Overview of glottic laryngeal cancer treatment recommendation changes in the NCCN guidelines from 2011 to 2022.

BACKGROUND: The treatment of glottic cancer remains challenging, especially with regard to morbidity reduction and larynx preservation rates. The National Comprehensive Cancer Network (NCCN) has published guidelines to aid decision-making about this treatment according to the tumor site, clinical stage, and patient medical status. AIM: The present review was conducted to identify changes in the NCCN guidelines for glottic cancer treatment made between 2011 and 2022 and to describe the published evidence concerning glottic cancer treatment and oncological outcomes in the same time period. METHODS AND RESULTS: Clinical practice guidelines for head and neck cancer published from 2011 up to 2022 were obtained from the NCCN website (www.NCCN.org). Data on glottic cancer treatment recommendations were extracted, and descriptive analysis was performed. In addition, a review of literature registered in the PubMed database was performed to obtain data on glottic cancer management protocols and treatment outcomes from randomized controlled trials, systematic reviews, and meta-analyses published from 2011 to 2022. In total, 24 NCCN guidelines and updates and 68 relevant studies included in the PubMed database were identified. The main guideline changes made pertained to surgical and systemic therapies, the consideration of adverse features, and new options for the treatment of metastatic disease at initial presentation. Early-stage glottic cancer received the most research attention, with transoral endoscopic laser surgery and radiotherapy assessed and compared as the main treatment modalities. Reported associations between treatment types and survival rates for this stage of glottic cancer appear to be similar, but functional outcomes can be highly compromised. CONCLUSION: NCCN panel members provide updated recommendations based on currently accepted treatment approaches for glottic cancer, constantly reviewing new surgical and non-surgical techniques. The guidelines support decision-making about glottic cancer treatment that should be individualized and prioritize patients' quality of life, functionality, and preferences.

Flexible endoscopic laser surgery for early glottic carcinoma.

OBJECTIVE: Flexible endoscopic laser surgery (FELS) is able to overcome some limitations of traditional transoral CO2 laser surgery. The objective of this study was to assess the efficacy of FELS in the treatment of T1-T2 glottic carcinoma. METHODS: We applied FELS for 120 patients with T1-T2 glottic carcinoma. Tumour ablation was performed with Nd:YAG laser. In 76 (63.3%) cases the intervention was performed under local anesthesia. Twenty nine (24.2%) patients (T1b - 2, T2-27) underwent postoperative radiation therapy (RT). RESULTS: Successful treatment, with local control and larynx preservation, was obtained in 106 cases (88.3%), with mean follow-up of 6.4 years. More than 50% of the patients were followed-up over 5 years. CONCLUSIONS: FELS can be proposed as an alternative treatment method for patients with early glottic carcinoma. The advantages of the method include: possibility of applying treatment under local anesthesia, that allows avoiding of general anesthesia and its related risks; applicability to patients with contraindications to general anesthesia and patients with anatomic particularities, that make transoral microsurgery impossible, allowing avoidance of the laryngofissure and tracheotomy.

Oncologic results and quality of life in patients with T3 glottic cancer after transoral laser microsurgery.

PURPOSE: CO2 transoral laser microsurgery (CO2 TOLMS) is an alternative approach to non-surgical organ preservation in selected T3 glottic squamous cell carcinoma (SCC). This study aimed to assess the oncologic results and quality of life (QOL) of patients with T3 glottic SCC after CO2 TOLMS. METHODS: Of the 44 patients who underwent CO2 TOLMS, 38 underwent QOL evaluations. QOL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 and head and neck module, Voice Handicap Index-30, and M. D. Anderson Dysphagia Inventory at least 6 months postoperatively. RESULTS: The patients were predominantly male (98%), with a median age of 61 years. Cordectomy type included 1 type III, 4 type IV, 31 type V, and 8 type VI according to European Laryngological Society classification. Two patients (5%) had cervical lymph node metastasis and 21 patients (48%) underwent postoperative radiotherapy. With a mean follow-up of 65 months for all patients, 10 (23%) had tumor recurrence (9 local, 1 distant). After salvage surgery, four patients lived without disease, and the larynx was preserved in two. The 5-year local control and overall and disease-specific survival rates were 78%, 75%, and 84%, respectively. The overall laryngeal preservation rate was 82% (36/44). Most patients had satisfactory QOL. CONCLUSIONS: In selected T3 glottic SCC cases, CO2 TOLMS can achieve favorable oncologic results and a satisfactory QOL.

