing individualized prediction tools into routine clinical decision making. The calculators predicted significantly worse than observed survival among patients who received induction chemotherapy and primary surgery, suggesting a need for updated consideration of modern treatment modalities. Further development of individualized prognostic calculators may improve risk prediction, treatment planning, and counseling for patients with laryngeal cancer. Cancer 2018;124:706-16. © 2017 American Cancer Society.

Evaluating Post-Radiotherapy Laryngeal Function with Laryngeal Videostroboscopy in Early Stage Glottic Cancer

Objective

Dysphonia is common among patients with early stage glottic cancer. Laryngeal videostroboscopy (LVS) has not been routinely used to assess post-radiotherapy (RT) voice changes. We hypothesized that LVS would demonstrate improvement in laryngeal function after definitive RT for early-stage glottic cancer.

Study design

Blinded retrospective review of perceptual voice and stroboscopic parameters for patients with early glottic cancer and controls.

Setting

High-volume, single-institution academic medical center.

Subjects and methods

Fifteen patients underwent RT for Tis-T2N0M0 glottic cancer and were evaluated with serial LVS exams pre- and post-RT. Stroboscopic assessment included six parameters: vocal fold (VF) vibration, VF mobility, erythema/edema, supraglottic compression, glottic closure, and secretions. Grade, roughness, breathiness, asthenia, strain (GRBAS) voice perceptual scale was graded in tandem with LVS score. Assessments were grouped by time interval from RT: pre-RT, 0–4, 4–12, and >12 months post-RT.

Results

60 LVS exams and corresponding GRBAS assessments were reviewed. There were significant improvements in ipsilateral VF motion (P = 0.03) and vibration (P = 0.001) and significant worsening in contralateral VF motion (P < 0.001) and vibration (P = 0.008) at >12 months post-RT. Glottic closure significantly worsened, most prominent >12 months post-RT (P = 0.01). Composite GRBAS scores were significantly improved across all post-RT intervals.

Conclusion

LVS proved to be a robust tool for assessing pre- and post-RT laryngeal function. We observed post-RT improvement in ipsilateral VF function, a decline in contralateral VF function, and decreased glottic closure. These results demonstrate that LVS can detect meaningful changes in VF and glottic function and support its use for post-RT evaluation of glottic cancer patients.