Current trends in initial management of oropharyngeal cancer: the declining use of open surgery

The widespread availability of novel primary treatment approaches against oropharyngeal cancers has provided several potentially curative surgical and nonsurgical treatment options for patients, generating both hope and controversy. As treatment is usually curative in intent, management considerations must include consideration of primary tumor and nodal disease control as well as long-term toxicities and functional outcomes. Anatomical and functional organ preservation (speech and deglutition) remains of paramount importance to patients with oropharyngeal cancer and the physicians involved in their care, accounting for the growing popularity of chemoradiotherapy and transoral surgical techniques for this indication. These novel approaches have greatly diminished the role of open surgery as initial therapy for oropharyngeal cancers. Open surgery which is often reserved for salvage on relapse, may still be an appropriate therapy for certain early stage primary lesions. The growing treatment armamentarium requires careful consideration for optimal individualized care. The identification of oncogenic human papillomavirus as a predictive and prognostic marker in patients with oropharyngeal cancer has great potential to further optimize the choice of treatment. In this review, novel primary therapies against oropharyngeal squamous cell carcinoma are presented in the context of anatomical, quality of life, and emerging biological considerations.     

Complications after CO2 laser surgery of laryngeal cancer in the elderly

Conclusion. Cancer of the larynx in elderly patients should be treated with curative intention, if the extension of the primary tumour allows safe resection. Transoral CO₂ laser microsurgery is associated with a low rate of major complications and can be regarded as suitable even for elderly patients. Age itself should never be the sole factor in deciding which therapy should be undertaken. Objectives. In the industrialized nations the age group beyond 75 years will grow steadily, requiring special attention by medical professionals in the future. Nowadays laryngeal cancer is often treated by transoral CO₂ laser microsurgery. Because of a variety of comorbidities, the incidence of perioperative complications in the group of elderly patients is of increasing interest. To date, no references in the literature have discussed complications after transoral CO₂ laser microsurgery in this age group. Patients and methods. Twenty-four patients over the age of 75 suffering from squamous cell carcinoma of the larynx and treated by transoral CO₂ laser microsurgery since 1998 were analysed for intraoperative and postoperative complications. Results. There was no evidence of surgery-related complications at all. Postoperatively, 6 of 24 patients complained about dysphagia. Due to intraoperative placement of nasogastric feeding tubes in these six cases further complications such as pneumonia resulting from aspiration could have been avoided.     

Neck management in patients undergoing postradiotherapy salvage laryngeal surgery for recurrent/persistent laryngeal cancer

OBJECTIVE: To determine a plan for the management of cervical lymph nodes in patients undergoing salvage laryngeal surgery (SLS) for recurrent/persistent laryngeal cancer after primary radiotherapy (RT). STUDY DESIGN:: Retrospective chart review. METHODS: Charts of 51 consecutive patients who had salvage total or supracricoid laryngectomy with or without neck dissection for recurrent/persistent laryngeal squamous cell carcinoma after primary RT from 1988 to 2005 in our institution were reviewed. No patients received concomitant or neo-adjuvant chemotherapy. Thirty-four patients underwent SLS along with unilateral or bilateral neck dissection, whereas 17 patients underwent the SLS without neck dissection. Reports of preRT and preSLS staging of the primary tumor and the neck, recorded using the TNM system, were reviewed. Reports of the final histopathologic examination for the excised laryngeal cancer and cervical lymph nodes were reviewed. RESULTS: Thirty-four patients underwent SLS with unilateral or bilateral neck dissection. The preRT staging of the primary tumor for those 34 patients showed that 32 (94%) were staged T-1 (14) and T-2 (18), whereas the preSLS staging of the primary tumor for those 34 patients showed that 29 (85%) were staged T-3 and T-4. The postSLS final histopathologic examination of the excised lymph nodes in those 34 patients demonstrated that 30 (88%) did not have any evidence of nodal metastasis. On comparing patients with and without nodal metastasis (on their postSLS final histopathology), we found that the preSLS neck staging, based on computed tomographic (CT) scanning of the neck, was significantly associated with the negative/positive postSLS status of nodal metastasis (P = .006). Of 29 patients staged preSLS as N-0, 28 (97%) patients did not have nodal metastasis on their postSLS final pathology (negative predictive value = 97%, confidence interval, 82.2-99.9). PreRT neck staging, preRT and preSLS staging of the primary tumor, along with laryngeal subsite involvement (supraglottis, glottis, subglottis) did not significantly correlate with the status of neck metastasis on final postSLS histopathology (P = .68, 0.78, 0.49, and 0.42, respectively). None of the 34 patients had any neck tumor recurrence in the postSLS follow-up period (median, 3 yr). In addition, all 17 patients who underwent SLS without neck dissection were staged N-0 both before RT as well as preSLS, and none developed neck disease in the postSLS follow-up period (median, 2.5 yr). CONCLUSION: Management of the neck in patients undergoing salvage total or supracricoid laryngectomy for laryngeal cancer recurrence/persistence after primary RT should be based on the preSLS CT staging of the neck. Patients staged N-0 preSLS are not likely to harbor occult nodal metastasis and therefore may not require elective neck dissection.     

