Management Of Laryngeal Cancer Research Articles

Volume‐based trends in laryngeal cancer surgery

Positive volume-outcome relationships exist for diseases treated with technically complex surgery. Contemporary patterns of laryngeal cancer surgery by hospital and surgeon volume are poorly defined. The Maryland Health Service Cost Review Commission database was queried for hospital and surgeon laryngeal cancer surgical case volumes from 1990 to 2009. Overall, 1,981 laryngeal cancer surgeries were performed by 288 surgeons at 41 hospitals. Cases performed by high-volume surgeons increased from 19% in 1990 to 1999 to 35% in 2000 to 2009 (odds ratio [OR] = 3.0, P<.001), whereas cases performed at high-volume hospitals increased from 33% to 39% (OR = 2.0, P<.001). High-volume surgeons were more likely to perform total laryngectomy (OR = 1.7, P = .001) and neck dissection (OR = 1.7, P = .002). High-volume hospitals were significantly associated with total laryngectomy (OR = 2.0, P = .003), neck dissection (OR = 1.8, P = .038), flap reconstruction (OR = 5.1, P = .021), prior radiation (OR = 3.0, P = .031), and increased mortality risk scores (OR = 3.2, P = .006). After controlling for other variables, laryngeal cancer surgery in 2000 to 2009 was associated with increased access to high-volume surgeons (OR = 1.9, P<.001) and high-volume hospitals (OR = 1.3, P = .040), a decrease in partial and total laryngectomy procedures (OR = 0.2, P<.001), an increase in neck dissection (OR = 2.2, P< 0.001), an increase in prior radiation (OR = 3.0, P<.001), increased case complexity scores (OR = 5.7, P<.001), and an increase in wound fistula or dehiscence (OR = 2.0, P = .015) compared with 1990 to 1999. The proportion of laryngeal cancer surgery patients treated by high-volume surgeons and hospitals increased significantly in 2000 to 2009 compared with 1990 to 1999, with a decrease in laryngectomy procedures and an increase in wound complications. These findings may be due to changing trends in primary management of laryngeal cancer.

CO2 laser transoral laser microsurgery of head and neck cancer: lessons learned over ten years

Background CO2 transoral laser microsurgery (TLM) is an emerging technique for the management of laryngeal cancer and other head and neck malignancies. This technique has become more widely used by head and neck surgeons progressively replacing traditional open surgical procedures because it is better at preserving organ function with lower overall morbidity. The CO2 laser is coupled to a micromanipulator and microscope, which provides enhanced tumor visualization and the ability to perform precise tissue cuts, obtain excellent hemostasis, and avoid damaging the surrounding tissues and structures that are transected during open surgical procedures. Objectives To summarize our experience using the CO2 laser for the transoral resection of head and neck cancer, and discuss strategies and solutions for situations encountered during laser resections. Material and methods The basic principles and approach of performing TLM using CO2 laser for different otolaryngologic malignancies will be discussed. The benefits of using CO2 TLM over traditional surgery, common complications, and different settings used depending on the location of the tumor and as well as the several lessons learned over the years will also be discussed. Conclusion CO2 laser is the best-suited laser for TLM in treatment of head and neck cancer. Over the years the improved instrumentation, demonstration of oncologic effectiveness, clinical experience using TLM and decreased morbidity has led to an increased utilization of TLM by head and neck surgeons. Successful surgery requires adequate visualization, precise cutting, controlled depth of tissue penetration, and ability to obtain tissue hemostasis. The full spectrum of laser power settings, spot sizes and energy pulse delivery modes is utilized to resect mucosa, fat, muscle, connective tissue and cartilage while avoiding inadvertent damage to nerves and large vessels, and obtaining adequate hemostasis.

