Transoral laser resection or radiotherapy? Patient choice in the treatment of early laryngeal cancer: a prospective observational cohort study

Vocal-cord Only vs. Complete Laryngeal radiation (VOCAL): a randomized multicentric Bayesian phase II trial

BACKGROUND

Radiotherapy, along with laser surgery, is considered a standard treatment option for patients with early glottic squamous cell cancer (SCC). Historically, patients have received complete larynx radiotherapy (CL-RT) due to fear of swallowing and respiratory laryngeal motion and this remains the standard approach in many academic institutions. Local control (LC) rates with CL-RT have been excellent, however this treatment can carry significant toxicities include adverse voice and swallowing outcomes, along with increased long-term risk of cerebrovascular morbidity. A recent retrospective study reported improved voice quality and similar local control outcomes with focused vocal cord radiotherapy (VC-RT) compared to CL-RT. There is currently no prospective evidence on the safety of VC-RT. The primary objective of this Bayesian Phase II trial is to compare the LC of VC-RT to that of CL-RT in patients with T1N0 glottic SCC.

METHODS

One hundred and fifty-five patients with T1a-b N0 SCC of the true vocal cords that are n ot candidate or declined laser surgery, will be randomized in a 1:3 ratio the control arm (CL-RT) and the experimental arm (VC-RT). Randomisation will be stratified by tumor stage (T1a/T1b) and by site (each site will be allowed to select one preferred radiation dose regimen, to be used in both arms). CL-RT volumes will correspond to the conventional RT volumes, with the planning target volume extending from the top of thyroid cartilage lamina superiorly to the bottom of the cricoid inferiorly. VC-RT volumes will include the involved vocal cord(s) and a margin accounting for respiration and set-up uncertainty. The primary endpoint will be LC at 2-years, while secondary endpoints will include patient-reported outcomes (voice impairment, dysphagia and symptom burden), acute and late toxicity radiation-induced toxicity, overall survival, progression free survival, as well as an optional component of acoustic and objective measures of voice analysis using the Consensus Auditory-Perceptual Evaluation of Voice.

DISCUSSION

This study would constitute the first prospective evidence on the efficacy and safety of VC-RT in early glottic cancer. If positive, this study would result in the adoption of VC-RT as standard approach in early glottic cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03759431 Registration date: November 30, 2018.

Shared Decision-making in Head and Neck Surgery: A Review

Importance

Shared decision-making is a partnership between physicians and patients whereby patient values and preferences are incorporated with the best medical evidence. Shared decision-making may reduce decisional conflict, improve value-choice congruence, and increase patient involvement. Despite potential benefit in many key areas of otolaryngology-head and neck surgery, both clinical and research focuses on shared decision-making are scarce. Head and neck surgical oncology is of particular interest owing to the frequency by which preference-sensitive decisions must be made. Information used in this review was obtained between January 1 and February 1, 2020.

Observations

Various conceptual models have been developed in an attempt to define the concept of shared decision-making. More than 40 instruments have endeavored to measure the construct of shared decision-making. However, in head and neck surgery, few studies to date have explicitly done so. Situations of clinical equipoise, such as in the management of indeterminate thyroid nodules and in the treatment of laryngeal cancer, are frequent. In contrast, value-option incongruence may occur when patient values do not align with the most oncologically sound treatment choice, such as when the resection and reconstruction of oral cancer may leave patients with significant sequelae. Several patient decision aids have been developed to improve shared decision-making in specific clinical scenarios, for example, in considering total laryngectomy or primary chemoradiotherapy.

Conclusions and Relevance

Despite its potential benefit, there is a dearth of research and clinical applications of shared decision-making in head and neck surgery. Shared decision-making represents an area of substantial need in this regard, and additional efforts should be put forth.

Long-term Oncologic Outcomes of 1188 Tis-T2 Glottic Cancers Treated by Transoral Laser Microsurgery

OBJECTIVE

To evaluate long-term disease-specific survival (DSS) and organ preservation (OP) rates in patients affected by Tis-T2 glottic squamous cell carcinoma (SCC) treated by carbon dioxide transoral laser microsurgery (CO₂ TOLMS).

STUDY DESIGN

Single-center retrospective cohort study.

SETTING

Tertiary academic hospital.

METHODS

The study included patients treated by CO₂ TOLMS for Tis-T2 glottic SCC at the Department of Otorhinolaryngology-Head and Neck Surgery of the University of Brescia, Italy, from 1988 to 2018. The male:female ratio was 11.2:1, and the mean age was 64 years (range, 31-95). T categories were distributed as follows: 124 (10%) Tis, 646 (54%) T1a, 172 (15%) T1b, and 246 (21%) T2.

RESULTS

Ten- and 20-year DSS rates were 97.6% and 96.3%, respectively, and 10- and 20-year OP rates were 94.7% and 93%. During the follow-up, 91% of patients were treated by CO₂ TOLMS alone, while the remaining needed adjunctive treatments. Assessing the impact of multiple sessions of CO₂ TOLMS, DSS showed no significant difference in terms of patients treated by 1, 2, or >2 procedures. Conversely, patients treated by >2 sessions of CO₂ TOLMS showed a significantly worse OP rate.

CONCLUSIONS

Our series validates CO₂ TOLMS as a long-term treatment strategy for early glottic SCC. Salvage CO₂ TOLMS provided optimal results in terms of DSS and OP in patients with recurrence after previous transoral surgery.

