Role of endolaryngeal surgery (with or without laser) compared with radiotherapy in the management of early (T1) glottic cancer: a clinical practice guideline

Squamous Cell Carcinoma of the Oral Cavity, Oropharynx, and Larynx: A Scoping Review of Treatment Guidelines Worldwide

Head and neck cancer (HNC) treatments have been based on single or multimodal therapies with surgery, radiotherapy (RT), chemotherapy, and immunotherapy. However, treatment recommendations among countries may differ due to technological/human resources and usual local practices. This scoping review aims to identify, compare, and map the clinical practice guidelines (CPGs) for treating squamous cell carcinoma (SCC) of the oral cavity, oropharynx, and larynx worldwide. A search strategy on global CPGs for HNC was performed by using five electronic databases and grey literature. CPGs were selected for inclusion using EndNote-20 and Rayyan online software. No language or publication date restrictions were applied. The results were analyzed descriptively considering the most updated CPG version. In total, 25 CPGs covering the head and neck region (10), the larynx (7), the oral cavity (5), and the oropharynx (3), were found in 13 geographical regions, and 19 were developed by medical societies from 1996 to 2023. Surgery and RT remain the main modalities for early-stage HNC, with surgery preferred in low-resource countries, and RT in selected cases, especially in the larynx/oropharynx aiming to achieve a cure with organ preservation. Human papillomavirus infection for oropharyngeal SCC is not tested in some Asian countries and there is still no consensus to treat p16-positive cases differently from p16-negative. Recommendations for larynx preservation vary according to facilities in each country, however, individualized choice is emphasized. Inequality across countries/continents is evident, with a similar pattern of recommendations among developed as well as developing ones. No CPGs were found in Latin America as well as Oceania countries, where the incidence of HNC is high and limitations of access to treatment may be encountered.

Prognostic factors of patients with initially diagnosed T1a glottic cancer: Novel nomograms and a propensity-score matched cohort analysis

The option of T1a glottic cancer treatments remarkably varied in different countries. This study aimed to construct predictive models to predict overall survival (OS) and cancer-specific survival (CSS) of patients with initially diagnosed T1a glottic cancer. And we used propensity score matching (PSM) to reassess the effect of treatments.Data of patients with initially diagnosed T1a glottic cancer were extracted from the Surveillance, Epidemiology, and End Results database. Patients with complete information were randomly divided into the training and the validation cohorts (7:3). Cox regression was conducted to screen significant predictors of the OS and the CSS. PSM was performed to mimic randomized controlled trials. Survival analyses were performed by Kaplan-Meier survival methods, and log-rank tests were utilized.A total of 2342 patients met the inclusion criteria. Survival analyses showed that patients who underwent primary site surgery would have better OS and CSS. Univariate analyses and multivariate analyses proved that stage, N stage, primary site surgery, and chemotherapy significantly affected both the OS and the CSS. Predictive nomograms were established to predict patients' prognosis. Finally, the OS and the CSS for patients who underwent primary site surgery alone were significantly longer than those who underwent radiation alone before and after PSM.We constructed nomograms predicting the OS and the CSS of patients with initially diagnosed T1a glottic cancer. Compared to our previous studies, this study indicated that primary site surgery may be superior to radiation and chemotherapy. At present, chemotherapy should be not recommended for T1a glottic cancer patients.

Early glottic tumours with anterior commissure involvement. Literature review and consensus document. Head and Neck and Skull Base Commission, SEORL-CCC

The choice of the most appropriate treatment in early-stage glottic cancer with anterior commissure involvement remains controversial. Its therapeutic management is complex because it is a significant prognostic indicator of local control with 37% recurrence, due to the difficulty in establishing tumour extension with understaging of up to 40%, and due to the comparison of results in series on tumours that behave variably as they progress, such as T1a, T1b and T2a with commissure involvement. Furthermore, the complexity of the surgical approach using transoral CO2 laser microsurgery requires surgical skill, appropriate equipment and experience. Aspects to be reviewed in this document are: an updated anatomical definition of the anterior commissure, tumour progression based on histopathological studies, usefulness of videostroboscopy and NBI in diagnostic accuracy, validity of imaging tests, oncological results published in series reviews, systematic reviews and meta-analyses, tumour margin treatment and voice evaluation.Finally, by way of a summary, the document includes a series of recommendations for the treatment of these tumours.

Prospective validation of an institutional treatment strategy for T1N0M0 glottic carcinoma

INTRODUCTION

The aim of this study was to assess the validity of a treatment strategy for T1N0 glottic squamous cell carcinoma.