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.     

Role of postoperative adjuvant radiotherapy for locally advanced laryngeal cancer: a meta-analysis

Background: Studies have shown mixed results on the role of postoperative adjuvant radiotherapy (PORT) in surgically managed locally advanced laryngeal cancer.

Objectives: The aim of this study is to review and investigate the role of PORT in patients with locally advanced laryngeal cancer using meta-analysis.

Materials and methods: Relevant studies were searched using PubMed and eligible information has been extracted. Then, meta-analysis of hazard ratio (HR) was performed to evaluate the role of PORT in locally advanced laryngeal cancer.

Results: This meta-analysis included 7 published studies containing 2007 patients. For overall survival (OS), patients of locally advanced laryngeal cancer who were treated with PORT have a combined hazard ratio (HR) of 0.67 with 95%CI (0.56, 0.79), compared to those who were not treated with PORT, which was significantly associated with better survival. PORT was also associated with a better disease-free survival (DFS) and local control rate (LCR) in patients with locally advanced laryngeal cancer. The pooled HR and 95%CI for DFS and LCR were 0.72 (0.53, 0.99) and 0.29 (0.09, 0.99), respectively.

Conclusions and significance: This study suggested that PORT could improve the survival of patients with surgically managed locally advanced laryngeal cancer.     

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.     

低温等离子手术治疗早期喉鳞状细胞癌整体预后及复发的相关因素研究

目的 探讨低温等离子手术治疗早期喉鳞状细胞癌(简称喉癌)的整体预后情况,并评估相关风险因素对患者无病生存期(DFS)的影响,从而分析影响手术疗效的因素,总结临床经验。方法 回顾性分析2013年4月—2020年12月接受经口内镜下低温等离子手术治疗、有完整随访资料的患者369例早期喉癌患者的临床资料。随访时间为32~124个月,中位随访时间72个月。并统计分析获得患者各项肿瘤学结果,包括DFS、总生存期(OS)、局部控制率(LC)、保喉率(LP)。结果 术后共计70例患者出现复发,40例死亡。所有患者总的1、2、5年DFS分别为89%(95%CI:86%~92%)、85%(95%CI:82%~89%)、80%(95%CI:76%~84%),中位DFS未到达。1、2、5年OS分别为97%(95%CI:96%~99%)、92%(95%CI:89%~95%)、89%(95%CI:85%~92%),中位OS未到达。且累及前连合显著影响患者DFS,但对OS没有影响。而ACI患者1、2、5年DFS分别为87%(95%CI:82%~92%)、82%(95%CI:77%~88%)、76%(95%CI:70%~82%)。而未侵犯患者1、2、5年DFS分别为92%(95%CI:87%~96%),89%(95%CI:84%~93%),85%(95%CI:79%~91%)。结论 等离子手术与CO₂激光手术或是单纯放疗的疗效较为接近。累及前连合与术后肿瘤切缘也是影响患者术后DFS的重要因素,并且术后复发患者的二次等离子手术并非禁忌。术前做好相应评估,在确认前连合区域外侧甲状软骨没有明显侵犯并且术前判断可以获得阴性切缘的情况下再考虑行等离子手术治疗,才能使患者获得最佳疗效。     

Long-term results of open cordectomy for the treatment of T1a glottic laryngeal carcinoma

Objective

To assess the long-term results and prognostic factors in patients who have undergone open cordectomy (OC) for the treatment of T_1a glottic laryngeal carcinoma.

Methods

One hundred four epidermoid cancer patients operated from January 1989 through December 1999 were included in the study. Clinical parameters, postoperative complications, and postoperative stay were retrospectively evaluated in all cases.

Results

Mean survival for the patients included in the study was 61.5 ± 24.8 months after the date of operation (range: 11–121 months). Ninety-four patients did not have recurrent tumor (90.4%). Local, regional and distant recurrence were linked with a statistical negative impact on survival rates (p < 0.05). Only sero-hematoma was significantly related to local recurrence (p < 0.05), whereas the remainder complications did not. None of the complications was associated with neck recurrence or distant metastasis (p > 0.05).

