Endoscopic treatment of cT2 glottic carcinoma: prognostic impact of different pT subcategories.

OBJECTIVES: The cT2 glottic squamous cell carcinomas are a heterogeneous group of lesions in terms of superficial and deep extension. As a consequence, they differ greatly in treatment indications and prognosis. The aim of the present study was to divide cT2 glottic tumors into subcategories according to radiologic and postoperative histopathologic information, in order to identify risk factors connected with determinate survival, local-regional control, and laryngeal preservation rates. METHODS: We retrospectively analyzed 55 cT2 glottic lesions treated at a single institution by carbon dioxide laser with at least 2 years of follow-up. Clinical, radiologic, surgical, and histopathologic data were reviewed, and the tumors were accordingly divided into 5 subcategories: I, or pT2 with lateral supraglottic extension (19 patients); II, or pT2 with lateral subglottic extension (6 patients); III, or pT2 with supracommissural and/or subcommissural extension (10 patients); IV, or pT2 with deep vocal muscle infiltration (14 patients); and V, or pT3, for superior and/or inferior paraglottic space invasion lateral to the thyroarytenoid muscle not detected before operation by computed tomographic scan (6 patients). RESULTS: The disease-free survival, ultimate local control with laser alone, and laryngeal preservation rates were compared for each subcategory. Statistically significant differences were found only for the pT3 subgroup (2-year rates of 16.7%, 16.7%, and 16.7% for pT3 versus 5-year rates of 80.5%, 84.7%, and 93.3% for the entire pT2 group). CONCLUSIONS: Endoscopic treatment of cT2 glottic tumors can be considered effective when the pT2 stage has been confirmed. In cT2/pT3 patients, after the first endoscopic resection that allows the correct pT staging, additional treatment should always be considered.

Analysis of recurrences in 322 Tis, T1, or T2 glottic carcinomas treated by carbon dioxide laser.

An endoscopic approach to early glottic carcinoma is considered a sound treatment for both previously untreated lesions and selected recurrent lesions. Between January 1988 and December 2000, we treated 322 patients by CO2 laser at a single institution; 37 had Tis, 191 T1a, 55 T1b, and 39 T2 lesions (mean follow-up, 77 months; range, 6 to 180 months). Kaplan-Meier curves showed a 5-year overall survival rate of 88%, a determinate survival rate of 99%, a disease-free survival rate of 81%, a rate of ultimate local control with laser alone of 91%, and a laryngeal preservation rate of 97%. Univariate and multivariate analysis showed that the only factor that statistically affected endoscopic control was lateral extension of the tumor with involvement of the bottom of the ventricle (hazard risk ratio, 4.0; 95% confidence interval, 1.71 to 9.35). The 58 recurrences were classified according to their location compared with the site of the primary tumor as follows: 14 in the same area (group A), 27 in adjacent subsites with superficial spreading or multifocal distribution (group B), and 17 in adjacent sites by submucosal diffusion to the visceral spaces, cartilaginous framework, or extralaryngeal tissues (group C). For each group, we analyzed the rate of patients who underwent salvage by endoscopic or open neck procedures and the rate of laryngeal preservation. Recurrences in groups A and B were endoscopically treated in 86% and 74% of cases, respectively. By contrast, in group C no patient was endoscopically cured, and there was a low laryngeal preservation rate (47%). The pathways of spread in recurrent carcinoma are therefore the single most important factor in predicting its endoscopic curability.

Carbon dioxide laser salvage surgery after radiotherapy failure in T1 and T2 glottic carcinoma.

OBJECTIVES: Recurrent glottic carcinoma after radiotherapy (RT) may be managed by open neck or endoscopic surgery. The impact of endoscopic treatment with CO(2) laser for recurrent glottic carcinoma after RT is reported. METHODS: We present the oncologic and vocal outcomes of a retrospective study based on a series of 16 patients with rT1 and rT2 glottic carcinoma who were endoscopically managed between February 1995 and December 1999 after RT failure. All patients were males with a mean age of 68.7 years (range, 50 to 87 years). Before RT, the lesions had been staged as T1 N0 in 11 patients and T2 N0 in 5, and after RT as rT1 N0 in 12 and rT2 N0 in 4. According to the European Laryngological Society classification, a total of 9 transmuscular, 3 total, and 4 extended cordectomies were performed. Mean follow-up was 45 months (range, 9 to 79 months). RESULTS: Endoscopic salvage surgery was successful in 14 patients. One of them developed a second recurrence and was definitively cured with an additional endoscopic procedure. Two of the 16 patients had recurrent disease after salvage laser surgery and died due to progression of disease. Ultimate local control with laser alone at 3 years was 87.1%, according to the Kaplan-Meier method. Laryngeal preservation was obtained in all survivors after endoscopic rescue surgery. Voice analysis showed a clear correlation between the amount of vocal cord tissue resected and decrease of the vocal outcome. CONCLUSIONS: The present series indicates that selected recurrences after primary RT for T1 and T2 glottic carcinoma are eligible for endoscopic salvage surgery with oncologic results comparable to those with open neck procedures but with a lower complication rate and a favorable functional outcome.

Preoperative and postoperative voice in Tis-T1 glottic cancer treated by endoscopic cordectomy: an additional issue for patient counseling.

Radiotherapy contends with endoscopic surgery for the role of treatment of choice for Tis-T1 glottic cancer. The amount of vocal cord to be surgically removed logically depends on the surface and deep extension of the neoplasm. Thus, a prerequisite for proper management includes an analysis of the voice changes after each of the progressive types of cordectomy described in the European Laryngological Society Classification. Between January 1998 and December 2000, 89 patients with glottic cancer (8 Tis, 63 T1a, 18 T1b) underwent different types of endoscopic cordectomy. Perceptual analysis (GRBAS scale); objective analyses of jitter, shimmer, and noise-to-harmonics ratio; and subjective (Voice Handicap Index) evaluation of voice were performed in 51 patients. Statistical evaluation of preoperative and postoperative objective results by analysis of covariance, as well as perceptual and subjective data, showed significant voice improvement after type I and II cordectomies, with the voice attaining nearly normal parameters. By contrast, after type III, IV, and V cordectomies, the vocal outcome was not significantly different from the preoperative pattern. It can therefore be concluded that type I and II resections, whenever indicated, are adequate procedures even for professional voice users. By contrast, accurate counseling is mandatory before type III, IV, and V cordectomies.