METHODS

One hundred and seventeen patients were prospectively treated according to institutional guidelines. using 1) laser microsurgery (L) for exophytic tumor, limited to one vocal cord, without extension to the anterior commissure or the vocal process of the arytenoid cartilage, 2) radiotherapy (RT) for large or infiltrative tumor reaching the anterior commissure or the vocal process of the arytenoid cartilage, poor endoscopic exposure and cT1b or 3) partial laryngectomy (PL) for tumor infiltrating the anterior commissure. Ninety-five patients were treated with RT and 22 with surgery alone (S) [L:19; PL:3].

RESULTS

The 5-year overall survival (OS) and disease-specific survival (DSS) were 81.5% and 97.1% (median follow-up: 73 months), respectively. There was no statistically significant difference in OS or DSS between patients treated with RT or S (logrank test: p = 0.974 and 0.978). The 5-year ultimate local control rate reached 98.3%. The local control rate with larynx preservation was 94.9% with no difference between RT (94.7%) and S (95.5%) (χ²: p = 0.891). Continued smoking after RT was significantly associated with a lower 5-year OS (77.9% versus 87%), [HR 3.458; p = 0.043 (95%CI 1.010-11.837)].

CONCLUSIONS

For patients with T1 glottic carcinoma, and based on our previous studies, these data prospectively confirm the oncologic validity of an institutional treatment strategy. Continued smoking after RT correlated with poor OS.

Double pyramid technique of transoral laser partial laryngectomy for radiorecurrent laryngeal cancer

Management of recurrent head and neck cancer is challenging. Surgical treatments for residual or radiorecurrent laryngeal cancer include total laryngectomy, open partial laryngectomy and transoral laser microsurgery (TLM). TLM has been shown to achieve good oncological and functional outcomes in radiorecurrent laryngeal cancer. We describe a case of a patient with radiorecurrent T2 (rT2) with impaired vocal cord mobility laryngeal cancer who underwent transoral laser partial laryngectomy using our proposed double pyramid technique. It encompasses two steps: resection of the superior and inferior pyramids. Full resection is achieved by staying close to the thyroid and cricoid cartilages. In this technique, the dissection principle is to remove anterior commissure in two pyramid fashions without having to actually follow the tumour. This method is easy and simple to master. Two years postoperatively, the patient has no signs of recurrence and is able to use her voice and has full swallowing ability.

Human Papillomavirus Subtype 16 and the Pathologic Characteristics of Laryngeal Cancer

OBJECTIVE

Laryngeal cancer is the most common type of cancer in the head and neck. Human papillomavirus (HPV) represents a group of >150 related viruses. Infection with certain types of HPV can cause some types of cancer. This study aimed to evaluate the sociodemographic and histopathologic characters of squamous cell carcinoma of the larynx and its relationship to HPV subtype 16 (HPV-16).

STUDY DESIGN

Cross-sectional.

SETTING

Tertiary university hospitals at 5 districts in Egypt (Minia, Cairo, Giza, Qaluobia, and Bani Seuif).

SUBJECTS AND METHODS

This cross-sectional study was conducted on 50 adult patients with laryngeal cancer who were admitted at 5 tertiary care hospitals in Egypt from January 2014 through December 2014. All patients were subjected to a comprehensive preoperative assessment, histopathologic assessments of tumor biopsies, and immunohistochemical staining for HPV-16.

RESULTS

HPV-16 immunostaining was positive in 9 patients (18%). A significant correlation between HPV-16 immunoreactivity and tumor grade (P < .001) was detected, with no significant correlation between HPV-16 immunoreactivity and other clinical and pathologic variables.

CONCLUSION

The frequency of HPV-16 in laryngeal carcinoma is 18%, and there is significant correlation between HPV-16 and tumor grade.

Laryngeal Preservation in Glottic Cancer

Objective

When total laryngectomy is not required, organ preservation surgery or radiotherapy is considered the standard of care for primary glottic cancer. These accepted treatment options are available for early and advanced glottic cancers due to equivalent locoregional control and survival rates. However, in today’s climate of accountable care, the financial burden of treatment choices continues to increase in significance. We therefore compared hospital charges and treatment-related morbidity between organ-preserving surgery and radiation with or without chemotherapy—herein, (chemo)radiation—in the primary treatment of glottic cancer.

Study Design

Nationwide Inpatient Sample Database was analyzed to assess clinical and financial information.

Setting

Population-based analysis.

Subjects

Patients (N = 5499) with primary glottic cancer undergoing treatment with laryngeal preservation strategies.