MicroRNA-384 regulates cell proliferation and apoptosis through directly targeting WISP1 in laryngeal cancer

Laryngeal cancer (LC) is an increasingly common malignant tumors of head and neck cancer. Aberrant expression of microRNA (miRNA) is closely related with LC development. In the current study, we investigated the biological function and underlying molecular mechanism of miR-384 in LC. The results showed that the miR-384 expression was markedly downregulated in LC tissue and cell lines (TU212 and TU686) as compared with that of adjacent nontumor tissues and a normal human bronchial epithelial cell line. Next, we performed gain-of-function and loss-of-function experiments in the TU212 and TU686 cells by transfecting the cells with miR-384 mimics, miR-384 inhibitor, or miRNA control. Moreover, results showed that miR-384 mimic remarkably inhibited LC cell proliferation, which was notably decreased by miR-384 inhibitor. Furthermore, miR-384 mimics notably increased the amounts of DNA fragmentation from the apoptotic cells (a hallmark of apoptosis) and the caspase-3 activity, whereas miR-384 inhibitor resulted in a decline of DNA fragmentation and the caspase-3 activity compared with its control. In addition, a dual-luciferase reporter assay confirmed that Wnt-induced secreted protein-1 (WISP1) gene was a direct target of miR-384. MiR-384 mimic remarkably inhibited the messenger RNA and protein expression of WISP1, which was upregulated by miR-384 inhibitor as compared to its control. WISP1 knockdown by small interfering RNA inhibited LC cell proliferation and promoted cell apoptosis. WISP1 overexpression partly abrogates the effect of miR-384 overexpression. Taken together, these data indicate that miR-384 regulates LC cell proliferation and apoptosis through targeting WISP1 signaling pathway, providing a novel insight into the LC treatment.

Effects of gold nanorods modified with antiepidermal growth factor receptor monoclonal antibody on laryngeal cancer cells

We aimed to evaluate the photothermal effects of gold nanorods (GNRs) modified with antiepidermal growth factor receptor (EGFR) monoclonal antibody (mAb) on laryngeal cancer cells. EGFR protein expressions in HEP-2 cells, and normal laryngeal epithelial and laryngeal cancer tissues were detected by western blot. The cytotoxicity against HEP-2 and BEAS-2B cells was tested by MTT assay, and the photothermal effects were assessed by near-infrared (NIR) irradiation. The apoptosis of HEP-2 cells was detected by flow cytometry. EGFR expression in laryngeal cancer tissues was significantly higher than that in normal tissues (P < 0.05). The inhibitory effects of GNRs and anti-EGFR mAb/GNRs on the apoptosis of HEP-2 and BEAS-2B cells were enhanced with increasing dose. AntiEGFR mAb/GNRs were more cytotoxic to HEP-2 cells and less cytotoxic to BEAS-2B cells than GNRs. NIR irradiation inhibited cell proliferation, which was enhanced with rising power, accompanied by continuously dropping survival rate. The apoptosis rate of the anti-EGFR mAb/GNRs group was significantly higher than that of the GNRs group, and the apoptosis rate of the irradiation + antiEGFR mAb/GNRs group also significantly exceeded that of the irradiation + GNRs group (P < 0.05). Anti-EGFR mAb/GNRs promoted HEP-2 cell apoptosis more evidently than GNRs did. Functional modification of GNRs augmented the targeted specificity to cancer cells, biocompatibility, and stability. Anti-EGFR mAb/GNRs have great potential in biomedical fields.

Treatment Preferences in Patients With Early Glottic Cancer

Objective:

For early glottic carcinoma, the 2 main treatment modalities are radiotherapy (RT) and transoral CO₂ laser microsurgery (TLM). The aim of this study was to investigate treatment preferences and considerations in patients with early glottic carcinoma (T1-T2) who were given a choice between TLM and RT.

Subjects and Methods:

Patients with early glottic cancer (suspected or confirmed extended T1 or limited T2) were counseled by an ENT-surgeon. A subset of 32 patients was also counseled by a radiotherapist. Treatment choice and considerations were recorded and analyzed.

Results:

Of 175 patients, 168 patients (96%) chose TLM, and 7 patients (4%) chose RT. The most common reason for choosing TLM was shorter treatment and more treatment options in case of recurrence. Subanalysis showed that additional counseling by the radiotherapist did not seem to affect our patients’ preferences for TLM in this group.

Conclusions:

The majority of patients in our study prefer TLM to RT when given a choice. Reasons given indicate that optimizing future treatment options and practical considerations seemed more important to our patients than primary functional outcome. Further research is needed to study patient-related and physician-related factors to gain more insight into this complicated process of shared decision making.

Psychological intervention improves life quality of patients with laryngeal cancer

BACKGROUND

The purpose of this study is to examine the effect of psychological intervention on the life quality of patients with laryngeal cancer.

METHODS

Two hundred and ten patients with laryngeal cancer were randomly assigned to the study group receiving psychological intervention and control group receiving routine nursing care. The Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and the Europe Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) were used to evaluate life quality.

RESULTS

There were no significant differences in the scores of HAMD, HAMA, and EORTC QLQ-C30 between the 2 groups before treatment (P>0.05). After treatment, the scores in the study group were significantly different to those in the control group (P<0.05). In addition, the satisfaction rate and compliance rate of patients in the study group were increased, compared to the control group (P<0.05).

CONCLUSION

Psychological intervention is beneficial in improving life quality in patients with laryngeal cancer after surgery.