Repeated transoral laser microsurgery for early and advanced recurrence of early glottic cancer after primary laser resection

Objectives

To analyze the oncological results of repeated transoral laser microresection (TLM) in case of failure after primary laser resection of early glottic cancer (pTis-pT2).

Methods

Fifty-six patients with local or loco-regional recurrence of early glottic cancer were treated between 1988 and 2005 by repeated TLM followed, if necessary, by neck dissection and/or adjuvant radio- or radiochemotherapy. Data on overall survival, disease-specific survival, and loco-regional control rates were analyzed retrospectively and calculated by the Kaplan–Meier method.

Results

Forty-four patients (78.6%) presented with early local recurrence (rTis-rT2N0; Stage I/II) and 12 patients (21.4%) had advanced local or loco-regional recurrence (pT3 and pT4N0/N+; Stage III/IV). Three- and five-year overall survival rates for patients with early and advanced recurrence were 75.1% vs. 51.6% and 61.6% vs. 25.8%, respectively. The corresponding three- and five-year disease-specific survival rates were 87.2% vs. 85.7% and 81.0% vs. 85.7%, respectively. Three- and five-year loco-regional control was significantly higher for patients treated for early recurrence (67.6% vs. 27.5% and 63.6% vs. 27.5%, respectively; p = 0.02). Salvage laryngectomy rates for patients with early and advanced recurrence were 9.1 and 25.0%, respectively. In patients with early local recurrence, anterior commissure involvement (n = 11) did not affect the oncological results.

Conclusions

In case of early local recurrence after primary TLM of early glottic cancer, further TLM seems to be justified as an organ-preserving treatment option. In contrast, salvage laryngectomy should be considered early for patients with advanced local or loco-regional recurrence.     

早期声门型喉癌钬激光与CO2激光手术对比研究

目的 比较钬激光与CO2激光手术治疗早期声门型喉癌临床疗效.方法 回顾性分析激光手术治疗早期声门型喉癌91例的患者临床资料(Tis,T1 N0 M0).依据治疗方式分为钬激光手术组56例,CO2激光手术组35例.对两组患者手术时间、出血量、并发症、住院时间、创面恢复时间和生存率等进行分析.结果 钬激光组与CO2激光组在...     

Quality of life,functional outcome,and costs of early glottic cancer

OBJECTIVE: To analyze quality of life, functional outcome, and hidden costs by primary treatment with surgery or radiation therapy in patients with early glottic cancer. STUDY DESIGN: Retrospective study in a tertiary care facility. METHODS: A group of 101 patients with carcinoma in situ and T1 invasive squamous cell carcinoma treated primarily with either surgery or radiation, between January 1990 and December 2000, were identified from searching our tumor registry. Patients completed two previously validated questionnaires and one local questionnaire. Statistical significance was assessed with the rank sum test, chi2 test, or Fisher's Exact test. RESULTS: Questionnaires were completed in 59% (44 of 74) of the surgical cohort and 41% (11 of 27) of the radiation therapy cohort. The primary surgical treatments were endoscopic excision (86%), hemilaryngectomy (12%), and total laryngectomy (1%). Patient-reported problems with swallowing, chewing, speech, taste, saliva, pain, activity, recreation, and appearance showed no difference between the endoscopic excision or radiation therapy cohorts. Comparing endoscopic excision versus radiation therapy, respectively, median number of treatments (2 vs. 35), total median travel distance (150 vs. 660 miles), total median travel time (180 vs. 1440 min), and total median number of hours of work missed (76 vs. 24) all differed significantly (P <.01). CONCLUSIONS: Almost all patients with early glottic cancer, whether treated with surgery or radiation therapy, reported excellent quality of life outcomes and functional results. In addition to actual costs, the hidden costs for radiation therapy versus endoscopic excision were all greater in terms of total number of hours of work missed, total travel time, and total travel distance.     

Long-term clinical outcomes of supracricoid partial laryngectomy with cricohyoidoepiglottopexy for glottic carcinoma

Abstract

Background: Laryngeal carcinoma should be treated with the intent of organ-sparing, and supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP) might be an important option.