Prognostic Accuracy of Computed Tomography Findings for Patients With Laryngeal Cancer Undergoing Laryngectomy

The indications for upfront laryngectomy in the management of laryngeal cancer are a functionless larynx and extralaryngeal extension. Practically, clinicians rely on imaging to predict which patients will have T4 disease. Our goal was to review the accuracy of preoperative computed tomography (CT) scanning in determining the necessity for initial laryngectomy for advanced laryngeal cancer. In total, 107 consecutive untreated laryngectomy specimens with high-quality, preoperative CT imaging interpreted by our neuroradiologists were reviewed. Radiographic findings, including sclerosis, invasion, penetration, extralaryngeal spread, and subglottic extension were correlated with pathologic findings. CT images were not reinterpreted, since our purpose was to assess the original interpretations. CT imaging reported 23 cases of thyroid cartilage penetration and 27 cases of extralaryngeal spread. Pathology reported 12 cases of thyroid cartilage invasion, 29 cases of penetration, and 45 cases of extralaryngeal disease. CT imaging identified 17 (59%) of 29 cases of pathologically documented thyroid cartilage penetration and 22 (49%) of 45 cases of pathologically documented extralaryngeal spread. Pathologically proven extralaryngeal spread without thyroid cartilage penetration occurred in 18 (40%) of 45 cases. The positive predictive values for thyroid cartilage penetration and extralaryngeal spread were 74% and 81%. Sclerosis was of limited value in predicting thyroid cartilage invasion or penetration. Cricoid or arytenoid destruction predicted for thyroid cartilage penetration at rates of 57% and 63%. CT imaging has clear limitations when deciding whether there is thyroid cartilage penetration or extralaryngeal spread of advanced laryngeal cancer. Extralaryngeal spread without thyroid cartilage penetration was more common than expected. Alternate methods of pretreatment assessment are needed.

Treatment Decision in the Management of Laryngeal Cancer: An Overview

AbstractA spectrum of treatment plans and surgical procedures are available for management of laryngeal cancer. Transoral laser resection has proved an effective, minimally invasive and functionally satisfactory procedure for management of suitable T1 and T2 glottic cancers, and stage I-III supraglottic cancers. Introduction of chemoradiotherapy has also made great impact on the laryngeal preservation. The treatment of laryngeal cancer should be individualized according to the size and extent of the tumor, the age and physical condition of the patient, and the skill and experience of the surgeon with various treatment modalities and surgical procedures.

Does Vocal Cord Fixation Preclude Nonsurgical Management of Laryngeal Cancer?

Does Vocal Cord Fixation Preclude Nonsurgical Management of Laryngeal Cancer?

Surgical voice restoration after total laryngectomy: An overview

Total laryngectomy is potentially a debilitative surgery resulting in compromise of some of the most basic functions of life including speech and swallowing. This may have a profound adverse effect on the patient's physical, functional, and emotional health, and may result in a decreased quality of life (QOL). Until the 1980s, total laryngectomy was regarded as a dreadful, but often, life-saving procedure for which there was little alternative, and was used as a last resort. At that time survival at any cost in terms of QOL was paramount and many laryngectomies were forced into an isolated life as a mute and dysphasic recluse. Most attempts at voice restoration produced inconsistent results and often techniques were laborious, expensive, and ineffective, particularly when carried out as a salvage procedure after failed radiotherapy. Progress in voice rehabilitation, following total laryngectomy, over the last 30 years, has made an enormous difference in the whole concept of the management of laryngeal cancers. Currently there are several options available for these patients, namely, esophageal speech, artificial larynx, and tracheoesophageal speech. The choice of speech rehabilitation varies from patient to patient, but tracheoesophageal voice has become the preferred method. This article provides a brief account of surgical voice restoration after total laryngectomy. Special emphasis has been given to the surgical technique, special considerations, complications, and the prevention / treatment of tracheoesophageal voice restoration.