Comparison of Voice Quality of Life in Early Stage Glottic Carcinoma Treated with Endoscopic Cordectomy Using Radiofrequency Microdissection Electrodes, Laser Cordectomy, and Radiotherapy.

PURPOSE: To compare the quality of life of patients with early glottic carcinoma who have been treated using three treatment modalities: endoscopic cordectomy using radiofrequency microdissection electrodes (ECRM), transoral laser cordectomy, and radiotherapy (RT). ECRM, transoral laser cordectomy, and RT can all be used as alternatives to invasive open surgery to treat the early stages of glottic cancer such as stage T1. Patients treated using these different modalities could have different outcomes with respect to voice quality of life. MATERIALS AND METHODS: The voice quality of life was measured in patients who underwent ECRM, transoral diode laser excision, or RT for early laryngeal cancer. Post-treatment quality of voice was assessed using the Turkish version of the Voice-Related Quality of Life questionnaire in all patients after 1 year of cancer-free survival. A comparison was then made between the outcomes of the three groups. RESULTS: The total score of the ECRM group, when compared independently to that of the laser and the RT groups, was found to be statistically higher in both cases. However, no statistically significant differences were found between laser and RT groups in terms of any parameters. There was a statistically significant difference between the RT group and the other groups in terms of percentage jitter, percentage shimmer, and fundamental frequency (F0) (P < 0.05). While the RT group had the longest maximum phonation time (P < 0.001), no significant differences were found between the maximum phonation time of the ECRM and the laser groups (P < 0.001). CONCLUSIONS: Overall, the worst outcome with respect to voice quality of life is seen with ECRM. Since there were no significant differences in quality of life between the other two treatment modalities, it is recommended to leave the choice between RT and laser surgery up to the patient.

AHNS Series - Do you know your guidelines? Principles of treatment for glottic cancer: A review of the National Comprehensive Cancer Network guidelines.

This article is a continuation of the "Do You Know Your Guidelines" series, an initiative of the American Head and Neck Society's Education Committee to increase awareness of current best practices pertaining to head and neck cancer. The National Comprehensive Cancer Network (NCCN) guidelines for primary and adjuvant treatment of cancer of the glottic larynx are reviewed here in a systematic fashion according to stage.

Transoral laser resection of glottic carcinoma: what is the significance of anterior commissure involvement?

BACKGROUND: The optimal management of glottic carcinoma involving the anterior commissure is controversial. METHOD: A retrospective analysis was conducted of 76 patients with glottic squamous cell carcinoma treated by transoral carbon dioxide laser resection by a single surgeon. RESULTS: Sixty-three patients (with tumour stage Tis-T3) were eligible for inclusion. Thirty patients had involvement of the anterior commissure; these patients were significantly more likely to have either uncertain or positive margins (63.3 vs 30.3 per cent, p = 0.012), and were also more likely to receive adjuvant radiotherapy (40 vs 3.2 per cent, p = 0.0005). The overall laryngeal preservation rate was 96.8 per cent; there was no statistically significant difference between those with and without anterior commissure involvement (96.7 and 96.9 per cent respectively). CONCLUSION: Transoral laser resection with the use of adjuvant radiotherapy in a minority of patients with adverse pathological findings can be recommended for the primary treatment of anterior commissure glottic cancer from an oncological perspective; excellent local control and laryngeal preservation rates can be achieved.

Magnetic Control of the Glottic Opening in an Ex Vivo Sheep Larynx Model: A Preliminary Study.