Conclusions

Open cordectomy is nowadays a valid technique for the surgical treatment of T_1a glottic laryngeal carcinoma. Its results are comparable with those of other more recent techniques.     

喉内镜下等离子消融术与开放性手术治疗早期喉癌的疗效对比

目的 探讨经支撑喉镜内镜辅助下等离子消融术治疗早期声门型喉癌的疗效,并与常规开放性手术作对比分析。 方法 回顾早期声门型喉鳞癌55例患者临床资料,按手术方式分为等离子组35例、喉裂开组20例,分析比较两组手术情况、并发症、复发率,并应用嗓音分析软件比较两组患者术后嗓音恢复情况。 结果 等离子组及喉裂开组患者在手术时间［(15.60±7.20)vs(94.00±9.95)min)］、术中出血［(8.94±8.06)vs(100.75±28.34)mL］、住院时间［(6.86±0.77)vs(11.45±1.05)d］、术后疼痛视觉模拟评分［(2.66±0.91)vs(4.65±1.04)分］及呛咳评分［(3.60±0.85)vs(6.05±1.23)分］的差异均有统计学意义(P<0.05);两组术后肉芽增生发生率及复发率差异无统计学意义(P>0.05);术后12个月嗓音分析两组嗓音参数(Jitter、Shimmer、HNR)均较术前好转,等离子组上述参数恢复情况均优于喉裂开组:基频微扰(Jitter)［(0.66±0.15)vs(0.78±0.18)%］,振幅微扰(Shimmer)［(4.57±1.14)vs(5.66±0.97)%］,谐噪比(HNR)［(17.41±2.58 )vs(15.39±1.63)dB］,组间差异有统计学意义(P<0.05)。 结论 经支撑喉镜内镜辅助下等离子消融术治疗早期喉癌疗效确切,较喉裂开术具有微创、高效、术后嗓音恢复好的优势。     

Changing trends in the occurrence and subsite distribution of laryngeal cancer in Finland

Cancer of the larynx represents worldwide approximately 1–2% of all cancers and generally occurs predominantly in males. Based upon many reports, the age-adjusted incidence of laryngeal cancer has been rising in recent years, especially among women. Squamous cell carcinomas arising in the glottic region are the most common of all laryngeal cancers and more prevalent than the supraglottic ones. Subglottic disease is still rare. The Finnish Head and Neck Oncology Group evaluated the present occurrence of laryngeal cancer by site and gender in Finland. The annual age-standardized incidence of laryngeal cancer is 3.2 per 100,000 for men and 0.3 per 100,000 for women. The proportion of females in the five university centers reviewed was 5%. During the 30-year time period from the early 1960s to the 1990s there has been a significant decrease in the laryngeal cancer incidence rates for males, but no change for females. Finland thus seems to be the only Western country with clearly declining occurrence rates in recent decades. In the same time period a clear decrease in the incidence of bronchial cancer has occurred in males and an increase in females. The results also show that in all five university hospital districts glottic cancer became more common (50–68%) in the late 1980s and 1990s, which is opposite to the situation in the 1960s when supraglottic localizations (65%) dominated in Finland. Received: 26 September 1998 / Accepted: 27 January 1999     

CO2激光联合低温等离子治疗早期声门型喉癌40例

目的 探讨CO₂激光联合低温等离子治疗早期声门型喉癌(EGC)的临床疗效。 方法 回顾性分析内镜下CO₂激光联合低温等离子治疗的40例EGC患者的临床资料,观察术后治疗效果及复发情况。 结果 所有患者首次手术均为内镜下CO₂激光联合低温等离子切除术,共随访4.2~32.0个月(平均18.6个月)。40例均未失访,复发1次3例,复发2次2例,复发率12.5%。复发后行喉全切除术2例,复发后行喉垂直部分切除术1例,复发后行颈淋巴结清扫术1例,复发后再行CO₂激光联合低温等离子切除术+气管切开术1例。 其中喉全切除再次复发行放、化疗及介入治疗,治疗效果差1例;喉垂直部分切除再次复发后选择放疗1例,治疗情况欠佳;余3例末次手术后恢复良好。术后肉芽组织增生9例,术后出现声带粘连4例。36例患者术后发音功能恢复满意,恢复欠佳2例,复发行喉全切除术后丧失发音功能2例。 结论 内镜下CO₂激光联合低温等离子治疗EGC可弥补激光和低温等离子单一治疗模式的不足、提高手术效率,临床有效可行。