Methods

Patients were subdivided by ICD-9 codes into 3 treatment groups: endoscopic resection, open partial laryngectomy, and (chemo)radiation. Treatment-related outcomes, charges, and length of hospitalization were analyzed among treatment groups.

Results

When adjusting for sex, age, race, comorbidity, and primary payer, (chemo)radiotherapy was associated with increased direct charges ( P < .001; coefficient, $23,658.99; 95% confidence interval [95% CI]: $10,227.15-$37,090.84) and length of hospitalization ( P < .001; hazard ratio, 0.593; 95% CI: 0.502-0.702) when compared with endoscopic surgery. As compared with open surgery, endoscopic surgery was associated with reduced hospital charges ( P = .012; coefficient, $11,967.01; 95% CI: $2,784.17-$21,249.85) and duration of hospitalization ( P < .001; hazard ratio, 0.749; 95% CI: 0.641-0.876).

Conclusions

This analysis suggests that increased utilization of endoscopic surgery in patients with primary glottic cancer not requiring total laryngectomy may lead to reduced financial burden and duration of hospitalization when compared with open surgery or (chemo)radiation therapy.

Transthyrohyoid access to the larynx for endoscopic resection of early-stage glottic cancer

BACKGROUND

The effectiveness of transoral microsurgery for early-stage glottic cancer relies on the possibility to obtain adequate exposure of the lesion. The purpose of this study was to design a new surgical technique allowing efficient endoscopic removal of these tumors in patients with unsatisfactory transoral exposure.

METHODS

A minimal invasive access to the glottis, made through the thyrohyoid membrane and the preepiglottic space, was used for endoscopic resection of an early-stage glottic tumor in a patient with a medical history of previous radiotherapy and unsatisfactory endoscopic exposure of the lesion.

RESULTS

This approach provided excellent exposure of the glottis and allowed endoscopic resection with adequate surgical margins. The surgical procedure and the postoperative period were uneventful. Functional outcomes were back to baseline after 1 month.

CONCLUSION

This technique represents an attractive solution for patients presenting with early-stage glottic tumors that cannot be exposed transorally and have contraindications to alternative therapeutic procedures. © 2016 Wiley Periodicals, Inc. Head Neck 38:1286-1289, 2016.

Simulation study of high-dose-rate brachytherapy for early glottic cancer

PURPOSE

External beam radiation therapy (EBRT) is effective for early glottic cancers, with cure rates of ∼90% for T1 tumors. EBRT has strengths but also disadvantages including radiation to healthy tissues and duration of 5-7 weeks. With advances in laryngeal framework surgery, new devices can provide reliable, minimally invasive access to the larynx. Such devices could be modified to insert brachytherapy catheters. Brachytherapy could provide focused radiation while limiting dose to normal structures in the larynx and neck. As a preliminary step, we performed simulations comparing EBRT to high-dose-rate brachytherapy to assess if this approach could provide dosimetric advantage.

METHODS AND MATERIALS

One- and 2-catheter brachytherapy simulations were performed for 3 patients with T1 glottic carcinoma. Percentage of dose delivered to the target and adjacent structures was compared with conventional EBRT using 3D and intensity-modulated radiation therapy approaches.

RESULTS

Percentage of structures exposed to 50% of the dose was lower for brachytherapy compared with 3D EBRT and intensity-modulated radiation therapy, particularly for the cricoid and contralateral arytenoid. Dose was also lower for the carotid-internal jugular vein complexes compared with 3D EBRT. Dose profiles did not differ significantly between 1- and 2-catheter simulations.

CONCLUSION

Brachytherapy can decrease radiation to normal tissues including laryngeal cartilages and carotid-internal jugular vein complexes. Recent advancements allowing catheter placement may afford the potential to decrease radiation to healthy tissues with decreased treatment time. However, careful, stepwise evaluation of feasibility and outcomes in model systems is required before recommending this approach for such high cure rate cancers in humans.

Treatment and Survival Trends in Glottic Carcinoma in Situ and Stage I Cancer From 1988 to 2012

OBJECTIVE

To identify trends in treatment and survival for patients with stage I glottic cancer and glottic carcinoma in situ (CIS).

METHODS

The 18-registry SEER data were analyzed for CIS and stage I glottic cancer. Treatment variables and observed and relative survival were assessed separately for stage I and glottic CIS.

RESULTS

Among 14 025 cases of stage I glottic cancer identified from 1988 to 2012, radiation was the most common treatment for all eras. An increase in surgical treatment occurred with a decline in combination therapy. There were 3169 cases of glottic CIS, with surgery the most common initial treatment but with radiotherapy increasing across the years. Relative survival was similar for treatment type and era of diagnosis. Among the 3738 patients with glottic CIS, 5.4% went on to develop invasive glottic carcinoma of any stage, with invasive cancer more common in patients treated by surgery alone compared to radiation or surgery with radiation.

