Photodynamic therapy and the treatment of neoplastic diseases of the larynx

Photodynamic therapy (PDT) is an innovative treatment involving the use of light-sensitive drugs to selectively identify and destroy diseased cells. Therefore, photodynamic therapy has the potential to treat and cure precancerous and early cancerous lesions (carcinoma in situ [CIS], T1 and T2) of the larynx while preserving normal tissue. Eleven patients with recurrent leukoplakia and carcinomas of the larynx were treated with PDT with follow-up to 27 months. One patient with a Tl verrucous carcinoma, 5 patients with T1 squamous cell carcinomas of the vocal cord failing radiotherapy, 1 patient with a T2 squamous cell carcinoma of the vocal cord failing radiotherapy, and 3 patients with CIS and severe atypia were treated with PDT and obtained a complete response and are disease free. One patient with a T3 carcinoma of the larynx was treated with PDT but died 4 weeks post-treatment of unrelated causes and could not be assessed. Photodynamic therapy is a promising therapy for treatment of precancerous and cancerous lesions of the larynx. This therapy may be particularly beneficial for the treatment of recurrent carcinomas of the larynx that have failed conventional radiotherapy, thereby preserving voice and eliminating the need for destructive laryngeal surgery.     

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。     

Treatment of carcinoma of the vocal cord a review of 20 years experience.

At the University of California, San Francisco, 323 patients were treated for carcinoma of the vocal cord between January 1956 and December 1975. Patients with early T1 or T2 lesions were treated with radiotherapy or conservative surgery. Patients with T3 or T4 lesions were treated with total laryngectomy, radiation alone, or combined therapy. Of the 247 patients treated with definitive radiotherapy, initial control of the primary lesion was achieved in 100% of T1S, 80% of T1, 52% of T2, and 50% of T3 and T4 lesions. Surgical salvage of radiation failures was 86%, giving ultimate control rates in this group of 100% for T1S, 97% for T1, 91% for T2 and 64% for T3 and T4. Involvement of the anterior commissure did not significantly affect local control or survival rates of the irradiated patients. Voice quality was satisfactory in 95% of controlled patients. Surgery alone was used as the primary treatment modality in 63 patients, with ultimate local control achieved in 75% of T1S, 83% of T1, 85% of T2, 81% of T3 and T4 lesions. Planned combined therapy was successful in 9/13 patients in whom it was used. The overall 3 and 5 year actuarial survival rates were 84% and 77% respectively; corresponding determinate survival rates were 90% and 86%.     

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.     

Results of treatment of 584 laryngeal cancers at the Ear-Nose-Throat Clinic of Marburg University

The results in the management of 460 vocal cord carcinomas and 124 supraglottic carcinomas are reported. Of the vocal cord carcinomas, 63.3% were diagnosed in the early Tis and T1 stage. Seventy-six tumors were resected endoscopically, 128 by laryngofissure and chordectomy. Not one of these patients has lost his life, larynx or voice. In bilateral tumors of the T1b category, 2 patients developed local recurrences and lost their larynx. Sixty-two carcinomas of the Tis, T1a and T1b categories were irradiated primarily. Two of these patients died and 14 underwent laryngectomy for local recurrence. In T2 carcinomas a 5-year cure rate of 87.5% was achieved by vertical partial resection. The 5-year cure rate after laryngectomy or laryngectomy with neck dissection for T2N0 and T2N+ carcinoma was 86.2% and 75.0% respectively. Most treatment failures were due to late metastases which could not be controlled. In T3 carcinomas with a 5-year cure rate of 71.4% (N0) and 70.0% (N+) respectively, treatment failures were also mainly seen in patients with N0 necks where we did not carry out a prophylactic neck dissection. Five-year survival rates for primary surgery in supraglottic T1-T4 carcinomas were 100%, 82.4%, 84% and 58.3%. The widely hel opinion that laryngeal carcinoma should only be subjected to surgery for irradiation failure can no longer be sustained. More patients lose their larynx or their life after irradiation of small carcinomas than after primary surgery. Furthermore, too many patients have to undergo two major cancer treatments (irradiation and salvage surgery). In larger carcinomas radiotherapy produces a lower survival rate and too many patients require two stressful cancer therapies. The number of retained larynges is not substantially higher than with primary surgery. Primary irradiation for selected cases should be part of every therapy concept that aims at an adequate and individual treatment of every patient.     