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

The role of open surgery for management of laryngeal cancer has been greatly diminished during the past decade. The development of transoral endoscopic laser microsurgery (TLS), improvements in delivery of radiation therapy (RT) and the advent of multimodality protocols, particularly concomitant chemoradiotherapy (CCRT) have supplanted the previously standard techniques of open partial laryngectomy for early cancer and total laryngectomy followed by adjuvant RT for advanced cancer. A review of the recent literature revealed virtually no new reports of conventional conservation surgery as initial treatment for early stage glottic and supraglottic cancer. TLS and RT, with or without laser surgery or CCRT, have become the standard initial treatments for T1, T2 and selected T3 laryngeal cancer. Photodynamic therapy (PDT) may have an emerging role in the treatment of early laryngeal cancer. Anterior commissure involvement presents particular difficulties in application of TLS, although no definitive conclusions have been reached with regard to optimal treatment of these lesions. Results of TLS are equivalent to those obtained by conventional conservation surgery, with considerably less morbidity, less hospital time and better postoperative function. Oncologic results of TLS and RT are equivalent for glottic cancer, but with better voice results for RT in patients who require more extensive cordectomy. The preferred treatment for early supraglottic cancer, particularly for bulkier or T3 lesions is TLS, with or without postoperative RT. The Veterans Administration Study published in 1991 established the fact that the response to neoadjuvant CT predicts the response of a tumor to RT. Patients with advanced tumors that responded either partially or completely to CT were treated with RT, and total laryngectomy was reserved for non-responders. This resulted in the ability to preserve the larynx in a significant number of patients with locally advanced laryngeal cancer, while achieving local control and overall survival results equivalent to those achieved with initial total laryngectomy. Following this report, similar "organ preservation" protocols were employed in many centers. By 2003, results of the RTOG 93-11 trial, utilizing CCRT as initial treatment, were published, demonstrating a higher rate of laryngeal preservation with this protocol. Surgery was reserved for treatment failures. This concept changed the paradigm for management of advanced laryngeal cancer, greatly reducing the number of laryngectomies performed. While supracricoid laryngectomy has been employed for selected patients, total laryngectomy is the usual procedure for salvage of failure after non-surgical treatment.

Does vocal cord fixation preclude nonsurgical management of laryngeal cancer?

To determine whether vocal cord fixation precludes nonsurgical management of T3/T4 laryngeal carcinoma. A retrospective chart review. Between 1989 and 2005 patient records with T3/T4 squamous cell carcinoma of the larynx with vocal cord fixation at presentation were reviewed. All were treated with a concomitant cisplatin-based chemoradiotherapy protocol and were part of the institutional head and neck cancer chemoradiotherapy registry. Only patients with adequate pre- and post-treatment fiberoptic evaluations were included. Charts were reviewed for demographics and tumor characteristics; return of vocal cord function; local, regional, or distant recurrence after treatment; and need for salvage surgery. The Kaplan-Meier method was used to estimate outcomes, and the log-rank test was used to compare those patients whose vocal cords remained fixed to those with recovery of function. Twenty-three patients met the inclusion criteria, 19 males and 4 females. The median age was 59 years (range, 39-73). Fourteen patients had T3 and nine had T4 tumors. Twelve patients recovered full range of mobility, three had partial recovery, and eight did not recover motion. The median follow-up was 68 months (range, 34-191). Comparing patients with post-treatment partial or fully mobile cords to those with persistent fixation revealed the following: A projected five-year overall survival of 100% versus 25%, (P < .001), freedom from recurrence of 86.7 versus 25% (P < .001), local control without surgery of 86.7% versus 30% (P = .003), and survival with functional larynx of 86.7% versus 25% (P = .008), respectively. Nonsurgical therapy in patients with pretreatment vocal cord fixation is feasible. However, persistence of vocal cord fixation after definitive chemoradiotherapy is a poor prognostic sign and early surgical intervention should be considered. Laryngoscope, 2009.

Organ preservation surgery for laryngeal cancer.

The principles of management of the laryngeal cancer have evolved over the recent past with emphasis on organ preservation. These developments have paralleled technological advancements as well as refinement in the surgical technique. The surgeons are able to maintain physiological functions of larynx namely speech, respiration and swallowing without compromising the loco-regional control of cancer in comparison to the more radical treatment modalities. A large number of organ preservation surgeries are available to the surgeon; however, careful assessment of the stage of the cancer and selection of the patient is paramount to a successful outcome. A comprehensive review of various organ preservation techniques in vogue for the management of laryngeal cancer is presented.

Chemotherapy Alone for Laryngeal Preservation—Is It Possible?