Aims/objectives: The purpose of this study was to evaluate the clinical outcomes of glottic carcinoma patients treated with CHEP.

Materials and methods: A series of 164 cases with glottic carcinoma undergoing CHEP from 2006 to 2010 was retrospectively analyzed.

Results: The 10-year overall survival (OS) rate, disease-specific survival (DSS) rate, and disease-free survival (DFS) rate were 77.6%, 78.8%, 74.1%, respectively. The OS, DSS, and DFS of patients with stage T1 were higher than patients with stages T2 and T3. Patients with locoregional recurrence and distant metastases had lower OS and DFS than patients with neither recurrence nor metastasis. The DFS of patients with advanced laryngeal carcinoma was worse than that of patients with early-stage carcinoma. T2 and T3 stages, locoregional recurrence, and distant metastases had predictive value regarding patient survival. Additionally, the decannulation rate of postoperative patients was 95.1%, and the nasogastric feeding tube removal rate was 100%.

Conclusions and Significance: CHEP provided reliable oncologic and functional outcomes, and it should be considered as a standard function-sparing option for glottic T1b, T2, and selected T3 carcinoma patients.     

Early glottic carcinoma involving the anterior commissure

Between 1958 and 1990 67 patients with an early glottic carcinoma involving the anterior commissure were treated by radiotherapy. Excluding three with carcinoma in situ, 64 had a T₁N₀M₀ squamous cell carcinoma; in eight of these (12.5%) the tumour was only located in the anterior commissure, in 45 (70.3%) it also involved one vocal cord and in 11 (17.2%) both vocal cords. The overall 5-year survival rate was 85%. For those with only anterior commissure involvement it was 60%, with involvement of one vocal cord and the anterior commissure it was 89% and with involvement of both vocal cords 82%. The 3-year recurrence rate was 58% for patients with involvement of only the anterior commissure, 24% with involvement also of one vocal cord, and 45% for those with involvement of both vocal cords. It was found that in cases of early glottic carcinoma, involving the anterior commissure and treated by radiotherapy, the prognosis for recurrence and survival was poorest when the carcinoma was only located in the anterior commissure, and it was concluded that this group of patients deserves special consideration.     

Impact of anterior commissure involvement on local control of early glottic carcinoma treated by laser microresection

OBJECTIVES: To analyze the impact of anterior commissure involvement on local control, survival, and laryngeal preservation in patients with early glottic cancer (pT1a-pT2a) treated with unimodality laser microsurgical resection. STUDY DESIGN: Retrospective review of 263 patients with early glottic cancer treated between 1986 and 1996. METHODS: Data on local control and overall survival rates were analyzed and calculated by the Kaplan-Meier method; the larynx preservation rates were given absolutely. RESULTS: Among 158 patients presenting with T1a glottic cancer, the anterior commissure was involved in 28 cases; the 5-year local control rate was 84%, and the larynx preservation rate was 93%. In the 130 cases without anterior commissure involvement, the 5-year local control rate was 90.0% and the corresponding larynx preservation rate 99%. In the T1b category consisting of 30 patients, anterior commissure involvement was observed in 16 patients; the 5-year local control rate was 73%, and the larynx preservation rate was 88%. In the 14 cases without anterior commissure involvement, the 5-year local control rate was 92% and the corresponding larynx preservation rate 100%. Seventy-five patients had T2a glottic carcinomas, with normal vocal cord movement. The anterior commissure was involved in 45 cases; the 5-year local control rate was 79%, and the larynx preservation rate was 93%. In the 30 cases without anterior commissure involvement, the 5-year local control rate was 74.0% and the corresponding larynx preservation rate 97%. CONCLUSIONS: This study shows the effectiveness of laser microsurgery for early glottic carcinoma regardless of anterior commissure involvement at presentation. This method can be performed as an outpatient procedure, even when conducting reresections.     