Radiotherapy for early glottic cancer and salvage surgery after recurrence

Early glottic cancer can be effectively treated with radiation or surgery, but recurrence is a possibility when using any of the treatment modalities.AimTo assess the outcome of radiotherapy as initial treatment in the control of squamous cell carcinoma of vocal cord (T1) and the effectiveness of salvage surgery (endoscopic or open) after treatment failure.Materials and MethodsA retrospective study was based on the analysis of medical records from 43 patients with T1 squamous cell carcinoma of the glottis, radiotherapy as initial treatment and follow-up period of five years.ResultsThe rate of recurrence after radiotherapy was 30.2% of the cases, mean diagnosis interval was 29.5 months. As an option for salvage treatment, patients underwent open partial laryngectomy or endoscopic surgery with control rates of 77.7% and 25% respectively.ConclusionOur cases showed high rates of recurrence after radiotherapy and open partial laryngectomy was more effective for the salvage surgery.     

Radiation failures in cancer of the larynx.

Overwhelming statistics have been published regarding the success of radiation therapy in the management of laryngeal carcinoma. The fate of those patients whose cancers are not controlled by radiotherapy is often left to speculation. An analysis is made of 61 patients with early and advanced laryngeal cancer treated initially with radiation therapy and subsequently operated upon because of recurrent or persistent tumor. Frequently, diagnosis of recurrence is difficult or delayed. Preservation of voice can only be accomplished when recurrence of T1 and T2 lesions is detected early and strict criteria are followed. Conservation surgery is not feasible for early lesions which progress after radiation failure. Advanced T2 and T4 lesions which become radiation failures also require laryngectomy for salvage. In cancer of the larynx, there is a definite, identifiable group of patients in whom surgery would be advisable as the initial therapy.     

Selective management of early glottic cancer

Seventy patients with stage I and II glottic cancer were treated at the University of Utah School of Medicine hospitals from 1980 through 1987. Forty-four patients had stage I cancer and 26 patients had stage II. The overall survival in the stage I group was 82%. Primary site control was 93% with only three deaths due to laryngeal cancer. Local control rates were 93% with CO2 laser excision, 80% with CO2 laser and irradiation, and 67% with radiation alone. Stage II glottic patients had an overall survival of 61.5% with a local control rate of 76%. Twenty-one of 24 patients were treated by full-course irradiation. Of the eight patients who recurred at the primary site, all were irradiation failures who had initial bulky disease and impaired vocal cord mobility. Selective CO2 laser excision was highly effective, whereas radiation therapy results were somewhat disappointing. Open partial laryngectomy should be considered in bulky stage II disease patients.     

Primary radiation therapy for T1 glottic cancer. Factors influencing local control

One hundred and seventy-four patients with early glottic cancer received radiation therapy on the kV250 and cobalt 60 machines. Crude survival rates at 5, 10 and 15 years were 83%, 73% and 60%, respectively. Salvage surgery for locoregional recurrences was successful in 85% of the patients. A significantly higher failure rate was noted in patients with a pre-existing chronic laryngitis, with lesions confined to the left vocal cord and in those treated with KV250 irradiation. The rate of second primaries in this case material was 11%, 70% of which were noted in the respiratory tract. Megavoltage radiotherapy offers excellent chances for cure in T₁ laryngeal carcinoma with preservation of good voice in most patients. Patients with chronic laryngitis carry a high risk of local recurrence and therefore should be considered for primary conservation surgery.     