OBJECTIVE/HYPOTHESIS: So far, a number of techniques have been described for the treatment of bilateral vocal fold paralysis. These techniques were reported to be successful in maintaining an adequate airway but also found to be associated with an increased risk of aspiration, dysphonia, and granulation tissue formation at the operation site. We aimed to investigate the effectiveness of a novel mucosa-sparing technique based on the generation of a magnetic field within the larynx for the tailored lateralization of the ipsilateral vocal fold. STUDY DESIGN: This is an ex vivo experimental study. METHODS: Twenty sheep larynges that were procured from the local slaughterhouse were used as a model. For each specimen, two neodymium (Nd) disc magnets with marked poles were used to create a unilateral attractive magnetic force at the glottic level. Following insertion of the magnets, the level of vocal fold lateralization was assessed under an operating microscope. The results were analyzed for their statistical significance. RESULTS: Before the procedure, the mean value of the glottic openings of all the specimens was 4.985 mm. The postprocedure mean value was 5.640 mm. The mean amount of increase in the glottic openings after the procedure was 0.655 mm. This change was found to be statistically significant (P < 0.05). CONCLUSIONS: A statistically significant increase in the cross-sectional area of the glottic region could be achieved. The mucosal integrity of the laryngeal airway was also preserved. The idea of "magnetic control of the glottic airway" is a novel concept but seems to be a promising option.

Factors leading to the use of alternate treatment modalities following transoral laser excision of T1 and T2 glottic squamous cell carcinoma.

BACKGROUND: CO(2) transoral laser surgery and radiotherapy are both recognized as acceptable treatments for early glottic squamous cell carcinoma (SCC) with similar rates of cure. The reasons why some of the patients in our series undergoing laser resection as their primary modality of treatment subsequently underwent radiotherapy or chemoradiotherapy will be discussed. METHODS: Retrospective study between January 2003 and August 2010 of all T1 and T2 glottic SCCs treated with laser resection at a major tertiary centre. Tis lesions were excluded. A review of the cases in which primary control with laser resection was not achieved was undertaken. Failure was defined as patients treated initially with laser resection who subsequently received radiotherapy, combined chemoradiotherapy or open surgery for the same tumour. Factors leading to failure were analysed, including tumour location, histology, stage and patient factors. RESULTS: Thirty-one patients were identified, with the majority (27) having T1 disease. Mean number of laser excisions per patient was 1.7. Local control rate was 71% with laser alone. One patient had nodal recurrence with no primary recurrence. Mean follow-up was 32 months. Of the nine patients in whom local control was not achieved with laser alone, all had tumour at or crossing the anterior commissure. Four patients were deemed potentially curable with further excision but chose radiotherapy. Two patients were deemed appropriate for radiotherapy and chemoradiotherapy. Three patients had loco-regional recurrence and underwent laryngectomy. All had anterior commissure involvement. CONCLUSION: Transoral laser excision is a safe, function-preserving treatment of early glottic SCC. Anterior commissure involvement was the major factor for potential failure with laser resection in T1 and T2 glottic tumours.

Type I gore-tex laryngoplasty for glottic incompetence in mobile vocal folds.

OBJECTIVE: To determine the effectiveness of gore-tex medialization thyroplasty for the management of glottic incompetence (GI) in patients with mobile vocal folds. METHODS: Twenty patients with glottic incompetence (GI) and mobile vocal folds were retrospectively analyzed after gore-tex medialization laryngoplasty. Pre- and postoperative outcome measures including grade, roughness, breathiness, asthenia, strain of the voice (GRBAS), glottal function index (GFI), and voice-related quality of life (VRQOL) were compared to detect surgical effectiveness. Two anesthetic subgroups were identified and compared: general anesthesia, via laryngeal mask airway (LMA) anesthetic, and local anesthesia. RESULTS: Statistically significant differences were identified between pre- and postoperative VRQOL (P<0.0001), GFI (P<0.01), and composite GRBAS (P<0.0001) after a mean follow-up time of 7.8 months. Both the LMA and the local anesthetic subgroups demonstrated similar significance across these measures. GFI and VRQOL scores demonstrate a moderate correlation (ρ=0.71). Perceptual voice quality (GRBAS) correlates slightly better with VRQOL scores (ρ=-0.6; P<0.01) than qualitative measures of glottal function (GFI) (ρ=0.43). CONCLUSION: Gore-tex thyroplasty provides reliable medium-term improvement in both perceptual and subjective voice parameters in the setting of GI with mobile vocal folds.

