早期声门型喉癌治疗方式的评价与选择

早期声门型喉癌（early glottic cancer，EGC）通常是指Tis-T2病变且无颈淋巴及远处转移者。放疗与手术治疗，包括开放性手术、支撑喉镜下激光手术（简称激光手术）和非激光手术等，均是EGC的有效治疗手段，并具有相近的治疗效果。由于尚缺少理想的前瞻性随机对照研究，还没有足够的证据表明哪种治疗方式对EGC具有更好的治疗效果，对其治疗方式的选择亦缺少统一的意见，现将国内外的主流意见总结如下。     

早期声门型喉癌的治疗进展

声门型喉癌占喉癌发病的70%,淋巴结转移少见。早期声门型喉癌常常引起声音嘶哑,就诊过程中,易于早期发现,在所有喉癌中预后最好。近10年来美国国家综合癌症网络(NCCN)指南中关于早期声门型喉癌的诊治经历20余次的更新,已逐步形成经口内镜下CO₂激光手术或单纯放疗为主的治疗模式。喉功能保留和嗓音质量是衡量治疗成功与否的关键因素,目前开放手术的应用越来越少,而首选CO₂激光手术还是单纯放射治疗方案的问题一直是悬而未决的。本文将分别介绍早期声门型喉癌的治疗进展及个性化治疗选择的关键要点,并总结影响肿瘤复发的预后因素及预测复发的生物学标志物,以期为指导早期声门型喉癌患者的治疗及随访提供临床参考。     

早期声门型喉癌的循证治疗方案

目的 通过1例早期声门型喉癌患者的治疗问题,检索当前最佳临床证据,针对患者具体情况为治疗提供依据.方法 在充分评估患者情况后,提出临床问题,检索Cochrane图书馆(2009年第1期)、美国国家指南交换中心NGC(2000-2009)、PubMed(1966-2009.12)、Embase(1980-2009.12)和CBM(1989-2009.12)数据库,收集相关证据,对所获证据进行评价,并结合医生的经验及患者的愿望制定治疗方案.结果 本文共纳入2篇临床指南,5篇RCT和1篇队列研究.证据结果表明,对于早期声门型喉癌的治疗,手术和放疗具有相似的5年生存率,目前缺少理想的前瞻性随机对照研究提供证据,还没有足够的证据表明哪种治疗方式具有更好的治疗效果,综合指南推荐、文献报道、临床经验及患者具体情况,对该例早期声带癌患者推荐方案为支撑喉镜下CO2激光手术,术后加行免疫治疗.结论 对于早期声门型喉癌治疗方式的选择缺少统一意见,需要遵循循证医学的原则,综合各方面因素考虑.     

早期声门型喉癌治疗的预后分析

目的探讨不同治疗方法对早期声门型喉癌的疗效影响。方法回顾性分析76早期声门型喉癌患者临床资料,包括开放性手术治疗患者59例,单纯放疗患者17例,采用Kaplan-Meier法计算生存率,Log-rank检验进行单因素分析,Cox比例风险模型进行多因素分析。结果患者总生存率为77.6%,开放性手术和放疗患者5年生存率为分别为78.0%和76.5%,两者比较差异无统计学意义。Cox多因素回归分析表明年龄、T分级、病理类型均是影响早期声门型喉癌患者预后的独立影响因素。结论单纯放疗对早期声门型喉癌可以得到与手术相似的长期生存率,年龄越大,T分级越晚,病理分型越差是早期声门型喉癌不良预后因素。     

CO2激光治疗喉癌前病变及早期声门型喉癌的疗效分析

目的 探讨CO2激光治疗喉癌前病变及早期声门型喉癌的临床效果.方法 选取2014年1月～2019年9月在我科行支撑喉镜下CO2激光显微手术治疗喉癌前病变及早期声门型喉癌患者30例(喉癌前病变20例,早期声门型喉癌10例),观察患者术后恢复情况.结果 30例患者均完成手术,术中均未出现并发症.3例患者因病灶累及前联合,术...     