CONCLUSIONS

Despite changes in treatment modalities for CIS and stage I glottic cancer, there have not been significant changes in survival for CIS, with slightly improved survival for treatment with surgery alone. Patients treated with surgery alone had an increased rate of subsequent invasive cancer.

Tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers: a critical appraisal

Objective:

The tumour–node–metastasis staging system has a dynamic structure that is continuously being updated as scientific data develops. This review discusses some suggested revisions on tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers.

Methods:

The seventh edition of The American Joint Committee on Cancer Staging Manual was reviewed and important issues that could be considered for revision were identified and discussed.

Results:

According to our assessment of the oncological outcomes of previous studies, the following factors should be considered for revision: anterior commissure involvement and subglottic extension in laryngeal cancers; underlying bone involvement in hard palate and upper alveolar ridge cancers; tumour thickness in oral cancers; and extracapsular spread and carotid artery involvement in neck metastases.

Conclusion:

Sufficient data on the prognostic importance of these issues have been reported. Suggested revisions in line with current knowledge on the clinical behaviour of upper aerodigestive tract cancers would improve the relevancy of staging.

Comparative effectiveness in head and neck malignancies

To date, there is limited comparative effectiveness research (CER) in head and neck surgical oncology. Several barriers exist, the most common of which include low patient accrual, selection bias inherent to observational studies, and the difficulty of integrating both clinical and functional outcomes. Areas in need of meaningful CER range from initial evaluation to post-treatment surveillance, as well as the identification and evaluation of significant quality metrics and patient-reported outcomes. Despite existing hurdles, careful study design and statistical analyses can address current gaps in head and neck cancer care.

Clinical practice guidelines and consensus statements in oncology--an assessment of their methodological quality

BACKGROUND

Consensus statements and clinical practice guidelines are widely available for enhancing the care of cancer patients. Despite subtle differences in their definition and purpose, these terms are often used interchangeably. We systematically assessed the methodological quality of consensus statements and clinical practice guidelines published in three commonly read, geographically diverse, cancer-specific journals. Methods Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents.

METHODS

Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents.

FINDINGS

Thirty-four consensus statements and 67 clinical practice guidelines were evaluated. The rigour of development score for consensus statements over the three journals was 32% lower than that of clinical practice guidelines. The editorial independence score was 15% lower for consensus statements than clinical practice guidelines. One journal scored consistently lower than the others over both domains. No journals adhered to all the items related to the transparency of document development. One journal's consensus statements endorsed a product made by the sponsoring pharmaceutical company in 64% of cases.

CONCLUSION

Guidance documents are an essential part of oncology care and should be subjected to a rigorous and validated development process. Consensus statements had lower methodological quality than clinical practice guidelines using AGREE II. At a minimum, journals should ensure that that all consensus statements and clinical practice guidelines adhere to AGREE II criteria. Journals should consider explicitly requiring guidelines to declare pharmaceutical company sponsorship and to identify the sponsor's product to enhance transparency.

Treatment and survival in 10,429 patients with localized laryngeal cancer: a population-based analysis

BACKGROUND

The objectives of this study were to identify factors associated with treatment differences, characterize changes in treatment patterns over time, and compare survival across treatment types in patients who received treatment for localized laryngeal cancer.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of patients who were treated from 1995 to 2009 for localized laryngeal cancer. Four treatment groups were defined: (1) radiation only, (2) local surgery only, (3) local surgery and radiation, and (4) open surgery with or without radiation. Variations in treatment rates between these groups were evaluated according to demographic factors, and differences in treatment rates across time were calculated. Associations between treatment and mortality were assessed using Kaplan-Meier methods. Cox proportional hazards regression models were used to adjust for potential confounding covariates.

RESULTS

In total, 10,429 patients with localized laryngeal cancer were identified. Most patients (57%) were treated with radiation only; 25% with local surgery and radiation, 9% with local surgery only, and 9% with open surgery with or without radiation. Race, age, and registry were associated with differences in treatment. Receipt of single-modality treatment increased and receipt of combined-modality treatment decreased over the study period. Better survival was observed with white race, younger age, and treatment with local surgery. Survival differences associated with treatment type were observed within 3 years of diagnosis and persisted beyond 5 years after diagnosis.

CONCLUSIONS

Although treatment patterns became more adherent to treatment guidelines over time, we identified survival differences associated with treatment type that warrant further investigation into treatment decision-making for patients with localized laryngeal cancer.