Thyroid dysfunction after radiation therapy in head and neck cancer patients

INTRODUCTION: The reported incidence of hypothyroidism following surgery and/or radiation therapy for head and neck cancer varies widely. Most patients undergo thyroid lobectomy during laryngectomy. Standard radiation treatment portals often include the thyroid gland. The insidious development of hypothyroidism may be misdiagnosed. This study examines the incidence of thyroid dysfunction in the setting of head and neck cancer therapy. MATERIALS AND METHODS: Thyroid function tests were performed on 100 consecutive patients treated in the head and neck tumor clinic. Statistical inferences on proportions were made using chi-square analysis. RESULTS: Therapy included surgery only (10 patients), radiation therapy only (28 patients), and combined therapy (62 patients). These patients experienced thyroid dysfunction in 0%, 29%, and 45% of individuals respectively. These differences were statistically significant (P < .05). The highest rate of dysfunction (69%) was associated with patients undergoing laryngectomy and radiation therapy. When laryngectomy was not performed, thyroid dysfunction occurred in 28%. CONCLUSION: The likelihood of thyroid dysfunction after radiation therapy is high particularly when combined with surgery in which thyroid lobectomy is performed and the contralateral lobe is potentially devascularized. These results suggest that radiation therapy is a primary factor in alteration of thyroid function. We recommend that routine thyroid function testing be part of follow-up of all head and neck cancer patients.     

The treatment of T3 glottic carcinoma with vertical partial laryngectomy

Total laryngectomy has traditionally been considered the optimal treatment for patients with advanced glottic carcinoma who present with a fixed true vocal cord. However, using whole-organ sectioning techniques, it has been demonstrated that vertical partial laryngectomy is a sound oncologic procedure for selected fixed vocal cord lesions. During the period 1969 to 1984, 27 patients who presented at UCLA with T3 glottic carcinoma were treated using vertical partial laryngectomy. Follow-up for these patients averaged 4.0 years. The absolute two-year disease-free survival rate for this group was 85% (23 of 27 patients), and the local cancer recurrence rate during a two-year postoperative interval was 11% (three of 27 patients). These encouraging results support the continued use of partial laryngeal surgery for a subgroup of patients with T3 glottic cancer. Successful patient selection requires a careful analysis of disease extent based on data obtained from physical examination, magnetic resonance imaging or computed tomographic scanning, and direct laryngoscopy.     

Partial laryngectomy to treat early glottic cancer after failure of radiation therapy

OBJECTIVE: To evaluate the role of partial laryngectomy to treat glottic cancer after failure of radiation therapy. DESIGN: A 12-year retrospective outcome analysis. SETTING: University referral center. PATIENTS: A total of 19 patients who underwent partial laryngectomy to treat glottic cancer after failure of radiation therapy. RESULTS: The follow-up period in this group ranged from 31 to 144 months. After surgery, a laryngocutaneous fistula was observed in 4 cases, and flap necrosis occurred in 2, but these complications were successfully managed. Maximum phonation time after surgery ranged from 3 to 28 seconds (median phonation time, 10.2 seconds). Of these 19 patients, 3 developed local recurrence. These cases were successfully treated with total laryngectomy. A surgical margin of less than 1 mm was found to be a significant risk factor for local recurrence after partial laryngectomy. CONCLUSIONS: These results indicate that partial laryngectomy is a useful option for the treatment of irradiation failure in the treatment of stage I and stage II vocal cord carcinomas. However, careful follow-up is mandatory for patients with a small surgical margin.     