低温等离子治疗早期声门型喉癌48例临床观察

喉癌是头颈部最常见的恶性肿瘤之一,手术是喉癌治疗的主要手段。目前早期喉癌多采用微创手术,早期喉癌患者术后由于最大可能保留了喉功能,生活质量明显优于中晚期患者,因此早期喉癌的治疗显得尤为重要。我科于2010年1月～2013年5月应用等离子射频消融术对48例Tis、T1早期声门型喉癌患者进行了治疗,并进行6个月～3年10个月的随访观察,本组复发率2.1%,2例失访,余患者均无复发,随访超过2年者22例,尚无死亡病例,整体疗效较满意。     

CO2激光手术治疗声门型喉癌疗效分析

OBJECTIVE: To evaluate the curative effect of CO2 laser in treatment of glottic carcinoma. METHODS: Retrospective analysis of 217 cases of early glottic laryngeal carcinoma treated with laser surgery were carried out. Among these cases, Tis were 22 cases, T1a 108 cases, T1b 38 cases, T2 46 cases, T3 3 cases. 1 case being applied vocal cord excision due to failure of tumor exposure. The follow-up period was 3 to 9 years. RESULTS: Relapse were detected in 21 out of 217 cases of glottic laryngeal carcinoma after CO2 laser surgery under self-retaining laryngoscope. The recurrent rate was 9.7% (21/217). Recurrent ratio of T1a, T1b, T2, T3 were 5.6% (6/108), 21% (8/38), 13.0% (6/46), 1/3 respectively, with significant differences among groups (chi 2 = 6.102, P < 0.01). The recurrent rate was 21.6% of tumors offended the anterior commissure, versus 5.1%(8/157) with no involvement of anterior commissure (chi 2 = 13.64, P < 0.01). 217 cases received laser surgery as the only treatment, 201 cases were still alive. 4 failed to be followed-up(taken into dead number), 12 cases were dead. 3 year survival rate was 97.2%(211/217), 5 year survival rate was 89.4%(118/132). CONCLUSION: It was reliable to use laser surgery in treatment of early glottic laryngeal cancer. The advantages of it included lower complication rate and vocal function was well retained.     

钬激光治疗早期声门型喉癌体会

目的探讨钬激光治疗早期声门型喉癌的安全性、可行性及治疗效果。方法回顾性分析显微支撑喉镜下钬激光手术治疗的16例早期声门型喉癌患者的临床资料并对其术后并发症、局部复发情况进行随访。结果 16例患者钬激光术后局部复发3例,通过再次手术或钬激光治疗达到局部控制,1例患者颈部淋巴结转移拒绝手术行放射治疗,局部未控并出现肺转移,后失访。结论钬激光治疗早期声门型喉癌安全,损伤少,但是也存在一定的缺点。对于T2及累及前联合病变存在一定风险及局限性,需要配合术中取切缘行快速切片病理检查,及操作者对钬激光切割深度的掌握来减少肿瘤局部复发,术后应严密随访。     

低温等离子射频消融与CO2激光手术治疗早期声门型喉癌疗效的Meta分析

目的 采用Meta分析的方法评价支撑喉镜下低温等离子射频消融与CO₂激光治疗早期声门型喉癌的临床疗效。 方法 计算机检索PubMed、EMbase、Medline、维普、万方、CNKI数据库。检索年限从建库至2019年5月1日。同时手检纳入文献的参考文献。根据纳入标准和排除标准筛选关于比较支撑喉镜下低温等离子射频消融术与CO₂激光手术治疗早期声门型喉癌疗效的文献。由2人单独进行文献的筛选、数据提取及文献的评价,使用Revman 5.3软件进行Meta分析。 结果 共纳入10个研究,1 055例患者。Meta分析结果显示:与CO₂激光手术相比,低温等离子射频消融术显著降低了患者的手术时间［SMD=-2.97,95%CI(-4.05,-1.90),P<0.00 001 ］、术后黏膜恢复更快［OR=5.53,95%CI(2.84,10.78), P<0.00 001］、术中出血量更多［SMD=-0.73,95%CI(0.09,0.71),P=0.01］,以上两种手术方式相比差异有统计学意义。复发率［OR=0.79,CI95%(0.46,1.36), P=0.39］、术后疼痛程度［SMD=-0.17,95%CI(-0.43,0.08),P=0.18］和术后发声质量［SMD=-0.21,95%CI(-1.13,0.71), P=0.65］两种治疗方式相比差异无统计学意义。手术时间及复发率的漏斗图未发现明显发表偏倚。 结论 低温等离子射频消融术治疗早期声门型喉癌在手术时间和术后黏膜恢复方面优于CO₂激光手术,但低温等离子射频消融术的术中出血量较多,而复发率、术后疼痛程度和术后发声质量,两种治疗方式相比差异无统计学意义。     

Functional outcomes after CO2 laser treatment of early glottic carcinoma

OBJECTIVES: To analyze vocal outcome after endoscopic CO2 laser treatment of early glottic carcinoma by perceptive and objective assessment. STUDY DESIGN: Retrospective study. METHODS: Retrospective analysis of 141 consecutive patients undergoing surgery for previously untreated early glottic carcinoma between October 1993 and July 2003. Five types of laser cordectomies as classified by the European Laryngological Society classification were performed. Comparison of voice results between the different types of cordectomies as well as with a control group was performed. RESULTS: There was no significant difference in the vocal parameters between subepithelial and subligamental cordectomies and controls (P > .05). There was, however, a significant difference between the groups of transmuscular, total, and extended cordectomies and controls (P < .05). CONCLUSIONS: Good oncologic results and vocal outcomes with no difference between controls and subepithelial and subligamental cordectomies support the use of CO2 laser endoscopic surgery as the first line of treatment for early glottic cancer.     

