Oncologic and functional outcomes of transoral CO2 laser cordectomy for early glottic cancer

ObjectiveTo investigate the oncological and functional outcomes of the patients treated with transoral CO2 laser cordectomy for early glottic cancer.Patients and methodsFifty-five consecutive patients who underwent CO2 laser cordectomy for early glottic cancer were retrospectively reviewed.ResultsOverall survival, larynx preservation, and relapse free local control rates were 96%, 100%, and 91%, respectively. Five patients with local recurrences were salvaged with re-cordectomy and/or radiotherapy. In type I cordectomy, VHI-10 consistently improved during postoperative course and VHI-10 at postoperative 12 months was significantly better than preoperative value (2.3 vs. 9.4, p = 0.02). Perceptual grading, MPT, MFR and AC/DC also improved and were better than preoperative values. In type III cordectomy, shimmer at 12 months after cordectomy was significantly better than preoperative value (14.7 vs. 9.3, p = 0.007).ConclusionsThese results further support the rationale of CO2 cordectomy as initial and salvage surgery for early glottic cancer.     

Prognostic role of margin status in open and CO2 laser cordectomy for T1a–T1b glottic cancer

Introduction

Cordectomy by laringofissure and transoral laser surgery has been proposed for the treatment of early glottic cancer.

The utility of second-look operation after laser microresection of glottic carcinoma involving the anterior commissure

Objectives/Hypothesis: Transoral laser microsurgery for the treatment of glottic carcinoma with anterior commissure (A‐com) involvement is associated with a high rate of recurrence. We prospectively evaluated the outcomes of laser microsurgery and the efficacy of second‐look operation in these patients. Study Design: Prospective evaluation. Methods: Twenty‐seven patients with glottic carcinomas involving the A‐com underwent transoral laser microresection. Twenty‐five patients underwent second‐look operations 3 months after laser surgery. Results: After transoral laser microresection, all patients achieved microscopic clear resection margins. Local recurrence was found in 7 of 27 patients (25.9%). Regional recurrence was found in two patients. Patients with recurrences underwent laser re‐resection or neck dissection; four received radiotherapy, two lost their larynxes, and three died of disease. At second‐look operation, early local recurrence was found in two patients, and anterior glottic webs and granulomas causing dysphonia were treated in 8 and 11 patients, respectively. Conclusions: Laser microsurgery is an effective treatment modality in early glottic cancer with A‐com involvement but is still associated with a high rate of recurrence. Second‐look operation may help detect early local recurrence and treat postoperative airway or voice problems.     

Endoscopic pharyngolaryngoplasty: A case report

IntroductionAny technique that allows decannulation of tracheostomy-dependent patients relieves their discomfort and reduces health costs.Case reportWe present the case of a 70-year-old tracheostomy-dependent patient with pharyngolaryngeal stenosis and a history of radiation therapy for laryngeal cancer in remission for 13 years and multiple decannulation failures. Endoscopic pharyngolaryngoplasty was performed using reconstructive transoral laser microsurgery techniques, allowing permanent decannulation. Endoscopic sutures secured by clips were performed to remodel the pharyngolarynx and prevent recurrence of synechiae.DiscussionEndoscopic surgery of the pharynx and larynx was initially developed for resection of small tumours. Reconstructive transoral laser microsurgery has been developed more recently. One of the objectives of this surgery is to reconstruct the pharyngolarynx to treat functional sequelae following surgery and/or radiation therapy for head and neck cancer. It allows reconstruction of the upper airways to restore mouth breathing in tracheostomy-dependent patients, thereby facilitating permanent decannulation.     

Transoral laser microsurgery as standard approach to hypopharyngeal cancer. Survival analysis in a hospital based population

Objective

Cancer of the hypopharynx remains one of the most challenging chapters in head and neck oncology. The objective of this study is to ascertain the relevance of a transoral laser approach as a valid functional option for treatment of cancer of the hypopharynx in Portugal, and additionally, to confirm the reproducibility of survival and functional outcomes described in other reference centers.

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.