Holsinger et al 1 report the results of a phase II trial testing chemotherapy alone as definitive treatment for preservation of the larynx in selected patients with stages II to IV laryngeal cancer. This study is the first of its kind in the United States, even though the approach has been tried in France by Laccourreye et al 2,3 in patients with T1 to T3N0 glottic cancers. In their study, Holsinger et al were careful to select patients with T2 to T4 cancers of the glottic or supraglottic larynx who could be treated with conservation laryngeal surgery. Using a regimen of cisplatin plus ifosfamide plus paclitaxel (TIP), chemotherapy alone proved successful, with no local or regional failures in 10 patients (32%) demonstrating biopsy-confirmed complete response (CR) out of 31 patients enrolled. These results are important because they underscore the sensitivity of squamous cell cancer of the larynx to cisplatin-based chemotherapy, the potential for chemotherapy as a single-modality treatment option in selected patients with laryngeal cancer, conservation laryngeal surgery as an organ-preserving option for appropriate patients selected by an experienced team, and the importance of a multidisciplinary care team in the evaluation, management, and follow-up of patients with head and neck cancer. Seven years were required for the accrual of nine patients with T3 or T4, N0 or N1 cancers suitable for conservation laryngeal surgery, in addition to the 22 patients with T2N0 or N1 cancers who were identified as being at high risk for recurrence with altered fractionation radiotherapy, and who were also candidates for conservation laryngeal surgery. These 31 patients, all of whom had excellent performance status, received either three or four cycles of TIP followed by response assessment. All patients achieved either a CR or partial response to TIP. If a CR was determined on the basis of imaging, endoscopic examination, and negative biopsy, additional cycles of TIP were administered (up to a maximum of six cycles), after which patients were rigorously monitored. Patients with less than a biopsy-proven CR underwent appropriate laryngeal surgery, with or without neck dissection and radiation, as indicated. A high rate of laryngeal preservation was achieved (83%; 95% CI, 65 to 94), significantly better than the rate of 60%, which had been determined— on the basis of previous studies 4,5 of stage III and IV laryngeal cancers treated for organ preservation in patients in whom total laryngectomy would otherwise have been required— sufficient for declaring the treatment a success. Clearly, the bar had been set too low for this patient group, in which stage II disease was predominant, and which was suitable for conservation laryngeal surgery from the outset. The estimated survival outcomes at 5 years were an overall survival of 83% (95% CI, 70 to 98) and a recurrence-free survival (deaths not resulting from study cancer were censored) of 73% (95% CI, 58 to 91), suggesting that the treatment approach was not detrimental. Standard of care management of laryngeal cancer varies with

Does Vocal Cord Fixation Preclude Nonsurgical Management of Laryngeal Cancer?

Does Vocal Cord Fixation Preclude Nonsurgical Management of Laryngeal Cancer?

State of head and neck surgical oncology research—A review and critical appraisal of landmark studies

Surgical literature has been criticized for the lack of high-quality research. The present review examines methodological quality of literature published in head and neck surgical oncology. We focus on landmark studies published on topics of best practice controversy, namely (1) the role of chemotherapy and organ-preservation protocols in the management of head and neck mucosal malignancies; (2) the role of selective neck dissection versus radical neck dissection; and (3) the role of laser microsurgery in the management of larynx cancer. Similar flaws were evident in selected landmark studies with the major issue being multiplicity in the form of multiple outcome analysis, comparison of multiple treatment groups, repeated measures over time, planned interim analyses, and subgroup analyses. The open nonrandomized controlled trial may be a feasible option in head and neck surgical research allowing for standardization, uniformity, consistency, and blinded outcome assessment.

Return of Vocal Cord Movement: An Independent Predictor of Response to Nonsurgical Management of Laryngeal Cancers

To determine whether return of vocal cord function after treatment of T2b/T3 laryngeal carcinoma is an independent prognostic factor for locoregional recurrence. A retrospective review of patients treated with radiation +/- chemotherapy between 2000 and 2005 for T2 with vocal cord paresis and T3 laryngeal carcinoma was conducted. Only those patients obtained from the tumor registry with pre-and posttreatment video stroboscopies were included. Patients' charts were reviewed for local and regional recurrence after treatment. Fisher's exact test was used to determine significant association between recurrence and possible risk factors. Fourteen patients met the inclusion criterion. Six patients had T2 lesions with vocal cord paresis, and eight patients had T3 lesions. Fifty percent of patients with T2 and 75% of patients with T3 lesions had return of vocal cord function after treatment. Five of 14 patients did not have return of vocal cord function, and of these, 100% had locoregional recurrence. Of the nine patients who had return of vocal cord movement, none of the patients had recurrence. The proportion of recurrence was significantly higher for those whose vocal function did not return compared with the patients whose vocal function returned (100% vs. 0%, P < .01). The immobile vocal cord is associated with a worse prognosis and is therefore factored into the American Joint Commission on Cancer staging for laryngeal tumors. We show that vocal cord immobility is an independent prognostic factor of recurrence even after treatment and can predict treatment failure in T2 and T3 lesions of the larynx.