Partial vertical laryngectomy for recurrent glottic carcinoma

Partial vertical laryngectomy for recurrent glottic carcinoma was performed in 61 patients according to stringent criteria. The great majority of the recurrent tumours appeared within 2 years of radiotherapy (80%). The mean follow-up after surgery was 79 months. At 5 years 85% of the patients were free of local recurrence. Nine patients (15%) developed a local recurrence; eight of them underwent total laryngectomy; one patient refused the operation and died. Seven patients died of other causes. The actuarial overall survival rate was 88% at 5 years. Post-operative complications were seen in 12 patients (20%); nine of these patients developed airway problems. One patient underwent total laryngectomy for severe aspiration, the others finally were decannulated. The results of this study indicate that partial vertical hemi-laryngectomy for irradiation failures is a safe procedure with good results without undue morbidity.     

咽喉反流对声门型喉癌中COX-2mRNA表达的影响

目的：探讨咽喉反流对环加氧酶2（COX-2）mRNA在声门型喉癌病变黏膜中表达的影响。方法：对40例声门型喉癌患者行电子鼻咽喉镜检查、反流检查计分量表（RFS）和反流症状指数量表（RSI）评分,将其分为声门型喉癌反流阳性组（20例）和声门型喉癌反流阴性组（20例）,另取10例癌旁2cm以上黏膜组织作为对照组。采用Real—timePCR方法,测定各组黏膜中COX-2tuRNA的表达情况。结果：声门型喉癌组COX-2mRNA的表达明显高于对照组（P〈O．05）;声门型喉癌反流阳性组的表达高于声门型喉癌反流阴性组（P〈0．05）。结论：咽喉反流因素可能通过组织损伤、炎症及细胞恶性转化使声门型喉癌的COX-2mRNA的表达升高。     

Health status and voice outcome after treatment for T1a glottic carcinoma

Radiotherapy as well as endoscopic laser surgery as the most widely used treatment modalities for T1a glottic carcinoma cause minor morbidity and negligible mortality and result in more or less comparable, excellent cure and larynx preservation rates. Therefore, other outcome measures such as voice-related problems and health status are important factors in the choice of treatment for T1a glottic cancer. The present study focuses on voice-related problems in the daily life of patients treated by radiotherapy or endoscopic laser surgery for T1a glottic cancer. Self ratings on health status assessed by means of COOP/WONCA health status charts and voice problems evaluated with a validated voice-specific questionnaire (the Voice Handicap Index) and overall judgment on voice quality were obtained. A total of 102 patients (56 treated by endoscopic laser surgery and 46 treated by radiotherapy) with at least 1-year follow-up were included. Response scores were high: 52 (93%) patients after endoscopic laser surgery versus 40 (87%) patients after radiation therapy completed and returned the questionnaires. A high percentage of patients reported voice problems in daily life: 58% of the patients following radiotherapy and 40% of the patients following endoscopic treatment had abnormal VHI scores. The difference between both treatment modalities proved to be significant. No significant differences were found concerning health status or overall judgment of voice quality. Moderate correlations were found between total VHI score and voice quality judgment and the COOP/WONCA social activities chart. This study reveals that treatment for T1a glottic cancer often does result in voice problems in daily life, negatively influencing patients social activities. Patients selected for endoscopic laser surgery on average report fewer voice-related problems than those who underwent radiotherapy.     

Clinical significance of beta1 integrin expression as a prediction marker for radiotherapy in early glottic carcinoma