Analysis of prognostic factors for Tis-2N0M0 early glottic cancer with different treatment methods

IntroductionIn many regions, laryngeal carcinoma is a common upper respiratory tract cancer, most commonly involving the glottic region. The treatment of early glottic cancer includes radiotherapy, open surgery and laryngeal laser microsurgery. However, the preferred treatment for early glottic cancer is still controversial.ObjectivesTo study the factors affecting the 5-year survival rate of T_is-2N₀M₀ early glottis cancer and to demonstrate the oncological safety of different treatments.Methods144 patients with early glottic cancer were analyzed retrospectively. All patients were clinically node negative. 53 patients underwent open surgery, transoral CO₂ laser microsurgery in 46 cases and radiotherapy in 45 cases. The patients were followed up for 26 ? 84 months, with an average follow-up period of 62.9 months.ResultsThe 5-year overall survival was 82.6%. The 5 year survival rates of open surgery, laser microsurgery and radiotherapy were 83.0%, 82.6% and 82.2%, respectively. There was no significant difference in 5-year survival rate among the three treatments (p = 0.987). In multivariate analysis, age, T-stage, pathological grading, and anterior commissure involvement were important prognostic factors for early glottic cancer.ConclusionThere was no significant difference in 5 year survival rate among patients treated by either radiotherapy, laser microsurgery or open surgery for early glottic cancer. We urge more attention to the age, T-stage, pathological grade, and anterior commissure involvement of the patients.     

Resultados oncológicos de la laringectomía de rescate en pacientes con carcinomas escamosos de laringe

ObjectiveTo analyse the oncological results of a salvage total laryngectomy in patients with a laryngeal carcinoma.Material and methodsRetrospective review of a cohort of 241 patients treated with a salvage laryngectomy after a local recurrence. The initial treatment received by these patients was radiotherapy (n = 201, 83.4%), chemoradiotherapy (n = 19, 7.9%), and partial surgery (n = 21, 8.7%),ResultsTotal laryngectomy as salvage treatment achieved local control of the disease in 81.3% of cases, with a 5-year specific survival of 65.3%. The variables related with specific survival in a univariate analysis were the location of the primary tumour, the local extension of the initial tumour and of the recurrence, the resection margins, and the pathological status of the neck dissections. According to the results of a multivariate analysis, the variables related to specific survival were the status of the resection margins, the presence of simultaneous regional recurrence, and the local extension of the recurrence.ConclusionThe 5-year specific survival of patients treated with a salvage laryngectomy was 65.3%. The variables related with the control of the disease were the status of the resection margins, the presence of simultaneous regional recurrence and the local extension of the recurrence.     

Successful 10-year outcomes after supracricoid partial laryngectomy for selected glottic squamous cell carcinoma classified as T3N0M0: A STROBE analysis

PurposeTo evaluate long-term oncological outcome for patients with selected glottic squamous cell carcinoma (SCC) classified as T3N0M0 treated by supracricoid partial laryngectomy (SCPL).Materials and methodsAnalysis of an inception cohort of 46 patients with isolated untreated SCC classified as T3N0M0 and minimum 10-year follow-up, consecutively treated by SCPL between 1982 and 2012 in a French university teaching hospital. The main endpoint was 5- and 10-year actuarial survival and local control estimates. Accessory endpoints comprised cause of death, screening for variables decreasing survival and increasing risk of local recurrence, oncologic consequences of local recurrence, and laryngeal preservation rate.ResultsFive- and 10-year actuarial survival was 78.1%, and 53.3%, respectively. The main causes of death were intercurrent disease and metachronous second primary, each in 33.3% of cases. Postoperative mortality (aspiration pneumonia) was 2.1%. There were no significant correlations between survival and any study variables. Five- and 10-year local control was 90.5%. Overall local recurrence varied significantly (P = 0.003), from 2.3% with negative margins (R0) to 100% with positive margins (R1) and/or dysplasia. Local recurrence was associated with a significantly (P < 0.005) increased risk of nodal failure and distant metastasis, and reduced survival. Overall laryngeal preservation was 89.1%.ConclusionThe present results suggest that SCPL should continue to be taught and that this type of partial laryngeal surgery should be included in the various organ-sparing strategies considered in advanced laryngeal cancer.     

Evaluation of robotic surgery for transoral resection of T1-2 squamous cell carcinoma of the tonsillar fossa

GoalTo evaluate transoral robotic surgery (TORS) for isolated previously untreated squamous cell carcinoma (SCC) of the tonsillar fossa classified as T1-2.MethodRetrospective analysis of two cohorts of isolated untreated T1-2 tonsillar fossa SCC consecutively operated on by a transoral approach, with (R = 21) and without (NR = 24) robotic assistance, in the period 2006–2014. Three main (survival, local control, and operative morbidity) and three secondary (pathologic data, incidence and duration of tracheotomy and nasogastric intubation, and hospital stay) endpoints were compared between groups. The significance threshold was set at P <  .005.ResultsThree- and five-year actuarial survival estimates were 80.2% and 74.5% respectively in group R, and 91.5% and 82.5% respectively in group NR (NS: P = .34). Three- and five-year actuarial local control estimates were 90% and 90% respectively in group R, and 95.8% and 91% respectively in group NR (NS: P = .81). There were no significant differences in morbidity, tracheotomy/nasogastric intubation time, or hospital stay. Positive resection margins (R1) were noted in 38.1% and 16.7% in groups R and NR, respectively (NS: P = .05) without significant impact on 5-year actuarial local control (P = 0.78).ConclusionRobotic assistance in transoral lateral oropharyngectomy for T1-2 tonsillar fossa SCC did not significantly impact oncologic or functional outcome.     