Videoendoscopic surgery for inaccessible glottic lesions.

OBJECTIVES: Lesions in the anterior segment of the vocal fold are sometimes difficult to access by means of conventional suspension microlaryngoscopy under general anaesthesia because of anatomical factors such as short, stout and inflexible necks, reduced jaw protrusion, and long incisors. Various techniques have recently been proposed for the management of inaccessible glottic lesions, most of which are performed under general anaesthesia. The use of flexible videoendoscopic surgery under topical anaesthesia in two cases of anterior glottic lesions that could not be treated by means of conventional suspension laryngoscopy is described. STUDY DESIGN: Case report. METHODS: A flexible videobronchoscope with an instrument channel was inserted transnasally on an out-patient basis. While the examiner carried out the endoscopy, an assistant maneuvered the biopsy forceps through the instrument channel, and removed the lesion. RESULTS: Both patients underwent successful removal of an anterior glottic polyp, and the one-year follow-up evaluation revealed normal anatomy of the vocal folds and normal vocal function. CONCLUSIONS: Flexible videoendoscopic surgery under topical anaesthesia is a safe, simple and minimally invasive procedure that can be considered as an alternative to traditional endoscopic surgery for inaccessible anterior glottic lesions.

[Selective neck dissection in the treatment of supraglottic carcinoma].

OBJECTIVE: To study the effectiveness of selective neck dissection (upper neck dissection, UND) in the treatment of N0 neck of supraglottic carcinoma. METHOD: The upper neck dissection was designed according to the lymphatic drainage of the supraglottic larynx for the management of N0 neck. The records of the supraglottic carcinoma of T1-4 N0-1 M0 cases (168 patients), who were treated in 1976-1990 at this hospital, were analysed retrospectively. RESULT: In this seires of 168 patients with no neck metastases pathologically a follow-up of five years after an upper neck dissection revealed a neck recurrence rate of 10.1% (17/168), which is comparable with those reported in the literature after selective neck dissection. Five year survival rate was 72.6% (122/168). CONCLUSION: Long-termed observation after UND for supraglottic carcinoma (T1-4 N0-1) resulted in satisfactory survival rates and regional control. It seems justifiable to do a selective neck dissection for N0 and selected N1 patients in order that more patients were exempted from enduring the morbidity following a comprehensive neck dissection.

[The post-operative recurrent laryngeal nerve paralysis and its course (author's transl)]. / Die postoperative Rekurrensparese und ihr Verlauf.

Benign diseases of the thyroid may also be the cause of pre-operative paralysis of the recurrent laryngeal nerves. the frequency of palsies in uncomplicated strumectomies is approximately 4 to 5%. A markedly higher risk exists in endothoracic goitres which must be delivered by thoracotomy, in recurrencies and thyroiditis. Dissection, crush lesions, strain and nerves mistakenly pulled into a ligature are the most frequent causes of injury; haematoma, oedema, heat by diathermy, lesions caused by a scar and a neuritis of the nerve are less common. 30 to 50% of unilateral laryngeal nerve palsies are without symptoms. An exact examination, however, reveals some alterations of the voice. A logopedic treatment combined with electro-therapy accelerates the compensation of the intact vocal cord. In bilateral paralysis of the recurrent laryngeal nerves a tracheotomy is necessary because of respiratory distress. After 6 to 9 months a glottis-widening procedure may be performed since no further recovery can be expected. A unilateral paralysis has a recovery rate of 40%; therefore in 2 to 3% of uncomplicated strumectomies a definite paralysis of the recurrent laryngeal nerve is observed.