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.

Quality of life and functional outcomes in the management of early glottic carcinoma: a systematic review of studies comparing radiotherapy and transoral laser microsurgery

Clin. Otolaryngol. 2010, 35 , 373–382 Background: Early glottic carcinoma can be managed by radiotherapy and transoral laser microsurgery with similar control and survival rates. The functional and quality of life outcomes of these interventions are therefore important to guide management. Objective of review: To compare the different treatment modalities for early glottic carcinoma with respect to quality of life, post-treatment voice character and swallowing outcomes. Type of review: A systematic review of the literature with defined search strategy. Search strategy: Searches of EBM databases, and literature databases using key words: glotti*, laryn*, neoplasm, radiotherapy and laser surgery from 1970 to November 2009. Articles were screened for relevance using pre-determined inclusion and exclusion criteria. Evaluation method: Articles reviewed by authors and data compiled in tables for analysis. Results: No randomised controlled trials were identified. There were 15 studies reporting vocal outcomes, and perception of voice disability was measured in eight studies; numbers were low in all the papers. Cumulatively, results for 880 patients were included, 448 had trans-oral laser microsurgery and 442 had radiotherapy. For vocal outcomes, 12 studies found no significant difference between radiotherapy and laser surgery, three reported superior outcomes for radiotherapy, whereas for the perception of voice disability, five reported no difference between treatment groups, while the remaining three reported conflicting results. Nine studies reported quality of life outcomes; seven of these reported no difference between the treatment groups in overall scores although some report differences in subsets of questions. Conclusions: The evidence base to date demonstrates comparable vocal and quality of life outcomes for radiotherapy and transoral laser surgery for early glottic carcinoma. There is a need for consensus on which measures of vocal quality and life satisfaction to be used in research trials to allow comparison between studies.     

CO_2激光联合等离子射频消融术治疗早期声门型喉癌临床观察

目的探讨CO2激光联合等离子射频消融术治疗早期声门型喉癌的方法及疗效。方法利用CO2激光联合等离子射频消融术治疗26例无淋巴结转移的早期声门型喉癌（Tis-T1）,其中Tis 8例,T1a11例,T1b7例。结果 CO2激光联合等离子射频消融术手术时间短,术中出血量少,瘤体切除彻底,均未行管切开,术后反应轻微,无并发症出现。所有患者术后随访9个月至3年,未见肿瘤复发。结论 CO2激光联合等离子射频消融术可以微创、有效的治疗早期声门型喉癌。     

早期声门区癌的手术治疗及疗效评估

目的 探讨T1、T2早期声门型喉癌的治疗方法。方法 对112 例T1、T2早期声门型喉癌(其中T1N0M0 80例、T2N0M0 32例)患者施行喉小部分切除术。结果 112 例患者切口均Ⅰ期愈合,6～7d拆线,术后2～3d恢复经口进食,术后第5～6d更换小号气管套管,1～2d后试堵管,平均戴管时间7.3d,拔管率100%;纤维喉镜检查见术后6个月声门裂形态接近正常且闭合严密。嗓音学分析结果示术前、术后1周与术后2个月、6个月Shimmer和NNE对比,差异有统计学意义(P<0. 01);随访满3年76例,全部生存;满5年36例,35例生存(1例不明原因死亡),生存率97.2%。结论 早期声门区喉癌施行喉部分切除术,疗效确切,可获得稳定的局部控制率。在彻底切除肿瘤的前提下,最大限度地减少了手术造成的创伤,住院时间缩短,患者及家属的经济负担减轻,最大程度地保留和重建了患者的喉功能。     

Oncological outcomes of early stage glottic squamous cell carcinoma treated with transoral laser microsurgery

