2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Zeitels and Burns

Figure 2.  (A) Office laryngoscopy of a patient with an extensive T2b carcinoma with its epicenter within the anterior commissure and extending onto the arytenoids bilaterally as well as into the subglottis bilaterally. A biopsy had been taken at another institution from the right vocal fold just in front of the vocal process. (B) Office laryngoscopy after staged potassium-titanyl-phosphate (KTP) laser treatment. Considering the extent of the disease in the anterior commissure and anterior subglottis, there was limited cicatrization primarily at the cephalad edge of the subglottis at its juncture with the anterior commissure tendon. This patient did not receive radiotherapy.

Results The staging for the 117 patients was T1a-71, T1b-11, T2a- 10, and T2b-25. All patients were followed for a minimum of 3 years and the average follow-up was 53 months. The “b” designation delineated bilateral disease. Disease control for T1 lesions was 96% (79/82) and for T2 lesions was 80% (28/35). All 10 of the recurrences were treated with radio- therapy so that 91% (107/117) of patients had radiotherapy preserved as a future treatment option. Fifty percent (5/10) of the recurrences were controlled with radiotherapy (Figures 3A and 3B), whereas 50% (5/10) failed radiother- apy (Figures 4A and 4B) and all died of disease. Four of 5 underwent a total laryngectomy, whereas one-fifth died of regional and distant metastasis without disease in the lar- ynx. Glottal/larynx preservation and survival were achieved in 96% (112/117) of patients; 99% (81/82) with T1 disease and 89% (31/35) with T2 disease. Discussion Successful management of early glottic cancer requires that the clinician integrate a complex algorithm of interdepen- dent issues including efficacy of cure, potential detrimental effects of those interventions on normal tissue and voice quality, age and vocal needs of the patient, skill sets of the surgeon, prior oncologic history of the patient, availability of technology, and repeatability of the treatment. Since any adequate treatment for early glottic cancer (endoscopic excision, transcervical excision, radiation therapy) results in a high cure rate, the primary metrics by which the clini- cian should judge the success of the treatment are the

resulting voice quality and preservation of future treatment options. We previously demonstrated that angiolytic 532-nm KTP laser treatment of early glottic cancer could be an effective microlaryngeal strategy to maximally preserve normal glottal tissue, allowing for optimal phonatory muco- sal vibration and postoperative vocal quality. 23 This investi- gation was followed by a large series including comprehensive examination of voice outcomes, which rein- forced the functional advantages of the technique. 37 However, oncologic efficacy remained in question since the initial 2008 report had a limited number of patients and most did not have 3-year follow-up. Consequently, the investigation herein provides substantial further data that support the promising observations from the initial pilot patient cohort. 23 There was an outstanding disease control rate for T1 lesions of 96% (79/82). The majority of T1 lesions (87%, 71/82) were unilateral. Two T1 lesions were salvaged with radiotherapy; 1 failed again after radiotherapy, underwent a subsequent total laryngectomy, and died. Therefore, for T1 glottic cancer, larynx preservation and survival were achieved in 99% (81/82) of patients and only 4% (3/82) received radiotherapy. Unlike T1 disease, the majority of T2 lesions (71%, 25/35) involved both vocal folds. Most of these lesions were classified as T2 due to involvement of the supraglottis and/or subglottis, and they did not have deep invasion into the paraglottic musculature leading to significant impaired mobility. A substantial number of the T2 lesions had an extensive geographic footprint (Figures 2A and 2B).

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