Factors associated with incomplete surgical margins in basal cell carcinoma of the head and neck

IntroductionCutaneous basal cell carcinoma recurrence is associated with inadequate surgical margins. The frequency of and the factors associated with compromised or inadequate surgical margins in head and neck basal cell carcinoma varies.ObjectiveThe purpose of this study was to evaluate the clinical and pathological factors associated with inadequate surgical margins in head and neck basal cell carcinoma.MethodsWe developed a cross-sectional study comprising all patients who had undergone resection of head and neck basal cell carcinoma from January 2017 to December 2019. Data on age, sex, head and neck topography, histopathological findings, and staging were retrieved and compared. Each tumor was considered an individual case. Compromised and close margins were termed “inadequate” or “incomplete”. Variables that were significantly associated with the presence of incomplete margins were further assessed by logistic regression.ResultsIn total, 605 tumors from 389 patients were included. Overall, sixteen cases (2.6%) were classified as compromised, 52 (8.5%) as close, and 537 (88.7%) as free margins. Presence of scleroderma (p = 0.005), higher Clark level (p < 0.001), aggressive variants (p < 0.001), invasion beyond the adipose tissue (p < 0.001), higher T stage (p < 0.001), perineural invasion (p = 0.002), primary site (p = 0.04), multifocality (p = 0.01), and tumor diameter (p = 0.02) showed association with inadequate margins. After Logist regression, multifocality, Clark level and depth of invasion were found to be independent risk factors for inadequate margins.ConclusionGross clinical examination may be sufficient for determining low prevalence of inadequate surgical margins when treating head and neck basal cell carcinoma in highly experienced oncologic centers. Multifocality, Clark level and depth of invasion were found to be independent risk factors for incomplete margins.     

Transoral laser microsurgery in advanced carcinomas of larynx and pharynx

Introduction and objectivesThere are several types of treatment for advanced squamous cell carcinomas of the pharynx and larynx. However, both open surgery and chemoradiation protocols have failed to improve control and survival. There is a tendency toward conservative treatment without worsening oncological outcomes. The objective of this study was to describe the effectiveness of organ-preserving CO₂ laser microsurgery for treating advanced carcinomas of the larynx and pharynx.Material and methodA retrospective review of 63 patients undergoing CO₂ laser microsurgery for the treatment of squamous cell carcinomas of the pharynx and larynx in advanced stages (stages III and IV) was performed. Tumour distribution was 14 patients with a tumour at the base of the tongue, 16 with a pyriform sinus tumour, 29 with a supraglottic tumour and 4 with a glottic tumour. Mean follow-up was 51 months.ResultsThirty-five percent of patients (23) had recurrences. The recurrence rate was 28% for base of tongue tumours, 50% for hypopharyngeal tumours, 27% for supraglottic tumours and 75% for glottic tumours. The 5-year disease-specific survival rate was 73.3% for all locations, with a range from 90% for supraglottic tumours up to 50% for glottic tumours. Thirty-four percent of patients had some type of complication after surgery. The most frequent complication was local bleeding (17%).ConclusionTransoral CO₂ laser microsurgery is an alternative for the treatment of carcinomas of the pharynx and larynx in advanced stages. Its oncological results are equivalent to other treatment modalities and its morbidity is lower.     

The role of separate margins sampling in endoscopic laser surgery for early glottic cancer

Conclusions Sampling surgical margins in trans-oral laser microsurgery for early glottic squamous cell carcinoma (SCC) may allow for increased local control rate, although with no difference in local control by endoscopic treatment alone. Objective To further delineate the role of routinely sampling separate surgical margins, in patients with early glottic SCC undergoing endoscopic laser resection. Methods A retrospective case control study. One hundres and two early glottic cancer patients staged Tis-T2 underwent endoscopic laser surgery with curative intent as the primary treatment. Separate margins from the surgical bed were sampled following complete tumor resection in 64 patients; in 38 patients no margins were sampled. Results Margin sampling showed a tendency towards reduced risk for local recurrence, adjusted HR?=?0.439 (p-value?=?0.096). However, there was no difference in local control by endoscopic treatment alone. The patients with sampled margins were further divided based on margins’ status: 39 (61%) had negative margins, and 25 (39%) had positive margins. Compared with negative margins, patients with positive margins showed increased risk for recurrence, adjusted HR?=?8.492 (p?=?0.008). When margins were not sampled the risk for local recurrence was increased compared to negative margins (adjusted HR?=?7.875, p-value?=?0.008), and relatively comparable to what was observed when sampled margins were positive (adjusted HR?=?0.927, p-value?=?0.88).     