Voice problems following limited surgical excision

The published literature contains relatively few references to vocal rehabilitation for persons with partial laryngectomy. Articles on various types of surgery indicate that many individuals develop satisfactory voice following limited surgery, particularly supraglottic procedures. An informal questionnaire completed by 10 laryngologists who had had substantial experience with sub-total laryngectomy revealed that an average of 25 percent of their patients with laryngeal cancer receive partial laryngectomy. Lesions limited to the epiglottis, supraglottic areas or one vocal cord are regularly treated by limited excision. Half of the questionnaires indicated that partial laryngectomy can be used for bilateral vocal cord lesions under certain circumstances. The questionnaire confirmed the published reports that most of the subsequent voices were satisfactory or good and many recover without special vocal retraining. None reported employment of partial laryngectomy for sub-glottal cancer. Hemilaryngectomy and cordectomy frequently resulted in some impairment of voice. Speech therapy is often recommended when possible. Therapy applicable to voice following partial laryngectomy combines five emphases: 1. strengthening glottic closure and loudness of the voice; 2. improving the efficiency of breath expenditure; 3. increasing the articulately skill and intelligibility of speech; 4. recognizing and compensating for hearing loss; and 5. aiding the patient to reduce detrimental environmental influences and to adjust to his environmental requirements.     

The results of radiation and surgical treatment of early vocal cord carcinoma (T1a, T1b)

Results of surgery treatment from the external access and radiotherapy in early, stage of vocal cords carcinoma were presented. Clinical material consisted of 94 cases with squamous cell carcinoma of vocal cords with stage T1a and T1b treated in Szczecin University Department of Otorhinolaryngology from 1987 to 1996. 51 cases were operated on (26 by chordectomy and 25 by frontolateral laryngectomy). Radiotherapy was applied in 43 patients. The 3 and 5 years' survival rate in the surgery group was 97% and after radiotherapy 88 to 80%. The functional results were also presented. It was concluded that the mode of treatment in early stages of vocal cord carcinoma should be individualized.     

Near total thyroidectomy is an optimal treatment for graves’ disease

Surgical management of Graves’ disease is still debated. We report our current experience with thyroidectomy for Graves’ disease at a tertiary center. A retrospective database of 132 patients who underwent surgery for Graves’ disease from January 1985 to December 2008 was collected. During that period, 16 patients underwent subtotal thyroidectomy and 116 patients underwent near total thyroidectomy. Eighty-seven patients (66%) underwent surgery for recurrent disease after medical therapy. Forty-five patients (34%) had surgery as a primary treatment, the indications were large goiter size in 22 (17%), patient preference in 19 (14%), and associated cold nodule in 3 (2%). The incidence of cancer was 4.4%. Permanent hypoparathyroidism was observed in one patient who underwent a second surgery for recurrence. Unilateral transitory vocal cord palsy was observed in nine patients (7%), bilateral transitory vocal cord palsy was observed in one patient, and no definitive vocal cord palsy was observed. Two patients (1.5%) experienced post-operative hemorrhagia requiring surgical revision. Near total thyroidectomy for Graves’ disease provides an immediate and definitive treatment with a low complication rate. Near total thyroidectomy offers an appropriate treatment for coexisting malignancy. This procedure can be safely recommended as a primary treatment, in experienced hands.     

Endoscopic laser treatment in pre-malignant and malignant vocal fold epithelial lesions

Endoscopic laser treatment was performed in 43 patients with pre-malignant or malignant vocal fold epithelial lesions, 10 were treated with endoscopic laser surgery for dysplasia, 12 for carcinoma in situ (CIS), five for verrucous carcinoma and 16 patients for squamous cell carcinoma (SCC). Thirty-two patients received laser therapy as their first therapy, whereas 11 patients had had previous radiation therapy for laryngeal carcinoma (n = 9) or CIS (n = 2). Recurrence after initial laser therapy necessitating re-treatment (a second laser treatment or radiotherapy) occurred in nine out of 32 patients (28 per cent), thus 23 (72 per cent) were maintained free of disease during the follow-up period. Besides the 32 patients without previous therapy, patients who had already undergone radiation therapy were also included in this study. In this group there were nine patients with SCC, one patient with CIS and one with dysplasia. They all underwent laser therapy. Four were free of disease during follow-up (36 per cent) and seven developed recurrences. Six (58 per cent of all patients with previous radiation therapy) underwent total laryngectomy.     