OBJECTIVE: To determine the significance of beta1 integrin expression as a prediction marker for the response to radiotherapy in patients with early glottic carcinoma. STUDY DESIGN: Retrospective study in a tertiary referral center. METHODS: Among the T1/T2 glottic carcinoma patients treated with radiotherapy from 1992 to 2002, 52 had more than 2 years of follow-up and available pretreatment biopsy specimens. The immunohistochemical staining was performed for the assay of beta1 integrin expression, and the staining pattern of each was classified as diffuse, localized, or negative. The associations between the patterns of beta1 integrin expression and clinicopathologic parameters, including response to radiotherapy, involvement of the anterior commissure, and grade of histologic differentiation, were evaluated. RESULTS: After radiotherapy, 42 patients remained tumor free, and 10 patients had recurrent or persistent disease. Six (12%) specimens were negative for beta1 integrin expression, 39 (75%) had a localized staining pattern, and 7 (13%) had a diffuse staining pattern. Recurrence rate was significantly higher in the diffuse group (53%) than in the localized (13%) or negative (17%) groups (P=.023). The pattern of beta1 integrin expression was also closely related to histologic differentiation (P=.008), although the association between response to radiotherapy and histologic differentiation was not significant CONCLUSION: The pattern of expression of beta1 integrin, which has been known as a stem cell marker of the epidermis, may be helpful in predicting the response to radiation in patients with early glottic carcinoma.     

CO2-laser treatment of recurrent glottic carcinoma

The records of 23 patients treated by CO₂-laser surgery for recurrent glottic carcinoma after radiotherapy were studied retrospectively to assess treatment results and complications. 15 patients (65%) were cured with one or more laser procedures. The remaining 8 underwent a total laryngectomy for a second or third recurrence. One patient (4%) died of disease. No major complications from C0₂-laser surgery were encountered. It is concluded that C0₂-laser surgery is a safe method of treatment of recurrent glottic carcinoma.     

Oncological outcomes of early glottic carcinoma treated with transoral robotic surgery

Objective

Although glottic level is an off-label use of da Vinci system, the feasibility and early-term outcomes of transoral robotic surgery (TORS) for the treatment of early-stage (Tis, T1, T2) glottic carcinoma have been documented. But little is known about the oncological outcomes. We investigated the oncological outcomes of TORS in patients followed at least three years and mean follow-up time was over five years.

Bipedicled strap muscle transposition for vocal fold deficit after laser cordectomy in early glottic cancer patients

OBJECTIVE: In treating early glottic carcinomas, the outcomes of endoscopic laser cordectomy have been proven to be valuable in local control, survival, and vocal function preservation. In some extended cases, however, laser cordectomy may leave patients with poor vocal function because of vocal fold deficit. This work assesses the vocal outcome of medialization laryngoplasty with bipedicled strap muscle transposition for vocal fold deficit resulting from laser cordectomy in early glottic cancer patients. STUDY DESIGN: A prospective clinical series. METHODS: Thirteen early glottic cancer patients who had vocal fold deficit caused by previous laser cordectomy underwent medialization laryngoplasty with bipedicled strap muscle transposition. The thyroid lamina on the cordectomy side was paramedially separated. The inner perichondrium was circumspectly raised from the overlying thyroid cartilage. After separating the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally. A bipedicled strap muscle flap was then transposed into the area between the lamina and the paraglottic soft tissue. The thyroid cartilages were carefully sutured back in position. All patients received pre- and postoperative voice assessments comprising laryngostroboscopy and vocal function studies. RESULTS: Vocal enhancement was present in 92% (12/13) of patients after medialization laryngoplasty with strap muscle transposition. The glottal closure and maximal phonation time were noticeably improved by surgery. No dyspnea or other significant complications were observed in any patients. CONCLUSION: The outcomes show that bipedicled strap muscle transposition is a prosthesis-free, safe, and valuable laryngoplastic technique for correcting glottal incompetence caused by endoscopic laser cordectomy in early glottic cancer patients.     