Transoral laser microsurgery for carcinoma of the supraglottic larynx

The study goal was to report the oncologic outcomes of transoral laser microsurgery (TLM) in the treatment of squamous cell carcinoma of the supraglottic larynx. A two-center prospective case series analysis. Thirty-eight patients underwent TLM for previously untreated carcinoma of the supraglottic larynx between 1997 and 2005. Pathological T stages were T1 in 8 (21%), T2 in 14 (37%), T3 in 8 (21%), and T4 in 8 (21%). Twenty-six patients (68%) had neck dissections. Thirteen patients (34%) received adjuvant radiotherapy. The mean follow-up for all patients was 31 months. The 2-year Kaplan-Meier estimates for local control were 97%; locoregional control, 94%; disease-specific survival, 80%; and overall survival, 85%. The overall functional laryngeal preservation rate was 79% (19 of 24). TLM is a safe and effective treatment for cancer of the supraglottic larynx. TLM is an emerging strategy in the management of laryngeal cancer.

Management of laryngeal cancer in an ENT Service in subSaharan Africa

The management of cancers of the larynx remains a challenge to most ENT specialists in Cameroon due to a multitude of factors linked to their management. The aim of this study is to identify the important factors that militate against the proper management of these cancers and to propose solutions. A retrospective study was carried out in the ENT service of the General Hospital of Douala over six years (April 1998 to June 2006). Eighteen cases of epidermoid cancers of the larynx were identified. Only 10 of the clinical records could be reviewed because the remaining patients refused to be treated in our unit immediately after they were informed of the diagnosis. All the cases were males with a mean age of 53. Most of the cases diagnosed were at the advanced stage of the disease (7T4, 2T3, 1T2). Six patients were treated with radiotherapy only, one with chemo-radiotherapy. Three patients had a full laryngectomy followed by radiation therapy in two cases. One of the cases operated developed a pharyngeal fistula. By the end of the third year only 30% of our patients still continued their follow-up. The therapeutic protocols used took into consideration the socio-economic status of the patients, the experience of the personnel in the management of laryngeal cancers and the treatment techniques and modes available in our hospital. Because of these factors, standard European and American recommendations for the management of laryngeal cancers could not be used. Government intervention to offer subventions for the high cost of work-up and treatment of these patients is a must for better results to be obtained. There is also a need for the creation of training, prevention and treatment centres for cancers of the larynx.

Molecular markers in laryngeal squamous cell carcinoma: Towards an integrated clinicobiological approach

Of the most frequent malignancies in the United States, cancers of the larynx and of the uterine corpus are the only ones not to show an increase in 5-year survival rates over the last 30 years. The increasing use of chemo- and radiotherapy and conservative surgery to preserve organs and their functions has probably led to a better quality of life in patients with laryngeal cancer, but has definitely failed to improve survival, which remains the primary aim. In our opinion, to reduce laryngeal cancer-related mortality, a change in clinical approach is required. We have reviewed the literature on the potential role of molecular markers in the clinical management of laryngeal cancer. We believe that some of the most significant biological markers might be integrated with the evaluation of behavioural risk factors, clinical TNM staging and histopathological grading for a novel clinicomolecular approach to laryngeal cancer. We foresee the use of the most promising biological markers in the phases of prevention, diagnosis, prognostic assessment and drug design.

Therapeutic management of laryngeal cancer. Results of a study of 356 patients from the Cancer Registry of the Somme, France

Conclusions. The global survival rate was low compared to those reported in the literature, in which the analyzed populations were selected according to the tumor stage or treatment. This study should be prolonged and should also involve other cancer registries in France in order to increase the number of patients and to analyze tumors of comparable stage and therapeutic management. Objective. To analyze the survival rate of a non-selected laryngeal cancer population from the Cancer Registry of the Somme, a French region. Material and Methods. A total of 356 patients were included in a retrospective study covering the period 1987–1997. Survival and prognostic factors were analyzed. Statistical analysis was performed using the Kaplan–Meier method, the Cox model and the χ2 test. Results. The 5-year global survival rate was 42% for males and 55% for females. Tumor localization, T, N and M stages and surgery were found to be significant prognostic factors. Sex and age were not statistically significant factors. For stage I tumors, surgery alone gave better results than radiotherapy alone in terms of global survival. No difference occurred in terms of local recurrence. A similar comparison was not possible for stage II–IV tumors owing to the small number of cases.