Role of supracricoid partial laryngectomy with cricohyoidoepiglottopexy in glottic carcinoma with anterior commissure involvement

ObjectivesTo analyze oncologic and functional outcomes after supracricoid laryngectomy with cricohyoidoepiglottopexy (SCL-CHEP) in glottic carcinoma with anterior commissure (AC) involvement, to determine predictive factors, and to compare results with those reported for other therapeutic strategies.Material and methodsA retrospective analysis included all patients who underwent SCL-CHEP for glottic squamous cell carcinoma with anterior commissure involvement in our institution, between 2000 and 2014. Swallowing function was evaluated on the DOSS (Dysphagia Outcomes and Severity Scale).ResultsFifty-three patients were included. Three-year overall, cause-specific and recurrence-free survival rates were 86, 95 and 80%, respectively. There were 5 cases of local recurrence (9%), all treated by total laryngectomy. Smoking was the only predictive factor of recurrence-free survival (P = 0.02). Mean DOSS score was 5.5 ± 0.9. DOSS scores ≥ 6 (normal oral feeding) were recovered by 59% of patients. T-stage ≥ 2 was the only predictive factor for DOSS score (P = 0.04).ConclusionIn glottic carcinoma with anterior commissure involvement, SCL with CHEP provided a local control rate of more than 90%, which is higher than reported with endoscopic surgery or external radiotherapy. However, contrary to LSC, salvage of local recurrence can often be obtained by conservative treatments after endoscopic surgery. Therefore, total-laryngectomy-free survival rates after SCL-CHEP and endoscopic surgery are finally comparable.     

Transoral laser microsurgery in previously irradiated patients with laryngeal cancer

Purpose

Early laryngeal cancer is successfully managed with transoral laser microsurgery. Previously radiated patients may experience more post-operative complications. We investigate disease-free survival and secondarily prolonged pain and chondronecrosis.

Materials and methods

Retrospective review of 52 patients undergoing transoral laser microsurgery after previous radiation.

Results

Mean disease-free survival was 36.7 months. Overall disease-free survival was 57.6% at 3-year and 48.4% at 5-year follow-up, with no significant difference between surgery within as opposed to after 60 months of radiation or within as opposed to after 12 months of radiation. Thirteen patients, all with surgery within 60 months of radiation, experienced prolonged pain. Twelve experienced chondronecrosis, all within 12 months of surgery.

Conclusion

Transoral laser microsurgery for early laryngeal cancer is an adequate therapeutic option in patients with history of radiation with comparable disease-free survival to other reports. Patients undergoing transoral laser microsurgery within 60 months of radiation treatment are more likely to experience prolonged pain.     

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.     

Management of stylohyoid syndrome: A systematic review following PRISMA guidelines

ObjectivesA systematic review of the literature on stylohyoid syndrome treatment was performed according to PRISMA guidelines.Material and methodsThree hundred and forty-nine articles were retrieved in the PubMed and Cochrane databases using the search-terms “stylohyoid syndrome” and synonyms. Articles documenting treatment and outcome with more than 1 month's follow-up were selected. Treatment-related complications and rate of cure, defined as disappearance of symptoms and/or of revelatory complication, were analyzed. Overall analysis was performed for series and a mixed logistic regression model for case reports.ResultsHundred and two articles (12 series, 90 case reports) were selected. The 12 series included 482 patients with pain syndrome managed by styloidectomy, with 84.2% and 73.7% cure rates for cervical and transoral approaches, respectively. There were no complications with the transoral approach, versus 1.2% transient facial paresis with the cervical approach. In the 90 case reports, 112 patients had pain syndrome (Group I) and 16 neurological deficit (Group II). Cure rate in Group I varied significantly (P = 0.005; OR 8.33, 95% CI [2.12–32.81]) from 64.3% following medical treatment (antiepileptics, muscle relaxants, analgesics, per os and/or locally injected anti-inflammatory drugs) to 91.8% following styloidectomy, without any significant impact of surgical approach (P = 0.1; OR 0.17, 95% CI [0.02–1.60]). In Group I, no complications occurred after medical treatment, versus 4.3% and 16.3% after transoral and cervical styloidectomy, respectively. In Group II, cure and complication rates were 87.5% and 6.2%, respectively. Due to the small sample size and heterogeneity of Group II, no statistical assessment of the contribution of styloidectomy to medical treatment (antiplatelet drugs, with or without stenting) was performed.ConclusionStyloidectomy appears to be the treatment of choice for stylohyoid syndrome. The surgical approach does not significantly influence the cure or complications rate.     