Partial laryngectomy for recurrent laryngeal carcinoma

From July 1975 to January 1998, 33 patients underwent partial laryngeal resection for residual or recurrent tumour after primary radical radiotherapy. Sixteen patients had T1 tumours on presentation, 14 were T2 and three were T3. Six patients underwent a supraglottic (horizontal) laryngectomy, 24 had a vertical partial laryngectomy, two had an endoscopic laser resection and one had an endoscopic laser resection followed by a vertical partial laryngectomy. The median time interval between radiotherapy and salvage surgery was 10 months (range 2-188 months). The median follow-up period was 41 months (range 12-185 months). There were five major postoperative complications (15%); two patients developed a pharyngeal fistula and three required further surgery for laryngo-tracheal stenosis. Twenty-five patients (76%) retained their larynx with satisfactory speech and swallowing. Eight patients (24%) had to be converted to a total laryngectomy, seven for recurrent disease and one for laryngeal stenosis. Of the eight patents converted, seven had normal swallowing and six developed good tracheo-oesophageal speech. Seven patients (21%) developed recurrent tumour after partial laryngectomy and were subjected to total laryngectomy; six of these seven were salvaged. Only one of the 33 patients died with recurrent tumour, giving an ultimate disease-related survival of 97%. Conservation laryngeal surgery for salvage of selected patients who fail radical radiation therapy is safe, effective, and results in reasonable preservation of laryngeal function.     

Carcinoma of the laryngeal glottis therapy and end results.

The end results of 264 patients with vocal cord carcinoma treated by either surgery or radiation therapy at the University of Illinois from 1955 to 1972 are analyzed. Stage I glottic carcinoma can be cured by either surgery or radiation alone (86 percent and 80 percent). Stage II glottic cancer treated by surgery has achieved survival rates of 70 percent. The five-year end results of Stage III glottic cancer are 49 percent for surgery and 30 percent for radiation. The management of glottic carcinoma, according to anatomic site and indications for various modalities are discussed.     

Phonomicrosurgical management of the disease of vocal fold]

OBJECTIVE: To find a way of reserving normal high quality phonatory function after vocal cord surgery. METHODS: Various benign lesions (vocal nodules, polyp of vocal cord, cyst of vocal cord, etc) as well as premalignant lesion and early glottic cancer were treated with minimally excision, lateral microflap, medial microflap, submucosal infusion, mucosal stripping or epithelium stripping of phonomicrosurgical techniques to achieve minimally invasion. RESULTS: The 1,044 (99.8%) patients suffering from vocal nodules, polyp or cyst and 12 Reinke's edema achieved a normal phonation within a week. The recovery of normal phonation in 20 Reinke's edema, 31 vocal cases needed 1-3 months, by mucosal stripping. The restoration of phonation on 5 papilloma, 36 early malignancy were better than trans-cervical operation. After 5 year follow-up, 3 cases of vocal cord premalignant lesions received the re-stripping operation. 32 cases of early glottic cancer remained tumor free, 5 cases relapsed and 2 cases received the re-stripping operation, and 2 cases received laryngectomy operation. CONCLUSION: The phonomicrosurgery may cure vocal disease and reserves good voice function.     

Laser excision of early vocal cord carcinoma: indications, limitations, and precautions

Forty-six patients referred for laser surgery of early vocal cord carcinoma were treated by laser excisional techniques with or without radiotherapy. Mean follow-up was 3.5 years. There was a 90% rate of carcinoma control (18 of 20 patients) in patients with untreated mid-vocal cord T1 carcinomas without involvement of the anterior commissure or vocal process or deep muscle invasion. Larger, more invasive T1 vocal cord tumors (13 patients) had laser excision followed by radiotherapy without recurrence. Careful patient selection and accurate histopathologic evaluation are key elements for successful treatment.