Organ preservation surgery for laryngeal cancer: The evolving role of the surgeon in the multidisciplinary head and neck cancer team

Total laryngectomy is in the doghouse. It is a procedure that was once heralded as a life saving intervention, standing the test of time for over a century. Now largely considered a salvage procedure, total laryngectomy is seen as a second choice following the failure of other approaches. Today, the first line treatment for many patients with advanced laryngeal cancer is the organ-preserving treatment of chemotherapy and radiation therapy. The VA trial showed us that chemotherapy and radiation therapy results in equal survival for patients undergoing total laryngectomy, compared with those who underwent induction chemotherapy and radiation therapy.’ The RTOG 97-l 1 trial demonstrated that concomitant chemotherapy and radiation are superior to either induction chemotherapy or radiation alone in the context of organ preservation for advanced laryngeal cancer. * Both valuable studies have significantly improved the management of laryngeal cancer. It has been suggested that concomitant chemotherapy and radiation therapy should now be the standard of care for laryngeal cancer, replacing total laryngectomy. Patients want to save their larynx, so of course chemotherapy and radiation treatment is good thing. Can there be too much of a good thing?

Carcinoma of the larynx: the Dutch national guideline for diagnostics, treatment, supportive care and rehabilitation

Purpose: This evidence based guideline aims to facilitate proper management and to prevent diverging views concerning diagnosis, treatment and follow-up of carcinoma of the larynx between the major referral centers for head and neck cancer in The Netherlands. Method: A multidisciplinary committee was formed representing all medical and paramedical disciplines involved in the management of laryngeal cancer and all head and neck oncology centers in The Netherlands. This committee reviewed the literature and formulated statements and recommendations based on the level of evidence and consistency of the literature data. Where reliable literature data were not available, recommendations were based on expert opinion. Results: Strict criteria have been proposed for the radiological diagnostic procedures as well as for the pathology report. For carcinoma in situ and severe dysplasia, microsurgery, preferably by laser, is proposed. For all other stages of invasive carcinoma, a full course of radiotherapy as a voice conserving therapy is the treatment of choice. Only in cases with massive tumor volumes with invasion through the laryngeal skeleton, primary surgery is inevitable. For rehabilitation and supportive care, minimal criteria are described. Due to the complexity of therapy and relative rarity of larynx carcinoma, all patients should be seen at least once in a dedicated head and neck clinic. Conclusion: This guideline for the management of larynx carcinoma was produced by a multidisciplinary national committee and based on scientific evidence wherever possible. This procedure of guideline development has created the optimal conditions for nationwide acceptance and implementation of the guideline.

Suggested classification of endoscopic laryngeal oncological surgery

It would be beneficial to use a common classification system for the various endoscopic surgery techniques employed in the management of laryngeal cancer. A common classification system would facilitate the collation of endoscopic surgery series results and the comparison of postendoscopy outcome with that of conventional treatment options. The classification system would also ensure methodological schooling. The European Laryngological Society has proposed a classification system of endoscopic cordectomies derived from a synthesis of current classifications. This system comprises eight types of cordectomy: the subepithelial cordectomy (type I), involving resection of the epithelium; the subligamentous cordectomy (type II), involving resection of the epithelium, the Reinke space, and the vocal ligament; the transmuscular cordectomy (type III), proceeding through the vocal muscle; the total cordectomy (type IV); and the extended cordectomy, encompassing the contralateral vocal fold and the anterior commissure (type Va), the arytenoid (type Vb), the ventricular fold (type Vc), and the subglottis (type Vd). Indications for performing those cordectomies may vary from surgeon to surgeon. The operations are classified according to the surgical approach and the degree of resection. They are not classified according to the instrument used. The same type of classification and synthesis for the supraglottic larynx has yet to be undertaken.