Materials and methodsThe records of patients treated with TLM with previously untreated early stage glottic squamous cell carcinoma were reviewed.ResultsA total of 201 patients were enrolled: 191 men (95.0%) and 10 women (4.98%). The anterior commissure (AC) was involved in 94 (47.8%) patients. The 3- and 5-year overall survival rates of all patients were 94.5% and 90.9%. The local recurrence rates were 30.8% in the AC involvement (AC+) group and 16.0% in the group without AC involvement (AC–). The mortality rates were 18.1% and 3.7% in the AC+ and AC– groups. The 3- and 5-year disease-free survival rates were lower in the AC+ group (89.1%, 82.5%) than that in AC– group (99.0%, 96.5%). Local recurrence rates were 25%, 22.7%, 23.4%, and 22.1% for Tis, T1a, T1b, and T2 lesions. The mortality rates were 0.0%, 4.6%, 12.8%, and 15.3%. Three- and 5-year disease-free survival rates did not differ significantly between the tumor stage subgroups. The mortality for patients with local recurrence was 22.2%, which was higher than that for those without recurrence. The organ preservation rate was 98.5%.PurposeThis study was to assess the rates of oncological outcomes in patients with early stage glottic squamous cell carcinoma treated with transoral laser microsurgery (TLM).ConclusionAC involvement was a predictor of local recurrence, and its presence was associated with a reduced survival rate and increased mortality after TLM. TLM got high survival rate and low recurrence rate. The staging and oncological outcomes did not differ between tumor stage subgroups.     

Radiotherapy. The mainstay in the treatment of early glottic carcinoma

Early squamous cell carcinoma of the glottis may be effectively treated with surgery or radiation therapy. Controversy exists as to whether radiation therapy effects survival at the expense of vocal function by ultimately requiring more total laryngectomies for salvage of local tumor recurrence. This study reviewed the medical records of 185 patients with T1 or T2, NO invasive squamous cell carcinoma of the glottis treated with primary radiation therapy between 1969 and 1984. All patients were followed up for a minimum of 5 years after completion of therapy. One hundred sixty-one patients met the criteria for local control analysis. Radiation therapy controlled disease in 93% (105 of 113) of patients with T1 lesions and 73% (38 of 48) of those with T2 tumors. Ultimate control of disease for T1 and T2 lesions, including surgical salvage, was 111 (98%) of 113 and 44 (92%) of 48 patients, respectively. The rate of successful surgical salvage was 75% (T1) and 70% (T2). The T2 lesions with impaired vocal cord mobility or anterior commissure disease were identified as being at increased risk for recurrence after primary radiation therapy. Overall voice preservation was 90%. Our data demonstrate that radiation therapy effects disease-free survival rates that are comparable to those produced by surgery, without sacrificing voice. Although a small percentage of patients with selected early glottic lesions may be more effectively treated with primary conservation surgery, these data do not support a change in philosophy concerning primary treatment of early glottic cancer with radiation therapy.     

Cricohyoidoepiglottopexy vs near-total laryngectomy with epiglottic reconstruction in the treatment of early glottic carcinoma

OBJECTIVE: To compare functional and oncological outcomes of cricohyoidoepiglottopexy (CHEP) and near-total laryngectomy with epiglottic reconstruction (NTLER) techniques in early glottic carcinoma. DESIGN: Case series, clinical study. SETTING: Two tertiary care referral centers. PATIENTS: Seventeen patients with T1b glottic squamous cell carcinoma were treated with CHEP and 21 were treated with NTLER. MAIN OUTCOME MEASURES: Fundamental frequency, maximum phonation time, maximum phonation intensity, Voice Handicap Index, and GRBAS (grade, roughness, breathiness, asthenia, and strain) scale were used to evaluate voice. Nasogastric tube removal times and late postoperative aspiration scales were used to evaluate swallowing ability. RESULTS: Fundamental frequency (P=.78), maximum phonation time (P=.44), and maximum phonation intensity (P=.94) measurements were not significantly different in the 2 groups. There was also no significant difference in mean Voice Handicap Index score (P=.62), mean decannulation time (P=.25), time to nasogastric tube removal (P=.12), or clinical grades of late postoperative aspiration (P=.87) between the 2 groups. The mean Voice Handicap Index score was 55.58 in the CHEP group and 52.78 in the NTLER group. According to the GBRAS scale, overall voice quality was moderately altered in both groups. All patients were successfully decannulated. In the CHEP and NTLER groups, the mean decannulation times were 27 and 20 days, respectively, and the nasogastric tubes were removed after an average of 23 and 17 days. The overall (Kaplan-Meier) survival rate was 94% in the patients who underwent CHEP and 90% in the patients who underwent NTLER (P=.76). The disease-free survival rates were 100% and 76% in the CHEP and NTLER groups, respectively (P=.07). CONCLUSIONS: Functional and oncological results appear to be similar with both treatment methods. If open surgery is planned, the choice between these procedures mainly depends on the experience and preference of the surgeon.