早期声门型喉癌低温等离子射频消融术后联合嗓音训练的嗓音学分析

目的 将嗓音训练方法应用于早期声门型喉癌等离子射频消融术后,探究其对嗓音功能恢复的影响情况。方法 严格按照纳入标准选取2019年1月—2020年12月牡丹江医学院附属红旗医院耳鼻咽喉头颈外科收治的早期声门型喉癌患者60例,均在支撑喉镜下用低温等离子射频消融术切除癌灶,再将患者随机分为两组,训练组患者于术后2周开始进行为期3个月的嗓音训练治疗,对照组患者术后仅定期复查。比较两组患者术前、术后3个月主、客观嗓音情况。结果 两组患者术前主、客观嗓音各项指标比较均无统计学意义(P均>0.05)。术后3个月,主观评估指标嗓音障碍指数(VHI)、CRBAS听主观评估中总嘶哑度(G)、粗糙度(R)、气息度(B)及客观评估指标基频(F0)、基频微扰(Jitter)、振幅微扰(Shimmer)、谐噪比(HNR),训练组各项主观评估指标低于对照组,差异有统计学意义(PP<0.05),训练组的F0和HNR均值优于对照组,但差异无统计学意义(P>0.05)。结论 嗓音训练联合低温等离子射频术治疗早期声门型喉癌,可以促进患者嗓音功能早期恢复,值得在临床推广应用。     

Voice in early glottic cancer compared to benign voice pathology

The purpose of this study is to compare (Dutch) Voice Handicap Index (VHIvumc) scores from a selected group of patients with voice problems after treatment for early glottic cancer with patients with benign voice disorders and subjects from the normal population. The study included a group of 35 patients with voice problems after treatment for early glottic cancer and a group of 197 patients with benign voice disorders. Furthermore, VHI scores were collected from 123 subjects randomly chosen from the normal population. VHI reliability was high with high internal consistency and test–retest stability. VHI scores of glottic cancer patients were similar to those of patients with voice problems due to benign lesions. Both groups of patients were clearly deviant from the normal population. Within the normal population, 16% appeared to have not-normal voices. Based on ROC curves a cut-off score of 15 points was defined to identify patients with voice problems in daily life. A clinical relevant difference score of 10 points was defined to be used for individual patients and of 15 points to be used in study designs with groups. Patients with voice problems after treatment for early glottic cancer encounter the same amount of problems in daily life as the other voice-impaired patients. The VHI proved to be an adequate tool for baseline and effectiveness measurement of voice.     

Transoral laser microsurgery for recurrence after primary radiotherapy of early glottic cancer

Objective

To analyze oncological results of transoral laser microsurgery (TLM) on recurrent early glottic cancer after primary radiotherapy.

Methods

The records of 53 patients treated by TLM for early (rTis–rT2) and advanced (rT3, rT4) recurrence after curative radiotherapy were retrospectively analyzed. Data on loco-regional control, overall survival, and disease specific survival were calculated by the Kaplan–Meier method. The larynx preservation rates were given absolutely.

Results

Mean post-therapeutic follow-up time after TLM for patients alive was 87.9 months. Twenty-two patients (42%) were cured by the first TLM procedure, but one of them underwent total laryngectomy after TLM due to chondronecrosis without evidence of residual tumor. Thirty-one patients (58%) developed another recurrence after TLM. Ten of them were cured by further laser procedures alone. Therefore, in 31 patients (58%), local recurrences were successfully treated by TLM alone. In 20 patients, recurrences could not be controlled by TLM: 14 patients underwent salvage laryngectomy and six palliative treatment. Three- and five-year loco-regional control rates for all patients were 46.1 and 38.8%. Three- and five-year overall survival rates were 67.5 and 53.3%. The corresponding 3- and 5-year disease specific survival rates were 68.6%, each. There was no statistically significant difference in loco-regional control or survival between patients presenting initially with early and advanced recurrence. Further recurrence after the first TLM procedure was associated with a statistically significant decrease in 3- and 5-year overall (56.6% vs. 81.8% and 40.2% vs. 70.5%; p = 0.03) and disease specific (48.9% vs. 100%, each; p = 0.001) survival. Ultimate local control rate including repeated TLM and salvage laryngectomy was 77.4%.

Conclusions

Many patients with recurrent glottic carcinoma after primary radiotherapy can be cured by single or repeated TLM as an organ-preserving procedure. However, in case of failure after TLM for the first recurrence, salvage laryngectomy should be considered early as local control by further laser surgery is unfavorable.