Salvage surgery for recurrence of laryngeal and hypopharyngeal squamous cell carcinoma: A retrospective study from 2005 to 2013

ObjectivesSalvage surgery is the gold-standard treatment for locoregional recurrence of laryngeal and hypopharyngeal cancer following radiation therapy. Imperfect oncologic and functional results, however, require patient selection. The main objective of the present study was to determine preoperative factors for survival. Secondary objectives were to study 5-year overall and disease-free survival, general and locoregional complications, and functional results in terms of feeding and tracheotomy closure.Patients and methodA retrospective multicenter study included 52 patients treated by salvage surgery for recurrence of laryngeal or hypopharyngeal squamous cell carcinoma after radiation therapy between 2005 and 2013.ResultsFactors associated with improved 3-year overall survival on univariate analysis comprised laryngeal primary (P = 0.001), laryngeal recurrence (P = 0.026), rT1, rT2 or rT3 rather than rT4 tumor (P = 0.007), previous chemotherapy (P = 0.036), and neck dissection during salvage surgery (P = 0.005), the last of these being confirmed on multivariate analysis. Five-year overall survival was 36.0% (range, 27.6–44.4%), for a median 23.04 months (95% CI, 19.44–26.64). Five-year disease-free survival was 23.5% (range, 16.0–31.0%), for a median 8.04 months (95% CI, 2.04–14.04).ConclusionSalvage surgery for laryngeal or hypopharyngeal cancer is difficult, and survival is not good. Laryngeal primary and recurrence location, moderate tumor volume and extension (< T4), prior chemotherapy and neck dissection during salvage surgery were associated with better overall and disease-free survival, which should enable better patient selection.     

The role of laser microsurgery in the treatment of laryngeal cancer

PURPOSE OF REVIEW: Transoral laser microsurgery has developed in recent years into a surgical method that combines a minimally invasive approach with the surgical precision of laser and microscope. The outcomes of laser microsurgical treatment of laryngeal carcinomas are reviewed and compared with the results of competitive standard procedures. RECENT FINDINGS: Laser microsurgery is widely acknowledged to have advantages in the treatment of early glottic carcinoma. In the treatment of glottic carcinoma causing impaired mobility or fixation of the vocal cord the role of laser surgery has not yet been definitively assessed. Based on published results, primary laser therapy can achieve local tumor control with a functional residual larynx in approximately 70-80% of cases. In patients with early or moderately advanced supraglottic carcinoma, laser microsurgery is comparable to open supraglottic laryngectomy in terms of local control and survival. With regard to organ preservation, laser microsurgery is comparable to open supraglottic laryngectomy but superior to radiotherapy. Microsurgery can preserve functionally important structures, allowing for early swallowing rehabilitation while avoiding tracheotomy. SUMMARY: This review elucidates the role of laser microsurgical partial resections of the larynx in comparison with other treatment modalities.     

Consensus statement on management in the UK: Transoral laser assisted microsurgical resection of early glottic cancer

Background: Transoral laser assisted microsurgical resection of early glottic laryngeal cancer is a relatively new treatment modality that is practised in many centres across the UK. In the absence of the results from randomised clinical trials, clinicians may be guided by an expert panel consensus statement on transoral laser assisted microsurgical resection of early squamous cell cancer of the larynx. Objective: To provide consensus recommendations on the various aspects of transoral laser assisted microsurgical resection for early glottic cancer. Evaluation method: Nine centres across the UK were invited to describe current practice and outcomes for transoral laser assisted microsurgical resection of early glottic cancer. Four working groups were created to draw consensus on standard of care, surgical procedures, outcomes measures and training/certification. The feedback from these groups was integrated into the consensus statement. Conclusions: The consensus meeting confirmed the stablished and widespread use of transoral laser assisted microsurgical resection for early glottic cancer throughout the UK. The common experience gained allowed a full discussion of all aspects of the management with consensus achieved in key areas of standards of care, surgery, histopathologic reporting, outcomes assessment and training. This consensus statement will result in closer auditing of management and dissemination of results.